|Year : 2020 | Volume
| Issue : 6 | Page : 1466-1469
An audit of brain tumor patients treated in 5 years at a single institute: Our regional cancer center experience
Pooja Nandwani Patel, Jigna Bhattacharya, Rakesh K Vyas, Unnikrishnan Suryanarayana
Department of Radiotherapy, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India
|Date of Submission||31-Mar-2016|
|Date of Acceptance||07-Apr-2018|
|Date of Web Publication||30-Oct-2018|
Pooja Nandwani Patel
A-101, Sankalp Sandipani Flats, Opposite Abhay Ghat, Near Chandan Khadhi Bhandar, Gandhi Ashram, Ahmedabad - 380 027, Gujarat
Source of Support: None, Conflict of Interest: None
Introduction: Brain tumors constitute a small presentation of all cancers (1.4%) and cancer related deaths (2.5%). Most of the brain tumors are malignant and carry bad prognosis and even if those which are benign still can interfere with brain functions that are required for daily living. We did an audit of brain tumor patients treated in our center and see their prognosis in correlation with different histological types.
Materials and Methods: We analyzed 497 patients treated at our center from June 2007 to June 2012 of different histological types. All the patients underwent complete central nervous system examination and thorough workup including hematological investigations, radiological investigations, and confirmation of histological type by biopsy. These patients were then treated with surgery followed by radiotherapy or upfront curative radiotherapy as per staging and then kept on regular follow-up as per institutional protocol.
Results: Majority of patients were astrocytomas (309 patients) followed by a pituitary adenoma (39 patients), oligodendroglioma (33 patients), medulloblastoma (22 patients), arteriovenous malformations (19 patients), craniopharyngioma (16 patients), and recurrent brain tumors (12 patients). There were few cases of central nervous lymphoma, meningioma, melanocytoma, ependymomas, schwannomas, hemangiopericytoma, gliosarcoma, and primitive neuroectodermal tumor. The histological types vary differently regarding presentation, treatment, and prognosis.
Conclusion: Astrocytomas are the most common tumors in presentation (309 patients) in which the high-grade astrocytomas carried worse prognosis. Benign tumors such as pituitary adenomas, schwannomas, and craniopharyngiomas had the best prognosis with survival seen up to almost last follow-up.
Keywords: 5 years, brain tumors, regional cancer center
|How to cite this article:|
Patel PN, Bhattacharya J, Vyas RK, Suryanarayana U. An audit of brain tumor patients treated in 5 years at a single institute: Our regional cancer center experience. J Can Res Ther 2020;16:1466-9
|How to cite this URL:|
Patel PN, Bhattacharya J, Vyas RK, Suryanarayana U. An audit of brain tumor patients treated in 5 years at a single institute: Our regional cancer center experience. J Can Res Ther [serial online] 2020 [cited 2021 Nov 27];16:1466-9. Available from: https://www.cancerjournal.net/text.asp?2020/16/6/1466/244443
| > Introduction|| |
Primary brain tumors are classified by their histological characteristics and their location and often further divided on basis of their invasiveness and malignancy. The most peculiar feature as far as sexual differentiation is concerned is in meningeal tumors which are more likely in females, unlike rest which are more common in males. Astrocytic tumors,,,,, form the major presenting components with a wide range of neoplasm differing by morphologic characteristics, age and sex distribution, location, invasiveness, and tendency for progression. Pituitary is benign tumors with good prognosis and as expecting long survival more conformal approach like stereotactic treatment is planned. Oligodendrogliomas are mostly located in cerebrum with the majority of presentation in adults and males. Medulloblastomas constitute 5% of all brain tumors and majority are children at presentation. Arteriovenous malformations (AVMs) are vascular anomalies consisting of fistulous connections of arteries and veins without normal intervening capillary beds. The most common complication is hemorrhage which can be fatal most of the times, and thus intervention such a embolization, surgery, or radiotherapy is advised. Craniopharyngiomas are benign tumors with good prognosis after surgery and radiotherapy., Central nervous system (CNS) lymphomas are sensitive to chemotherapy and radiotherapy, and thus an optimal combination of radiotherapy and chemotherapy is used., Meningiomas are benign tumors of the meninges and accounting for 10%–20% of all brain tumors. They have a uniform age distribution which mostly peaks in midlife. Meningiomas are more frequently seen in women than men. Ependymomas usually expand locally along the ependymal space and disseminate through cerebrospinal fluid (CSF) space. However, in recent times with robust evidence role of radiotherapy is only local deferring spinal radiotherapy even in high-risk spaces with negative spinal scan and negative CSF cytology. Schwannomas are generally benign tumors of cranial nerves and account 8%–10% of brain tumors. They are also seen twice more common in women than men. There is very rare incidence of cases such as hemangiopericytomas, gliosarcoma, and primitive neuroectodermal tumor (PNET) seen in daily practice.
| > Materials and Methods|| |
There have been a lot of epidemiological studies until date still there is no common consensus on the intensity and nature of risk factors for primary brain tumors. The role of genetics is also playing an important role in the etiology of primary brain tumors like other malignancies too. As the environmental factors are concerned, therapeutic ionizing radiation is the only established risk factor for brain tumors. There is also considerable concern over the health effects of using cellular telephones, as a risk factor for the development of brain tumors; however, studies have failed to establish significant association until date.
We conducted this study to see the different histological type's brain tumor presentation at our center. We also evaluated their prognosis by calling them to the hospital or taking history and updates telephonically. We evaluated 497 patients treated at our center from 2007 to 2012 of different histological types. Out of these 497 patients, 478 patients were adults signifying more adult presentation of brain tumors. Out of these 497 patients, there was more predisposition for males accounting for 344 patients. All the patients underwent complete CNS examination and extensive workup including confirmation of histological type by biopsy. These patients were then treated with surgery followed by radiotherapy or upfront curative radiotherapy as per staging and institutional protocol. These patients were then kept on regular follow-up with clinical and radiological intervention as per protocol. Those patients who could not come physically to the hospital were then contacted telephonically to assess the survival rates. Since these histological types vary completely different from each other regarding presentation, treatment, and prognosis the survival rates were assessed separately from 3 months to 7-year survival, maximum survival noted.
The major bulk of brain tumors were astrocytomas, 309 patients in total and major of these were Grade IV astrocytomas (glioblastoma multiforme) 240 patients followed by 41 patients of Grade II astrocytoma (fibrillary astrocytoma), 15 patients of Grade III astrocytomas (anaplastic astrocytomas), and finally, 13 patients of Grade I astrocytoma (pilocytic astrocytoma). These astrocytoma patients underwent surgery which was from minimal to maximum like only biopsy (in eloquent areas or dominant hemispheres), subtotal or near total resection, and gross total excision (nearly impossible as aggressive total excision surgeries lead to normal brain injury while operating). These patients were then radiated to total dose of 54 Gy (Gray) (low grade) to 60 Gy (high grade) depending on the grade of disease. Glioblastoma multiforme and Grade III astrocytomas (anaplastic astrocytomas) were also given concurrent and adjuvant chemotherapy as per protocol.,, The next order of common presentation was pituitary adenomas total 39 patients out of which in 17 patients stereotactic radiotherapy (SRT) treatment was done. SRT was done in 15 patients, and stereotactic radiosurgery (SRS) was done in 2 patients. Next in order were Oligodendrogliomas seen in 33 patients in total comprising of 12 patients each in grade II and grade III followed by 5 patients of grade I and 4 patients of grade IV. All these patients underwent surgery first followed by radiotherapy as per astrocytoma module. Medulloblastomas were seen in 22 patients with more males and children at presentation. These tumors were also treated with a combination of surgery and radiotherapy. The radiotherapy given here is craniospinal irradiation as there is a high chance of relapses at neuraxis. AVMs were seen in 19 patients, and the treatment mostly is surgery except in eloquent and deep-seated places where surgical excision is not possible, and hence, radiotherapy was given. In certain cases, patients were also taken for embolization first followed by low-dose radiotherapy used as sclerosing dose., Mostly, these patients were treated with stereotactic conformal treatment – SRS in 18 patients with dose of nearly 18–24 Gy depending on the size of nidus having excellent complete obliteration rate of 95%–100%. Patients of AVM who were operated and not included in this study had comparatively more complication rates signifying SRT treatment as safer and noninvasive method. Craniopharyngiomas were seen in 16 patients in which SRT was done in 6 patients. At our center, we do frame-based SRT treatment on linac (X knife) with Gill Thomas Cosman frame in SRT and Brown-Robert-Wells frame in SRS treatment. There were 9 patients of CNS lymphomas and they being sensitive to chemotherapy and radiotherapy were treated with combination of radiotherapy and chemotherapy. Meningiomas were seen in 8 patients with more predilection in females (seven patients) as seen in a review of literature too. There were few representation of other brain tumors such as melanocytoma (eight patients), ependymomas (seven patients), schwannomas (six patients), hemangiopericytomas (four patients), gliosarcoma (three patients), and PNET (two patients). All the above minor representing tumors were operated at first place followed by radiotherapy accordingly.
| > Results|| |
These patients after thorough workup were treated according to institutional protocol. They were treated with two-dimensional (2D) radiotherapy planning in the majority of cases with stereotactic planning done in 62 patients. The stereotactic planning included SRS in 32 and SRT in 30 patients. The major bulk of presentation was astrocytomas where out of total 309 patients, 211 patients were male, and 98 were female. Glioblastoma multiforme had the worst prognosis, and pilocytic astrocytomas had the best prognosis. The details of the sex representation are seen in [Graph 1].
