Personalized medicine, surgical innovations advance pediatric brain tumor care

The Neuro-Oncology Treatment Program at the Hyundai Cancer Institute at CHOC is doing more than providing the most advanced care for pediatric brain tumors — it’s also helping to shape the future of personalized medicine and surgical innovations.

CHOC offers a full range of standard treatments for brain tumors, as well as personalized therapies for many tumor types, such as medulloblastomas, based on genetic subtyping. Experimental treatments are available through Children’s Oncology Group and other consortium and industry-driven clinical trials. Some of these studies — including a trial developed by a CHOC neuro-oncologist to investigate a vaccine for diffuse intrinsic pontine glioma — are part of CHOC’s robust early-phase clinical trials program, according to Dr. Chenue Abongwa, pediatric neuro-oncologist at CHOC.

Dr. Chenue Abongwa
Dr. Chenue Abongwa, pediatric neuro-oncologist at CHOC

CHOC also partners with some of the country’s foremost healthcare institutions, including Mayo Clinic, to apply the latest genomic sequencing and molecular studies in studying each individual tumor.

When a patient presents with a brain tumor, a wide range of specialists are involved from the beginning. “We have a multidisciplinary neuro-oncology tumor board that includes neurologists, neurosurgeons, neuroradiologists, radiation oncologists, pathologists and a neuro-oncologist, and we involve other specialists as needed,” says Dr. Abongwa. “This expertise allows us to select the treatment likely to be the best option for each child while minimizing the risk of side effects.”

Each patient at CHOC is treated via an individualized, precision medicine approach. When surgery is necessary, CHOC has four highly experienced, board-certified pediatric neurosurgeons who can apply some of the most advanced surgical capabilities. “We have the latest in surgical navigation, and we partner with neurologists at CHOC to offer surgical neuromonitoring to track certain nerve potentials during resections,” says Dr. Suresh Magge, medical director of neurosurgery at CHOC and co-medical director of the CHOC Neuroscience Institute. “If we’re operating near the brain stem, it’s important to know if there’s potential for damage in surrounding structures.”

Dr. Suresh Magge
Dr. Suresh Magge, medical director of neurosurgery at CHOC and co-medical director of the CHOC Neuroscience Institute

Several of the surgical therapies CHOC offers are minimally invasive alternatives to craniotomy. One example is endoscopic surgery, which may be appropriate for tumors located in the ventricles. Neurosurgeons can visualize and resect these tumors using an endoscope inserted through a small incision.

“Certain tumors, especially those located deep in the brain, are amenable to laser interstitial thermal therapy (laser ablation),” Dr. Magge says. “This has revolutionized the treatment of certain types of lesions. We can insert a catheter through a small incision down to the deep part of the brain and ablate the tumor without harming surrounding structures. A ROSA™ (robotic stereotactic assistance) robot allows us to insert the laser with a high degree of precision. Patients experience minimal blood loss and typically go home within a day.”

Once treatment concludes, patients ultimately enter the Neuro-Oncology Treatment Program’s longstanding late effects program. This multidisciplinary program provides long-term follow-up of patients and connects them with specialists who can treat endocrine, neurocognitive, psychosocial and other side effects of treatment.

“For some tumors, such as medulloblastomas, we’ve reached the point where we’re achieving good rates of cure, as high as 80% or more,” Dr. Abongwa says. “So now we’re focused on minimizing the long-term effects of treatment. Most institutions don’t have a strong, long-term follow-up program for pediatric patients. Over time, our program has become quite robust and multidisciplinary. That’s another area of benefit that we offer our patients. We’re a child- and family-focused institution. That focus is evident in all the programs and services that are available to our patients.”

Our Care and Commitment to Children Has Been Recognized

CHOC Hospital was named one of the nation’s best children’s hospitals by U.S. News & World Report in its 2020-21 Best Children’s Hospitals rankings and ranked in the cancer specialty.

Learn how CHOC’s pediatric oncology treatments, expertise and support programs preserve childhood for children in Orange County, Calif., and beyond.

I’m a pediatric neurosurgeon. Here’s why I’m excited about the technology at our fingertips.

By Dr. Suresh Magge, medical director of neurosurgery at CHOC, and co-medical director of the CHOC Neuroscience Institute

Even as a child, I was fascinated with science, and it was ultimately the concept of using science and technology to help people that drew me to medicine. Today, I’m more excited and optimistic than ever about our ability as clinicians to provide best-in-class treatment to the patients we have the privilege to care for – particularly in a minimally invasive way.

While every effort is made for nonsurgical intervention, neurosurgery can often be the answer to saving or improving a child’s life. At CHOC, we are committed to creating a personalized treatment plan for each child, based on his or her needs.

