Innovations Transforming Childhood Cancer Surgery with Dr. Timothy Lautz

Childhood cancer surgery requires far more than removing a tumor. Surgeons are balancing effective cancer treatment with protecting a child’s growth, organ function, fertility, and long-term quality of life. In this episode, Dr. Timothy Lautz, Director of Surgical Oncology at Lurie Children’s, discusses how advances in pediatric cancer surgery are improving outcomes for children. He explains how his team uses innovative techniques, including fluorescent agents that help surgeons identify tumors during surgery, kidney-sparing procedures that preserve organ function, and collaborative, multidisciplinary care that supports children throughout treatment and survivorship.

Show Notes

• Lautz’s path to pediatric surgical oncology grew from a desire to care for children, ultimately finding that surgery offered the most immediate and tangible way to change the course of a family’s life during a cancer diagnosis.
• Patients at Lurie Children’s are cared for by a multidisciplinary team, where surgeons, medical oncologists, radiation oncologists, and other specialists work together to build a unified treatment plan centered on both cure and long-term well-being.
• Surgery remains a critical part of treatment for many childhood solid tumors, whether removing the primary cancer, treating disease that has spread, or carefully determining when surgery can be combined with chemotherapy or radiation for the best possible outcome.
• Lautz’s team is leading efforts to use fluorescent-guided imaging agents that make hidden tumor cells light up, helping surgeons find cancer nodules while avoiding larger, more invasive procedures.
• Innovation in pediatric oncology surgery is increasingly focused on preservation of fertility, organ function, and healthy tissue whenever possible so children can thrive long after treatment ends.
• Lautz shares how he collaborates with pediatric urologists to perform kidney-sparing procedures for select children with kidney tumors. These advanced surgeries aim to remove cancer while preserving as much healthy kidney tissue as possible, to keep more normal kidney function without compromising cancer care.
• Many clinical trials and national collaborations are underway at Lurie Children’s to make the future of treatment and surgery less invasive and more targeted, through robotics, new dyes, and precision-based treatment strategies.

Transcript

[00:00:00] Erin Spain: This is "Precision Perspectives on Children's Surgery" from Ann & Robert H. Lurie Children's Hospital of Chicago. I'm your host, Erin Spain. On this podcast, we introduce you to surgeons at one of the country's most renowned children's hospitals to find out how they are transforming pediatric medicine. Surgery is an important part of treatment for many childhood cancers, but removing tumors in growing children requires skilled precision, and protecting a child's long-term health and development is always top of mind. Our guest today, Dr. Timothy Lautz, is director of surgical oncology at Lurie Children's and a nationally recognized expert in the surgical treatment of pediatric solid tumors. We welcome him to the show today to talk about how his team treats complex childhood cancers, new technologies that light up tumors during surgery, and how collaboration across specialties is helping to preserve organ function and improve outcomes for children. Welcome to the show, Tim.

[00:01:06] Dr. Timothy Lautz: Thank you, Erin. It's wonderful to be here.

[00:01:07] Erin Spain: Some listeners may remember that we had you on the show a few years ago.

[00:01:11] Dr. Timothy Lautz: Yep.

[00:01:11] Erin Spain: We were talking about robotic surgery then in pediatrics, so let's refresh people a little bit about you. I'm curious what led you to pediatric surgery and what drives you to continue seeking out the latest advances in pediatric surgical oncology?

[00:01:25] Dr. Timothy Lautz: I actually came to pediatrics before I came to pediatric surgery. I come from a family of pediatricians and knew I was interested in caring for children, and I actually knew that I was interested in oncology as a medical student. But then I rotated on my surgical rotation and realized that the job as a pediatric surgeon allowed you to have a really tangible, immediate impact on these patients and their families, so it became the perfect marriage of these different interests.

[00:01:50] Erin Spain: Let's talk about when families come to Lurie Children's and they have a child facing a cancer diagnosis; this is often the worst time in these families' lives. What do you want them to know about the care and expertise available here?

