PATTERN OF CENTRAL NERVOUS SYSTEM NEOPLASMS: A STUDY OF 106 CASES

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1 JK-Practitioner volume 17 No. 4 October- December 2012 epidemiology PATTERN OF CENTRAL NERVOUS SYSTEM NEOPLASMS: A STUDY OF 106 CASES Tamkeen Masoodi, Ram Kumar Gupta, J. P. Singh, Arvind Khajuria. Tamkeen Masoodi, M.D. Pathology, Ram Kumar Gupta, Associate Professor, Department of Pathology,,Arvind Khajuria, Prof. and Head Department of Pathology; J. P. Singh, Consultant Neuro Surgeon. ASCOMS & Hospital, Sidhra, Jammu. Correspondence: Dr. Tamkeen Masoodi Senior Resident, Department of Pathology SKIMS, Srinagar Tel Abstract The study comprised of 106 cases of central nervous system neoplasms. The age of the patients ranged from 4 to 82 years with a mean age of years. Maximum number of cases (47.1%) were seen in the age group between years. Overall males were slightly more frequently affected than females, the male: female being 1.12:1.CNS neoplasms occurred predominantly intracranially in 86.8% cases and spinal tumors constituted 13.2% cases. The commonest presenting symptoms were headache (60.3%), motor weakness (35.8%) and seizures (31.1%). Frontal lobe was the commonest intracranial site (20.7%) and dorsal region, the most frequently (42.9%) involved site in spinal cord. Tumors of the neuroepithelial tissue were the commonest comprising 53.7%. Astrocytic tumors were the commonest neuroepithelial tumors (77.1%) with glioblastoma forming the largest subtype of astrocytic tumors (40.9%) with a mean age at diagnosis being 50 years. JK-Practitioner 2012;17(4): Key Words: Central nervous system (CNS), tumor, intracranial, spinal cord 42

2 INTRODUCTION s u b j e c t s o f s t u d y. For the retrospective 4 years, the Central nervous system neoplasms represent a unique, histopathological reports maintained in the heterogenous population of neoplasms and include both histopathology section of the department were reviewed benign and malignant tumors. The tumors of central and hematoxylin and eosin stained slides of every cases nervous system are reported to be less than 2% of all re-examined. The clinical information was obtained 1 malignancies.in India, tumors of the CNS constitute from the case records of the patients retrieved from the 2 about 1.9% of all tumors.the age distribution of CNS department of Neurosurgery. For the prospective 1 year, tumors is said to be bimodal,one peak in children and after assessing the gross features of the specimen 3 then second peak in years of age.males are received, adequate representative areas were taken and involved more frequently, meningiomas being an processed under standardized conditions for paraffin exception with higher rates in females. Heritable embedding. The sections were stained with H & E. syndromes and ionizing radiations are the only two Histological characterization of the tumors was done as 4 5 established causes of primary CNS neoplasms.the per WHO classification. signs and symptoms of intracranial tumors depend on the size of tumor, its location and its rate of growth. RESULTS According to the WHO classification tumors of CNS During this study 106 cases of CNS neoplasms were comprise more than 50 clinico-pathological found. Patients age ranged from 4 to 82 years with a 5 entities.the major categories include the tumors of mean age of 43.3 years. Peak incidence was in neuroepithelial tissue, cranial and paraspinal nerves, years of age and majority of cases (47.1%) were seen meninges, sellar region, lymphomas and between years age group. Age wise distribution of haematopoietic neoplasms, germ cell and metastatic different tumor types is shown in Table 1. Males slightly tumors. The present study was conducted with a view to outnumbered females with a male to female ratio of have insight into the pattern of CNS neoplasms in our 1.12:1.However the male to female ratio in case of region due to rarity of study on the subject. meningioma was 1:4.25. Majority of the tumors were intracranial, 92 cases (86.8%) whereas the remaining 14 MATERIAL AND METHODS (13.2%) were spinal. Of the intracranial cases 82 The study was conducted in the Postgraduate (89.1%) were supratentorial and 10 (10.9 %) were Department of Pathology in collaboration with infratentotrial. Majority of the cases were found in Department of Neurosurgery,Acharya Shri Chander cerebrum. Frontal lobe was the commonest intracranial College of Medical Sciences and Hospital, Sidhra, site involved (20.7%) and dorsal region was the most Jammu over a period of 5 years from November 2005 to frequently (42.9%) involved site in spinal cord. Site of October 2010 (retrospective period of 4 years and different tumor types in brain is shown in Table 2. prospective period of 1 year).106 cases of CNS Headache was the most common symptom (69.6%) neoplasms reported during this period comprised the encountered in intracranial tumors followed by seizures Table 1: Histological types of CNS neoplasms Histology Male Female Total % Astrocytoma Oligodendroglioma Ependymoma Oligoastrocytoma Medulloblastoma Meningioma Schwannoma Pituitary adenoma Craniopharyngioma Lymphoma Haemangiopericytoma Total % 43

