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Cross-Post: Brain Tumors in Children

By Brain Tumor, Pediatrics, Tumor, Tumor SeriesNo Comments

From time to time on Neurosurgery Blog, you will see us cross-posting pieces from other publications that are worthy of sharing with our readers. Since we are in the middle of our focus series on tumors, we wanted to bring attention to an article published in The New England Journal of Medicine (NEJM) on May 19. Alan R. Cohen, MD, FACS, FAAP, FAANS, discusses recent changes to the classification and management of brain tumors in children. In 2021, the World Health Organization introduced changes in brain tumor taxonomy, emphasizing molecular diagnostic features. These changes reflect the trend of assigning diagnostic categories based on genetic features that, in many cases, drive prognosis and offer potential targets for treatment.

Brain tumors are the leading cause of death from cancer in children. Tumors of the central nervous system (CNS) account for 20% of childhood cancers and are second only to leukemia in frequency. Recent diagnostic and therapeutic advances have improved survival and quality of life for many children with CNS cancers. Sadly, however, the prognosis for many children with brain tumors remains poor.

Click here to read the full NEJM article.

To learn more about Dr. Cohen’s work as a pediatric neurosurgeon and how he uses humor (and Elvis) to bring joy to his patients and their families, check out this oldie but goodie from Good Morning America.

Editor’s Note: We hope that you will share what you learn from our posts. We invite you to join the conversation on Twitter by following @Neurosurgery and @NSTumorSection and using the hashtag #TumorSeries.

Alan R. Cohen, MD, FACS, FAAP, FAANS
Department of Neurosurgery, Johns Hopkins University School of Medicine
Baltimore, Md.

May 23, 2022
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University of Miami Increases Neuro-Oncology Collaboration and Mentorship Through Innovative New Fellowship Program

By Brain Tumor, Tumor, Tumor SeriesNo Comments

Neurosurgery has a long history of mentorship through a trainee’s dedicated time under a more experienced surgeon’s tutelage. Surgical training has long been considered a more advanced form of apprenticeship, mastering a skill under a more experienced practitioner’s guidance. In this tradition, the Sylvester Comprehensive Cancer Center — part of the University of Miami Miller School of Medicine — has launched an International Neuro-oncology Scholars Program (INOSP) that allows neurosurgery trainees to join internationally renowned brain tumor experts in other countries to increase their experience.

The goal is to enhance education and facilitate multi-institutional collaboration. The INOSP program is made possible by a generous gift from a grateful donor family. The plan is to support four traveling rotations each year.

Charles Teo, MD, IFAANS, left, with neurosurgery fellow Daniel Eichberg, MD.

“INOSP represents a unique resource offered to our fellows to visit and learn from world-renowned experts in neurosurgical oncology,” said neurosurgeon Ricardo J. Komotar, MD, FAANS, FACS. He continued, “The goal of the program is to enhance further their neurosurgical training so that they may be able to translate these techniques to our patients. With this international collaboration, we ultimately hope to improve clinical outcomes and enhance surgical education.”

The inaugural recipient of INOSP was neurosurgery fellow Daniel Eichberg, MD, who spent two weeks in Sydney, Australia, learning from highly accomplished neurosurgeons Charles Teo, MD, IFAANS and Michael Sughrue, MD, at Prince of Wales Hospital in Randwick, Australia.

“The opportunity to learn minimally invasive keyhole approaches for complex brain and skull base tumors in one-on-one training sessions from two of the most experienced neurosurgeons in these techniques was a powerful experience and augmented my skillset for cranial neurosurgery,” said Dr. Eichberg.

Dr. Sughrue and Dr. Teo have developed the world’s most advanced technology for mapping the brain’s functional and structural connectivity, which may be markedly abnormal in patients with brain tumors. Providing a better understanding of an individual’s connectome — a map of the brain’s overall connectivity — may critically impact brain tumor surgical outcomes by minimizing postoperative deficits, predicting recovery and maximizing the amount of tumor that can safely be removed during surgery.

Furthermore, this brain mapping technology uses machine learning and artificial intelligence techniques to guide non-invasive transcranial magnetic stimulation (TMS)-based neuro-interventional rehabilitation to improve postoperative brain tumor patients’ strength and speech deficits.