[00:02:03] Dr. Timothy Lautz: What's wonderful about Lurie Children's and our cancer program is it is truly multidisciplinary. This is a team, and the whole team is here for you and your child through the entire process. It's a big team including the medical oncologist, the surgical oncologist, radiation oncologist and many others. But that team is working closely together. We're meeting on a regular basis, discussing your child holistically, and we are all on the same page about how to provide the best care. The other aspect of it is those members of the team are national and international experts in what they do. They participate in the Children's Oncology Group, which is the thought leader that brings together experts across the country to do clinical trials. It's those clinical trials that have really advanced the care of children over the past decades, and they're involved in multiple other venues where they are at the forefront of care. As an example, I am currently the chair of the American Pediatric Surgical Association Cancer Committee, where our group is involved in providing education to other pediatric surgeons around the country about the most modern, up-to-date treatment for these patients. I'm involved in several of the committees in the Children's Oncology Group, including helping to lead some of the studies that are underway. I'm even involved in international collaborations, including some that bring together experts from Europe and North America to combine our data and really take the best of all the trials we've done all over the world to understand how we can advance the care of children.

[00:03:34] Erin Spain: The field of pediatric surgery has really evolved over the past couple of decades from the time when you started out as a trainee. Tell me about this.

[00:03:42] Dr. Timothy Lautz: In the past, pediatric surgeons were true generalists doing everything, and that worked great for a long time. But medicine has become more complex, and with that, we as surgeons have had to evolve, leading to further subspecialization. That is really one of the beauties and advantages of the care we can offer at Lurie Children's: By being a destination children's hospital, we have surgical experts in all areas of pediatric surgery. It really is the difference between having a generalist who takes care of oncology one day, colorectal surgery the next day, and maybe a chest wall condition the following day at some of the community hospitals, compared to here at Lurie Children's, where each of my partners is uniquely focused on one or two specialty areas of surgical care. This allows people to really elevate the entire group because I have partners who are—just as I'm deeply involved nationally and internationally in oncology care—just as involved in the care of complex congenital colorectal conditions or fetal conditions that require in utero procedures in every other area of surgical specialization. We all elevate the group, but we also rely on each other. We know which areas we're experts in, and we know which areas our partners bring a different, unique expertise. We work together as a group to ensure that any child who comes to the Department of Surgery at Lurie Children's is going to get a true expert.

[00:05:10] Erin Spain: I'm curious: How often are you able to offer something brand new to a patient that's just come across your desk, and it's something that might work for this individual? Does that happen very often?

[00:05:21] Dr. Timothy Lautz: It does. Clinical trials are a hard thing for families to understand at first, but this is what allows our care to keep advancing. This is really what has made pediatric cancer care so unique over the years—the fact that we are always pushing the envelope and enrolling patients on new studies to try to get better and better. That includes trials for new chemotherapy regimens that we conduct through the Children's Oncology Group. We're actually doing a study right now that is looking at two different surgical techniques for removing cancer nodules in the lung to see which one is better. Then we're doing other trials just here at Lurie Children's, where we look at new agents that can light up tumors to help us see them. We're doing trials where we're collaborating with colleagues from St. Jude Children's Research Hospital to look at the ability to locate the lymph nodes where kidney tumors drain so that we can, instead of just taking out all the lymph nodes in the area, only take out the ones most likely to contain tumor cells. With every patient that comes in the door, we're asking if there is something new, something better that we can do that will help both the child we're caring for and all future children facing these diseases.

[00:06:29] Erin Spain: When families are coming here for the first time, I know you all work together as a team, but they're learning about the oncology group and the surgery group. Can you talk a little bit about specifically the role surgery plays in treating childhood cancers?

[00:06:42] Dr. Timothy Lautz: We always say that for most tumors, the treatment is multimodal, which means that in many cases successful treatment requires the care of multiple specialists. It will require the care of the oncologist and the surgeon. When we talk about the primary tumor, the spot where the tumor arose, it's really important that we treat that, and surgery is the mainstay of treatment for the primary tumor. In some cases it's surgery alone. In other cases it's surgery plus radiation. In cases where we can't safely remove the tumor, we can treat them with radiation alone. It's those careful discussions we have in our tumor boards with all the specialists involved where we decide exactly which modality or modalities are best for treating the primary tumor. Surgery also plays a role sometimes for removing tumors that have spread. One of the most common locations where tumors can spread is to the lung. For many of those tumors, doing surgery to remove all the spots in the lung is really important. That's actually the subject of that clinical trial that I'm leading on a national level right now to understand whether it's just as good to do that with a camera and small incision as opposed to the old-fashioned way of making a big incision between the ribs.

