0:08 Hello, I'm a James Ausman. I'm introducing this section on pediatric neurosurgery brain tumors, which is part of the SNI Digital meeting
0:19 on June fifth and sixth, two thousand and twenty one
0:24 that. We're sure an international meeting with participants from over one hundred from one hundred countries or more,
0:32 this session is moderated by Chandra Day, was your party.
0:36 Abu Jury from India is professor and head of neurosurgery at Bombay Hospital Institute In Mumbai,
0:45 India, He is accomplished in endoscopy surgery, Pediatric neurosurgery and cerebrovascular neurosurgery.
0:56 The neurosurgeons in India, I found were extremely capable people are very busy, cause there weren't a lot of them and.
1:06 They, they did very very good work, but often didn't have time to write. Chandra has done an outstanding job, has run a number of courses,
1:18 Zoom courses throughout India, and is well recognized.
1:23 His assistant moderator is Shlomo Constantino, who is a head, a pediatric neuroscience and neurosurgery at the Hershey
1:32 Medical Center in Tel Aviv, Israel. Trauma is an excellent teacher, very practical person, and in pediatric neurosurgery for years, and has an excellent practice, an excellent reputation. They've assembled some participants from around the world, Sergio Cabral Hero from a Sau, Paulo, Brazil is professor of of neurosurgery, Their rakesh July is from. Mumbai, India, he's a neuro oncologist who specializes in radiation oncology,
2:11 Dr. Cole Carney Professor of neurosurgery from the University Of Toronto Hospital from sickkids, Ebay, Kulkarni, has his name Sandy Lam is Professor Neurosurgery at a pediatric hospital in Chicago, shaded with Northwestern University.
2:31 She was with us as a resident. You see how he did an outstanding job. Nobel Tangle is a young neurosurgeon who's in pediatric neurosurgery at the Red Cross Children's Hospital in Cape Town, South Africa, Delightful young experienced pediatric neurosurgeon you'll hear from her and Frank Von, Calling Berg. Frank is a professor of Paediatric neurosurgery. A university in Leuven in Belgium, so there's a number of people here you will hear in the in the audio you'll see on the video, and they're going to discuss two subjects. The first half hours going to be devoted to Crania fringe Yoma, and what is the? What are the treatments for the present cases, and and talk about the various approaches, I shined a real show an endoscopic approach there in which they're introducing a new concept where you can. Remove actually grossly the tumor. It's a very interesting video to see and their new advances in the molecular structures of Crimea, for N Geom, all of which will are making it more approachable and treatable that it had been in the past second half is going to be devoted to megaloblastic doma, another common pediatric brain tumor I'd seen around the world and. Various people will discuss that from their perspective isn't a resurgence and radio therapists. In addition to the chemotherapy, We hope you enjoy the sessions. Is an outstanding session. In my opinion, Thank you very much for coming, so welcome friends, so we are at this and I and Neurosurgeon World Education Summit and. In the periodic demonization we are going to discuss Lucas is today. Ah, we have a lot of friends gathered here. A lot of young people from several countries in the world have joined us and we hope that this case discretion alum will be have touched us from them as well recruit beyond sitting, and I will be discussing the case, Sir amongst ourselves as well as we regulon, so this is a nine year old boy. He came to us with early morning headaches associated with vomiting intermittently for a year, and they became worse in the last two months. This is one of the problems in the developing countries. That there is a late presentation. The vomiting typically relieved after the headache. Ah. He has had been autumn will end in Atlanta, Pd, natural history in autumn milestones, and there were no changes in diet, weird or urinary frequency, Ah before, so I will straight away, take your to the imaging. I want know before that we certainly had a clinical examination reassured him to be reasonably cooperative. That was at once, papillary mind bought the eyes, and the remaining examination was normal, so at this stage the first investigation. Now it is fortunately in India, we have several admirers, and this was the investigation done at that time, Ah.
5:54 Would you like to commend Shlomi on this Mod?