As a result of the international collaboration fostered by INOSP, Sylvester and the University of Miami Department of Neurosurgery will partner with the Sydney team in the Glioma Connectome Project. This endeavor seeks to learn how gliomas cause the brain to reorganize its connectome and initiate a TMS Neuro-interventional Rehabilitation prospective clinical trial.

“Not only are we now able to give our neurosurgical fellows access to additional world-renowned brain tumor experts and each of their unique skills, but we are also seeing that these new international relationships lead to groundbreaking global collaborative research and enhanced clinical trials that will continue to allow us at Sylvester to be able to provide the most advanced and world-class brain tumor treatments possible to our patients,” said program co-director Michael E. Ivan MD, MBS, assistant professor of neurosurgery.

Ashish Shah, MD; Alexis Morell, MD; Ricardo J. Komotar, MD, FAANS, FACS and Christopher A. Sarkiss, MD

Additionally, in 2019, the AANS/CNS Tumor Section, in conjunction with the CNS Foundation, created the International Observership Program, which will allow an Argentinean neurosurgeon to participate as an observer for three months at the University of Miami in the division of surgical neuro-oncology. The rotation focuses on all central nervous system tumors, with participation in clinic, conferences, surgery, and consultations.

Editor’s Note: We hope that you will share what you learn from our posts. We invite you to join the conversation on Twitter by following @Neurosurgery and @NSTumorSection and using the hashtag #TumorSeries.

Ricardo J. Komotar, MD, FAANS, FACS
University of Miami Miller School of Medicine
Miami, Fla.

May 10, 2022
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The Long Game: The CNS’ Investment in the NINDS/CNS Getch K12 Scholar Award

By Career, DEI, Guest Post, HealthNo Comments

In 2012, the Neurosurgeon Research Career Development Program (NRCDP) set a goal to grow a diverse corps of neurosurgeon scientists at institutions across the United States. The Congress of Neurological Surgeons (CNS) and the CNS Foundation became early partners in this effort by establishing the National Institutes of Neurological Disorders and Stroke (NINDS)/CNS Getch K12 Scholar Award, named in honor of the CNS Past President Christopher C. Getch, MD, FAANS, a respected neurosurgeon, friend and leader, who passed away unexpectedly soon after his presidency.

Having invested $500,000 to fund Getch Scholars alternate years since 2015, why is the CNS doubling down with a $1,200,000 pledge for the next five years to make the Getch K12 award annual?

According to the CNS Past President Ganesh Rao, MD, FAANS, who championed the CNS’s investment in the K12 Awards, “NRCDP is a major driver for improving neurosurgical patient care. Support for neurosurgical research is critical, particularly at the beginning of one’s career; the commitment to mentorship is unparalleled, and we are seeing increasingly diverse awardees. I am a firm believer that the K12 program will improve neurosurgery overall.”

New data from Emad N. Eskandar, MD, FAANS, director of the NRCDP, reveals that the program has successfully hit the three drivers mentioned by Dr. Rao. The result is a remarkable increase in overall grant support for neurosurgeons.

Protected Research is Linked to Subsequent Funding

The following data points demonstrate the continued success of K12 scholars:

  • From 2013 through 2017, the NRCDP supported thirteen scholars. Eleven out of the thirteen scholars received subsequent National Institutes of Health (NIH) funding for an overall success rate of 85%.
  • The second five-year cycle, 2018 through 2022, looks equally promising. During this period, the NRCDP supported sixteen scholars. Thus far, six have completed the program, and three have received additional substantive grants.
  • The number of years from a scholar’s initial NRCDP application until they obtained subsequent NIH funding also revealed success. Within five years, 50% of program alumni received NIH funding, and 85% received NIH funding within nine years.

According to 2017 winner Jennifer Strahle, MD, FAANS, “Winning a K12 award provided me with time and resources to complete the foundational hydrocephalus and iron metabolism experiments that laid the groundwork for my subsequent successful R01.”