[00:07:57] Erin Spain: You said this is fairly common that this happens—the tumor goes from another part of the body and spreads to the lungs?

[00:08:01] Dr. Timothy Lautz: Yeah, it depends on the tumor type. For some tumors like the bone tumor called osteosarcoma, this is pretty common for it to spread to the lungs. For other tumors, it's more rare, but it is something that we treat very regularly.

[00:08:13] Erin Spain: And so what makes these surgeries particularly challenging when the cancer spreads to the lungs?

[00:08:18] Dr. Timothy Lautz: It's finding the right balance. If we're going to operate on the lungs, we need to remove all the nodules. But we want to do that as minimally invasively as possible. When we make a bigger incision, we can use our hands to feel all the surfaces of the lungs to find even very small nodules—sometimes down as small as a grain or two of sand. But when we're not able to feel with our own hands, we need other tools to help us find those nodules. That's where some of the innovative things we're doing can help us find those small nodules without the big incision. That includes fluorescent dyes that target the tumor cells and make them light up with a special camera. We are leading the charge on this both nationally and internationally.

[00:09:07] Erin Spain: So was Lurie Children's the first pediatric hospital to use this fluorescent agent?

[00:09:11] Dr. Timothy Lautz: There are a couple of different fluorescent agents. There's an old fluorescent agent that's been around for about 50 years and was adapted for this purpose, and we were not the first to use that, but that agent has a lot of limitations. It's very hit-or-miss on whether it will light up the nodule. We were the first institution to study a new drug called Cytalux, which is much more specific for targeting cancer cells. We're currently leading a clinical trial of this medication and approach to lung surgery, and we look forward to reporting the results.

[00:09:45] Erin Spain: So how many surgeries have you done so far using this new agent?

[00:09:49] Dr. Timothy Lautz: With the new agent, we've done about 10 operations, but we've done many more with the old agent.

[00:09:53] Erin Spain: A consideration that families might not think about right away is how cancer treatment could affect a child's fertility later in life. How do you and your colleagues think about fertility preservation when planning this treatment plan for children and adolescents?

[00:10:07] Dr. Timothy Lautz: This is such an important question. In the past, we used to think that was a future problem. But what we know is when you talk to patients years later, thinking back about these long-term late effects is really important. The great news is we've become so good at treating childhood cancer that most patients will be long-term survivors, and so this really matters. Many, but not all, of the medications that we use to treat cancer can impact long-term fertility, and we're really good at doing a risk assessment. We know based on what treatments the child will get what the impact on their long-term fertility is likely to be. We have an amazing team led by one of my partners who has focused her career on this specific problem. I'm also very involved in that process, and we're able to provide families with this comprehensive risk assessment. If the child will be at higher risk of future infertility, then we can offer options for fertility preservation for children of all ages and pubertal developments. In the past, we always had options for patients who are post-pubertal—they could do things like sperm banking or egg harvesting. But now we have newer options that can even offer hope for those who are pre-pubertal at the time of their treatments.

[00:11:27] Erin Spain: That sounds so futuristic; how does that work?

[00:11:30] Dr. Timothy Lautz: How it works is instead of preserving a sperm or an egg, we are preserving the tissue that will produce those in the future. So we're preserving ovarian tissue or testicular tissue that can then in the future be reimplanted or manipulated in a test tube to produce those eggs and sperm in the future.

[00:11:49] Erin Spain: So have we actually gotten that far yet where some of these patients now, they're in their 20s or 30s and they want to start families, and you've been able to use that tissue? Have we gotten there yet?