When surgery is necessary, we strive to perform minimally invasive surgery whenever possible for the myriad benefits it brings our patients. Minimally invasive neurosurgery offers a smaller incision, less pain, minimal blood loss, shorter time spent in the operating room, shorter recovery time, shorter hospital stays and hidden scarring.

There are a number of tools that we use to make surgery less invasive. For example, we can use a small camera, called an endoscope, to look inside the brain without having to make a large incision. In some surgeries, we can use a specialized robot, called a ROSA robot, to allow for precise placement of catheters or electrodes, and to operate on tiny areas of the brain.

Here are four surgeries I’m excited about as a pediatric neurosurgeon. In each surgery, the child is asleep and does not feel any pain during surgery. 

  1. Endoscopic surgery — This option for many types of brain surgery allows the neurosurgeon to identify and treat conditions deep within the brain. A tube-like instrument with a camera is inserted into the brain through a small incision in the skull. In some cases, we can insert the tube through the nose and avoid making any incisions in the skull. This allows the neurosurgeon to have a clear picture of the tumor. Then, we use specialized surgical instruments to remove the tumor or damaged area. When possible, we use this technique for brain tumors, hydrocephalus, arachnoid cysts, craniosynostosis and skull base surgery. In treating craniosynostosis, endoscopic surgery can replace larger and more invasive surgeries but still achieve excellent outcomes.
  2. Responsive neurostimulation (RNS therapy) —The RNS system is similar to a heart pacemaker. By monitoring brain waves, it can detect seizure activity and then the system can respond to stop the seizure. What simultaneously amazes me and comforts families about this piece of technology is that patients can’t feel the device once it’s programmed. They don’t feel pain or anything unusual. Studies show RNS therapy reduces seizures and improves quality of life for most people who have used it.
  3. Deep brain stimulation This surgical treatment can offer lasting relief for many children who experience abnormal movements. CHOC offers DBS surgery for children with movement disorders of all degrees, including very complex cases. We are one of the only centers in the world to use a multiple stage approach that allows us to better target the correct areas of the brain, without the need to wake a child during surgery. DBS surgery at CHOC involves the placement of electrodes in the brain and wires that connect to a stimulator device implanted in the chest. The device is like a pacemaker; it sends impulses to the electrodes that tell the brain to stop or minimize uncontrolled movements throughout the body. Our specialized team places up to 12 electrodes, when needed, to target different areas of the brain to attain a good outcome. Surgeries take place in a state-of-the-art operating room at CHOC, which includes the latest navigation system for safer, more precise procedures and the ROSA 3D-mapping robotic system that aids surgeons in locating the exact areas to operate.
  4. Laser Interstitial Thermal Therapy (LITT) – Also known as laser ablation, this emerging technology provides pediatric patients with epilepsy and other conditions a range of benefits more traditional procedures can’t match and offers a potential solution for brain tumors that are hard to reach with traditional surgery. Instead of doing a craniotomy where a large incision is made to open up the skull, the neurosurgeon first makes a small hole in the skull just a few millimeters in a diameter. Then, under MRI visualization, the neurosurgeon can precisely position the laser probe and deliver heat to the specific area, which destroys the abnormal tissue. Laser ablation is especially useful in patients with tumors or seizure-generating abnormalities deep within the brain. Precision is essential in implanting the catheter, which guides the laser, since it allows the neurosurgeons to limit the thermal energy delivered to the tumor area only. Most LITT is minimally invasive and requires a short time in the operating room, and patients are often able to go home the next day.

Throughout my career, I’ve been fortunate to see firsthand how neurosurgery has advanced tremendously over the years, particularly through research and innovation.

I’ve had the privilege of studying and providing care at a number of institutions – Harvard, the National Institutes of Health, the University of Pennsylvania, Boston Children’s Hospital, and Children’s National Hospital (Washington, DC) — before coming to CHOC. At each of these institutions, it’s evident that through innovative technology and minimally invasive surgery, we as neurosurgeons can alleviate suffering and have a significant impact on the lives of children.

As a team here at CHOC, we always ask ourselves, “What is the best thing we can do for each child in the least invasive method, with the least amount of pain?” and then we try to do it in the most compassionate way possible.

It’s an exciting time in medicine, in part thanks to advances in technology — especially the pieces of technology that allow us to provide these minimally invasive surgical options that make a true impact on children and their families.

For more information about the CHOC Neuroscience Institute, click here.

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Research Shows Endoscopic Strip Craniectomy is Strong Alternative to Open Approaches for Craniosynostosis

Minimally invasive endoscopic strip craniectomy offers a strong alternative for infants with craniosynostosis, according to a growing body of research in pediatric neurosurgery.

