When Precision Counts


    Empty bed with teddy bear waiting for patient
    A cuddly teddy bear patiently awaits the return of its owner, who is
    undergoing an operation in the St. Jude surgical suite.


    St. Jude surgeons are world renowned for innovative approaches that save the lives of children with cancer and other diseases.


    Mick’el Wilson was 15 months old when his grandmother noticed that he had blood in his diaper and a firm, bloated belly. After examining the toddler, doctors discovered that Mick’el had advanced bilateral Wilms tumor, a cancer of both kidneys.

    “I was shocked. Scared,” says Mick’el’s father, Tommie.

    When chemotherapy and radiation failed to shrink the tumors, doctors at their local hospital announced there was nothing more they could do.

    “I didn’t want to sit on the front row at a funeral,” recalls Mick’el’s mom, Tameka.

    Andrew Davidoff, MD

     “Because of our extensive experience surgically managing children with cancer, I feel we have a more aggressive willingness to perform complex surgical procedures rather than saying they can’t be done,” says Andrew Davidoff, MD, St. Jude Surgery chair. 

    The family requested a second opinion, and within days Mick’el was under the skilled care of Andrew Davidoff, MD, Surgery chair at St. Jude Children’s Research Hospital. The renowned surgeon is an expert in bilateral Wilms tumor.

    Davidoff and his colleagues perform about 1,600 operations each year to diagnose and treat cancer and other life-threatening diseases. They partner with St. Jude oncologists, radiation therapists, pathologists, anesthesiologists, nurses and basic scientists to plan and deliver the best treatment for children with solid tumors. Their specific expertise includes complex surgical procedures to treat kidney, neuroendocrine, eye and bone cancers.

    “In addition to the technical aspects of these procedures, understanding what is appropriate for each patient is even more important in children with cancer,” Davidoff says. “It means knowing when surgery is appropriate and when it is not. If surgery is appropriate, is the best timing before or after chemotherapy? How aggressive or conservative should we be with the surgery, and is surgery the only way to cure the cancer?”


    Preserving kidney function

    Bilateral Wilms tumor occurs in only 30 U.S. children each year. Nearly 20 percent of those children have their surgery performed at St. Jude.

    “Because of our extensive experience surgically managing children with cancer, I feel we have a more aggressive willingness to perform complex surgical procedures rather than saying they can’t be done,” Davidoff says. “While most other surgeons would remove one or even both kidneys, our approach is to save as much normal kidney on both sides when possible. That’s where experience counts.”

     When doctors at another hospital ran out of options to treat Mick’el Wilson’s aggressive kidney tumor, his mom obtained a referral to St. Jude. “I didn’t want to sit on the front row at a funeral,” she says. Andrew Davidoff, MD, surgically removed a softball-sized mass from Mick’el’s left kidney and another the size of a tennis ball from his right kidney. Today, Mick’el is a bright and energetic 9-year-old with normal kidney function. 

    Not only does this approach, called nephron-sparing surgery, maintain excellent survival rates, but it also helps children with this rare cancer avoid kidney failure, dialysis and transplantation. The No. 1 goal is always cure, but improving quality of life is a priority as well.

    Davidoff surgically removed a softball-sized mass from Mick’el’s left kidney and another the size of a tennis ball from his right kidney. Today, the active 9-year-old is five years cancer-free with normal kidney function.

    Davidoff has performed more than 50 such surgeries and publishes the results so the medical community can learn from the St. Jude model. Early results from cases like Mick’el’s show promise not only for cures but for avoiding complications after surgery.


    Experience and expertise

    Neuroblastoma is the most common solid tumor in children next to brain tumors and accounts for 7 to 10 percent of all childhood cancers in the U.S. By the time neuroblastoma is diagnosed, the cancer has usually spread to other parts of the body. Outcomes for the disease vary widely.

    “In some children, the disease can be very non-aggressive,” Davidoff says. “We remove the tumor with surgery, and the children are cured. Others with advanced disease may require surgery, chemotherapy, radiation and bone marrow transplantation and still the survival rate is only 30 percent.”

    When venturing into this complex territory, St. Jude surgeons meticulously separate the tumor from delicate blood vessels that nourish the kidneys, liver, intestines and other structures. The surgery requires precision and skilled hands to prevent damage to vital organs.

    “It’s a challenging and tedious surgery in which we have a lot of experience and expertise,” Davidoff says.

    St. Jude surgeons also team with oncologists to incorporate new surgical techniques and approaches into clinical trials for neuroblastoma.


    Improving care for children with eye cancer

    The St. Jude retinoblastoma treatment team is one of the most recognized in the country and is a textbook example of how research in St. Jude laboratories improves outcomes for patients in the clinic.

    “Our basic scientists are able to develop preclinical models and identify pathways we can exploit with novel targeted therapies that we hope will reduce the toxicity of treatment, preserve vision and make patients’ lives better,” says Matthew Wilson, MD, ocular oncologist. He and Rachel Brennan, MD, a pediatric oncologist and retinoblastoma expert, are part of the team that treats children with retinoblastoma.