5:59 Well, I, I see the
6:02 impressive right of close with the extravasation of fluid around Event, Wilson, Vs, obviously the reason of the all of the popular demo, a super stellar rumor, and I would guess that some calcifications I would like to see a C T scan if it's available. So lead to serious consequences from the enemy here, we have a cystic and solid pump, and and the solid component is mainly in the cellar. The cystic component is a growing up works, and this is the C D scan. Okay, So we've got it all we've got it all, so we have a solid component in the cellar and we have a super sello says that blocks the third ventricle. This is the reason. I could with my group separately so well,
6:56 it is one of the rapidly deteriorating,
7:01 and on he has this narrows, the flows of with a super seller Tomorrow are aware of. Would you like to tell us what what should we do in this kind of a patient for the hydrocephalus, which is probably the predominant A reason why he's don't have such a severe him. So I'm sorry to join the sugar. You said he. He is now rapidly deteriorating. Is that right, Yes, Yes, so in in that situation, I mean it, as surely pointed out, this is a predominantly cystic tumor, looks like a cranial for Joma, with the with that calcified solid component in the cellar, causing obstructive hydrocephalus, and usually I'd like to get some baseline testing of of vision, and in men's hormone status, but. It is child is rapidly deteriorating. I think the the hydrocephalus needs acute, and what I would do. I mean our our our approach When you have a predominantly cystic tumor like this is actually to direct, and our initial mode of therapy for the tumor at at the cyst, as well, and so I think you could probably deal with that and treat the hydrocephalus by doing an endoscopic approach through the frontal horns into the foramen of Monroe. It looks like it's going to be dilated. In that in the area of the cyst, and and under the under scope out, I put in a rut a reservoir, a catheter to decompress the cessnock. I'd watch it decompressing usually that relieve the hydrocephalus, and and we, then you use that catheter for interferon therapy after, but I'd like to. I'd I would get a full assessment of of what his vision status is like, and and what is under can status as like as well before making definitive decisions about about the final management of the tumor.
8:46 Great, so did you would you like do
8:50 agree with that. Would you do something more than just putting a catheter
8:55 that I know it's a very good case. They think is a to get cranial studying job way feeding her. Couldn't y'all hypertension. It's kind of emerged Asa. And that I have to protect ticket. Dads are guided by endoscopy, copia evacuated the Cs to, as it's possible, Not a lot because of the Kirkpatrick stay inside of the seas. You can solve the tumor and the hydrocephalus. The fire first step, then I'd like to know that autumn will. Now. How is dermal? Now in this patient is dead? Did the array shelf of the, and now I can direct his or her, if not, if there is no hormonal alteration, I introduce, Eat their fill
9:37 grid, So this is what we actually dare die. I usually like to. I, the gathered automatically and assist, rather than putting a beauty that was one point. A witcher. Obey also made, and says you also made, so we are getting into the cyst. One of the problem is spillage. What portion at undergo undercoat of St Ives, does not seem to have much of a reaction, and the Ah. The only other way you can probably do it is or tried to put the.
10:08 Stylish than the reason why the straightaway to the the catheter straight away, rather than Nha trang to perforated, but this seems to have worked quite well for us, and we put in a catheter, We decompressed assist, and the headaches improved remarkably and the harmony the revolution was sent. It takes about three days for all the reserves to come back, and during this time the child was settling will, and we also got to this is the full Reduce can be sure. Resolution of hydrocephalus, and at this time we do to be in a C D scan to see what we should do do, as are our future treatment. All the hormone report came back as normal. Ah, so how would you go? I heard further
10:55 this as a boy when there is no visual field defects, or very likely this is a retro guys middle kind of a dual Martin.