“The data has been clear that this is a very effective surgery with excellent results, and it’s less invasive than the traditional open approaches for treating craniosynostosis,” says Dr. Suresh Magge, medical director of neurosurgery at CHOC and co-medical director of the CHOC Neuroscience Institute. “A lot of the research that we and other groups have done shows that results are either as good or can even be better in certain aspects of facial growth compared to open vault reconstruction.”

Dr. Suresh Magge
Dr. Suresh Magge, medical director of neurosurgery at CHOC and co-medical director of the CHOC Neuroscience Institute.

Dr. Magge’s research on the topic has included:

Traditional surgery for craniosynostosis is an open cranial vault reconstruction, in which a surgical team takes apart the skull in order to reshape the skull plates. If craniosynostosis is diagnosed early enough – preferably before four months of age – minimally invasive endoscopic surgery can correct this condition. Small incisions are made and, using a camera, the fused portions of the skull are removed.

While both the traditional cranial vault reconstruction and the minimally invasive surgery can offer excellent surgical results, the minimally invasive approach generally involves less blood loss and swelling, smaller incisions, reduced need for blood transfusions, less time under anesthesia and shorter hospital stays. Pediatric patients usually go home the day after surgery. Once surgery is completed, the patient is fitted for a cranial molding helmet he or she must wear for a few months that helps guide the skull correction over time.

“We have an outstanding craniofacial team, including neurosurgeons, plastic surgeons and maxillofacial surgeons, here at CHOC, and we strive to offer an individualized approach to each patient,” Dr. Magge says. “Physicians need to know that craniosynostosis requires an early diagnosis so that parents have the option of the minimally invasive surgery. At the same time, we want to give parents different options when it comes to surgery.”

Dr. Magge recently joined CHOC after an 11-year tenure as a pediatric neurosurgeon at Children’s National Hospital in Washington, D.C., where he started the medical center’s minimally invasive craniosynostosis program and was the director of neurosurgery fellowship training. He completed his neurosurgery residency training at the University of Pennsylvania and his pediatric neurosurgery fellowship training at Boston Children’s Hospital.

While Dr. Magge has a wide-ranging clinical practice, his special clinical and research interests include craniosynostosis, brain and spinal tumors, especially diffuse intrinsic pontine gliomas, and pediatric neurovascular disease, including arteriovenous malformation and Moyamoya disease. In his new role at CHOC, Dr. Magge looks forward to contributing to the growth of CHOC’s neurosurgical programs, including the brain tumor program, neurovascular program, epilepsy program, robotic surgeries and more. 

“It’s such an exciting time here at CHOC, from how we’re building and growing our programs to driving clinical innovation, as well as training the next generation of pediatric neurosurgeons through our affiliation with the University of California, Irvine,” Dr. Magge says. “We’re always asking ourselves, ‘What’s the best thing we can do for each child in the least invasive manner with the least amount of pain?’ and then doing so in a compassionate manner.”

Our Care and Commitment to Children Has Been Recognized

CHOC Hospital was named one of the nation’s best children’s hospitals by U.S. News & World Report in its 2020-21 Best Children’s Hospitals rankings and ranked in the neurology/neurosurgery specialty.

USNWR Neurology and Neurosurgery award

Learn how CHOC’s neuroscience expertise, coordinated care, innovative programs and specialized treatments preserve childhood for children in Orange County, Calif., and beyond.

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Virtual pediatric lecture series: Minimally invasive surgery for craniosynostosis

CHOC’s virtual pediatric lecture series continues with “Minimally invasive surgery for craniosynostosis.

This online discussion will be held Thursday, Jan. 14 from 12:30 to 1:30 p.m. and is designed for general practitioners, family practitioners and other healthcare providers.

Dr. Suresh Magge, medical director of neurosurgery and co-medical director of the CHOC Neuroscience Institute, will discuss several topics, including:

  • Diagnosing craniosynostosis and differentiating craniosynostosis from plagiocephaly.
  • Recognizing the early signs of craniosynostosis and understanding when to refer a patient to a neurosurgeon.
  • Differentiating open versus minimally invasive treatment of craniosynostosis.
Dr. Suresh Magge, medical director of neurosurgery and co-medical director of the CHOC Neuroscience Institute

This virtual lecture is part of a series provided by CHOC that aims to bring the latest, most relevant news to community providers. You can register here.

CHOC is accredited by the California Medical Association (CMA) to provide continuing medical education for physicians and has designated this live activity for a maximum of one AMA PRA Category 1 Credit™. Continuing Medical Education is also acceptable for meeting RN continuing education requirements, as long as the course is Category 1, and has been taken within the appropriate time frames.

Please contact CHOC Business Development at 714-509-4291 or BDINFO@choc.org with any questions.

