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Fighting a Brain Tumor with Technology and Compassion Above: Trevor Tollefsen and younger brother Tannor (right) challenge each other to computer games as Trevor recovers from follow-up surgery in 2004. About a month before his seventh birthday, Trevor Tollefsen started falling down. At first, Val Saio and Trisha Tollefsen thought their active 6-year-old was just being clumsy. Then one day Trisha's parents also noticed their grandson's behavior and suggested that he go to Kapi'olani's emergency room. "And so we took him," says Saio. "The emergency room (ER) doctors did equilibrium tests, like put your finger out and touch your nose. They were concerned and did a CT scan. Then they asked us to come into the conference room. On the board was a drawing of a head and a little ball where the brain is. They said there was a tumor there. This was on a Saturday. They said they needed to go in right away to get the tumor out. At that point they didn't know if it was cancerous or not, and it was decided to do the surgery on Monday." Four days before his seventh birthday, Trevor was admitted to Kapi'olani for an operation that would reveal he had a cancerous brain tumor. The condition is known as medulloblastoma, a malignant tumor of the central nervous system in the cerebellum, the part of the brain controlling balance and coordination in the trunk of the body. This type of tumor is located close to the brain stem, which is responsible for swallowing, breathing, eating, and other essential skills of daily life. The two brothers today, Tannor, 8, and Trevor, 13 (right). Almost six years later, Trevor is now in the eighth grade, loves to play computer games, and is cancer-free. But the road to recovery has not been easy. Following the operation, he had to learn to walk, talk, and eat again. Trevor has regained about 90 percent of function on the right side of his body. "These are all things we were told might happen," Saio says. "Although he has more medical challenges ahead, there is also a sense of power in him today. He can deal with pain. And he is more considerate of others when they're in pain or sick." Saio says pediatric neurosurgeon Michon Morita, M.D. has immensely helped the family navigate the medical challenges. "We didn't know what to think at first. We heard from the doctors and nurses in the ER that Dr. Morita was the best neurosurgeon around. He made us feel really comfortable. He explained how he was going to open up the skull to get into the brain and take out the tumor. When they took Trevor into the operating room, his mom and I walked down the long hallway to go to our car. It was devastating for Trish. We walked outside and she fainted. Those were the longest hours of our lives -- waiting for Trevor to get out of surgery." When Dr. Morita told the family he was able to clean out the tumor, "I offered to wash his car for the rest of his life," Saio says. "I even asked him where his car was. And the offer still stands!" The goals for the surgery were to biopsy the tumor to confirm whether it was malignant, remove enough of its mass to unblock brain fluid pathways, and then try to remove it entirely to improve the curative effects of later chemotherapy and radiation treatments. Michon Morita, M.D. The biggest challenge was to remove the tumor and its blood supply without damaging adjacent structures, such as the brain stem, on which the tumor sat. Brain stem damage can mean that a patient may lead a severely disabled life, including not being able to walk again and needing a tracheotomy and feeding tube. "Trevor's case is an example where modern technology has really improved people's lives," Dr. Morita says. "Fifty years ago, a medulloblastoma was 100 percent fatal. The cure rate is now better than 50 percent, meaning that more than half of children with this kind of tumor will never have a recurrence." Dr. Morita was able to remove the entire tumor -- bigger than a golf ball but smaller than a tomato -- then confirm its removal with a postoperative MRI scan. "The treatment, in general, is dependent on these kinds of good imaging studies," he says. "The fact that MRI and CT scanners are readily available here helps to diagnose cases early, when they are still curable." Another key tool is the operating microscope. Dr. Morita explains that since it was developed in the 1970s, its gradual dissemination and application for a wide range of procedures has revolutionized neurosurgery. Wielding the latest technological tools, however, is only one of the challenges in pediatric neurosurgery. The human element is another important part. "I went into the field because of professors who were excellent role models for how to perform the best technical surgery and at the same time be very compassionate -- putting the patient and their families first," Morita says. Telling a family that their child has a malignant brain tumor is a heartbreaking experience for the physician as well as the parents. "Doctors are human beings, and there is a natural tendency to want to create some emotional distance. If all of us lived and died with every patient, we couldn't come to work. But my role models in medical school also showed how to maintain compassion for the patients and families. They inspired me." Trevor's family is grateful for the personal and compassionate care they received from Dr. Morita. "His encouraging words, his demeanor, how he carries himself, helped us through this process," Saio says. "We will be forever grateful to him. We put everything in God's hands, and God provided us with Dr. Michon Morita." When Precision Counts Daniel Donovan, M.D. When a pediatric neurosurgeon operates on the brain of a child to remove a tumor, for example, the brain demonstrates a natural ability to regain function. In recent years, surgeons have been giving nature a boost with the use of increasingly sophisticated techniques to make sure they are removing just the tumor. "Determining where the tumor stops and where the brain starts is half the battle," says Daniel Donovan, M.D., a pediatric neurosurgeon at Kapi'olani. Of the approximate 3,000 neurosurgeons in the U.S., only about 200 specialize in pediatrics. Dr. Donovan is one of two pediatric neurosurgeons in the state. "I tell parents the great thing about kids is that they don't know they should be sick," Dr. Donovan says. "They just want to get back to normal so they keep trying. Children have greater plasticity in the brain than adults, meaning that they can grow new nerve cells on a limited basis and have a better ability to form new pathways around an injured area. With time, therapy, and perseverance, they are often able to improve." One surgical advance that he expects in the not-too-distant future is the ability to inject dye into the vein of a patient. Tumor cells will take up the dye and clearly define the boundaries of the tumor, greatly improving the surgeon's precision. A new technique that has already debuted in the operating room is real-time surgical navigation. With the assistance of a three-dimensional image produced by MRI, the surgeon can accurately determine the location in the brain and see what's going on, allowing for quicker and safer interventions. Another advance is intraoperative neuromonitoring. It allows the surgical team to monitor, in real time, what is happening in the sensory and motor pathways and to observe the functioning of the cranial nerves to help reduce the possibility of permanent injury. "In one recent case, we were operating on an 8-year-old boy to remove a tumor from the brain stem," Dr. Donovan says. "As I was shaving down the tumor, the monitoring system indicated an impact to the nerve to the patient's tongue. So I stopped at that point. This kind of technology is immensely helpful for removing a tumor from the brain stem, which is a critical area. It allows for far greater precision without permanent injury to the brain and a subsequent loss of function."