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Operating in the delicate anatomy of the brain - a privilege and a responsibility

'The child is the priority' was the title of the inaugural lecture by oncological neurosurgeon Eelco Hoving. A lecture that carried weight, as shown by the case Hoving outlined about 8-year-old Max with medulloblastoma type 3. Max's situation shows how difficult this diagnosis is for a child and his family, what we have already achieved with scientific research and where we need to look further to find answers.

Max and his parents had been seeing the GP for months because he was vomiting constantly, says Hoving in his lecture, but the doctor only considered a brain tumor when the position of his eyes changed. A tumor was found on the CT scan. Then an uncertain period begins in which the family and the child live between hope and fear.

Of the 120 children diagnosed with a tumor in the central nervous system per year in the Netherlands, 40 percent die. It is the form of childhood cancer with the highest mortality rate. The development of the brain is central to a child. ‘The brain is intangible, except for a neurosurgeon,’ Hoving jokes. The delicate anatomy of the brain makes surgical removal of a brain tumor very precarious.

Hoving held his lecture 'The child is the priority' on March 5, 2019, in the Academy building following his appointment as Professor of Oncological Neurosurgery in Children at Utrecht University. ‘An asset to Utrecht,’ Frank Miedema, former dean of the Faculty of Medicine, praised him.

Precarious surgery

This is also apparent from Max's story. Although there is no tumor visible on the scans after the operation, an undesirable consequence has happened. Max cannot talk anymore – a phenomenon known as cerebellar mutism syndrome that often occurs as a result of surgery near the cerebellum. The speech often comes back after a few days. ‘It is a privilege to operate in the beautiful anatomy of the brain,’ says Hoving, ‘but also a great responsibility.’

In the past decades, research has shown that it is not always necessary to remove the entire tumor. Scientists recorded the survival of dozens of operated patients. This showed that leaving behind small pieces of tumor tissue provides an equal chance of survival as removal of the entire tumor. The leftovers are destroyed by the treatment that follows after the surgery. With this knowledge, surgeons can avoid sensitive areas to prevent brain damage.

Leftovers remain behind in Max's head too. A heavy treatment course follows. The figures say that Max has a 40 percent chance that the tumor will return – a recurrence. If that is the case, it looks bad for Max. The cancer cells that were not sensitive to the treatment then return which means treatment did not and will not work.

Eelco Hoving
Prof. dr. Eelco Hoving held his speech following his appointment as Professor of Oncological Neurosurgery in Children at Utrecht University. 
Foto: Marco Hofste

Research into treatment strategies

Hoving says that the neuro-oncological research at the Princess Máxima Center – which he coordinates – therefore focuses on more knowledge about possible treatment options. The scientists are looking for alternative ways to get medication to the tumor, trying new compounds on tumor cells in culture, working on a method to make the tumor visible during surgery and investing in neuropsychological research. Hoving is optimistic about the future of child neuro-oncology. ‘We put our energy into creating what can be.’