|Year : 2020 | Volume
| Issue : 2 | Page : 75-79
A retrospective analysis of 128 patients of primary intracranial tumors treated at a tertiary cancer center in Nashik, Maharashtra
Department of Radiation Oncology, Shri Guruji Rugnalaya, Nashik, Maharashtra, India
|Date of Submission||09-May-2020|
|Date of Acceptance||29-Nov-2020|
|Date of Web Publication||26-Dec-2020|
Dr. Girish Bedre
Babasaheb Ambedkar Vaidyakiya Pratisthan's, Shri Guruji Rugnalaya, Gangapur Road, Nashik - 422 005, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Brain tumors are a heterogeneous group of neoplasms. They are classified into various subgroups depending on the cell of origin and their molecular signature in the 2016 WHO classification. Their incidence is very low. Males are most commonly affected than females and have bimodal age peak. Headache and vomiting are the most common presenting symptoms followed by seizures. The best imaging modality for accurate diagnosis is Magnetic Resonance Imaging (MRI) with contrast along with various other sequences. In almost all CNS tumours, maximal safe resection is the primary treatment. Accurate histopathological diagnosis with molecular markers helps in planning adjuvant therapy and prognostication.
Materials and Methods: This is a retrospective analysis of 128 patients of primary intracranial tumours treated at a private tertiary cancer centre during September 2014 to February 2020. In this analysis, we have analysed the data with respect to various factors like age at diagnosis, sex ratio, symptomatology, location of tumours, imaging modality, surgical details and histopathological diagnosis.
Results: In our analysis, we found maximum cases in 5th decade of life. Overall, males were most commonly affected than females (1.5 :1). Convulsion was the most common presenting symptom. MRI was done in 91.5% cases for initial diagnosis. The most common histology was glioblastoma multiforme and 116/ 128 patients underwent surgery as the primary treatment. Immunohistochemistry & molecular testing was done in only 30 patients. Radiotherapy with or without chemotherapy was offered to most of the cases and 61.9% patients were treated with IMRT or VMAT.
Conclusion: To our knowledge, this is the first report with large patient cohort from a private non academic institution and represents a real world day to day scenario. The distribution of cases with respect to age, male to female ratio, commonest pathological subtype were found to be consistent with the available literature except the presenting symptom. There is a need of improved pathological & radiological reporting.
Keywords: Astrocytoma, primary intracranial tumours, retrospective analysis
|How to cite this article:|
Bedre G. A retrospective analysis of 128 patients of primary intracranial tumors treated at a tertiary cancer center in Nashik, Maharashtra. Int J Neurooncol 2020;3:75-9
| Introduction and Background|| |
Brain tumors are a heterogeneous group of neoplasms. They are classified into various subgroups depending on the cell of origin and their molecular signature in the 2016 WHO classification. They account for <2% of all neoplasms. In general, males are affected more commonly than females except for meningioma where females are almost three times more commonly affected than males. Brain tumors are the most common solid tumors in childhood and in adults; the peak age incidence is in the age group of 45–70 years. The symptoms depend upon the location, size of tumor, and rate of growth. Headache and vomiting are the most common presenting symptoms due the raised intracranial pressure. Many patients present with seizures and hemiplegia due to the infiltration of brain tissue by the tumors. The most suitable investigation of choice where brain neoplasm is suspected is magnetic resonance imaging (MRI) with contrast along with various sequences which help at accurate diagnosis. These MRI sequences include spectroscopy, diffusion, perfusion, tractography, etc. MRI not only gives accurate diagnosis but also aids in planning for the surgery and postoperative radiation therapy.
For accurate histopathological diagnosis, a well-trained pathologist is a prerequisite along with availability of various IHC and molecular marker panels.
In general, the outcomes of primary brain tumors have improved over the last two decades owing to the improved imaging and histopathology, better neurosurgical techniques, high precision radiotherapy facilities, availability of effective chemotherapy and better understanding of tumor biology.
| Materials and Methods|| |
This is a retrospective analysis of all primary intracranial tumor patients treated at a tertiary cancer center in Nashik, Maharashtra, India.