3 Table 2: Age wise distribution of different tumor types. Histology = >70 Total yrs yrs Astrocytoma Oligodendroglioma Ependymoma Oligoastrocytoma Medulloblastoma Meningioma Schwannoma Pituitary adenoma Craniopharyngioma Lymphoma Haemangiopericytoma Histology Table 3: Clinical presentation of different tumor types Headache Vomiting Astrocytoma Oligodendroglioma Ependymoma Oligoastrocytoma Medulloblastoma Meningioma Schwannoma Pituitary adenoma Craniopharyngioma Lymphoma Haemangiopericytoma Weakness Seizure Table 4: Site wise distribution of tumor-brain Site No. of cases Visual Disturbance % Frontal lobe Parietal lobe Temporal lobe Occipital lobe Multilobe involvement Cerebellum Sellar/Suprasellar Cerebellopontine angle Thalamus Hypothalamus Other sites Total % Cranial Nerve Palsy Sensory Disturbance Papilledema 44

4 Fig. 1: Astrocytoma Grade IV abutting normal brain tissue (H&E X 100) epidemiology Fig.2: Psamommatous meningioma, showing numerous psammomatous calcifications. (H&E X 100) (35.9%), visual disturbances (29.3%),weakness limbs (Cerebellopontine angle).all the CP angle tumors (28.3%),sphincter disturbance(8.7%) and personality presented with hearing loss and 6 of the 7 spinal cases changes (3.3%).Spinal cord tumors mostly presented presented with motor weakness. Histologically the with weakness limbs(85.7%),followed by pain (57.1%) neoplasm showed either Antoni A pattern or a mixture of and sphincter disturbance (21.4%).Table 3 depicts the Antoni A and Antoni B patterns. clinical presentation of different tumor types. In an 5 cases of ependymoma were seen, 2 being intracranial overall study of both brain and spinal cord tumors, and 3 spinal. Two of the spinal cases were of astrocytoma was the commonest tumor(41.50%) myxopapillary type located in filum terminale. followed by meningioma (19.81%), pituitary adenoma Medulloblastoma constituted 3.8% (4 cases) of all CNS (11.32%), schwannoma (11.32%), ependymoma neoplasms, out of which 3 cases were seen in children ( % ), m e d u l l o b l a s t o m a ( % ), and 1 in adult. Histologically all the cases showed oligodendroglioma (2.84%), lymphoma (1.89), classic pattern. oligoastrocytoma (0.94%), craniopharyngioma Oligodendroglial tumors were reported in 3 cases, one (0.94%), haemangiopericytoma (0.94%) as shown in being grade II and two grade III. All cases were seen in Table4. Astrocytoma comprising of 44 cases (45.1%) females in the age range of years. 2 cases constituted the largest group of the present study. constituting 1.8% of all CNS neoplasms were diagnosed Regarding astrocytoma, 2 (4.5%) were WHO grade I,12 as Primary CNS lymphomas. Both were seen in elderly (27.2%) WHO grade II, 12 (27.2%) WHO grade III and males. Histologically both were Non-Hodgkin 18 (40.9%) WHO grade IV (glioblastoma).maximum Lymphoma one diffuse large cell type and other small number of cases (75%) were seen in years age cell type. 1 case each of oligoastrocytoma grade II, group. Frontal lobe was the most common site of craniopharyngioma and haemangiopericytoma was involvement by these tumors. Meningioma comprised seen. the second most common group of tumors involving CNS constituting 19.8% of all tumors. Out of 21 cases of DISCUSSION meningioma,18 were intracranial and 3 spinal.20 cases Tumors of the central nervous system are rare showed histological features of grade I of WHO and neoplasms constituting less than 2% of all malignancies. only one case showed grade II (atypical) histology. Male Bimodal peak of CNS tumors is reported, one in to female ratio was 1:4.25.Headache was the most children and other in years age group. This was common presenting symptom seen in 57.14% of cases. not observed in our study which may be due to less 12 cases of pituitary adenomas were seen.age ranged number of cases. However the peak incidence was seen from years. Headache and visual disturbances between years and majority of cases (47.1%) were the commonest presenting symptoms seen in 75% 6, 7 were seen between years similar to other studies of patients. Half of the patients (6 cases) had functioning. Males are affected more than females, meningiomas and other half (6 cases) non-functioning tumors. Out of being an exception with higher frequency in females. 6 hormonally active tumors,4 had hyper-prolactinemia We also found a slight male predominance though less and 2 growth hormone excess.3 out of 4 females 6, 7, 8, 9 as compared to others.meningiomas were more presented with ammenorhea,2 males had acromegalic common in females with a male to female ratio of 1: , 11, 12 features and 1 male presented with infertility. as observed by others. Histologically they showed either a diffuse, Intracranial cases constituted 86.8% and spinal 13.2% 2,13 trabeculated or papillary pattern. Out of 12 cases of similar to that observed by other studies.frontal lobe schwannoma, 7 were spinal and 5 intracranial 45 was the commonest site (20.7%) of involvement in brain

5 tumors This is in agreement to the findings of Torres et Journal of Neurosurgery 1982 Apr; 56(4): al, Andrews et al, Jalali and Datta and Jamal et al 7. Jamal S, Mamoon N, Mushtaq S,et al. Pattern of.dorsal region was the most frequently (42.9%) Central Nervous System (CNS) Tumours: A study of 2,15 involved site in spinal cord as observed by others. 430 cases. Pak J Pathol 2005; 16(4): In the present study astrocytomas were the commonest 8. Patty I S H. Central Nervous System Tumors: A tumors (44 cases) constituting 41.5% of all CNS Clinicopathologic Study. J Dohuk Univ 2008; 11(1): neoplasms. Ahmed et al, