Tumor Resection

Why is this surgery done?

Brain tumors, either malignant (cancerous) or nonmalignant (not cancerous), are abnormal growths of tissue that originate in the cells of the brain.

A nonmalignant tumor does not contain cancerous cells and, once removed, typically does not come back. Most nomalignant or benign brain tumors have clear borders, meaning they do not invade surrounding tissue. These tumors can cause symptoms similar to cancerous tumors because of their size and location within the brain. It’s important to note that some lower-grade tumors can turn into higher-grade tumors over time.

Malignant brain tumors contain cancer cells. They are usually fast growing and invade surrounding tissue. Malignant brain tumors rarely spread to other areas of the body, but they may grow back after treatment.

Brain tumors are the most common solid tumors in children. Approximately 4,000 children and adolescents in the U.S. are diagnosed with primary brain tumors (tumors that originate in the brain) each year. Those that occur in infants and children are different from adult brain tumors, both in terms of the type of cells and the responsiveness to treatment.

There are many types and subtypes of brain tumors. Some of the more common ones that we treat include:

  • Low-grade gliomas
    • These are the most common form of brain tumor and develop from glial cells. These cells make up more than half of the brain and help neurons function normally. There are several types of glial cells, and gliomas are named for the types of glial cells in which they develop. 
    • Examples include pilocytic astrocytoma, pilomyxoid astrocytoma, ganglioglioma, pleomorphic xanthoastrocytoma and oligodendroglioma.
  • Anaplastic astrocytomas
    • This is a rare brain tumor that develops from brain cells called astrocytes, which regulate the transmission of electrical impulses in the brain. In most cases, these tumors develop slowly, although they can also grow rapidly. This condition affects males slightly more often than females and can occur at any age.
  • Ependymomas 
    • These tumors can form anywhere in the fluid-filled pathways in the brain or spinal cord. About 5% of pediatric brain tumors are ependymomas. These types of tumors typically don’t grow into normal brain tissue, resulting in a greater chance of success in removing the tumor surgically. 
    • Most ependymomas affect the brain stem and cerebellum. These areas control the following functions:
      • Brain stem: controls breathing, heart rate and the nerves and muscles used in seeing, hearing, walking, talking and eating.
      • Cerebellum: controls movement, balance and posture.
      • Cerebrum: controls voluntary movement, as well as thinking, learning, problem solving, speech, emotions, reading and writing.
      • Spinal cord: carries messages between the brain and the rest of the body. 
  • Medulloblastomas 
    • These are tumors that develop in the womb and remain in the baby’s brain after birth. They are the most common central nervous system (CNS) embryonal tumors. They are more commonly diagnosed in children under 10 years of age. These tumors arise from the roof of the fourth ventricle and grow to fill the fourth ventricle. They form in cells of the cerebellum. This type of tumor typically starts in the brain and spreads through the brain and spinal cord. Medulloblastomas are fast-growing tumors that can sometimes spread to the bone, bone marrow, lung or other parts of the body. When the tumor grows, it presses on the brain and/or spinal cord, preventing it from functioning correctly.
      • Prognosis depends on age at time of diagnosis (less than two years old likely with worse prognosis), amount of resection (best prognosis if able to resect all but 1.5 cm2), presence of drop metastases, and the molecular profiling of the tumor. All patients will require chemotherapy (and craniospinal external beam radiotherapy if older than 3 – 4 years of age). 
  • Choroid plexus papilloma/carcinoma
    • These tumors generally occur in the ventricles (fluid spaces deep inside the brain). They may be benign or malignant.
  • Embryonal tumors 
    • These tumors develop in embryonic cells in the central nervous system (CNS) during the gestation period of a fetus. After birth, most CNS embryonal tumors in children become malignant. These malignant tumors are likely to grow quickly and spread into other parts of the brain and spine.
  • Meningeal tumors
    • These tumors develop in the meninges, the tough membrane that surrounds the brain and spinal cord. Meningeal tumors are often benign but may become malignant. 
    • They are rare in pediatric patients.

The exact cause of brain tumors is not fully understood. Researchers have found that some of the chemical changes that occur in normal brain cells may lead to brain tumors. Most brain tumors involve abnormalities in genes that control the cell cycle (when cells grow, divide and die). These abnormalities cause uncontrolled cell growth.

Other than exposure to radiation, there are no known lifestyle-related or environmental causes of childhood brain tumors. If your child has a brain tumor, it is important to remember that there is nothing you or your child could have done to prevent it.

Symptoms of a brain tumor depend on the size, type and location of the tumor. Symptoms may be caused by a tumor pressing on a nerve or harming a part of the brain. They may also be caused by a tumor blocking the fluid that flows through and around the brain or brain swelling because of the buildup of fluid.