11:06 Can I undertake the latest asked justice the point that you made about the the concern with spillage of the cyst contents? I, I, as you know, I've not really noted that to be a concern or an issue, and I'm just curious. If if other people worry about that cause, I, I've actually stopped really worrying. It better yet has not been an issue in terms of of a concern. After
11:29 Shlomi. You have any relation grew, reacted badly, but steadily with steroids. Well, I agree the spillage is not a big problem. I would like to keep the cats are inside. This is because if you elect to treat, either by interferon, our, which I would not favor in this case, But if you would like to send the radio therapy, or you go transfer Nigel through the cellar, it is nice to have assist. Because the system reacts last we've seen of the proton therapy. We've seen cysts. Staying there for a year, and sometimes for two years and then they return to the treatment. So is very nice to keep the catheter in the Cis, and it's a challenge, Because sometimes if you go one centimeter to be a once limited to shallow, you're going to lose lose the suit and regarding the tumor, there are options out there and and I, I guess the controversy will never end or me. I would drain the system. And sent to radio therapy by proteins nuisance for me, because I think interferon is a temporizing measure, and though usually does not cure, there have been suggestions to Jeff's followed after your brain dis -ease I think the German study of Of following was was averted because all of the tumors, all of the for from Dumas grew at one point, so I'm waiting. May give the advantage of you were very young children, not to eradicate them when they're young, but the pumas when roads have any tried above three or four, I would rent assistance, and for a radiation, the problem was that transfer idol. I've seen a couple on at least hand in the last few years,
13:30 You lose day. You get a diabetes insipidus if you remove those tumors. You're going to get the eye and it is such a shame to bake a boy that is preserved and the printer logically and give him the art. Of course, the, I can be managed. If the thirst mechanism is there, so my choice would be drainage and radiotherapy, upfront,
13:55 Frank, What would you do in such a case? Yes, I want first to give a small comments, because you said Chung that that. In developing countries, the diagnosis is often made after the delay of one year and just want to say that in Belgium, which is not considered a developing country, these diagnoses are also made quite late, and at many tourists are a lot bigger than this one algorithm patient,
14:28 so I think because it's only in the world at Wendy's children have complaints. Even when the vision is getting bad day are just advanced in the classroom closest to the teacher before the city scanner, Omar is made
14:49 on the on the treatment. I think at what we would have done was also put a catheter in the cyst and an endoscopic guidance. And leave it there with a resume for us and then go for radiotherapy personally At making the hole for the candidate. I would have taken a small biopsy of the cyst wall to be sure that it's a cranial for Ngoma to convince radio therapists that it is a great new fighting G, Oh, my, and not some sort of colloid cyst, because they don't always believed with allergy
15:30 or.
15:32 And then the radiotherapy, and not go off to the nodule tumor in the in the cellar. The child was nine years old. I think sixers or six years ago, said the seven years old
15:51 are the few cases where I send children to my colleague, who's doing the end of it, You reply. Surgery, they all got diabetes insipidus and and
16:07 fool yourselves and and never completely section,
16:12 But it's only see or four cases.
16:16 Dr. Tango. What what is your experience in your country? How would you manage this?
16:23 Thank you for the question, so united South Africa, they teach, teach busy a lot. Bigger the one thing in terms of endoscopy and doing in a Maya for both
16:35 situations. Obviously I'm still junior my career way. They see Cecily pigeon You. I get quite a bad chemical meningitis. We think he needs his of three -foot and I might admire reasonable. Anything near the child is Indians at the age for radiotherapy Need tried to tie them with into for a student. The shots nine years old and he showed me. If this these improvements offices decompression, I want to, If one would follow up, and they become symptomatic reversed regular therapy, just in case of you know my first of the optic nerves, the one business that I saw anymore, but that's what we would kind of do or decompress the cyst, and will follow up with imaging.
17:24 Rakesh I would like you to get in now to tell us, Sir, what are the implications of the cyst in terms of planning radiation therapy And do you need to update your law Radiation from a lot of radiation field. If you have a sister, There
17:41 are ten of the present age is not an uncommon situation as you join our directness, and I tend to agree with all the all the colleagues who have said. About the indication of radiation, his seven year old, so we would are definitely in my permits institution. We used to do with I am Rt, or audibly remake technology, but now we have Proton therapy, They may guided one in India, as well, so we have in the last two and a half years, number of them, including with yourself up a pathetic. We always try to top that when you go see article on face, Because occasionally the young person, especially in this case, because he is fundamentally impact. You are tempted occasionally observe very closely when units. We just know that this is going to record. So if they tell us no, No, it's very likely that it feels so great and also am encouraged by the fact that the vision is impact so another country again, as perhaps is the case, in many other places, also the follow up in order to be so good and we don't want to want to come back and embarrassed region, so we would go ahead with radiation coming to go specific point. In particular is brought on, as some of you may know it's a particle beam have been any different density has to be very meticulously incorporated in the planning system because it can actually flow the door, so you have to be extra careful in a letter to Santa. We do have weekly, and when I enter daily, Cd as a part of imaging, won't be seated on the machine before your fleet, and the other psychological example, changing one's haven't ordered as much as. White percent to fourteen percent of change in the cystic memorial was in injuries, and sometimes we have seen the degrees on so, and that can change up the road on planning. So in on. I'm gonna have to be stuck at for of his Donald. It's not such a big deal. All If you have protocols in place, you can manage the stupid white velvet
19:40 Ronnie having go. I have you joined Us Army's.