While all K12 awards provide two years of protected research time, unique to the Getch award, the awardee may remain at their institution. Preserving this continuum of established relationships and research in their home laboratory is essential to the CNS.

Babacar Cisse, MD, of Weill Cornell Medical School and a 2018 winner of the NINDS/CNS Getch K12 Scholar Award, explained, “When I was hired by my chairman, we both agreed that I needed at least 50% of protected research time. The K12 solidified that agreement and extended it to 5 years.” Three years later, Dr. Cisse is about to publish his findings for the first time.

Diversity of Neurosurgeon Scientists is Just Beginning

The CNS shares the NIH goal to increase the diversity of all health care providers and, in particular, researchers. According to NRCDP data, the K12 program has seen critical areas of improvement since 2012:

  • In the first five years (2013-2017) of the NRCDP, two (15%) of the total thirteen scholars were women, and zero (0%) were underrepresented minorities.
  • In the second five years (since 2018), female scholars increased to three (20%) and underrepresented minorities increased to four (27%).

Sustainable Mentorship

Like all early-career neurosurgeons, mentorship and a community of colleagues are valuable to the K12 awardees. All awardees must attend the annual retreat hosted by the CNS for five years, and new awardees seek the guidance of the Advisory Committee and past K12 winners. Since awardees are committed to attending the retreat for five years, mentees naturally transition into mentors. One awardee responded, “the NRCDP K12 community represents an important community of mentors and colleagues with whom we can envision and affect future paradigm changes in the care of patients with neurological diseases.”

Galvanizing Investment

Compared to other surgical specialties — including orthoapedic surgery, otolaryngology and urology — neurosurgery saw a significant increase in grant funding from 2012 to 2021 (265%). One cannot help but marvel at the increased funding that has occurred since the inception of the NRCDP.

The CNS and the CNS Foundation are proud partners of the NIH, the Foundation for the National Institutes of Health, the NINDS and the NRCDP. The future for our specialty is bright.

Editor’s Note: We hope that you will share what you learn from our posts. We invite you to join the conversation on Twitter by following @Neurosurgery, @CNS_Update and @NINDSnews.

Alexander A. Khalessi, MD, MBA, FAANS
UC San Diego Medical Center
San Diego, Calif.

May 6, 2022
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Socioeconomic Status and Short-term Glioblastoma Survival: Does it Make a Difference?

By Brain Tumor, Tumor, Tumor SeriesNo Comments

The recent COVID-19 pandemic highlighted socioeconomic differences in health care access detrimental to the outcome, including a per capita excess mortality highest among the Black and Latino population. The prognostic role of socioeconomic factors for patients diagnosed with glioblastoma multiforme (GBM) has been hotly debated. GBM is the most common malignant primary brain tumor in adults and affects 3.3 percent of pediatric brain tumor patients. The disease has made headlines in recent years with the diagnosis of high-profile political figures such as President Biden’s son Beau Biden and the late Sens. Ted Kennedy and John McCain. Significant advances in surgical and adjuvant treatments for this disease have had a positive impact on short-term survival. Yet, there is a still-very-low five-year survival rate in adults, around 5.5 percent. As new therapeutic approaches develop, prolonging short-term survival coupled with high quality of life remains a priority when caring for patients with GBM.

Our medical predecessors named the deadliest brain tumor “glioblastoma multiforme” long before the field of molecular biology was established. Yet, they already recognized the complexity of this disease and its heterogeneity by calling it multiforme. We now know that its molecular features are numerous. Different “clusters” of cells with different molecular signatures pose a significant challenge in developing patient-specific therapies even within the same tumor. In addition to differences in each tumor’s molecular signature, other environmental factors might contribute to the speed of disease progression.

 

A recent study collected data from 28,952 patients diagnosed with GBM from the publicly available National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) cancer registry. The authors found that socioeconomic status affected overall short-term survival, and patients with higher median household incomes had significantly higher short-term survival. Additionally, patients owning a private insurance plan had lower short-term mortality than those who were Medicaid recipients. When considering the ethnic background, Asian/Pacific Islander patients had the highest short-term survival. Black patients with GBM had the highest mortality due to non-GBM related causes, such as cardiac and stroke events.