During September 2014 to February 2020, a total of 128 patients of various primary intracranial tumors were treated. They were operated at various institutions and referred to our center for further management. The information was extracted from the patients' records retrospectively. The collected data were analyzed for demographic details and various other factors of importance.
| Results|| |
In our analysis, the age range of patients was from 4 years to 84 years, with most cases in the 5th decade of life (32 cases, 25%) [Chart 1].
Overall, males were more commonly affected than females (77 males: 51 females, i.e., 60% males and 40% females).
The most common symptom at presentation was convulsions in 31 patients (24.2%). Headache with or without vomiting was recorded in 27 patients, but it was the presenting symptom only in 19 patients, whereas 14 patients (10.9%) presented with hemiplegia or monoplegia. In 47 patients, the presenting symptoms were not recorded; hence, the information was not available.
For diagnosis, the most common investigation done was contrast-enhanced MRI in 108 patients (only 1 patient had MRI with magnetic resonance spectroscopy), first computed tomography (CT) scan, and then, MRI was done in 9 patients, CT scan only in 5 patients, and in 6 patients, it was not known which radiological imaging was done for the diagnosis. Radiological diagnosis was provided in only 52/122 patients which is very low about 42.6% only.
The maximum tumor size ranged from 2 to 9.6 cm. The number of patients with supratentorial tumors was 110 (85.93%), whereas 18 (14%) patients had infratentorial location of lesions. Of all patients, 93% patients had intra-axial tumors and 7% had extra-axial tumors. The right-sided cerebral location was in 53 patients (41.7%), whereas left-sided cerebral location was seen in 41 patients (32.3%). The most common location of lesions was frontal lobe area 41/128 (32%) followed by temporal lobe area 34/128 (26.56%), whereas the tumor was multicentric in five patients and cerebellum was involved in 8.7% cases (11 patients) [Table 1].
Histologically, the most common tumor type was glioblastoma multiforme in 51/128 patients (40%), astrocyoma in 29 (28%) cases (WHO Grade I, II, and III), and oligodendroglioma in 13 (10%). Other distinct tumor types were medulloblastoma in nine patients (7%), whereas sellar-suprasellar tumors were seen in six patients (4.5%) [Table 2].
The primary treatment of choice was surgery in 116/128 cases. Five patients had only biopsy (3 stereotactic and 2 open) while 6 patients of brain stem glioma and one patient of high-grade glioma did not undergo any surgery or biopsy. Out of 116 patients who were operated, 45 patients (35.1%) underwent near total or gross total excision of tumor as per surgical notes. Partial or subtotal excision was done in 17 patients (13.28%), while in 54 patients (42.2%), the extent of surgery was not recorded.
The immediate postoperative imaging was done in 33 patients (25.78%), of which CT scan was done in 28 and MRI in 5 patients. In 61 patients (47.65%), data on postoperative imaging was not available; no imaging was done in 29 patients (22.65%) and 10 patients were not eligible for postoperative imaging [Chart 2]. Out of the 33 patients in whom the postoperative imaging was done, residual disease was seen in 12 patients.
In 30 patients out of 128, immunohistochemistry or molecular tests were done. The main markers done were Mib-1, p53, IDH 1, and ATRX. The IDH 1 and ATRX were done in 23 patients each; Mib-1 in 26 patients and p53 in 20 patients [Table 3].
|Table 3: Patients according to immunohistochemistry/molecular test results|
Click here to view
The treatment offered at our center was radiotherapy alone in 29.7% of patients, radiotherapy with concurrent temozolomide in 68.75% of patients, while 1 patient did not take any treatment and one patient was advised observation. Postradiotherapy, adjuvant chemotherapy received by 46.9% of patients. Information on adjuvant chemotherapy was not available in 3.9% of patients while remaining patients did not receive any chemotherapy after radiation [Table 4]. In those patients who received radiotherapy, majority of the patients (61.9%) were treated with intensity modulated radiation therapy or volumetric-modulated arc therapy, and remaining patients were treated with three-dimensional conformal radiotherapy.
| Discussion|| |
In our analysis of 128 cases, male-to-female ratio was 1.5: 1, whereas there is no specific sex predilection for central nervous system (CNS) malignancies except for meningioma where females are affected more commonly than males. In our analysis, males are slightly more commonly affected than the females. This finding is similar to the reports of Masoodi et al., Ghanghoria et al., and Sajeeb Mondal et al.