19:46 Well, she hasn't joined us, but Rakesh one of the points which was made to, was you wanted to have with his store vital to the report. I mean, morphologically. This does nothing goes, but could any of her in German art only on imaging, but also on Sir, Inspection had surgery. What do you insist on a biology now leaked and tool? It could be part of the oncology, bringing us because that it's kind of. I didn't know that training you may say on whatever you may call, and I'm in both of us knowing many of us know that occasionally you do have surprises, and in a young the giant aggregate. It is a big deal, and you know it's like and life long thing. So ideally, Yes, we would like to have his apology in my practice as well so we can to insist upon to have a policy that district benefit,
20:37 so we have now. He did do about the twentieth patient, so with this kind of a protocol, that once after we put the system, the, it is too small and it is very difficult to operate, does not advisable to go for a radical surgery. We would probably doing can fed on therapy, Ah in a child about three years, but if the child is otherwise intact, and the
21:06 his eye. Radiology is favorable, like in this patient, you have a win, edit, or sphenoid sinus, and I, we we, during the war or after the competition returned to go, transfer, Northern and Lake, In this patient, We have done our carotid book had ordered exposure. We have dinner them at a mall. After that, we are regulating the, and did it into and sinus opening of the Ah corridor for the tomorrow and. You will find that all the solid your is in the cellar on. Once you have made an incision into the caption.
21:47 You'll get all the calcium out.
21:57 Was the calcium comes out. The rest of the series stars are getting brain and the caption
22:05 what is over? Experience mainly is that once you have been the cyst, Ah, unlike Go. One of her colleagues.
22:13 Said that once you get this out.
22:21 What have you and here you will find that it is not just pulling, you are easing out to gently with your suction, and you will find. As we go along, the cyst wall is coming out to rarely easily. The normal pituitary is here at the back,
22:40 and the dome of the cyst has almost completely fallen into. You're a sailor, and this is a portion attached to one side. That there has been no, we're just using the tumor out. We are not pulling the tumor out, and I think this kind of up a cyst wall falling into your field will not happen unless you have previously done Narcisse decompression by the Ah, endoscopy girl or intraventricular kind of an approach, and the whole tumor has come out. You can actually start seeing this inside, and you'll be able to see a duck. Pituitary stalk plastered onto the one side over here, which was incorrect.
23:27 Ah, The closure is of course in three layers, with fact Fisher, and none is accepting flap, and this patient, the recovered quite well, following surgery, He had the mandatory or diabetes, insipidus, hypernatremia had seizures for a day, and this took about three days to recover. But from post operative Florida today, he record that to normalcy needed minute in for about two three weeks, and thereafter that has been reduced, and he's only on highest on currently, and this as they might done at three months where he is receiving the only steroids an actor, those of about five milligrams saw off a high sun in the morning as I explain, in the morning and five in the evening, and this is the postoperative scan.
24:17 So my question is, I know that there is a lot of discussion on how radical one should be, but when the patient is hormonally and back, when the hypothalamus is not in ward, or should we do radical surgery are a narc, which can be a great deal is still a matter of controversy, and I'd be very happy to hear from all the faculty that obedience.
24:42 Well, this is Sandy Lam that that was a great case. Thank you for showing that, and I think it highlights a lot about the whole spectrum of options for approaching this and and and I'm glad you showed the that the at reception and spectrum a part of the spectrum as well, so I, I. In terms of the the first decision point for addressing the hydrocephalus, and assist, absolutely agree and discard pick approach, and and job at getting a a a sample of the lesion for our pathology collegian for the whole multi disciplinary care, and and Jeff for discussion for radiation, I absolutely agree and I think the other point is. Contribution to the discovery and science, or if you are at the center that participates in a registry, and we send all of our cranial fearing, Gee Alma a cyst fluid and any tissue sample to Colorado, and with a Todd Hankinson group and they have eighteen centers and. The ad storing the tissue and having a collaboration with Uk, so that if you are able to safely obtain a tissue sample, I think that's an important component as well, and then putting a catheter under direct visualization, is there was an additional sis. If and if you're able to configure your your catheter in a way to be able to have. Address multiple cystic cavities said that's also a consideration in this case, that was not, and then I think the really the big decision point is if you are going to consider surgical resection with the goal of maximal safe resection. And that then you're you're timing is is just as you showed at its upfront right, it's before you go to radiation.
26:46 And and then you you choose that path. I think that The the way to run into a lot of trouble is if you choose radiation upfront, and then later on decide to go for a maximal safe resection. Because that makes fed the tissues much more difficult to work with. So am I and I think this case was was wonderfully chosen because you were able to highlight a lot of the controversies and the ways that to all of us her approach this differently.
27:16 What is the situation in Canada? I know in Europe? A radical dissection is what actually given up. Do you have any views on this? So I. I, we usually puts on in a. In a case like this, I think The The The the treatment algorithm would have been. You know, put the the The The says catheter in drain the cyst, and we probably would have started with interferon, recognizing that's not a cure, obviously, but The, I think our our philosophy is at this at this as a A. Potentially chronic conditions. And and to manage it as such, and to try to minimize the.
29:01 The diabetes insipidus saw the. We have the patience. We updated. Like this. We have about twenty five percent patients were required to a long -term diabetes insipidus statement, Otherwise of Allah that have have ever assembled. The children actually did not required any medication for diabetes insipidus beyond twelve months, that is solid experience of, so yes, I mean all this has to be explained. That is extremely important. Rakesh, would you say anything on
29:35 this? Ah, the
29:37 joys of approach yet he with when you have a complete excision order, when you do not see any discernible tumor on the post operative, am out, I e, there is still a possibility of recurrence, So what is the status of the radical resection about the raid unwatchable for upfront radiation?
29:58 You know when we were students, we were taught that you speak to, then your surgeon. If that has anything left me at the stock in vitro. Don't see anything on the amount. It's going to go, so probably treat radiation, but it has a little been on time. Emma eyes are much nicer. There is a greater cooperation. I think in the boss then was not so much interaction also as a multidisciplinary approach, as was mentioned by one of the speakers. I think if you one way of closely. What us are not the me and you and me, We have a number of cases which we are falling very closely, so that is a very reasonable approach. As an additional punches. We always tried to avoid as much as possible especially in young children even in rodents, but and act of the day in many countries, I have a feeling based base model and bring open general oncology, Sometimes miss chances the best John, so you have to really individualize and customize to each child and the family.
30:55 In the mangle your comments before I go to a literal European colleagues.
31:01 Thanks. I think that has been been covered already started having additional comments except out as quite impressed the the endoscopic approach and sense of its women to come and there for five years. All I just wanted to ask what is your age limits for going into Slavic a pediatric patient.
31:23 We have greeted as young as sir, two years ten months, but generally we would not consider below the age of five months, unless they have a very good editor. The sphenoid, Ah, then flow me. I think of you and Frank were to come in before we moved to the next case. I just want to make sure you call me up as a European were preventable. How the European, ancient African, wherever trailer.
31:53 You can choose to be aware. Well. I think I think what is striking is really the relative coherence of potential and solutions among this group sitting here, because if you would add on a adult neurosurgeons, you would see a much more aggressive, Sir, reply opinion, and the, it's hard to convince them that the. Where'd your therapy principle is effective for for cranial bring humus? The the problems I face is one we have large cranial print. Your most was large solid component. We recently had a couple of. Let's a fall of five centimeter diameter perennial plant yoma with a small cyst, or no, said What do you do then so so I would like to. The reverse of the question, the wreckage, and asked what would be his upper limit of four proton beams of any red radiotherapy with with a large grain print, German would making up for sending me the cranial point during my few centimetres centimeter for from Joma, would that make a difference for you in terms of morbidity of your regular therapy and efficacy of though?
33:17 That's a great question, and we do see such cases of problem comes. If the gazette upfront case obviously as small as as more duma that we have to treat. It is better, and particularly, we have any good by them at the long -term efficacy of radiation, know that all Cds with a bullhorn off almost hundred occupations, or the with seven years with the respective neuroendocrine Europe, all going to get that is. Seven years, cinema island of ninety five percents of that I completely agree is pretty effective. The problem actually comes in recurrent. Sometimes patients have
33:54 observed not given radiation. It's a small one second. We it comes to centimeter location, or you operate suddenly after three four surgeries. You have no force and of humor, and then a descent to be funny aviation, and they'll bulls an extremely difficult too much because they have such so many surgical resection. Said. Solid approach also has been, as I mention, he tried to intervene as early as possible, obviously as you know the logic or two at the more side effects omelet. There is a small benefit walked on, Because brought on, even if it's a launch of tumor, I have to say you can achieve beautiful dose distributions particular to the left people can buy, and also to the other organs at risk,
34:39 but the pituitary hypothalamic excess, of course, part of the target volume. We cannot avoid it, so you know it's one case to case basis
34:47 to serve. You
34:50 have you become more concentrated, audio still doing some ma endoscopic resections.