Some of the most common symptoms of brain tumors include:

  • Frequent headaches
  • Seizures
  • Nausea and vomiting
  • Pain or stiffness in the neck
  • Loss of balance or trouble walking
  • Weakness in the legs or arms
  • Blurry vision
  • Back pain
  • Changes in bowel function
  • Trouble urinating
  • Confusion or irritability

Many other conditions can cause the same symptoms, so it is important to check with your child’s doctor for an accurate diagnosis. Only a doctor experienced in recognizing the exact combination of symptoms that indicate a brain tumor can make a firm diagnosis.

Diagnosis of a brain tumor starts with a physical exam and medical history. Other procedures and tests may be needed to diagnose a brain tumor including , head , magnetic resonance imaging () scan or lumbar puncture/ (although rarely performed before the tumor is removed).

How is the tumor resection done?

A customized treatment plan is put together for your child based on:

  • The type of brain tumor
  • The tumor’s location and size
  • Your child’s age and general health
  • Your child’s tolerance for treatment
  • You and your child’s preferences

Treatment for a brain tumor may include one or a combination of the following options:

  • Neurosurgery or open microsurgery.  Surgery to remove the tumor is often the first step of brain tumor treatment. This type of surgery requires a highly specialized and meticulous approach and depends on the location of the tumor within the brain. This approach involves making an opening in skull, removing a piece of bone followed by its replacement at the end of the operation and using a microscope or special high-powered loupes (glasses) to visualize the tumor and remove it. Your child will need to stay in the hospital for a few days after surgery, with the length of stay determined by the extent of surgery. Your child will undergo a brain MRI with and without contrast after surgery to make sure that complete removal of the tumor has occurred.
  • Anti-seizure medicines. These medicines may be prescribed to relieve nerve pain and to prevent or stop seizures. A seizure is a surge of electrical activity in the brain that can cause violent shaking of the body and loss of physical control.
  • Stem cell transplant (also known as bone marrow transplant). This type of transplant is an infusion of healthy bone marrow to replace damaged or diseased bone marrow.
  • High-dose chemotherapy. During this procedure, very high doses of chemotherapy (medicines designed to treat cancer) are given to the patient, usually by intravenous (IV) line.
  • Radiation. This treatment uses high-energy particles or waves to kill cancer cells by damaging their DNA.
  • Proton therapy. This treatment is a form of radiation therapy that uses proton beams to destroy cancer cells.
  • Steroids. These medicines may provide temporary relief of brain tumor symptoms, such as swelling and fluid retention around the tumor.
  • Ventriculoperitoneal (VP) shunt. This surgical procedure relieves the pressure of hydrocephalus (excess fluid within the ventricles of the brain). A shunt is a thin tube that allows excess fluid to flow to another area of the body.
  • Speech-language therapy. Brain tumors and their treatments may affect your child’s ability to speak and swallow. Speech-language pathologists help patients regain those skills or compensate for diminished skills.
  • Physical therapy. Brain tumors and their treatments may impair your child’s balance, range of motion and strength. Physical therapists help patients regain those skills or compensate for diminished skills.
  • Occupational therapy. Brain tumors and their treatments may impair your child’s ability to perform the functions of daily life, such as eating, going to the restroom, dressing and bathing. Occupational therapists help a patient manage these daily functions.

Rehabilitation includes treatment to help your child recover lost or diminished physical functions caused by the brain tumor or its treatment. Rehabilitation may include speech-language, physical or occupational therapy.

Follow-up care includes regular monitoring for worsening of symptoms, effectiveness of treatment and, if the tumor was removed, recurrence of the tumor by means of follow-up brain MRI studies.

Your child’s prognosis (long-term outlook) depends on:

  • The type of tumor
  • The size and location of the tumor
  • Metastasis (spreading of cancerous tumors)
  • The tumor’s response to therapy
  • The age and overall health of your child
  • Your child’s tolerance of specific medicines, procedures or therapies

Each child’s prognosis is unique to his or her individual situation. Prompt and aggressive treatment based on an accurate diagnosis gives your child the best chance to overcome the tumor and any damage it may have caused. Treatment sometimes causes side effects, and these also affect your child’s prognosis. Recurrence of the tumor is sometimes possible, and this can have a significant effect, as well.

What are my risks? What are common complications?

Risks of the surgery include but are not limited to:

  • Bleeding
  • Infection
  • Cerebrospinal fluid (CSF) leak
  • Seizures
  • Inability to completely remove the entire tumor and possible damage to the surrounding brain tissue, which may lead to a decrease in your child’s ability to walk, talk and control movements

Risks without surgery include:

  • Progressive growth of the tumor, which can lead to seizures; and pressure on the surrounding brain, which may cause a decrease in your child’s ability to walk, talk and control movements
  • Hydrocephalus due to blockage of CSF flow and enlargement of the ventricles, which may need to be diverted away from the brain by placing a shunt

What do I need to know before surgery?