[00:11:58] Dr. Timothy Lautz: So the science is there with the ovarian tissue, with the testicular tissue. It is still in the realm of discovery. There have been no human births yet from pre pubertal testicular tissue, but there have been primate births using this technology, so we know it's going to work in the future.

[00:12:14] Erin Spain: Another exciting procedure I want to talk about that has to do with preserving healthy tissue is a recent kidney-sparing surgery that you worked on with one of your colleagues, Lurie Children's urologist Dr. Ed Gong. You were able to remove just part of a damaged kidney and help it to remain functioning in the body. Is that right?

[00:12:32] Dr. Timothy Lautz: That's right. This is called a partial nephrectomy, and it's a well-defined, well-established operation for many adult tumors. But for pediatric tumors, there have been few opportunities to use this technology, and we're really helping to push the envelope on using this kidney-preserving approach. For many children who develop tumors in their kidney, the tumor is very large and takes up the entire kidney, so they will need to have the entire kidney removed. But there is a population of children with kidney tumors where we can adapt our approach to provide this nephron-sparing or kidney-sparing surgery. The first example is children in their teenage years who have the type of tumors more common in adults. These types of tumors tend to be a little bit smaller and are really approachable by these kidney-sparing surgeries. We've talked in the past about robotic surgery, and this actually brings those two together because for those smaller tumors in the kidney, we can do a robotic approach to remove the tumor with a small cuff of normal kidney around it and preserve the majority of that kidney, which is wonderful for future function. But it's not just for those teenagers with adult-type tumors; we're actually finding more opportunities to use this for younger children with the tumors that occur in that age group, usually something called a Wilms tumor. Those Wilms tumors often aren't picked up until they're so large that they do require the complete kidney to be removed. Some of them occur in children who have predisposition syndromes or genetic conditions that we know make them at risk for developing these tumors. Those kids are being screened with ultrasounds, which allows us to find these tumors at an earlier point in their growth, when they're still small enough that we can often just remove part of the kidney. Even if they've gotten bigger, we can actually treat with chemotherapy to shrink them down. Then once they're smaller, we can do surgery to preserve some of the kidney. This is so important, particularly for the children who have these predisposition syndromes, because we know they are at risk for additional tumors in their kidney, and we want to save every last bit of normal kidney. By having this proactive approach to doing everything possible to preserve the kidney, we can ensure the likelihood of long-term kidney health is optimized. It is definitely a more involved operation, but the benefits of it are immense. The collaboration between me, as the pediatric surgical oncologist focused on tumor surgery, and Dr. Gong, the urologist focused on kidney health, allows us to use that teamwork to ensure great outcomes with this more complex surgical approach.

[00:15:50] Erin Spain: So you two are side by side together in the OR during this procedure?

[00:15:54] Dr. Timothy Lautz: Yeah, we are. He and I work great together and we really think alike and act alike and operate alike. We work hand in hand for the entire procedure.

[00:16:02] Erin Spain: Was Lurie Children's one of the first pediatric children's hospitals to offer this procedure?

[00:16:07] Dr. Timothy Lautz: It's been slowly adapted at a small subset of high-volume quaternary care children's hospitals. We've learned over the past decade or so the importance of this, particularly for patients who have these predisposition syndromes. We've been at the forefront of offering this approach. But where we've really been at the forefront in pediatrics is this robotic partial nephrectomy approach for the teenagers who have tumors that are more common in adults.

[00:16:35] Erin Spain: So you talk about this partnership with urology, but there's also this partnership with the families, because if this is one of the first times someone has done a surgery like this, that can be a little scary, maybe, for parents and the kids. How do you talk to them about this and reassure them that this is something that is going to be beneficial, that they should try?

[00:16:53] Dr. Timothy Lautz: Yeah, every surgical operation involves a really comprehensive discussion with the families, including the risks and benefits of a standard approach and the risk and benefits if we're doing something newer. And we of course talk through that in great detail. The most important thing before we offer something new to a family is making sure that we know that we have the expertise to do it safely and that the data sometimes sort of extrapolated from what we know in adult patients shows that this is safe and is effective. So in the instance of the teenagers, we know from vast adult experience that for the type of tumors that we see there, the robotic surgery is safe and effective. And what's interesting is us as surgeons, we actually train in adult patients before we become pediatric specialists. So Dr. Gong and the urologic surgery world and me in the general surgery world had of course done these types of operations on adults prior to becoming pediatric specialists. So we have the experience with these types of procedures, and it's really just about innovating them into a smaller patient population.