    “The ability to examine and observe the eye and understand the size and number of tumors in the eye is just as important as treatment,” Wilson says. “With aggressive surveillance and careful examination of the eye, we’re able to judiciously apply the laser and cryotherapy to treat tumors, save the eye and preserve as much vision as possible.”

    Built for children

    St. Jude will soon have a new operating room and surgery complex that will double the size of the current space. The new facility is designed to provide optimal care to patients and families who look to St. Jude for treatment and to further the hospital’s commitment to education and training.

    The facility will include:

    • Integrated Operating Rooms with imaging and pathology services to encourage real-time interaction during surgery
    • Adjacent Intensive Care Unit (ICU) to reduce transport time for critical patients for surgery
    • Spacious, connecting parent rooms in the ICU
    • High-tech observation rooms to train surgeons and fellows from around the globe, which will help improve outcomes for children worldwide. Nearly every new pediatric surgeon in the U.S. and Canada participates in training at St. Jude.
    • Air-filtration technology to maintain a germ-free environment
    • State-of-the art technology to better assess how cancer affects the eye in children with retinoblastoma and other diseases that secondarily affect the eye
    • A modular design to incorporate the latest surgical equipment as technology advances

    In addition to the retinoblastoma group, patients receive support from an an eye clinic and many other services both during and after therapy. Because of this teamwork, the hospital’s investigators recently achieved a 100 percent five-year survival rate for children with retinoblastoma in one or both eyes at diagnosis.

    Researchers continue to create new treatment options for patients whose cancer has spread beyond the eye, as well as develop new routes for delivering drugs while avoiding radiation and minimizing long-term effects of therapy.


    Saving lives and limbs

    When Bhaskar Rao, MD, joined St. Jude in the 1980s, amputation was inevitable for children facing surgery for osteosarcoma and Ewing sarcoma, the most common bone cancers in children. St. Jude was one of the few centers that offered an alternative—saving their limbs as well as their lives.

    Today, the offer still stands as St. Jude surgeons help children maintain function of their arms and legs.

    “Approximately 90 to 95 percent of our patients with bone tumors will have some sort of limb salvage,” says Rao, a pioneer in limb-sparing procedures. “Our approach is chemotherapy to shrink the tumor to an operable size; then we perform the limb-sparing surgery.”

    Rao and orthopedist Michael Neel, MD, remove the diseased bone and replace it with a custom-made, expandable prosthesis. Because bone cancer primarily affects adolescents, growing patients return to St. Jude for outpatient procedures to lengthen the prosthesis and to maintain the same limb length on either side. After surgery, children undergo extensive rehabilitation and support care to help them maintain normal function.

    The local recurrence rate for St. Jude patients who have undergone surgery for Ewing sarcoma is below the 10 percent national average. Rao attributes the outcome to experience, supportive care and unmatched follow-up care.

    “At some centers, the surgeon operates on patients and sends them back to the oncologist and then the surgeon never sees the patient again until they encounter complications,” Rao says. “Here, we provide continuity of care for patients until they are 18 years old or until 10 years after diagnosis, whichever comes later.”

    St. Jude surgeon

    The surgery team at St. Jude performs about 1,600 operations each year to diagnose and treat cancer and other life-threatening diseases.

    Patients treated at St. Jude are eligible to receive comprehensive screenings and health assessments related to their cancer—for a lifetime.

    “This level of follow-up care is not available in many places,” adds Rao, who also serves as Surgery director for the St. Jude International Outreach Program.

    Looking ahead, surgeons are evaluating and exploring new limb-sparing techniques to improve survival and help children live normal lives after treatment.


    Minimally invasive techniques

    Minimally invasive surgery is an alternative approach to diagnose and treat solid tumors, depending on the size and location of the tumors. John Sandoval, MD, uses the tools of the trade to view and investigate tumors in the chest and abdomen. He makes small incisions to perform biopsies, sample lymph nodes and remove abdominal tumors and lung lesions.

    “We are staying mainstream and contemporary and attempting to push the envelope in laparoscopic surgery in children with solid tumors,” Sandoval says.

    There are advantages for patients who qualify for the technique: less pain, quicker recovery, a speedy return to therapy and fewer long-term functional complications.

    In 93 percent of procedures performed between 1994 and 2004, patients were able to receive an accurate diagnosis relying solely on the minimally invasive techniques performed at St. Jude. A follow-up study will be published this year to identify improvements and trends from the past decade. Sandoval anticipates the success rate to rise to nearly 100 percent.

    Minimally invasive surgery is relatively new to pediatric oncology when compared to traditional surgery. Sandoval and his colleagues are helping to establish consensus guidelines for the appropriate use of these techniques in children with cancer. This provides the ideal opportunity for St. Jude to help shape the future of minimally invasive surgery in pediatric oncology.


    Abridged from Promise, Spring 2014

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