MARTY MOSS-COANE: Welcome to our webcast. I'm Marty Moss-Coane. Cancers of all kinds are frightening illnesses and the idea of a brain tumor seems especially threatening. So when parents face the news that their child has been diagnosed with a brain tumor, the impact can be tremendous. Fortunately, many pediatric brain tumors can be completely cured with modern surgical techniques and other treatments.
Joining us today to discuss the different options are two experts and let me introduce them to you. Dr. Fred Epstein is founding director of the Institute for Neurology and Neurosurgery at the Beth Israel Medical Center in New York. Welcome, Dr. Epstein.
FRED J. EPSTEIN, MD: Thank you.
MARTY MOSS-COANE: And Dr. George Jallo is an attending pediatric neurosurgeon at the same Institute. Dr. Jallo, nice to have you here with us as well.
Dr. Epstein, let me begin with you. How do you approach parents if surgery is the option? How do you speak to this issue to them?
FRED J. EPSTEIN, MD: You know, I think the first thing is for parents to understand that you truly care and that we're all human beings that want the same thing for our children. The next thing you have to do is you have to be honest, families have to understand what's involved in surgery, what the hazards are, what it's going to be like afterwards. And make as complete an explanation as possible.
One of the things that I think is critical is no matter what you say, it has to be presented in a way that a family can survive with it. There are different ways of doing that. Honest? Yes. People have to know. And look, thank goodness, most of these tumors are benign and curable.
MARTY MOSS-COANE: Let me turn to you because I know there are extraordinary options really. When a child has a brain tumor, what are some of those surgical options that they have?
GEORGE JALLO, MD: The options for a brain tumor is to take it out as safely as possible. And the technology that we have today makes it -- makes us able to do craniotomies that we wouldn't do years ago.
MARTY MOSS-COANE: And describe for us then, what you do? And I have a feeling this is pretty cutting-edge stuff.
GEORGE JALLO, MD: The technology that we have now -- we have image guidance. What that allows us to do is do an MRI the morning of surgery and when we bring the child to the operating room we're able to guide the craniotomy flap, the skin incision and guide us through the brain to any tumor wherever it may be located near vital structures, like optic nerves, big blood vessels or the brain stem -- and get there safely and be able to remove the whole tumor as safe as possible.
MARTY MOSS-COANE: So you're working with a computer though?
FRED J. EPSTEIN, MD: Yeah, we do. One of the things that amazes me, Dr. Jallo, who has been working with the computer when I've seen him do this. And it still is incredible to me, is yes, you can approach tumors anywhere in the brain through the smallest opening. It's what's called minimal surgery. To think of taking out a big brain tumor through a 1.5 or 2 inch incision so a child may be able to go home in three days with a Band-Aid, is really a testimony to the technology and the skill of those that are expert in using it.
MARTY MOSS-COANE: So those days of the great incision over the top of the head -- those days are gone.
GEORGE JALLO, MD: Definitely.
FRED J. EPSTEIN, MD: Hair shaves are gone.
MARTY MOSS-COANE: Hair shaves as well.
FRED J. EPSTEIN, MD: Very important.
MARTY MOSS-COANE: What kind of instruments do you use?
GEORGE JALLO, MD: We use microsurgical instruments that have been around for years. It's just allows us to do it in a much smaller opening than we would have many years ago.
MARTY MOSS-COANE: I'm curious too then, so let's go into the operating room. You have the child there sedated. You've identified, isolated where you're going to make this incision.
GEORGE JALLO, MD: Yes, using the computer system, the Image 9 System, we're able to just map on the surface of the head where it's going to be and plan as straight an incision -- to be able to make an incision a couple inches long. Then turn the craniotomy flap that's an inch or maybe two inches wide in diameter.
MARTY MOSS-COANE: I'm interested what a craniotomy flap is?
GEORGE JALLO, MD: It's just the removal of the bone or the skull.