[00:17:54] Erin Spain: I want to talk about more of these innovations, because you co-lead the PSORC research group, which focuses on developing new surgical techniques and clinical trials in pediatric surgery. What else is on the horizon right now through that group or other groups that you're involved with? What kind of innovations are you most excited about that are forthcoming?

[00:18:13] Dr. Timothy Lautz: We're really interested in this fluorescent-guided surgery space. The idea is using special targeted dyes to light up tumors so that we can get a negative margin when we remove the primary tumor, which means making sure that we have a healthy cuff of normal tissue around the tumor since that is so important for long-term outcomes. It means being able to find lymph nodes involved with tumors and finding tumors that have spread to other parts of the body, such as what we were talking about with the lung. As I mentioned before, there's this older agent called ICG, which has been used for decades and has significant value, but it has a very nonspecific way that it lights up the tumor cells. We're looking for newer, better ways to light up only the tumor cells without giving us any background in normal tissue so that we can really distinguish tumor tissue from normal tissue. But it's more complicated than that, because all tumor cells are not the same. We're trying to understand what agent is best for tumor A, tumor B or tumor C. We actually take this all the way to the lab to understand that. We're looking at pathology slides and the dyes that will light up those different types of tumors. Then we look for opportunities to partner with industry to bring these new agents into pediatric practice so that we can do better, more complete surgery. We're advocating for the children because industry will generally gravitate toward adult patient populations where there's a bigger market share, but we're trying to convince them that looking for opportunities to bring these to pediatric practice is really important and essential.

[00:19:57] Erin Spain: So looking toward the future, with all these advances in pediatric oncology, what do you hope the future looks like for children who are facing these diagnoses?

[00:20:05] Dr. Timothy Lautz: That's such a great question. Let's go 100 years in the future first. The hope is that we get to the point where you don't need surgeons anymore—that you get to the point where other treatment options are so good that we can infuse something into a vein and not have to do any surgery. But the reality is we're a far distance from that, so doing better, less invasive, more precise surgery is the short-term goal. There's other innovations, too. People are coming up with blood tests that can detect if there are any small amounts of viable tumors within the body, and that can guide what we do. People are coming up with tests that can help us to understand if something left behind on a CT scan is truly a live tumor or whether that's something that we can just leave behind. The goal is to understand which patients have good expected outcomes and can actually do fewer treatments. We can look at the genetic composition of the tumor and say this patient's going to do really well—we don't care if there's a little something left on the scan, or we don't need to give this strong chemotherapy that's going to impact fertility, or we don't need to do radiation that might cause second cancers later in life. So really to de-escalate therapy in patients expected to have excellent outcomes while finding new, better treatment options for those who have the more difficult-to-treat tumors. That risk stratification approach is making a huge difference now and will continue to make a big difference in the future.

[00:21:35] Erin Spain: How do people find their way to Lurie Children's and to you when they are facing a childhood cancer diagnosis?

[00:21:42] Dr. Timothy Lautz: We are open and accessible to families at all times. We want to make it really easy for families to get the information and care they need. Many families find us through the clinical trials that we have ongoing, and that is certainly always an option. We have an easy second opinion program that you can find on our website. All of those referrals come in and get reviewed by our solid tumor coordinator, who brings in the different team members needed for each specific tumor type. Our typical next step is a telemedicine appointment where a surgeon and a medical oncologist meet with the families to talk about the information they've already received from their initial institution and potential additional options we might offer. In many cases, that just means providing reassurance that the care they're getting is exactly right and that we would do the same thing. But in some cases, we are able to offer something new or something different, and then we can provide an opportunity for the family to transfer their care here. That involves bringing their imaging records and their pathology records over for us to review. The process is very easy. You can reach out to us on our website and we will get back to you immediately.