34:57 Yes, as they entered, the youngest patients, is I think is Julia, result is the same against the bank of this benighted, but the one thinking that the games that have similar case like that, I corrected the. Because if the fact that, perhaps you'll have the sales of the cranial, pretty sure that the girl, so by their turns this the night did they catch the cuttack Second point of view. I'm delighted to see it in the beginning of the seriously. They asked, but and in the beginning I don't do that to send them is the boss he has marquee credited for the Joma. I don't do that, but to now. It's made that can make it applies to see the upkeep, but way defer to begin the day that the search. What what do think about that?
35:49 Will I think to another tour? Guys? When could I knew how to enjoy my? It certainly makes it difficult to, and that is one reason why you cannot even think of doing good article reception
36:01 from a transcranial approach I think for this particular. What kind of a which is tropez Mill does not have a field effect, sort of optic model deficit, and I have the lie. Is. When edited These, these are our indications to go for this kind of oral surgery. Ah. I think A, Ah. Frank, you have any last command before we move, Ash, know just a little survey, impressive video of this transition idol resection, I personally. Never did transient idol surgery, so I have to send these patients to my colleagues and I was impressed. That's all that I want to say. I think I. I personally have started to thinking that the probably that happens to the hypothalamus can be minimized were draining the cyst, and thereafter it becomes easier to from the experience we have had so far. Ah, we don't try to we waited article unless it feels so easily. Otherwise the patients go for either put on a proton radiotherapy. I will move to the next gear. Sir. I would request Shlomi to moderate this case. The general. Will you will you show the case young named Fearless, Showing the second case is a six year old boy who presented with giddiness and vomiting for about a week, has headaches for the two days before he came to us, and the patterns, nor disdain balance while walking does the day before he came. And only after year this fall, they brought it to us, there was a clear or taxi gate, and this was the skin
37:48 any popular demand.
37:51 There is there was papillary. The mother. The child was very very difficult to examine, was very cranky.
37:59 Well, I must say that I didn't really bother to look into his eyes and
38:06 isn't restricted. Sunny, Was it restricted on. I'm alive. I mean
38:14 he has his where we can. The moment. This is the post contrast image.
38:24 This is in the coronal and Seattle will endure. This is the spectroscopy. And this is the diffusion restriction.
38:37 What do you call it beer? But if you an image as well, you insist on spinal imaging before the surgery every night, Yes, If the patient on climate a little us, we will do was fine screen, but many a times what happens, these patients come in a bad condition and do they come with and a moderator from outside in such patients. We do it post resection. Am I right that, then we was fine screen. But this was frankly a short diffusion restriction, so how do we proceed? Do I, I think please sir, take over earth gloomy yet, so the first thing is the controversy about how to deal with the Csf patients on the hydrocephalus and that there are several options here, so let's let's hear the The young Alex thirty, would it would you start with? How to deal with the hydrocephalus? What would you do
39:39 the first week? You can do that third debate Take lost on me of his chances. The danger job. When you're going to surgeon is, Am I going to do a surgery at one or two days after I puts Ashanti? If I'm going Wait when the wiki I'd let their demented
39:57 one located sanding.
40:01 Actually, put in ventricular, lost me and crunch. It will help
40:08 if the patient needs further imaging or spine imaging, and it helps with the sedation, and then also peri operatively after I do the post your face, a tumor resection that the Csf diversion actually helps with the one closure and healing, and then I see if I can actually win the ventricle, asked me to take it out. It is that if the patient cannot have the ventricle, asked Jimmy weaned, I do, and and a skeptic third ventricle asked me at that time through the same tracked.