FRED J. EPSTEIN, MD: Let's look at it this way a little bit if I may. And I'm still listening because it's really so incredible when I watch what you do here. See when we open up the craniotomy flap and we look at the surface of the brain -- supposing the tumor is two or three inches in. In the past, you see particularly if it's a small tumor, you wouldn't know how to go at it. Where do you go? Do you go in front? Do you go behind? Do you ride over it? Think of taking a small splinter out of your child -- having to find it.
Well, in the brain, this was a huge problem. Now what surgeon such as Dr. Jallo can do is they can plan before how they're going to go at it. They can map a projectory [sic] on a computer and then that computer in the operating room will direct them in the safest projectory [sic] through the brain to a small tumor deep within so it can be removed and cured.
MARTY MOSS-COANE: And using this model here, let's say the tumor is somewhere in here --
GEORGE JALLO, MD: Let's say on this model the tumor is up here. Well, if you're going to make the incision, it's back here. It's a big distance to get there. And many years ago you'd have to make a big opening just to get this whole area exposed and try to find it. With the technology that we have now, we know the tumor is there. And using computer technology and a pointer similar to this, we can just point and plan the best trajectory to that area and just do it with the smallest opening possible.
MARTY MOSS-COANE: What are some of the risks associated with surgery?
GEORGE JALLO, MD: The risks with surgery are just for any operation that any child is going to go with -- there's risks of anesthesia. There is always the risk of a hemorrhage. There's risk of infection. But those are all trivial with the state that medicine is in today.
FRED J. EPSTEIN, MD: George, why don't you tell them -- somebody comes with a brain tumor. You pointed back there. What will you tell the family the risk is to having a bad outcome and percentage?
GEORGE JALLO, MD: It's on the order of 1%.
MARTY MOSS-COANE: 1%.
FRED J. EPSTEIN, MD: It's amazing, isn't it?
MARTY MOSS-COANE: It is amazing. Are there though neurological risks if you're going into the brain? You're near the spinal column, all of that.
GEORGE JALLO, MD: There is always -- there are always some risks for some weakness or some nerve injury. But with what we can do today, again it's on the order of percentage points. We are able to do this so safely today it's probably safer than driving a car.
MARTY MOSS-COANE: Really. Can you typically remove the whole tumor?
GEORGE JALLO, MD: In children, since most tumors are benign, they tend to be well circumscribed. We probably can remove most, if not all the tumor completely.
And if you don't --
MARTY MOSS-COANE: I was going to say if you can't remove --
GEORGE JALLO, MD: If you can't and then we've got other therapies for it. I mean such as you can just watch it. If it's a benign tumor, you can just watch it. Some of these tumors will disappear if you get the majority of them. Others may require some therapy such as radiation therapy or chemotherapy. But again, that depends upon the tumor type that it is.
FRED J. EPSTEIN, MD: But again the cancerous tumors that may require chemotherapy -- everybody is always scared of the cancerous tumors, understandably -- a lot of them are curable now. A lot of them are curable which is what's so incredible considering what they were a few years ago.
MARTY MOSS-COANE: I'm interested in how long you might follow-up a child's progress after surgery for a brain tumor?
GEORGE JALLO, MD: You’d have -- after surgery they go home within the first week. We see them within a couple weeks after surgery, then a couple months. And then on the magnitude of may -- on the order of an annual visit. It's more to just say hello than --
MARTY MOSS-COANE: Really? More than anything else.
GEORGE JALLO, MD: -- more than anything else.
MARTY MOSS-COANE: How about for you in terms of watching a child's progress and sort of just making sure that everything is okay?
FRED J. EPSTEIN, MD: I think it's the same thing. You know, a child comes in a looks good. You sit there looking at each other not knowing what to say. We get the MRI scans every year or so. You have to follow it. But there's not much to do.
MARTY MOSS-COANE: Are there other medications used with the treatment of brain tumors?
GEORGE JALLO, MD: Really, besides chemotherapy and radiation therapy, when they're in the hospital we may give them a couple doses of steroids just to help with some of the swelling and to alleviate some of the symptoms while they're there. Other than that that's -- we really don't hide any complaints with other medications.
MARTY MOSS-COANE: How about seizure medications? Is that something that's ever prescribed?