In the spotlight: Dr. Suresh Magge

CHOC is excited to welcome pediatric neurosurgeon Dr. Suresh Magge as co-medical director of the CHOC Neuroscience Institute and neurosurgery medical director for CHOC, bringing a wealth of expertise that will continue to advance the institute as a leading destination for care.

Dr. Magge will bring clinical experience, innovation and the latest techniques to CHOC, following an 11-year tenure at Children’s National Hospital in Washington, D.C., where he started the medical center’s neurosurgery fellowship training program and was the director of medical student education in pediatric neurosurgery.

“My approach is to meld the latest in clinical medicine and research to find the best treatment for each child,” Dr. Magge says. “I always try to use a patient-centered approach, using precision medicine to perform the most minimally-invasive surgery possible.”

 Dr. Suresh Magge, co-medical director of the CHOC Neuroscience Institute and neurosurgery medical director

While Dr. Magge has a wide-ranging clinical practice, his special clinical and research interests include brain and spinal tumors, especially diffuse intrinsic pontine gliomas; minimally invasive craniosynostosis surgery; and pediatric neurovascular disease, including arteriovenous malformation and Moyamoya disease.

Craniosynostosis refers to the premature fusion of the skull, causing problems with skull growth. During his time at Children’s National Hospital, Dr. Magge started the region’s first minimally invasive craniosynostosis program – something he is looking forward to expanding at CHOC.

“This condition used to require a large surgery in which the surgeon would take apart the skull and put it back together,” Dr. Magge says. “Kids generally do well after the surgery, but it is quite invasive. Now we can do a less invasive surgery that uses minimally invasive techniques that is shorter, involves less blood loss, and quicker surgical recovery. This is an alternative that I’m excited to expand here.”

He also looks forward to contributing to the growth of CHOC’s brain tumor program, neurovascular program, epilepsy program, robotic surgeries and more.

Even as a child, Dr. Magge was fascinated with science. He loved everything from chemistry to biology, but it was ultimately the concept of using science to help people that drew him to medicine.

After graduating from Harvard Medical School, during which he completed the Howard Hughes Research Fellowship at the National Institutes of Health, Dr. Magge completed his residency in neurosurgery at the University of Pennsylvania.

He found that pediatric neurosurgery was his life’s calling, and he then completed a fellowship in pediatric neurosurgery at Boston Children’s Hospital. He has since been in practice at Children’s National Hospital before coming to CHOC.

“Neurosurgery has advanced tremendously over the years through research and innovation,” he says. “Through surgery, we can alleviate suffering and have a significant impact on the lives of children.”

Pediatric neurosurgery allows Dr. Magge to combine his love of science with helping children and families through their toughest times.  

“When parents hear that their child needs neurosurgery, it’s a very traumatic time,” he says. “We try to take a personalized approach and take parents through this process in the most compassionate way possible.”

Dr. Magge is excited about the growth of CHOC’s neurosurgery division and neuroscience institute. He says that the strength of the Neuroscience Institute comes from the collaboration of different neurological providers within one institute.

He joins an expert team of neurosurgeons, including Dr. Michael Muhonen, former co-medical director of the Neuroscience and former neurosurgery medical director, whose numerous contributions in the role made an invaluable impact on children and families. Dr. Muhonen will remain in active clinical practice at CHOC, with an increased focus on hydrocephalus clinical care, research and new technology design.  

The neurosurgery division also includes Dr. William Loudon, who has years of experience in pediatric neurosurgery and brain tumor research, and Dr. Joffre Olaya, who specializes in epilepsy and functional neurosurgery. 

“We have four highly trained, highly respected pediatric neurosurgeons with many years of experience,” Dr. Magge says. “Each surgeon brings a wealth of experience and a personalized approach.”

Dr. Magge plans to advance the path of the Neuroscience Institute toward becoming a world-class destination for neurological care. He plans to expand neuroscience research programs, saying that the ultimate goal is to cure neurologic disease through research, as well as to educate future pediatric neurosurgeons in partnership with UC Irvine.

Further, Dr. Magge’s appointment coincides with significant infrastructure changes underway at the Neuroscience Institute: CHOC recently opened its new state-of-the-art outpatient center, establishing a clinical hub for caregivers to serve patients and families in a centralized location. Additionally, plans are underway to expand the hospital’s inpatient neuroscience unit.

Throughout Dr. Magge’s years of neurosurgery, he has learned about resiliency from his patients. “I am constantly inspired by the strength and perseverance that patients and families show in the face of adversity.”

A parent himself, Dr. Magge enjoys spending time with his wife and two young sons. Together, they ride bikes, play sports, hike and travel – especially to national parks. A competitive tennis player growing up, he still likes to play tennis when he can and also enjoys dabbling in photography.

Learn more about the CHOC Neuroscience Institute.