Toba Niazi, M.D., a pediatric neurosurgeon at Nicholas Children’s Hospital in Miami, Florida, talks about new technology that is saving children with brain tumors from additional surgery.
Interview conducted by Ivanhoe Broadcast News in April 2017.
Are brain tumors common to see in children because I don’t think people realize what you see in your practice?
Dr. Niazi: As a pediatric neurosurgeon we’re biased in that, that’s what we see but it’s the number one solid form of tumor in children. It’s the most common. Now it’s actually even the number one cause of death in children with cancer. It’s a fairly common thing in our practice but otherwise looking at the wide spectrum of other disease processes that occur in children it’s not that common. Again it’s our biased nitch that we see.
Is it difficult to treat in certain cases, give us an idea of what basically happens?
Dr. Niazi: We look at brain tumors and we have a pretty good sense of their behavior pattern based on how quickly a child gets sick or how long the symptoms have lasted for. Also the imaging findings give us a good idea of is it a more aggressive tumor, meaning malignant. Or a more benign tumor where we can just take it out and they don’t require any further treatment. The final answer comes from actually taking a piece of the tissue and putting it under a microscope and having our pathology colleagues tell us what the diagnosis is.
Do you normally do surgical procedures then when you treat, you have to?
Dr. Niazi: Most times we will offer surgery. There are a few brain tumors in children specifically that are located in the brain stem in the pons that are typically inoperable where we may offer a biopsy but are unable to achieve a surgical cure.
When you do surgery are there many risks involved or give us an idea.
Dr. Niazi: Its brain surgery so there is always risks involved with any brain surgery but you have to weigh the risks of surgery against the risk of the disease developing and progressing and not having a diagnosis. I think when you look at a child who comes in who is otherwise very sick from pressure on the brain or not being able to have a healthy brain because of that pressure it’s important that we relieve that pressure, figure out what’s going on. Essentially to say you know there are obviously risks of surgery and we need to inform the families. The risk of having this tumor progress without doing anything is much more concerning. That’s why we’re here.
The symptoms that a child might present with when they come to you, the pressure on the brain what might a child maybe in the very beginning be complaining about, what might happen?
Dr. Niazi: In very young children, you can have a rapid increase in their head growth with some eye changes where they’re not able to look up. That can be in very young children who can’t really tell you what’s going on. You can also see children who are throwing up in the morning so morning MSS or having vomiting in the morning with severe headaches, difficulty with ambulation and walking or seizures. Those are all fairly common findings of children who have some sort of process going on in their brain that shouldn’t be there.
Going back to the surgery, when you’re in there how does this IMRI or intraoperative MRI, what is that and how is it working for you guys?
Dr. Niazi: We’re really excited to have that here at Nicklaus Children’s Hospital. It’s really been a labor of love that John Ragheb has been working on for about the last decade or so. Essentially what it does is it allows us to be able to get an MRI scan either during or right after surgery to make sure that our surgical goals have been met. For example, it allows us to take a brain tumor out and then immediately when we think that we’re done we’ll get an MRI scan and insure that we’ve got the majority of the tumor out. If there’s a piece of that tumor that’s remaining that we weren’t able to discern during surgery then we can go back in and take that last piece out. What it really does is it’s another great aid and it’s really the gold standard for making sure that our surgical goals are met. To make sure that we don’t have to put any child through more than one procedure if we haven’t gotten all of the tumor out initially. Also it prevents us having to give this child another dose of anesthesia the next day. Typically prior to having IMRI we would finish our surgery and we would wake the child up and then the next day or the day after we’d get an MRI scan to see if our surgical goals had been met. This really eliminates another step in the process and it’s better for the patient.
You’re saying this can be done right after the surgery or right in the middle.
Dr. Niazi: Right during the surgery correct. If there’s any sort of question we can get an MRI during surgery. Obviously we’ve been doing this a while and so we have a fairly good idea of what’s going on. In order to make sure that our surgical goals have been met and to reduce another anesthetic for this child on another day if we can all do it in one setting it would be idea.
Does this wheel in, it’s like a massive piece of equipment.
Dr. Niazi: With the new building expansion here it had to be built in to the hospital, essentially two rooms. The intraoperative MRI is in one room and then our operating suite is in another room. When we’re ready to get the MRI scan what we’ll do is we’ll open up that door that connects the two rooms. Make sure that they’re both sterile and then what happens is they glide in together.
Are you using it now all the time during these procedures and are you finding that it’s extremely useful. Does it happen a lot that you’re seeing that there are parts of maybe a tumor still left that you can go back and get?
Dr. Niazi: We’ve had this since the beginning of this year and we are using it quite often to make sure that we really make sure we meet all of the surgical goals and decrease the anesthesia time and another antiseptic for a child after surgery. I think that we’re using it well and I think that it’s a great extra tool for us.
Tell us a little bit about your patient and how did he come to you and what he went through with the procedure, how he’s doing now.
Dr. Niazi: Willie came to us fairly sick and he was complaining of headaches off and on. Mom said he had some regression in his symptoms and mom really noticed that he just wasn’t doing well. He was throwing up and complaining of headaches. She took him to the hospital and then he came to see us and he was very sick when we saw him. He had a lot of pressure on his brain from a mass that was growing really in the center of his brain and not allowing the normal fluid drainage of the cerebral spinal fluid tract. Essentially there was a blockage of the drainage system of the fluid pathways of the brain that were making him very sick and causing pressure to build up in his brain. We really had to treat him very quickly. Willie did undergo an immediate emergency procedure when he got here. We didn’t have any imaging on him. We got a CAT scan and then quickly wheeled him up to the OR to place a drain and also we put a camera in to the fluid spaces of the brain to see if we could biopsy this lesion. We were able to get one very small biopsy that wasn’t very diagnostic but it did treat the pressure in his brain. Then we went ahead and we got an MRI scan after that procedure and we saw the true extent of this mass. He was scheduled for a more definitive surgery with the intraoperative MRI scan.
With that do you feel you were able to remove the tumor completely?
Dr. Niazi: The location of Willie’s tumor is such that if I did get a complete resection I would leave him fairly neurologically sick. I have a patient who is otherwise doing very well. My initial guess on his tumor was that it would be a more benign type of tumor or a low grade tumor. To try to take everything out and hurt him neurologically would not be the best thing in his case. Knowing that this tumor came from a vital part of his brain called the thalamus we knew that we wouldn’t be able to get a complete resection. We wanted to be able to de-bulk it as much as possible and help to open up the fluid pathways in his brain.
How is he doing now?
Dr. Niazi: He’s coming today but I hear he’s doing very well and kind of back to his normal routines and recuperating very well.
Is there a chance of recurrence in his case?
Dr. Niazi: He has a low grade tumor so it’s something that we’re going to watch. Again, because of the location of it we weren’t able to take all of it out we knew that going in. We’re going to watch and if it does show evidence of some growth then we have other treatments that we can give him that work very well. It’s something that you know it’s a watch and wait and treat according to how things are behaving and how he’s doing.
He’s doing much better. Do you feel this is something that at least is a game changer in what you guys do?
Dr. Niazi: I think it’s great that we’re able to have a very clear picture of whether or not our surgical goals have been met. It’s really the gold standard and really how we should be moving forward with children’s care in terms of brain tumors and in terms of epilepsy. Any sort of lesion in the brain I think that this really needs to be the gold standard.
END OF INTERVIEW
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