GEORGE JALLO, MD: Occasionally, but again, yeah, most tumors in children are in an area that don't cause seizures.
MARTY MOSS-COANE: I know this is a complicated procedure and it sounds like there are many different levels of physicians and even nurses involved in the treatment of brain tumors. Give us a sense of the team of doctors that are involved, the specialists involved in something like this.
GEORGE JALLO, MD: I think Dr. Epstein --
FRED J. EPSTEIN, MD: Well, I think -- you've alluded to something that's very important. I think one of the most important advances in contemporary medicine, in neurosurgery in particular, is it's not a one-person show.
MARTY MOSS-COANE: Really.
FRED J. EPSTEIN, MD: It's not a neurosurgeon alone. It's a team that has to work together and have an integrated effort looking at something -- all aspects. You have the neurosurgeon. You have the neurooncologist. That's a neurologist that specializes in tumors. They're the experts in chemotherapy. You have the radiation oncologist. The neuroradiologist. I think that this may be the most important singular advance, the recognition that one has to have a cooperative effort through different disciplines, all directed at the same thing. Because we all come at it from different directions, but have something to offer.
MARTY MOSS-COANE: Would you agree with that?
GEORGE JALLO, MD: Yeah. It's not a one-man show. It's a team approach and you need all the members of the team to treat a child.
MARTY MOSS-COANE: We're just about out of time. Any final thoughts? Any final comments about surgery and the treatment of brain tumors in children.
FRED J. EPSTEIN, MD: I'll make one comment. What about a tumor we can't remove completely and it's cancerous. What are we going to say to families? And I'll tell you what I say to families. We now with surgery and with cooperating with our oncologists can extend life for a long time. And it's very possible in a finite period of time, we're going to have a whole new approach and even those children to look so hopeless today -- there may be a light at the end of the tunnel. I don't know how long the tunnel is there, but we're working in that direction.
MARTY MOSS-COANE: Great. Well, I thank you. Do you want to add anything before we say good-bye?
GEORGE JALLO, MD: No.
MARTY MOSS-COANE: Well, I want to thank you both very much for joining us today on our webcast. Thank you. And thank you for joining us. I'm Marty Moss-Coane.
Joining us today to discuss the different options are two experts and let me introduce them to you. Dr. Fred Epstein is founding director of the Institute for Neurology and Neurosurgery at the Beth Israel Medical Center in New York. Welcome, Dr. Epstein.
FRED J. EPSTEIN, MD: Thank you.
MARTY MOSS-COANE: And Dr. George Jallo is an attending pediatric neurosurgeon at the same Institute. Dr. Jallo, nice to have you here with us as well.
Dr. Epstein, let me begin with you. How do you approach parents if surgery is the option? How do you speak to this issue to them?
FRED J. EPSTEIN, MD: You know, I think the first thing is for parents to understand that you truly care and that we're all human beings that want the same thing for our children. The next thing you have to do is you have to be honest, families have to understand what's involved in surgery, what the hazards are, what it's going to be like afterwards. And make as complete an explanation as possible.
One of the things that I think is critical is no matter what you say, it has to be presented in a way that a family can survive with it. There are different ways of doing that. Honest? Yes. People have to know. And look, thank goodness, most of these tumors are benign and curable.
MARTY MOSS-COANE: Let me turn to you because I know there are extraordinary options really. When a child has a brain tumor, what are some of those surgical options that they have?
GEORGE JALLO, MD: The options for a brain tumor is to take it out as safely as possible. And the technology that we have today makes it -- makes us able to do craniotomies that we wouldn't do years ago.
MARTY MOSS-COANE: And describe for us then, what you do? And I have a feeling this is pretty cutting-edge stuff.
GEORGE JALLO, MD: The technology that we have now -- we have image guidance. What that allows us to do is do an MRI the morning of surgery and when we bring the child to the operating room we're able to guide the craniotomy flap, the skin incision and guide us through the brain to any tumor wherever it may be located near vital structures, like optic nerves, big blood vessels or the brain stem -- and get there safely and be able to remove the whole tumor as safe as possible.
