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   Table of Contents - Current issue
Coverpage
July-December 2020
Volume 3 | Issue 2
Page Nos. 63-110

Online since Saturday, December 26, 2020

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REVIEW ARTICLES  

Gliomas: The history of diagnosis and classification: Part 1 p. 63
Amitava Ray, Meenakshi Swain, Rahul Lath
DOI:10.4103/IJNO.IJNO_15_20  
Over the last few years, there has been a shift from a 100-year-old tradition in classifying and grading brain tumors. Whereas traditional teachings were based on the observation of individual cells and identification of distinct recognizable patterns formed by these cells, modern classification demands the incorporation of molecular markers into the traditional systems of grading, causing considerable disruption in conventional histopathological approaches. The objective of this article is to highlight the advancements in grading and classification, to document the evolution of glioma prognostication, nil and nil the major events that marked turning points in its history. This review article is an exhaustive review of the literature that summarizes the changes in glioma classification over the last 100 years – from the early macroscopic inspections done at autopsy in the late 19th century to the first introductions of molecular markers by the World Health Organization. At this time of change, this article gives us a glimpse of how grading and classification has evolved as science has progressed, providing a glimpse into the future. Understanding the history of grading and classification is the key to better understanding the integrated histopathological and molecular approaches of today.
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Gliomas: History of diagnosis and classification: Part 2 p. 68
Amitava Ray, Swain Meenakshi, Lath Rahul
DOI:10.4103/IJNO.IJNO_200_20  
In the first article of this series, we traced the history of glioma classification from the middle of the 19th century to the start of the current revolution in classification driven by molecular markers. Although molecular markers were used sporadically in the past to enumerate specific cancer dysregulated pathways, it was never an integral part of the classification. This article tries to summarize the changes that have taken place since the recommendations following the Haarlem meeting in 2014. The objective of this article is to highlight how molecular classification impacts diagnosis, prognostication and management of brain tumors, and the integration with traditional histopathology. This review article is an exhaustive review of the literature summarizes the gradual evolution in glioma classification starting with 1p19q as described in the late 20th century, the value of methyl-guanine-DNA methyltransferase promoter methylation leading up to the World Health Organization 2016 classification. It touches upon the current trends of transcriptomic and epigenetic classifications, highlighting the advantages and pitfalls of each testing method. At this time of rapid advancement, this article helps us understand current grading and classification, offering insights into how this may evolve in the future. Understanding the concepts of integrated molecular and histopathological grading holds the key to future research in the field. It will also be invaluable in being able to choose the best therapeutic option for patients, for whom a plethora of diverse management options may be available.
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ORIGINAL ARTICLES Top

A retrospective analysis of 128 patients of primary intracranial tumors treated at a tertiary cancer center in Nashik, Maharashtra p. 75
Girish Bedre
DOI:10.4103/IJNO.IJNO_11_20  
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.
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Adjuvant use of fluorescein sodium for maximizing resection of high-grade gliomas: An institutional experience with review of the literature p. 80
Ashish Acharya, Sarvpreet Singh Grewal, B Paul Sudhakar John, Ravindra Kumar Bind
DOI:10.4103/IJNO.IJNO_20_20  
Background: The extent of resection of high-grade gliomas (HGGs), in order to limit tumor recurrence and above all to improve disease-free survival rates cannot be overstated. Several fluorescent biomarkers have been tested and are in use to aid intraoperative identification of residual tumor; 5aminolevulinic acid and fluorescein sodium are now playing a pivotal role in glioma surgery. A retrospective analysis on 29 patients operated for HGGs and the results are presented here. Materials and Methods: Data of 29 consecutive patients with HGG have been collected in our study (16 males and 13 females; mean age: 60.3 years, range: 23–90 years). Fluorescein (7 mg/kg of body weight) was injected intravenously right after the induction of general anesthesia. A YELLOW 560 filter was used on a Leica M530 OHX surgical microscope (Leica microsystems, Wetzlar, Germany) to aid in a complete microsurgical tumor removal. Glioma resection and quality of life were evaluated preoperative and postoperatively. Results: Gross total resection was achieved in 41.3% (n = 12) of patients. A subtotal resection (>95%) was achieved in 48.2% (n = 14) of them, while a PR (<95%) was obtained in 10.3% (n = 3) of patients. Overall, in 89.6% (n = 26) of patients who underwent fluorescence-guided surgery, the resection rate achieved was >95%. No adverse effects correlated to fluorescein have been recorded. Conclusions: Fluorescein proved itself to be safe and abundantly effective in the resection of HGGs, allowing a high rate of gross total removal of contrast-enhanced tumor areas.
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Intracranial meningiomas: Experience at a tertiary health-care center in India p. 87
Saurav Kumar Besra, Viraat Harsh, Hitesh Kumar, Jeevesh Mallik, Chandra Bhushan Sahay, Anil Kumar
DOI:10.4103/IJNO.IJNO_5_20  
Introduction: Intracranial meningioma is one of the most common primary intracranial tumors. It constitutes 10%–15% of all brain neoplasm across the globe, whereas in India, their occurrence varies from 11.6% to 21%. These tumors are neuroectodermal in origin and are believed to arise from arachnoid cap cells. These tumors are mostly histologically benign with <0.2% showing metastasis. Total excision of tumor is the treatment of choice. Patients and Methods: The survey intended to study the incidence of meningioma among other intracranial tumors, the clinical profile of the patients, surgical outcomes, and long-term results. The study included all the cases of intracranial meningioma admitted in the Department of Neurosurgery, Rajendra Institute of Medical Sciences, Ranchi, between the time period of January 2012–December 2015. All patients, irrespective of age and sex, who were diagnosed of intracranial meningioma based on clinical data, radiological evidence, and histopathology, were included in the study. A total of 106 patients were included in the study. Results: The study revealed that the incidence of intracranial meningioma among other brain tumors is 14.45% and the disease shows a female preponderance. Meningiothelial meningioma is the most common histological variant reported during the study. Seizure and cranial nerve damage were the common complications observed among the patients during the follow-up study. Total excision of the tumor is the treatment of choice. Seventy-seven percent of the patients show good recovery with Glasgow Outcome Score of 5. Conclusion: Intracranial meningiomas are common intracranial tumors. They affect people in fifth decade of their life and show a female preponderance. They commonly present with symptoms such as seizure and headache. Meningothelial meningioma is the most common histological subtype. Total excision of the tumor mass has been found effective in preventing reoccurrence. Microsurgical techniques give good results with minimum mortality.
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Stereotactic radiosurgery for single or oligometastatic brain lesions: A single institutional experience p. 93
Lalit Kashyap, Sayan Paul, P Vijay Anand Reddy, Kausik Bhattacharya, Prashant Upadhyaya, P Vijay Karan Reddy, Madhuri Kavikondala, K Shilpa Reddy
DOI:10.4103/IJNO.IJNO_14_20  
Aim: Intracranial metastases are the most common neurologic complications of systemic cancer. Stereotactic radiosurgery (SRS) is a proven modality for treating single or oligometastatic brain lesions. In this retrospective study, we have analyzed patients data treated in our hospital with SRS. Materials and Methods: The analysis included 52 patient's data treated between August 2010 and January 2018. These include the patients in the complete remission of the primary disease and have recurred in the brain with one to four metastases after a significant disease-free interval. Patient's case sheets and treatment planning system data were analyzed to collect the data for this study. Results: Median follow-up was 10 months (range, 1–37 months). There were twenty cases of Ca (cancer) lung, 13 cases of Ca breast, 5 cases of Ca rectum, 4 cases of Ca endometrium, 2 case of Ca esophagus, and 1 case each of alveolar rhabdomyosarcoma of right parotid, Ca ovary, Ca vaginal vault, Ca lacrimal gland, Ca colon, Ca urinary bladder, and Ca prostate. These patients who had a recurrent disease in the brain were treated with doses ranging from 15 to 20 Gy in single fraction, 24 Gy in 3 fractions, 27 Gy in 3 fractions, or 30 Gy in 5 fractions. Median progression-free survival was 9 months, and median overall survival (OS) was 12 months in these patients. Conclusion: Frameless SRS is an effective treatment of delivering high-dose radiation to patients who develop one to four brain metastasis with comparable median progression free and OS to the previously reported data.
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CASE REPORTS Top