The above study also corroborated that Non-Hispanic White (NHW) represented 80 percent of the patients affected by GBM, while they only represent 60 percent of the U.S. population. The higher incidence of GBM in the NHW population corroborates previous studies. Multiple factors can contribute to this discrepancy, including the possibility that this increased percentage is biased by health care access disparities. Other factors that may contribute to such discrepancy could be related to differences in tumor genetics, highlighted by the glioma genome-wide association study (GWAS).

Providing the best care to all patients regardless of ethnic background and socioeconomic status remains a high priority in all medical and surgical disciplines, including neuro-oncology. Moving forward, additional studies are needed to deepen our understanding of the impact on the outcomes of such factors. Further clarifying and identifying differences in health care access, socioeconomic factors, and racial diversities will allow us to develop new and more focused strategies to fight GBM and co-morbid non-GBM related causes of death in our patients.

Editor’s Note: We hope that you will share what you learn from our posts. We invite you to join the conversation on Twitter by following @Neurosurgery and @NSTumorSection and using the hashtag #TumorSeries.

Isabelle M. Germano, MD, MBA, FAANS, FACS
The Mount Sinai Medical Center
New York, NY

March 11, 2022
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Neurosurgical Oncologists as Champions of Diversity, Equity and Inclusion

By DEI, Neuro-oncology, Tumor SeriesNo Comments

Recent events of systemic discrimination have led to national introspection on the importance of tolerance and diversity. The tragic killing of George Floyd in May 2020 was a sentinel event that raised awareness of the pervasive nature of systemic discrimination and served as a significant impetus for positive change. This was a clear reminder that we still face substantial challenges to tolerance and equal treatment for all as a society. It is also a unique opportunity to reflect on our common purpose as humanity.

In the immediate aftermath of Mr. Floyd’s death, many organizations issued statements reaffirming their commitments to promoting and advancing diversity through anti-discriminatory policies and initiatives. On their part, the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) released the following joint statement:

As a profession, we in neurosurgery aim to promote the highest quality of patient care and advance the specialty of neurosurgery and neurosurgical education while espousing the values of integrity, leadership, excellence, and professionalism. As organizations and as a profession, we are committed to inclusion and diversity within our neurosurgical community. As neurosurgeons, we are committed to providing the highest quality of care to all segments of our society. Indeed, our principles are only relevant to the extent they apply to the most disadvantaged in our society.

The Society of Surgical Oncologists (SSO) also released a similar statement:

The Society of Surgical Oncology condemns racism and violence in all forms. We recognize racism as an underpinning to health disparities, and recent events serve as a clarion call to all of us that there is a need to do more than what we do on a daily basis — provide the best cancer care to individual patients regardless of race, ethnicity, gender, sexual orientation, or socioeconomic status.

Diversity requires the core elements of equity and inclusion. Equity requires deliberate, fair and just treatment of our patients and colleagues irrespective of their background. Inclusion requires a conscious effort in thoroughly engaging diverse patients and colleagues in all aspects of the care we deliver and the decisions that govern our care through tolerance. Through equity and inclusion, our colleagues and patients feel respected and valued.

A firm commitment to the core elements of diversity is critical to the impactful delivery of neurosurgical care to society’s most vulnerable members. In treating life-threatening disorders of the nervous system, neurosurgeons can positively impact patients from all works of life. To render the best possible care, neurosurgeons should understand the diverse patient population they serve in the context of race, gender and ethnicity. When we deliver neurosurgical care in an atmosphere of tolerance and understanding, we serve as role models to those who look up to us.

Neurosurgical oncologists are integral to cancer care in the central nervous system, one of the most critical battle lines in the fight against systemic cancer-related morbidity and mortality. Despite advances in oncology, there is still a considerable disparity in cancer care. Racial and ethnic minorities and lower socioeconomic patients are disproportionately impacted by cancer. As part of the multidisciplinary management of diverse patients with central nervous system tumors, neurosurgical oncologists perform surgeries, stereotactic radiosurgery and clinical trials. Therefore, it is imperative for neurosurgical oncologists to incorporate diversity-informed clinical decision-making approaches to positively impact cancer patients who are affected by health disparities. Moreover, neurosurgical oncologists should be mindful of the barriers and challenges to recruiting underrepresented minorities into clinical trials, given historical precedence of mistrust. Identifying, acknowledging and addressing such barriers would undoubtedly enhance participation.

From a workforce perspective, organized neurosurgical oncology should strive to reflect the diverse cancer patient population they serve. Concerted efforts are needed to diversify the pool of neurosurgeons. We should strive to attract, train and mentor neurosurgeons from under-represented groups into the subspecialty of neurosurgical oncology. If we embrace diversity efforts, we should also establish benchmarks to assess progress in this journey. Beyond diversity in its members’ composition in general, neurosurgical oncology should strive to include diverse membership and leadership in committees. Such diversity efforts will strategically position us to address the neurosurgical oncologic needs of a multifaceted society uniformly.

As a profession, we should strive for the ideals of diversity and its associated tenets of equity and inclusion. Neurosurgical oncologists are in a unique position to understand and reduce health disparities. Our patients deserve that from us. We should never forget that our future is only as bright as the future of the patients whom we serve.

Editor’s Note: We hope that you will share what you learn from our posts. We invite you to join the conversation on Twitter by following @Neurosurgery, @AANSDiversity and @NSTumorSection and using the hashtag #TumorSeries.

Arnold B. Etame, MD, PhD, FAANS

Moffitt Cancer Center

Tampa, Fla.

February 2, 2022
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Introduction to Tumor Focus Series: Bringing “Better” to Our Patients in Multiple Ways

By Tumor, Tumor SeriesNo Comments

Neurosurgery has historically been a uniquely wide-ranging and varied specialty. Unlike other specialties that focus on a particular organ system or body region, neurosurgery is quite literally a “head-to-toe” specialty dealing with the brain, spinal cord, peripheral nerves and the other organs intimately related to the nervous system. Neurosurgeons classically had to be experts in a wide variety of surgical procedures and disease processes. As medical knowledge and technology have advanced, neurosurgeons have evolved with medicine to become experts in particular disease processes, leading to a reorganization of neurosurgery into sub-specialty disciplines.

Over the years, the Neurosurgery Blog has partnered with various neurosurgery subspecialty sections to provide an update on the state of the subspecialty, highlight current issues, add to the conversation and portray their concerns to a non-specialized audience. Today’s neurosurgeon must be facile in many different areas — both medical and non-medical. As medical care and health care delivery have grown increasingly complex, neurosurgeons must wear several hats: surgeon, team-member in multi-disciplinary care teams, teacher, scientist and advocate.

We partnered with the AANS/CNS Joint Section on Tumors for the following series of blogs. Under the guidance of Tumor Section chair, Jason P. Sheehan, MD, PhD, FAANS, and AANS/CNS Washington Committee representative, Michael A. Vogelbaum, MD, PhD, FAANS, members of the section came together and produced a sweeping overview of ongoing topics:

  • Arnold B. Etame, MD, FAANS, leads us off with a piece about diversity in neurosurgical oncology. Isabelle M. Germano, MD, FAANS, FACS, then tackles disparities in access to care and outcomes in brain tumor patients.
  • Ricardo J. Komotar, MD, FAANS, FACS, reports on efforts in education and collaboration on an international scale. Edjah E. Nduom, MD, FAANS, speaks to brain tumor advocacy, providing an overview of the outward-looking direction of some of our efforts.
  • Michael Lim, MD, FAANS, and Nader Sanai, MD, FAANS, bring us two pieces highlighting the ability of neurosurgeons to translate discoveries from the lab into patient care and back again and how neurosurgeons contribute to drug development in the increasingly complex fight against brain tumors. These pieces are complemented by an article by Manish K. Aghi, MD, PhD, FAANS, updating the role of neurosurgeons in clinical trials and research in neurosurgical oncology.