Next in order of presentation were pituitary adenomas, 39 patients in total – 31 males and 8 females. These benign tumors had the best prognosis and were treated with best conformal stereotactic treatment. This information is also displayed in [Graph 1]. Oligodendrogliomas were seen in 33 patients with the majority being males (21 patients). The prognosis was better in low grades as compared to high grades and much better when compared to astrocytomas. Medulloblastomas were more common in males 17 out of 22 patients. Majority were children, and since these tumors have a high propensity of seedling in the spine, they were treated with best possible excision of brain lesion with radiation to the entire cerebrospinal axis. AVM was seen in 19 patients, and good obliteration rates were achievable with stereotactic treatment reflecting good survival rates. Craniopharyngiomas were seen in a total of 16 patients with good prognosis as displayed in [Graph 2]. There were few recurrent brain tumors seen in 12 patients. Most of these tumors were low-grade astrocytomas in the past and due to neoplastic transformation turned into higher grades (4–10 years) with worse prognosis in mere months. CNS lymphomas were seen in total 9 patients with fair response to chemotherapy and radiotherapy. Meningiomas were seen in total 8 patients out of whom 7 were females. All these tumors have fair prognosis mostly being low grades and best treated with surgery and radiotherapy. Ependymoma was seen in 7 patients and prognosis is good even when patients were treated with local fields only without spinal radiotherapy in high-risk cases with documented spinal magnetic resonance imaging and CSF cytology negative. Schwannomas were seen in 6 patients and as being benign were treated with stereotactic treatment – SRS done in 5 patients with good results. Rest all minor presentations including melanocytomas, hemangiopericytomas, gliosarcoma, and PNET have their data represented in [Graph 2].
| > Discussion|| |
We conducted this study for assessing the brain tumor data at our hospital and correlating with literature the presentation as well as the prognosis of brain tumor patients at our center. The most apparent feature which became obvious was the major bulk of presentation in brain tumor patients are the males and adult patients at presentation. The data of the patients treated over the past 5 years have also shown an increasing trend of brain tumor incidence with no direct causal factor found.
Our majority of patients were planned with 2D radiotherapy planning with acceptable results. The results as seen in [Graph 2] suggest similarity regarding prognosis of various histologies as seen in review of literature implying 2D radiotherapy planning as acceptable and adequate modality of treatment for majority of patients' at least in our set up like regional cancer center where balancing workload, resources, and workforce is a major area of concern. Few of the patients were also offered stereotactic conformal treatment including SRS and SRT. Stereotactic conformal treatment allows best conformality with reduced toxicities and is the best option that can be offered to patients expected with best prognosis such as pituitary adenoma, craniopharyngiomas, and AVM. We in the future would also like to study the change in histological type presentation if any as compared to the past years and the relationship of environmental factors most commonly being the cell phone usage. Until date, there has been no causal relationship between the use of cell phones and brain tumors incidence, but the increasing incidence of brain tumors patients makes many questions of change in patterns unanswered.,
| > Conclusion|| |
Astrocytomas are the major representation in brain tumors with high grades more at presentation and glioblastoma multiforme fairing the worst prognosis. Other tumors have their presentation as seen in literature and best managed with multidisciplinary approach including neurosurgeon, radiation oncologists, medical oncologists, neurophysicians, radiologists, psychiatrists, radiographers, and other staff members including nurses and social workers. Other benign tumors such as pituitary adenomas, schwannomas, and craniopharyngiomas had the best prognosis with survival seen up to almost last follow-up. We would like to do extended follow-up of this study again to see difference in histological types if any.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| > References|| |
Ostrom QT, Gittleman H, Farah P, Ondracek A, Chen Y, Wolinsky Y, et al
. CBTRUS statistical report: Primary brain and central nervous system tumors diagnosed in the United States in 2006-2010. Neuro Oncol 2014;16:760.
Vuorinen V, Hinkka S, Färkkilä M, Jääskeläinen J. Debulking or biopsy of malignant glioma in elderly people – A randomised study. Acta Neurochir (Wien) 2003;145:5-10.
Gorlia T, van den Bent MJ, Hegi ME, Mirimanoff RO, Weller M, Cairncross JG, et al.
Nomograms for predicting survival of patients with newly diagnosed glioblastoma: Prognostic factor analysis of EORTC and NCIC trial 26981-22981/CE.3. Lancet Oncol 2008;9:29-38.