MARTY MOSS-COANE: So you're working with a computer though?
FRED J. EPSTEIN, MD: Yeah, we do. One of the things that amazes me, Dr. Jallo, who has been working with the computer when I've seen him do this. And it still is incredible to me, is yes, you can approach tumors anywhere in the brain through the smallest opening. It's what's called minimal surgery. To think of taking out a big brain tumor through a 1.5 or 2 inch incision so a child may be able to go home in three days with a Band-Aid, is really a testimony to the technology and the skill of those that are expert in using it.
MARTY MOSS-COANE: So those days of the great incision over the top of the head -- those days are gone.
GEORGE JALLO, MD: Definitely.
FRED J. EPSTEIN, MD: Hair shaves are gone.
MARTY MOSS-COANE: Hair shaves as well.
FRED J. EPSTEIN, MD: Very important.
MARTY MOSS-COANE: What kind of instruments do you use?
GEORGE JALLO, MD: We use microsurgical instruments that have been around for years. It's just allows us to do it in a much smaller opening than we would have many years ago.
MARTY MOSS-COANE: I'm curious too then, so let's go into the operating room. You have the child there sedated. You've identified, isolated where you're going to make this incision.
GEORGE JALLO, MD: Yes, using the computer system, the Image 9 System, we're able to just map on the surface of the head where it's going to be and plan as straight an incision -- to be able to make an incision a couple inches long. Then turn the craniotomy flap that's an inch or maybe two inches wide in diameter.
MARTY MOSS-COANE: I'm interested what a craniotomy flap is?
GEORGE JALLO, MD: It's just the removal of the bone or the skull.
FRED J. EPSTEIN, MD: Let's look at it this way a little bit if I may. And I'm still listening because it's really so incredible when I watch what you do here. See when we open up the craniotomy flap and we look at the surface of the brain -- supposing the tumor is two or three inches in. In the past, you see particularly if it's a small tumor, you wouldn't know how to go at it. Where do you go? Do you go in front? Do you go behind? Do you ride over it? Think of taking a small splinter out of your child -- having to find it.
Well, in the brain, this was a huge problem. Now what surgeon such as Dr. Jallo can do is they can plan before how they're going to go at it. They can map a projectory [sic] on a computer and then that computer in the operating room will direct them in the safest projectory [sic] through the brain to a small tumor deep within so it can be removed and cured.
MARTY MOSS-COANE: And using this model here, let's say the tumor is somewhere in here --
GEORGE JALLO, MD: Let's say on this model the tumor is up here. Well, if you're going to make the incision, it's back here. It's a big distance to get there. And many years ago you'd have to make a big opening just to get this whole area exposed and try to find it. With the technology that we have now, we know the tumor is there. And using computer technology and a pointer similar to this, we can just point and plan the best trajectory to that area and just do it with the smallest opening possible.
MARTY MOSS-COANE: What are some of the risks associated with surgery?
GEORGE JALLO, MD: The risks with surgery are just for any operation that any child is going to go with -- there's risks of anesthesia. There is always the risk of a hemorrhage. There's risk of infection. But those are all trivial with the state that medicine is in today.
FRED J. EPSTEIN, MD: George, why don't you tell them -- somebody comes with a brain tumor. You pointed back there. What will you tell the family the risk is to having a bad outcome and percentage?
GEORGE JALLO, MD: It's on the order of 1%.
MARTY MOSS-COANE: 1%.
FRED J. EPSTEIN, MD: It's amazing, isn't it?
MARTY MOSS-COANE: It is amazing. Are there though neurological risks if you're going into the brain? You're near the spinal column, all of that.
GEORGE JALLO, MD: There is always -- there are always some risks for some weakness or some nerve injury. But with what we can do today, again it's on the order of percentage points. We are able to do this so safely today it's probably safer than driving a car.
MARTY MOSS-COANE: Really. Can you typically remove the whole tumor?
GEORGE JALLO, MD: In children, since most tumors are benign, they tend to be well circumscribed. We probably can remove most, if not all the tumor completely.