40:42 You. Would you? Would you wouldn't even be made the same setting as they used to remove, looked at. Didn't he added a beautiful. Are the reason impregnated Dvd? Yeah, it was interesting because we had a similar discussion. If you weeks ago, when an hour seemed colleague, mohamed it, but they'll get from pyro, does a lot of these said they do only chance, because in their setting me with these get infected, so so it's it's geographically the moment sometimes because handling and easy deal for a few days until it cleared and the challenger, then it may leak may lead to who other troubles, so if you have a good, I see you. The first now, and you can clean it that could be nice, because not all of them will require shop that that that that would be nice. What do you say? What do you do in Toronto for pipe handling the hydrocephalus, E D, v D at the time of resection, so we would this child, We plan for a a fairly acute resection of the tumor, and we would do an easy day just prior to tumor resection, rather the tango. What would you do? As I said, I'm still very early in my career with the big, plus your face itchiness. I, I do it with a puppy. Got you observing me, so we start with an Edi. This gives us enough time to get cranium spine imaging, cause places up with bladder sensation. It's very difficult to see whether they sugar coating things. You do it on the next available, and it's a snake, so he begins an emergency. Do a Mri cranial as fine a drink. In response to the restriction on our elites, later snakes,
42:30 so even the or in Ethiopia can be a temporizing measure, especially for places that are not have built the duties numerous in the middle of the night or have no availability or the next day that that sounds reasonable. I'm I'm pulled off the Tv's I must say, Because when you finish the surgery if you do proper removal. The aqueduct is fully open, so what is the sense of doing and E t be? When the brain, Sammy's first and thoroughly by the tumor, so I'm not against it, but I've been losing a little bit my enthusiasm for doing, and even an E T V as a temporizing metro, but the it's also have a valid option. The new sat there shores that the surgery genre year, so we, I mean. It is that anybody who will propose a E D V post before surgery, or even now, you know in place of a. Really,
43:34 none of our panelists are as varied in an actuary thing, and perished, said it is quite quite
43:42 quite common, right, Yes, that they, they propose it to forward your inevitable chauffeurs a duma, Okay, so we. We did a Mic line craniotomy. We buy, usually inaccurate conditions. We do even a C one law monogamy, and then the the tumor is being dissected out by the dealer will approach
44:08 the billions not far too long, but I can pause forward if we have pressure of time, or sir, nor do let him out in order to kind of a tomorrow.
44:23 We are proceeding further with removal. We can start seeing the photo to integral to Florida, Now Genre. How's the patient positioned facedown Patient is positioned facedown? Yes. But?
44:43 Definitely didn't want to have to do any me and split. The gimlet is nicely feeling out now,
44:50 and this is the last dual. Coming out
44:55 and backward up is getting free. Now. You can start seeing their credit now
45:02 and the layer of tumor on there, so luckily, except for of Ah,
45:10 we thought was, I didn't where there was. It really no additives. We could get the whole tumor out. You can see a couple of
45:19 places latest some irregularity, but otherwise the whole floor is clean and you got the whole thing removed from all. Begs to Ah. And this is the immediate post -operative C D scan, and this is the
45:38 eye can to find the immediate post -op A motto. But the shorter quite a radical excision. This is the immediate histopathology is one he joined us to yet
45:51 no
45:53 corn, nor did the middle of last Ama was the report, and then as a, as currently practiced, we bought a
46:04 monocle or biology done, this seems to be a non, Ssh Nona. Oh, really, we were able to blue Nds, the human. Ah, no metastasis observed on spying screen
46:23 or brain skin, so how do we proceed further that? But generally me ask you a question of principle. I see everything worked so well in Mumbai, where I think I'm gonna come to moon by my. My medal of stones are not so nice. You know that you're into the pit now go. On the sides and and I have a lot of ridiculously the supreme. It doesn't happen. The friggin multi, Northern or two motors, probably to the group that easier to remove. I. This is the post -op scan. Am I scanned If you would like to see the electorate. Does anybody use sitting position any more anybody, and the manner of pointless, and we've never used it, Note, know. The sitting position is kind of dead, but most greedy Africa, while indications that that isn't his thing, and one asked, The panelists, also does anybody share my opinion that we acquired too aggressive in metal or blood dormers. Then we should be
47:28 Because the oncologist that twisting our arms according to this criteria have not believe more than a juicy season, etc, etc.
47:39 Why I'm in the minority again,
47:44 I think, as long as it comes out easily years, but I wouldn't like to remove parts which are a very either into the brainstem, but I would like to hear the sand decided to award their pursuit
47:58 the seeds in their problem with my oncologist all the time, and I'd remove the credit their medulloblastoma. I, I put my mind that the face of my own college. He then tried to remove as a possible, and then they feed. Oh, lets me see Stadiums is love pizza, and I completely remove the children attend the same problem As you know. I wish I wish the oncologist will find the solution. Then that puts us that we so aggressive. Yeah, I can.
48:34 Yeah, I think I think. Most people would accept that the on metastatic presentation not to be aggressive was the initial German. Right now. I think everybody would accept that so love, and to give neoadjuvant right away writings, instead of gaining this twenty percent at, Please support your face of youth is like I find the mutism to be so tricky. Sometimes you have a tumor that comes out so beautifully. And the patients still have muted the. What are your tricks to avoid routed
49:14 to any? The,
49:18 luckily, this patient came out quite well, but I would like to know water. However hatred would be this patient, told Frank,
49:29 well, I think care we were there for.