Most of the cases were found in the fifth decade of life; 32 cases (25%) followed by the 4th decade; 27 cases (21%). This is similar to the age distribution of adult CNS cases in reports by Masoodi et al., Dhar et al., and Neha Yadav et al. The pediatric cases (less than 18 years) were only 9 (7%), and majority were medulloblastomas and brain stem gliomas. The same findings are noted by Sajeeb Mondal et al. This low number of cases in the pediatric age group is probably due to the referral bias from neurosurgeons that they refer selected pediatric cases for radiotherapy.
In our review, convulsion was the most common presenting symptom seen in 24.2% (31/128) patients followed by headache with or without vomiting in 21% (27/128) patients. In literature, headache with or without vomiting is the most common presenting symptom as reported by Neha Yadav el al., Sajeeb Mondal et al. (headache – 48.5% and seizures – 36.9%) and Dhar A et al. (headache – 71%). This variation is mostly due to the fact that in 37% of our cases (47/128), the presenting symptom was not recorded. The second possible reason could be that the seizure being a very significant symptom, patients immediately reach hospital for treatment, and hence, it is properly recorded.
In our analysis, the number of patients with supratentorial location were 109 (85.2%) and remaining had infratentorial location. The right sided tumours were more common than left sided tumours (41.7% right vs. 32.3% left). This finding is similar to the findings of Dhar A et al. The most common site of disease was frontal lobe area in 32% patients followed by temporal lobe area in 26% cases. In literature also frontal lobe is the commonest location of tumours followed by temporal/temporoparietal area as reported by Neha Yadav et al. (frontal-25.5%; temporoparietal-13.2%), Mondal et al. (Frontal-33.84%), Jalali R and Datta D et al.,; Dhar et al. (frontal-36%, temporal-27%). The cerebellum was affected in 8.7% patients, similar to the finding of Sajeeb Mondal et al. (cerebellum-9.23%).
The glioblastoma multiforme was the most common histopathological subtype accounting for 40% cases. Other astrocytic or glial tumours were 28%. Similar findings have been reported by Masoodi et al., Yadav et al., Sajeeb Mondal et al. and Dhar A et al.
A prospective report of CNS tumours published by Jalali R and Datta D from Tata Memorial Hospital, India have also reported similar findings regarding the male to female ratio (1.5:1), commonest frontal location of tumours, astrocytomas and Glioblastoma as commonest histology [Table 5].
In our analysis, the contrast-enhanced MRI was done in 117 patients out of 128 which shows that the availability of MRI is widespread and it has become affordable too. However, the radiological differential diagnosis was given only in 52 cases. This observation highlights the need of improvement in reporting standards. Other MRI studies such as MR spectroscopy and MR perfusion were very occasionally done for diagnostic purpose; only one patient had MR spectroscopy in our study.
Extent of resection is one of the most important prognostic factors for all CNS tumors and especially for astrocytomas; greater the excision, better the outcome as reported by Matthew M. Grabowski et al. In our study, 116 cases were operated, but the extent of resection was not recorded in 54 cases (46%). This observation demands better documentation of this important prognostic factor.
Since the 2016 WHO classification has incorporated the molecular markers in diagnosis, the practice is slowly changing and more and more patients are being advised these tests, especially, the IDH 1 mutation, Mib-1 index, p53, and ARTX. Tests such as MGMT methylation and 1p 19 q codeletion, though very useful, were done only in 3 patients and 1 patient, respectively, the reason being its high cost. We also observed that the reporting pattern has still not changed much, and the old nomenclature is often followed. This observation demands that the pathologists at nonacademic institutions needs to update themselves in this regard.