And if you don't --
MARTY MOSS-COANE: I was going to say if you can't remove --
GEORGE JALLO, MD: If you can't and then we've got other therapies for it. I mean such as you can just watch it. If it's a benign tumor, you can just watch it. Some of these tumors will disappear if you get the majority of them. Others may require some therapy such as radiation therapy or chemotherapy. But again, that depends upon the tumor type that it is.
FRED J. EPSTEIN, MD: But again the cancerous tumors that may require chemotherapy -- everybody is always scared of the cancerous tumors, understandably -- a lot of them are curable now. A lot of them are curable which is what's so incredible considering what they were a few years ago.
MARTY MOSS-COANE: I'm interested in how long you might follow-up a child's progress after surgery for a brain tumor?
GEORGE JALLO, MD: You’d have -- after surgery they go home within the first week. We see them within a couple weeks after surgery, then a couple months. And then on the magnitude of may -- on the order of an annual visit. It's more to just say hello than --
MARTY MOSS-COANE: Really? More than anything else.
GEORGE JALLO, MD: -- more than anything else.
MARTY MOSS-COANE: How about for you in terms of watching a child's progress and sort of just making sure that everything is okay?
FRED J. EPSTEIN, MD: I think it's the same thing. You know, a child comes in a looks good. You sit there looking at each other not knowing what to say. We get the MRI scans every year or so. You have to follow it. But there's not much to do.
MARTY MOSS-COANE: Are there other medications used with the treatment of brain tumors?
GEORGE JALLO, MD: Really, besides chemotherapy and radiation therapy, when they're in the hospital we may give them a couple doses of steroids just to help with some of the swelling and to alleviate some of the symptoms while they're there. Other than that that's -- we really don't hide any complaints with other medications.
MARTY MOSS-COANE: How about seizure medications? Is that something that's ever prescribed?
GEORGE JALLO, MD: Occasionally, but again, yeah, most tumors in children are in an area that don't cause seizures.
MARTY MOSS-COANE: I know this is a complicated procedure and it sounds like there are many different levels of physicians and even nurses involved in the treatment of brain tumors. Give us a sense of the team of doctors that are involved, the specialists involved in something like this.
GEORGE JALLO, MD: I think Dr. Epstein --
FRED J. EPSTEIN, MD: Well, I think -- you've alluded to something that's very important. I think one of the most important advances in contemporary medicine, in neurosurgery in particular, is it's not a one-person show.
MARTY MOSS-COANE: Really.
FRED J. EPSTEIN, MD: It's not a neurosurgeon alone. It's a team that has to work together and have an integrated effort looking at something -- all aspects. You have the neurosurgeon. You have the neurooncologist. That's a neurologist that specializes in tumors. They're the experts in chemotherapy. You have the radiation oncologist. The neuroradiologist. I think that this may be the most important singular advance, the recognition that one has to have a cooperative effort through different disciplines, all directed at the same thing. Because we all come at it from different directions, but have something to offer.
MARTY MOSS-COANE: Would you agree with that?
GEORGE JALLO, MD: Yeah. It's not a one-man show. It's a team approach and you need all the members of the team to treat a child.
MARTY MOSS-COANE: We're just about out of time. Any final thoughts? Any final comments about surgery and the treatment of brain tumors in children.
FRED J. EPSTEIN, MD: I'll make one comment. What about a tumor we can't remove completely and it's cancerous. What are we going to say to families? And I'll tell you what I say to families. We now with surgery and with cooperating with our oncologists can extend life for a long time. And it's very possible in a finite period of time, we're going to have a whole new approach and even those children to look so hopeless today -- there may be a light at the end of the tunnel. I don't know how long the tunnel is there, but we're working in that direction.
MARTY MOSS-COANE: Great. Well, I thank you. Do you want to add anything before we say good-bye?
GEORGE JALLO, MD: No.
MARTY MOSS-COANE: Well, I want to thank you both very much for joining us today on our webcast. Thank you. And thank you for joining us. I'm Marty Moss-Coane.