Neuro-Oncology Training For The Child Neurology Resident
Neuro-Oncology Training For The Child Neurology Resident
Neuro-Oncology Training For The Child Neurology Resident
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J Child Neurol. Author manuscript; available in PMC 2022 January 01.
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Introduction/Background
Cancer is the leading cause of non-accidental death in children. In the United States, about 1
to 2 children per 10,000 are diagnosed with cancer each year.1 The two most common types
are leukemia and central nervous system (CNS) tumors, the latter being the most common
solid tumor and the largest cause of childhood cancer-related mortality.2 Over time, cure
of pediatric cancers has been improving and now approaches 80%.3 With improvements
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in therapeutics and overall survival, both short and long-term neurologic adverse effects
resulting from underlying disease and its treatments are better appreciated.4 Neuro-oncology
is a rapidly evolving subspecialty that involves the management of patients with primary or
metastatic central and peripheral nervous system neoplasms, as well as any other disorders
or complications affecting the nervous system that result either directly or indirectly from
CNS or systemic malignancies and related treatment (Table 1). Neurologists serve a critical
role in the multidisciplinary management of these complex patients. As leaders of the Child
Neurology Society Special Interest Group in Neuro-Oncology, we propose the following
considerations to promote sufficient exposure, minimize knowledge gaps and optimize
training experiences in neuro-oncology for child neurology residency programs.
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Corresponding author: Nicole Ullrich, MD, PhD, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115, Tel:
617-355-2751, Fax: 617-730-0282, [email protected].
Malbari et al. Page 2
the neurology inpatient and outpatient services at a center without a dedicated neuro
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Medical knowledge:
This is a fertile area for residents to practice localization, pathologic investigation and
diagnostic skills for primary and secondary brain and spinal cord tumors as well as treatment
and the early and late neurologic sequelae.
Residents will have the opportunity to develop and maintain compassionate therapeutic
relationships that can help to guide families through diagnosis and treatment. In addition,
they will learn to participate within the multidisciplinary team to improve and optimize care.
Professional issues:
Residents will learn to deal ethically and professionally with patients and families who have
a wide range of understanding of neurologic issues and prognosis and with families who
need additional information to make diagnostic decisions regarding the care of children
whose prognoses may be poor. Training also includes the discussion of complex medical
issues, treatment of disease, supporting children and their families during an acute medical
crisis, and how to support them when there is a terminal diagnosis or a need for end-of-life
care.
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Systems-based practice:
Residents will recognize that the effective diagnosis and treatment of CNS tumors is based
on collaboration with pathology, oncology, neurosurgery, rehabilitation medicine and other
professionals. Increasing the interactions with and understanding of the complex system will
allow residents to be effective advocates for their patients.
nervous system neoplasms, acute and long-term neurologic complications of cancer and
related disorders, side effects of treatments and supportive care measures. Trainees should
be familiar with hereditary disorders that predispose to CNS tumors.5–8 These can be
accomplished at all types of training programs by incorporating a didactic lecture series as
well as expanding the residents’ clinical experiences by providing increased exposure to this
patient population.
Patient care:
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The clinical experience must include practice in both the inpatient and outpatient areas.
These experiences include the management of patients with primary neuro-oncologic
problems and consultations requested by other services (ie oncology, pediatrics, neurology,
ophthalmology, physical medicine and rehabilitation, neurosurgery, radiation oncology and
neuropsychology). The ideal experience is one in which the resident provides supervised
consultations of patients with primary CNS tumors and neurologic complications in children
with systemic cancer, as well as those of stem cell transplant and cellular therapies, although
the latter may not be feasible at all training sites. The neurologic issues can be divided
roughly into two groups: direct cancer related toxicity and indirect neurologic effects of
treatment (Table 1). At presentation, the most common symptoms of CNS tumors include
headache, seizures, changes in vision, ataxia and altered mental status.9 Treatment related
toxicities can occur from surgery, chemotherapy, radiation and immunotherapy and can
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occur at any time during or even many years after completion of therapy. The most common
reasons for inpatient neurologic consultation in pediatric patients with cancer are altered
mental status, seizures, pain and headache management and peripheral nervous system
issues (sensory and motor).9 The spectrum of neurologic symptoms also includes diagnosis
and treatment of toxic, nutritional or metabolic encephalopathy, chimeric antigen receptor
T cell (CAR-T) therapy, CNS and systemic infections, cerebrovascular disease, increased
intracranial pressure and paraneoplastic disease. As many novel therapies have only recently
been used in the pediatric setting, the toxicities in children are not well known.
them molecularly targeted agents and immunotherapy. This will include participation in
interdisciplinary management of patients with neuro-oncologic disorders. When feasible,
the resident will gain exposure to clinical trial development and its relevance to the use of
targeted and novel therapeutics.
Survivors of childhood cancer should be followed into adulthood and monitored for
multisystemic effects of treatment. Long term neurologic sequelae include, but are not
limited to, difficulties with cognitive function (in particular, difficulties with memory,
processing speed and attention), hearing loss, visual field deficits, motor deficits,
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Conclusions
The field of Neuro-oncology is a diverse and complex one. Neurologists serve a critical
role in the multidisciplinary management of these complex patients, and it is important to
optimize their specialized training to care for this population whether as a neuro-oncology
subspecialist or general child neurologist. Training programs should use the opportunity
to give residents exposure to these patients following a core content and common set of
training experiences; potential approaches could be as described above. Neurology residents
are often the first subspecialist a family may meet after presenting to the emergency room
with an undiagnosed brain or spinal cord tumor tumor. Therefore, astute clinical acumen
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References
1. Ullrich NJ. P SL. Neurologic Complications of Pediatric Systemic Cancer. In: Schiff DAI, Wen P
(eds) ed. Cancer Neurology in Clinical Practice. Totowa, NJ: Springer, Cham; 2018:607–619.
2. Dang M, Phillips PC. Pediatric Brain Tumors. Continuum (Minneapolis, Minn.). 2017; 23(6,
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Neuro-oncology):1727–1757.
3. Shapiro CL. Cancer Survivorship. The New England journal of medicine. 2018; 379(25):2438–
2450. [PubMed: 30575480]
4. Waber DP, Pomeroy SL. Introduction: survivors of childhood cancer: the new face of developmental
disabilities. Dev Disabil Res Rev. 2008; 14(3):183–184. [PubMed: 18924153]
5. Ranger AM, Patel YK, Chaudhary N, Anantha RV. Familial syndromes associated with intracranial
tumours: a review. Child’s nervous system : ChNS : official journal of the International Society for
Pediatric Neurosurgery. 2014; 30(1):47–64.
6. Ullrich NJ. Neurocutaneous Syndromes and Brain Tumors. J Child Neurol. 2016; 31(12):1399–
1411. [PubMed: 26459515]
7. Hottinger AF, Khakoo Y. Neurooncology of familial cancer syndromes. J Child Neurol. 2009;
24(12):1526–1535. [PubMed: 19955345]
8. Ullrich NJ. Inherited disorders as a risk factor and predictor of neurodevelopmental outcome in
pediatric cancer. Dev Disabil Res Rev. 2008; 14(3):229–237. [PubMed: 18924162]
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9. Armstrong C, Sun LR. Neurological complications of pediatric cancer. Cancer Metastasis Rev.
2020.
Table 1.
Seizure/Epilepsy Seizure/Epilepsy
Headache Headache
Visual acuity/visual fields changes Drug specific toxicities (ie retinal changes)
Table 2.
1. Residents will demonstrate an understanding of the epidemiology of childhood CNS tumors and prognosis of the subtypes
2. Residents will understand the typical presenting signs and symptoms of a primary or secondary CNS tumor
3. Residents will obtain and document the history and physical examination of a child/adolescent with a primary or secondary CNS tumor,
including neuroimaging and pathology
4. Residents will demonstrate an understanding of the World Health Organization classification’s system, histopathology of CNS tumors,
and will participate in neuropathologic review
6. Residents will learn to distinguish CNS tumors from potential mimickers such as demyelinating disease, vascular malformations and
infections
7. Residents will recognize the findings and associated tumor-related complications of neurocutaneous disorders, specifically
neurofibromatosis type 1, neurofibromatosis type 2, tuberous sclerosis complex, von Hippel-Lindau disease
8. Residents will attend outpatient neuro-oncology clinic and neurocutaneous clinic, if feasible. Other options include attending general
neurology clinic, genetics clinic, and neurosurgery clinic
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9. Residents will provide consultation for neurologic issues, including seizures, raised intracranial pressure, headache, infection, peripheral
neuropathy, and vasculopathy
10. Residents will use a developmental framework to evaluation of children treated for a primary or secondary CNS tumor and refer when
appropriate for hearing assessment, visual acuity/visual field testing, neuroendocrine testing, neurocognitive assessment, school-based
assessments
11. Residents will learn to diagnose and manage acute and long-term neurologic complications of the tumor and treatment
12. Residents will gain competency in identifying patient populations at risk of specific long-term complications based on treatment
intervention and age of treatment
13. Residents will develop an understanding of issues related to families in crisis and end of life
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