Through this report, we want to present the real world data of day to day clinical practice in nonacademic institutions. This data also highlights the challenges for oncologists in deciding adjuvant therapy. These realities force the oncologists to make a best decision about further treatment out of available information. We also recognize the limitations of this paper as being retrospective in nature and biased referral pattern.
| Conclusion|| |
The distribution of cases with respect to the factors like age, male to female ratio, commonest pathological subtype were found to be consistent with the available literature. Although, headache is the commonest presenting symptoms in literature, in our study convulsion was most common. We found that the pathological reporting is still as per older classification and pathologists need to adapt to the latest WHO classification. The radiological reporting needs to provide differential diagnosis and not just the description of scan findings. Molecular testing is needed in more and more cases for better prognostication. To our knowledge, this is first such report with a large patient cohort from a private non academic institution and hence it carries a lot of importance in understanding and improving the management standards in the real world scenario.
The authors would like to thank Dr. Bhushan Nemade, Radiation Oncologist, Nashik. All neurosurgeons who referred the patients to us and all the staff of our radiation oncology department.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Louis DN, Ohgaki H, Wiestler OD, Cavenee WK: WHO classification of tumours of the central nervous system, 4th
edition. Lyon, France: World Health Organisation; 2016.
Stewart BW, Kleihues P. Tumours of the nervous system In: World Cancer report. IARC Press, Lyon, France 2003.
Lantos PL, Louis DN, Rosenblum MK: Tumours of the nervous system. In: Graham DI, Lantos PL eds, Greenfield's Neuropathology, 7th
ed., Arnold, London, 2002.
Masoodi Tamkeen, Ram Kumar Gupta, J.P.Singh, Arvind Khajuria. Pattern of central nervous system neoplasms: A study of 106 cases. JK- Practitioner 2012; 17:42-6.
Shikha Ghanghoria, Rakesh Mehar, CV Kulkarni, Meena Mittal, Ashok Yadav, Harshul Patidar. Retrospective histological analysis of CNS tumors – A 5 year study. Int J Med Sci Public Health 2014;3:1205-7.
Sajeeb Mondal, Rajashree Pradhan, Subrata Pal, Biswajit Biswas, Arindam Banerjee, Debosmita Bhattacharyya: Clinicopathological pattern of brain tumors: A 3-year study in a tertiary care hospital in India. 2016. Clinical Cancer Investigation Journal 2016;5:437-40.
Dhar A, Bhat AR, Nizami FA, Kirmani AR, Zargar J, Ramzan AU, et al
. Analysis of brain tumors in Kashmir Valley - A 10 year study. Bangladesh J Med Sci 2014;13:268-77.
Jalali R, Datta D. Prospective analysis of incidence of central nervous tumors presenting in a tertiary cancer hospital from India. J Neurooncol 2008;87:111-4.
Yadav N, Kataria SP, Sharma J, Singh S, Marwah N, Kumar S et al
. Retrospective analysis of incidence of central nervous system tumours in a tertiary care centre: A 3 year study, Journal of Datta Meghe Institute of Medical Sciences University 2018;13:30-33.
Ghosh A, Sarkar S, Begum Z, Dutta S, Mukherjee J, Bhattacharjee M, et al
. The first cross sectional survey on intracranial malignancy in Kolkata, India: Reflection of the state of the art in Southern West Bengal. Asian Pac J Cancer Prev 2004;5:259-67.
Matthew M. Grabowski, Pablo F. Recinos, Amy S. Nowacki, Jason L. Schroeder, Lilyana Angelov, Gene H. Barnett et a
l. Residual tumor volume versus extent of resection: predictors of survival after surgery for glioblastoma. J Neurosurgery, 2014;121: P 1115-23.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]