Stupp R, Mason WP, van den Bent MJ, Weller M, Fisher B, Taphoorn MJ, et al.
Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N Engl J Med 2005;352:987-96.
Mirimanoff RO, Gorlia T, Mason W, Van den Bent MJ, Kortmann RD, Fisher B, et al.
Radiotherapy and temozolomide for newly diagnosed glioblastoma: Recursive partitioning analysis of the EORTC 26981/22981-NCIC CE3 phase III randomized trial. J Clin Oncol 2006;24:2563-9.
Stupp R, Hegi ME, Mason WP, van den Bent MJ, Taphoorn MJ, Janzer RC, et al.
Effects of radiotherapy with concomitant and adjuvant temozolomide versus radiotherapy alone on survival in glioblastoma in a randomised phase III study: 5-year analysis of the EORTC-NCIC trial. Lancet Oncol 2009;10:459-66.
Buckner JC, Shaw EG, Pugh SL, Chakravarti A, Gilbert MR, Barger GR, et al.
Radiation plus procarbazine, CCNU, and vincristine in low-grade glioma. N Engl J Med 2016;374:1344-55.
Okamoto Y, Di Patre PL, Burkhard C, Horstmann S, Jourde B, Fahey M, et al.
Population-based study on incidence, survival rates, and genetic alterations of low-grade diffuse astrocytomas and oligodendrogliomas. Acta Neuropathol 2004;108:49-56.
Packer RJ, Rood BR, MacDonald TJ. Medulloblastoma: Present concepts of stratification into risk groups. Pediatr Neurosurg 2003;39:60-7.
Pollock BE, Garces YI, Stafford SL, Foote RL, Schomberg PJ, Link MJ, et al.
Stereotactic radiosurgery for cavernous malformations. J Neurosurg 2000;93:987-91.
Maruyama K, Kawahara N, Shin M, Tago M, Kishimoto J, Kurita H, et al.
The risk of hemorrhage after radiosurgery for cerebral arteriovenous malformations. N Engl J Med 2005;352:146-53.
Milker-Zabel S, Debus J, Thilmann C, Schlegel W, Wannenmacher M. Fractionated stereotactically guided radiotherapy and radiosurgery in the treatment of functional and nonfunctional adenomas of the pituitary gland. Int J Radiat Oncol Biol Phys 2001;50:1279-86.
Stripp DC, Maity A, Janss AJ, Belasco JB, Tochner ZA, Goldwein JW, et al.
Surgery with or without radiation therapy in the management of craniopharyngiomas in children and young adults. Int J Radiat Oncol Biol Phys 2004;58:714-20.
DeAngelis LM, Seiferheld W, Schold SC, Fisher B, Schultz CJ; Radiation Therapy Oncology Group Study 93-10, et al.
Combination chemotherapy and radiotherapy for primary central nervous system lymphoma: Radiation Therapy Oncology Group Study 93-10. J Clin Oncol 2002;20:4643-8.
Ferreri AJ, Abrey LE, Blay JY, Borisch B, Hochman J, Neuwelt EA, et al.
Summary statement on primary central nervous system lymphomas from the eighth international conference on malignant lymphoma, Lugano, Switzerland, June 12 to 15, 2002. J Clin Oncol 2003;21:2407-14.
Debus J, Wuendrich M, Pirzkall A, Hoess A, Schlegel W, Zuna I, et al.
High efficacy of fractionated stereotactic radiotherapy of large base-of-skull meningiomas: Long-term results. J Clin Oncol 2001;19:3547-53.
Flickinger JC, Kondziolka D, Niranjan A, Maitz A, Voynov G, Lunsford LD, et al.
Acoustic neuroma radiosurgery with marginal tumor doses of 12 to 13 Gy. Int J Radiat Oncol Biol Phys 2004;60:225-30.
Bassal M, Mertens AC, Taylor L, Neglia JP, Greffe BS, Hammond S, et al.
Risk of selected subsequent carcinomas in survivors of childhood cancer: A report from the childhood cancer survivor study. J Clin Oncol 2006;24:476-83.
Interphone Study Group. Brain tumour risk in relation to mobile telephone use: Results of the INTERPHONE international case-control study. Int J Epidemiol 2010;39:675-94.
Hardell L, Carlberg M, Hansson Mild K. Pooled analysis of case-control studies on malignant brain tumours and the use of mobile and cordless phones including living and deceased subjects. Int J Oncol 2011;38:1465-74.
Bauman G, Yartsev S, Coad T, Fisher B, Kron T. Helical tomotherapy for craniospinal radiation. Br J Radiol 2005;78:548-52.