01/ Meet an expert: Dr Marisa Schwab
Dr Marisa Schwab is a Clinical Assistant Professor of Pediatric Surgery at Stanford University and practices at Lucile Packard Children’s Hospital Stanford. She completed her medical training at Georgetown University School of Medicine, her general surgery residency at UCSF, and a pediatric surgery fellowship at Stanford University. She has considerable experience in CLMs and is a founding medical advisor for the CLM Society.
What made you want to be a pediatric surgeon?
Growing up, I thought I wanted to become a pediatrician because I loved working with kids and families. I then fell in love with surgery and shadowed a pediatric surgeon in college and realized she had my dream career! I love the technical precision and complex decision-making required in pediatric surgery, combined with the incredible relationships I get to develop with my patients and their families.
What led you to focus on CLMs?
I’ve been very interested in the chest, both from a pulmonary standpoint but also chest wall anomalies. I did my pediatric surgery fellowship at Stanford, where I was fortunate to meet many families who were diagnosed in utero, and then take care of their children after birth. This exposure to children with CLMs sparked so many questions for me. It was clear that this was a field with such a need for people to specialize in, both from a clinical and research standpoint.
I think we are at an inflection point in the understanding of CLMs, where we’re learning more about their true incidence and natural history. Collaborative initiatives such as the CLM Registry led by Dr. Kunisaki, represent a significant step forward in generating the high-quality, multicenter evidence necessary to advance the field.
Are some kinds of CLM more challenging than others? Either from a purely surgical perspective or from a management/counseling perspective?
From a decision-making and counseling perspective, bilateral lesions and multiple lesions are tricky. Certain types of very small asymptomatic lesions also make the operative versus non-operative decision-making more complex.
From a technical standpoint, older children who have had recurrent infections are a lot more challenging. For example, teenagers who were only diagnosed with a CLM after having severe recurrent pneumonias and have a lot of scarring in their chest can be very challenging.
How often do you see high-risk CLM cases? What sort of percentage of cases become high-risk?
Because Stanford is a quaternary center and we have a fetal treatment center, we commonly get referrals for potential high-risk cases. Thankfully, these are still the minority of the CLM patients we see.
In what kinds of situations do you and your team recommend early surgery?
The timeframe is evolving as we learn more about the disease and the risks and benefits of early versus late resection. The current inclination in the United States is to operate early, at the 2-6 month mark, since data currently show a trend toward lower postoperative complications among high-volume surgeons. For this reason, at Stanford we have been recommending early resection.
Can you describe what a normal day looks like for you? How do you balance surgeries with management and family counseling?
Part of what I love about my job is the variety of patient ages and problems, the mix of scheduled and surprises, and the need to efficiently juggle everything. My schedule is a mix of being the on-call surgeon, performing elective operations on kids of all ages, seeing patients in clinic, doing prenatal counseling with expecting families. I also do a lot of research, collaborate with other surgeons on multi-institutional projects, and teach students, residents, and fellows.
When I’m the pediatric surgeon on duty, my day starts with an early run before heading to the hospital. I round on all the surgical patients in the hospital with my team, see any new children who may have a surgical problem, and operate on patients who need an emergency operation. As a pediatric surgeon, I intersect with many different providers in the hospital so I’m always coordinating with the neonatologists, pediatricians, oncologists, and many other teams.
What is the most challenging aspect of your job?
I went into pediatric surgery because I love being able to offer a solution to families at a critical moment in their child’s life; in other words, I love being able to fix kids. When a child has a problem I can’t fix or has a complication despite meticulous planning and execution, it’s devastating. These moments serve as a constant reminder of the privilege and responsibility I carry as a pediatric surgeon.
What is the most rewarding part of your job?
Watching kids go back to their normal, active lives after surgery is the best part! For those that I follow long-term, it’s incredibly rewarding to watch them grow up, meet their milestones, and live fulfilling lives out of the hospital.
What are some of the biggest unanswered questions about CLMs?
We still don’t know how to predict which patients and which CLM types are more likely to cause symptoms and infections. We need to have a better understanding of the natural history of these diseases, both before and after birth, so we can have a personalized approach for every patient.
At Stanford, what does prenatal counseling typically look like? What is a typical trajectory for newly diagnosed CLM families?
The Stanford Fetal Treatment Center organizes prenatal counseling for all families diagnosed prenatally with a CLM. These consultations are multidisciplinary, meaning a neonatologist, pediatric surgeon, and fetal treatment center nurse meet with the family all together. We tailor every session, since every family is unique and comes with different expectations, questions, and needs. We work with the mother’s obstetrician to decide whether she can deliver locally or may need a higher level of care with a delivery at Stanford. I always tell families it’s not their one chance to ask questions – the goal is for future parents to have a team they can reach out to for the remainder of pregnancy with all their CLM questions.
What are three things you want families to know right away when they first get this diagnosis?
1) The vast majority of children with a history of CLM live healthy, active, normal lives.
2) Even though CLM sounds really scary, CLMs are something we as medical providers at children’s hospitals are very familiar with and know how to manage.
3) Most babies with a CLM diagnosed prenatally will be asymptomatic after birth, and will get surgery at a young age. While you will remember this for the rest of your lives, your child will have no recollection of their CLM history.
What are three things a family might consider asking their medical team when they first get this diagnosis?
1) Is there any uncertainty about the diagnosis?
2) What is my CVR, and how often will I get ultrasound scans from now on?
3) Do you see any other or associated anomalies (such as hydrops)?
For families deciding whether to operate or not, what kinds of questions should they bring to their medical team to help them make a decision/what kinds of things should they be thinking about to help them reach a decision?
Shared decision-making is crucial for this discussion. Before the clinic visit, think about what matters to you and what causes you anxiety. Will the idea of knowing your child has this lung malformation keep you up at night? Would you be willing to have your child undergo surveillance imaging yearly if you pursue observation?
Ask your medical team their hospital’s volume of CLM, their rate of thoracoscopic versus open resections for CLM, their average length of hospitalization after CLM resection, what the surveillance protocol is (do they do annual imaging with radiation?).
Anything else you want to say!
You deserve to have all your questions answered and feel like you have all the information necessary in order to make the right decision for your child. There is a lot of valuable information online, but you should also always have access to medical providers who can give you personalized advice for your child.