If your child is diagnosed with brain tumor, the pediatrician will refer them to a pediatric neurosurgeon for consultation. You will then meet with the neurosurgeon to discuss the brain tumor and need for treatment. Questions and concerns regarding the type(s) of treatment offered will be addressed at that appointment. If any additional tests are needed, they will be explained and ordered at that time.

Our brain tumor program at Goodman Campbell Brain and Spine provides patients with a multidisciplinary approach to personalized care and a depth of expertise. New patients and those with progressive tumors are presented at a weekly tumor board in which we work together to confirm diagnoses and develop comprehensive treatment plans. Our hospital team is made up of pediatric oncologists, neurologists, neurosurgeons, pathologists and neuroradiologists, rounded out by pediatric nurse practitioners, child life specialists, and physical, speech and occupational therapists.

You will receive communication before coming to the hospital with specifics on where to go the day of surgery and instructions for the day before and day of surgery. This information will include details about home medications and when to stop eating and drinking.

The length of surgery will depend on the degree of difficulty of the surgery for removal of the brain tumor. Your child will spend at least 2 – 3 nights in the hospital. The first night will be in the pediatric intensive care unit (PICU) for close monitoring. Your child will come out of surgery very sleepy and their medical team will likely give them medicine that makes them extra sleepy for the first 12 hours after surgery to help with pain control.

Your child will be given intravenous (IV) fluids, pain medications and anti-nausea medication until they are able to take medications by mouth. IV antibiotics will be given for 24 hours after surgery. Steroids will be ordered for the first 48 hours through the IV. Due to the fact steroids can upset the stomach, your child will be given medication to help to decrease stomach upset while they are receiving the steroids. Your child will be started on a stool softener immediately after surgery to prevent constipation. A seizure medication is also given to protect against possible seizures. Your child may go home on this medication and may need to continue it for several months.

Your child will have a rubber tube in their bladder (Foley catheter) to drain their urine while sedated and also additional monitoring devices to closely monitor their blood pressure and heart rate. The Foley catheter will remain in place until the child can get out of bed to go to the bathroom.

In some circumstances, your child may have a cerebrospinal fluid drainage tube connected to a sterile collection bag to relieve pressure on the brain, depending on whether there was hydrocephalus present before the surgery. This external ventricular drain (EVD) helps to regulate the pressure caused by an increase in CSF. We will start to raise the drain within a few days, and remove it if your child’s brain is able to maintain a normal pressure.

Your child will be allowed to drink and eat slowly as soon as they are able, and they will be allowed to get up out of bed as soon as they are awake and the extra monitoring devices and bladder catheter have been removed.

Your child will be discharged from the hospital once their pain is well controlled with oral pain medications, and they are able to eat and drink, go to the bathroom and walk around the room.

The pediatric neurosurgery providers at Goodman Campbell Brain and Spine are specially trained on this diagnosis and are experts in the care of brain tumors. We know it can be a scary time, and we have a team of medical professionals who are available to answer any questions or discuss any concerns that you might have.

General discharge instructions

In order to be discharged from the hospital, your child will need to be able to:

  • Urinate without any problems
  • Tolerate oral/tube feeds without vomiting
  • Have pain controlled with oral pain medications
  • Pass gas and have a bowel movement
  • Be fever free for 24 hours

The course and length of stay is variable for these patients. It can range from 3 – 5 days to up to a month, depending on any complications that were present prior to or after the surgery.

Your child may need to go to outpatient physical, occupational and/or speech therapy once discharged from the hospital. The social worker will help to set this up as close as possible to your home.

A child is usually out of school for at least two weeks while they heal. Some children may require a more specialized time frame.

A child is not to participate in any sports, and must keep their feet on the ground at all times (no swinging, jumping, climbing or running) for 4 – 6 weeks after surgery, until they are cleared to do so during a followup visit.

What should I expect while recovering?

There will be a follow-up appointment with neurosurgery two weeks after the surgery or sooner if needed.

Reasons to call the neurosurgery office include:

  • The incision has any swelling, redness or drainage
  • Fever of 101.5 degrees or higher
  • Seizures
  • Persistent vomiting
  • Worsening pain
  • Trouble going to the bathroom
  • Any numbness, tingling or weakness in the arms or legs

The region of the incision is typically sore after surgery. This should gradually improve and be relieved by the oral pain medications prescribed for your child.

Tiredness and fatigue are also very common and will gradually improve with time. It is common for it to take up to three months before your child feels “back to normal.” Make sure they have plenty of rest during the day and eat healthy foods (avoid candy, soda and fast food). Set regular bedtime and wake-up times to ensure they get plenty of sleep.

Treatments

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