49:35 Given steroids and not put the Dvd immediately and put the evening just before the surgery, and tried to renew it and remove it absolutely was first at the beginning of surgery. He really was put. The patient was operated within twenty four hours of presentation to us. Then and then at the same approach these down, I always stand at the left side of the patient, and I look into the aqueduct direction
50:03 and I tried to remove.
50:05 As much as possible, if possible, completely and leave as little as possible, and not try to leave at one point, five millimeters like the oncologists. A limit is at, but when I saw the the two images preoperatively. It looked like almost all the tumor was surrounded by a small
50:30 Css lane. Invented guns. I think this is very importance
50:37 and I will have developed first using the accuser.
50:43 You use accuser. I did not use to serve, because it was coming nicely in suction and my tumor forceps, so I did not that needed the Coisa.
50:55 If I may say that Sandy Sandy worried your trick to avoid muted. I, I don't. I think. If I had that can we, we would all know it, and we would all be doing at Shama, and I think we've all faced this challenge that we do technically the best surgery we can and we still have patients that we have to go through that journey of mutism for so at overtime I might bony, opening, it has actually gotten bigger and sue to try to avoid manipulation of of the Burmese, or or oven. Or even that Sheila Wheeler splitting, I actually tried to allow the cerebellum you to to be able to relax out and and work really read out from the door, and I always do a C one laminectomy so that that direction from coming from that see one area looking up towards the aqueduct is is really ergonomic and open to try to avoid manipulation, and then to have that kind of long, cotton, lloyd, or heightened Patty to lay down and protect. The brainstem and I think over the course of all of our careers, we've seen a shift in thinking about how to treat mental last, Oh man, that the role of an oncology, and and really, you know having this be a medical diseases, Especially at time of recurrence, It is a evolving and emerging at at. The concept that I, I'd love to hear Dr. Kulkarni actually see how in the course of his career, especially with my tailor, and and the whole earth with a group being your immediate partners, How you've seen that change in how you approach surgery and treatment overtime
52:40 so that you may resemble the minutes lived, so maybe oh, but it has to make a comment and then darkish, Okay, good. Yeah, so did does to Sandy's point out. You're clearly. We're we're looking at more individualized treatment now, and and in a more nuanced way I don't know that it's It's radically affected our our surgical approach, though, and due to which loamy was saying about in the, the aggressiveness were still aggressive, rightly or wrongly with surgery, and I'm sort of okay with that, because if I knew that more aggressive surgery led to more mutism, I, I'd be hesitant about it, but as we've just pointed out. We have some surgeries that you think are the easiest most beautiful operations, and you think the kid's going to be fine and they end up with mutism and then others. Where you it? It's a really tough operation and you think all this gets in trouble and and they're fine and so I, I can't correlate the aggressiveness of my resection with their outcome. It, which is frustrating, but it also gives me some cover in feeling okay to be aggressive with these up with the surgeries.
53:41 Thank you, so maybe maybe Rutgers last one. Tell us what it's really justified. If you sent Medulla blow summers were protons. Oh, yes, absolutely, I think it is Am very nice indication, because it can spare a significant amount of tissue, but I wanted to make a comment on the oncology perspective from the Monica point of view, so obviously the larger the tumor, this one point, five square centimeter to be the cutoff shorts twenty thirty percent difference in outcome, but also was spotted by a rather retrospective group. Analysys of seven hundred rotations where they saw, which was the tuna in Mali, currently, which made the greatest impact of surgical resection, and actually, it was the brew for the one that we are talking about, which actually happens to be the largest group, and I could see we have no, this radio genomic sterling, publishing your oncology, and based on characteristic, in that, I, as you can actually predict, to some extent asked what this woman might be more regularly, and the envy and the near -total resection, What's this other section was? Most recluse named in Montgomery, running out of time.
54:49 If yes, sir, we are the time. Okay very last minute.
54:54 If it is looking like a vintage pathway toward the Cp angle. They are the best few months. If you want to leave a little bit. That's okay. Because they're the outcome is exited epic genre. We're gonna wrap up. Right, Yes, Thank you very much loamy Sandy, so do all of having. Rogers, I'm sorry why he could not join us. I'm sure there are some technical issues and thanks Mike. For all that invent. Sir, Thank you very much for we should be leaving. Because we are too made the stage for the next to a session of
55:31 the language named for. And the people that much thank you.
