Year : 2019 | Volume
: 2 | Issue : 1 | Page : 1--2
World Health Organization 2016 update on classification of central nervous system tumors: The road ahead
Department of Neurosurgery, Seth G. S. Medical College and King Edward VII Memorial Hospital, Mumbai, Maharashtra, India
Dr. Dattatraya Muzumdar
Department of Neurosurgery, Seth G. S. Medical College and King Edward VII Memorial Hospital, Parel, Mumbai - 400 012, Maharashtra
|How to cite this article:|
Muzumdar D. World Health Organization 2016 update on classification of central nervous system tumors: The road ahead.Int J Neurooncol 2019;2:1-2
|How to cite this URL:|
Muzumdar D. World Health Organization 2016 update on classification of central nervous system tumors: The road ahead. Int J Neurooncol [serial online] 2019 [cited 2020 Feb 26 ];2:1-2
Available from: http://www.Internationaljneurooncology.com/text.asp?2019/2/1/1/259560
The 2016 World Health Organization (WHO) classification of central nervous system tumors is an updated version of 2007 classification. The primary objective of this update was to allow uniformity and eliminate interobserver variation among the pathologists. In addition, the addition of the genetic basis of tumorigenesis or molecular marker would facilitate clinical, experimental, and epidemiological studies. It would also be helpful to develop effective targeted treatments and prognostication.
The Indian Society of Neurooncology has adapted the WHO 2016 update and its suitability to the practice of neurooncology in the Indian scenario. The aim of formulating the Indian guidelines of the WHO 2016 update is directed toward creating a uniform diagnostic and therapeutic protocol for the treatment of brain tumors. There is a likely indifference among senior clinicians and allied community to perform these molecular studies, but perseverance in educating them with evidence-based documentation would help overcome their resistance. Over the past 2 years, a predetermined effort has been made to disseminate the concept and educate the clinicians by conducting continuing medical education programs and symposia in various parts of the country.
The centers of excellence in the management of brain tumors in the country have taken a lead in molecular oncology and establishing laboratories to perform molecular testing of brain tumors at relatively affordable rate. Some institutions even offer financial help to overcome the costs toward molecular testing. The smaller centers in the country, where brain tumor surgery is performed, are expected to send the tumor sample to the nearest higher center of excellence.
However, in a diverse country like ours, the path is riddled with hurdles on many fronts and fraught with challenges. There are certain concerns that need to be addressed to make the implementation a success.
The practice of neurooncology is still not organized throughout the country. The vast population spread in the remote interiors of India still does not have easy access to the urban centers for further treatment. Poverty, illiteracy, and geographical factors are the some of the contributory factors. In the urban setting, there are various small nursing homes and hospitals, which do provide service, but there is a lack of integrated effort to provide a comprehensive treatment. The workload in public and teaching hospitals with a long waiting list of patients compromises timely service and dedicated time toward education and research.
The success of the WHO 2016 update on brain tumors would be fulfilled when it would help make a visible change in the practice of neurooncology in India. The ISNO guidelines for diffuse gliomas are the first step in this regard. Even the cost of conducting the molecular tests has been subsidized for the sake of resource constraint patients. However, this would hold merit only if it is ensured that the guidelines are put into practice. The practice of brain tumors is diverse and bizarre in India except in few dedicated centers of excellence in the country. The following points need to be taken into consideration. The treatment of brain tumors has become comprehensive and multidisciplinary. The stand-alone practice is dwindling, suboptimal, and at times, counterproductive. There has to be dedicated tumor board or joint neurooncology meetings held weekly in the centers conducting brain tumor surgery. It has to be made mandatory in tertiary and secondary hospitals (academic as well as nonacademic) equipped to deal with brain tumors. Neurosurgeons, radiation oncologists, or pathologists can spearhead tumor boards as per the logistics of the treating center. The tumor board in charge should be dedicated to neurooncology, enthusiastic, inquisitive, and ability to be all-inclusive, fair, working in harmony with other specialties of the multidisciplinary team. There could be debates or discussion, but a general consensus should be attained at the end of the meeting. The most important aspect would be neuropathology wherein the diagnosis would be discussed in light of the molecular study and open to suggestions by the tumor board. This would help to elucidate risk stratification of diffuse gliomas in light of clinical and radiological features. It would readily identify patients for escalation or deescalation of treatment, thus attaining a balance in treatment protocols. It would also raise different questions about the biology of the tumor and promulgate research hypothesis for future studies. The advantage of conducting such meetings would be a learning experience for all about each other's specialties. Furthermore, it increases the respect for each other's specialties understanding the complexity of the subject and viewpoint of colleagues. Hospitals, which conduct brain tumor surgeries but do not have the requisite facility to conduct tumor board, can join a larger group or a center of excellence in the nearest area so that patients get the full benefit of the facilities. A reasonably good follow-up of patients can also be ensured in this manner. Brain tumor samples also can be preserved for further studies and research on the subject to evaluate new targeted treatments. The neurosurgeons are the fulcrum to spearhead the process. They are the primary consult and patients develop a bond and repose full faith in the treating neurosurgeon. It is imperative that neurosurgeons became neurosurgeon-scientists, which in itself is a huge challenge.
The neuropathologist should order the molecular studies in consultation with the treating neurosurgeon to maintain continuity in the treatment process. This will help avoid unnecessary tests being performed. If not adhered to judiciously, performing a “Glioma panel” arbitrarily will add to the cost substantially and provide suboptimal results.
The patient usually pays for the entire treatment cost in India for the surgery and hospitalization. Few have insurance, which covers the cost partly or in totality. Usually, in either case, the cost toward molecular studies is not covered by insurance, and the patients have to bear the cost for the same, which can be an additional burden. It then becomes optional and not given due importance. In public hospitals, the cost toward molecular studies is more than the total cost of surgery and hospitalization. This needs to be addressed, and maybe financial assistance can be sought from governmental or philanthropic agencies.
The patients and their families need to be made aware of the advances in diagnostics of brain tumors. They should be educated about the types of molecular studies and its need in a brief and lucid manner, in the language that can be understood by them. This will help create faith and confidence in the entire process, thus clearing any unnecessary doubts.
The above observations and recommendations should be able to steer the utility of molecular studies in a comprehensive manner and help establish a continuum in the long and difficult treatment paradigms for a glioma patient.