[00:22:50] Erin Spain: Actually, it's fantastic that people don't have to make the trip in person for that second opinion.

[00:22:54] Dr. Timothy Lautz: When we first meet families, they are totally overwhelmed. They've just received this devastating new diagnosis, and all they're thinking about is getting the tumor out and getting their child cured. We are right there with them, but we have the ability to think more long-term about some of the concerns we know from other families will be on their minds 10 years or 20 years from now. Something so wonderful about our team is that we can provide counseling for all of that. Because we are thinking about not only the immediate treatment but also the late effects, the way that we treat the patient right from the beginning is impacted. We talked about fertility preservation; if we know that the chemotherapy regimen is going to place the child at risk for future infertility, then right away, when we're doing the initial procedures to start their treatment, we are doing the fertility preservation procedure so they can rest easy that the future concern is being addressed. It's also related to the area of risk stratification. By doing these comprehensive tests, including in many cases genetic profiling of the patient's tumor, we can reduce the therapy intensity for patients who don't need intensive therapy while using targeted agents for patients who have more difficult-to-treat tumors. All of this is working together to lower the risk of long-term late effects. In fact, we have a whole clinic focused on what we call survivorship. How do we care for patients after they've completed their treatment and finished their five years of surveillance, and they're now in that long-term survivor phase?

[00:24:32] Erin Spain: Tell me about all the different ways that Lurie Children's is innovative when it comes to pediatric surgery and oncology.

[00:24:38] Dr. Timothy Lautz: It goes back to the multidisciplinary team. There's innovation happening at all the different areas of care for these children. From the medical oncology side, we are deeply involved in the Children's Oncology Group and can offer all the most up-to-date clinical trials for new chemotherapy approaches and new targeted agents that take into account the specific genetic mutations a child might have. Not only are we looking at these late-phase trials, but in many cases we can offer early-phase trials for new, novel treatments that offer hope for patients with more relapse or refractory tumors. Our colleagues in radiation oncology are also at the forefront. We partner with Northwestern Medicine for this and offer proton therapy, which is a unique, targeted modality for ensuring that the radiation is truly only treating the tumor cells and not impacting the healthy normal tissue around them. In the surgical field, we have all sorts of innovations underway. We are actively involved in all the different Children's Oncology Group trials. We're involved in trials with another organization called the Pediatric Surgical Oncology Research Collaborative, or PSORC, and I'm vice chair of that organization, which brings together surgical experts from over 40 of the nation's biggest children's hospitals. In that group, we're looking at some very specific surgical questions that are hard to address at any single hospital. But by bringing people together from all these different institutions, we're really moving the needle on the surgical care of children with cancer. Robotics is a big part of what we do, and we are committed to doing minimally invasive surgery whenever possible. The robot really allows us to do that. We are doing more complex pediatric surgical oncology operations with the robot, and that means smaller incisions and quicker recovery—in many cases home within one to two days after surgery and back into activities a week later.

[00:26:45] Erin Spain: What drives you to be leading these consortiums, to be taking on these research projects? I mean, you're a busy guy; you're also in the OR quite a bit, but what makes you want to keep doing better?

[00:26:54] Dr. Timothy Lautz: It's teamwork all across the board. The teamwork here at Lurie Children's allows us to provide better care to the children who come here, but it's also teamwork across the country and the world that is going to move the needle. Pediatric cancer, thankfully, is very rare, but that means that no one institution is going to have enough volume or experience to really innovate and move things to the next level. By working together, we can do that. Different places do things differently. For some of these tumors, the approach that American institutions and European institutions have taken has been different. By bringing our data together, we can see what works for one tumor and what works for a different tumor. We can all learn from our collective experience in a way that really hasn't been possible until recently. I want to be at the forefront of all of that.

[00:27:44] Erin Spain: We are so happy to have you on the podcast. Thank you for your time today.

[00:27:48] Dr. Timothy Lautz: Thank you, Erin.

[00:27:49] Erin Spain: For more information, including how to make a referral or an appointment, visit luriechildrens.org.