Primary trans-calvarial lymphoma: A rare entity p. 98
Ayush Jain, Shilpa Sankhe, Soniya Patankar
DOI:10.4103/IJNO.IJNO_17_20  
Primary trans-calvarial lymphoma with both intracranial and extracranial extension is a scarcely described entity in published literature. Most often, these lesions are misdiagnosed as hematomas or meningiomas. We hereby report an interesting case of a 60-year-old female presenting with a large scalp mass. The diagnosis at the time of referral was an organized scalp hematoma. Magnetic resonance imaging of the brain revealed a large isointense enhancing mass lesion with transcalvarial extension involving the scalp as well as the meninges. Histopathology and immunohistochemistry confirmed a diagnosis of diffuse large B-cell lymphoma. Our case was unique in that the presentation was with a large scalp lesion with a reasonable meningeal component and invasion of the superior sagittal sinus without any associated focal neurological deficit.
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Primary cerebral neuroblastoma in young adult p. 101
Vinodh Kumar Selvaraj, Deleep Kumar Gudipudi
DOI:10.4103/IJNO.IJNO_19_20  
Neuroblastoma is an embryonal malignancy of the sympathetic nervous system arising from pluripotent sympathetic cells (neuroblasts). It is the most common extracranial solid tumor in infants. Although it can arise anywhere along sympathetic chain, it is extremely unusual for neuroblastoma to present as intracranial lesion and that too in a young adult. Here, we describe a 24-year-old male presented with complaints of headache and retro-orbital pain. Magnetic resonance imaging (MRI) of the brain revealed a left occipital lobe mass lesion. He underwent left parieto-occipital craniotomy and near-total excision. Postoperative MRI showed minimal residual lesion. Initial histopathological examination was reported as a malignant round cell tumor. However, block and slide review with immunohistochemistry markers was suggestive of neuroblastoma. He received adjuvant radiation of 50.4 Gy in 28 fractions, followed by eight cycles of adjuvant chemotherapy with lomustine and cisplatin. At 3-year follow-up, MRI showed post-operative gliosis in left parietal lobe with no evidence of recurrence.
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Imaging spectrum of atypical meningiomas p. 104
Rasiq Aslam, Musaib Ahmad Dar, Suhail Rafiq, Aijaz Mohideen
DOI:10.4103/IJNO.IJNO_2_20  
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LETTER TO EDITOR Top

Aerobic exercise for improving cognitive function in adult brain tumor patients p. 108
Chidiebere Emmanuel Okechukwu
DOI:10.4103/IJNO.IJNO_18_20  
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ERRATUM Top

Erratum: Primary central nervous lymphoma of cerebellopontine angle germinal center type: Report of a rare case p. 110

DOI:10.4103/2590-2652.305066  
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