Academic publishing, the Journal of Neuro-Oncology, and the dissemination of scientific results, particularly in the era of the COVID-19 pandemic, are at the center of a piece by Dr. Sheehan and Christopher P. Cifarelli, MD, PhD, MMM, FAANS, FACS. Dr. Vogelbaum presents “A Neurosurgical Perspective on Multidisciplinary Care for Patients with Brain Tumors,” emphasizing the team-based nature of neuro-oncology care today.

In the era of a worldwide pandemic and an increasingly complex care delivery environment, neurosurgeons are playing more and more roles in delivering better care to our patients. This is especially true in the field of neurooncology. We hope that these blogs inspire you to join the efforts of this important field. The amount of work that the members of the section and the authors, in particular, put into these issues outside of patient care is astonishing and deserves credit!

Editor’s Note: We hope that you will share what you learn from our posts. We invite you to join the conversation on Twitter by following @Neurosurgery and @NSTumorSection and using the hashtag #TumorSeries.

Clemens M. Schirmer, MD, PhD, FAANS, FAHA
Chair, AANS/CNS Communications and Public Relations Committee
Geisinger
Wilkes Barre, Pa.

January 20, 2022
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Neurosurgery Lost a Leader, and I Lost a Dear Friend — Randall W. Smith, MD, FAANS(L)

By Guest Post, Loss of LifeNo Comments

On Oct. 25, neurosurgery lost a leader, and I lost a dear friend. Randy’s accomplishments in organized neurosurgery, especially in California, are too numerous to list and have been chronicled by others in recent days. Today, I want to tell you the main lessons Randy taught me over our decade-long friendship.

  • Your biggest supporters may not be who you think. As a young female neurosurgeon starting in the California Association of Neurological Surgeons (CANS) and the Western Neurosurgical Society (WNS), Randy didn’t care who I was or what I looked like as long as I showed up and worked hard. Once I proved myself, he went to great lengths to support me and promote my career. This is the very definition of sponsorship, which I have found much more helpful than mentorship.
  • Actions speak louder than words. Randy could spot nonsense from a mile away and did not hesitate to call it out. I have met very savvy and politically correct leaders in my time who have done nothing to help foster diversity and inclusion in neurosurgery. When it came to supporting equality, he made the necessary changes in our organizations to make them better.
  • Work-life balance is best when you don’t try to separate them. Randy loved neurosurgery. When he retired from clinical practice in 2004, he was still very engaged in organized neurosurgery. In California, it is no secret that Randy was the backbone of the two influential organizations: CANS and WNS. He attended all the board and executive committee meetings and was part of every critical decision until his death. Randy was constantly curious about the advances in the field of neurosurgery and strived to make the lives of working neurosurgeons better. He involved his whole family — his wife Flo is like a surrogate mom to many of us. Randy taught me that I wouldn’t constantly feel like I had to choose by blending my life and family with my work. He has seen my children grow up and developed an independent friendship with my husband. It well-demonstrated that we are all happier and less likely to develop “burnout” if we feel part of a community.
  • Listen to your instincts. As the COVID-19 Delta variant surge was starting to wane in September, there was still considerable uncertainty about holding an in-person meeting for the WNS. After much planning and consideration, we decided to go for it and held the annual meeting in New Mexico. I do not regret that decision for one minute. It was an engaging, safe and productive meeting and allowed us to connect in person for the first time in nearly two years. This felt even more precious with my older colleagues. I didn’t know at the time that the picture you see here would be the last night I would spend time with Randy. I can just hear him saying: “Just go for it, kid.” Thanks, Randy. I will.

As we get ready to sit down with our families and friends for Thanksgiving, I encourage you all to reflect on how fortunate neurosurgery is to have had such an icon in our field. He will be missed.

Editor’s Note: An issue of the CANS newsletter that will be entirely dedicated to commemorating Randall W. Smith, MD, is planned for mid-December. You are encouraged to submit personal remembrances if you’d like them included in this issue. Please send your memories to mabousamra@aol.com or emily@cans1.org. The deadline for submission is Nov. 28. Additionally, we encourage everyone to follow @Neurosurgery and @CaNeuroSurgeons.

Ciara D. Harraher, MD, MPH FAANS
Stanford Department of Neurosurgery
Dominican Hospital
Santa Cruz, Calif.

November 23, 2021
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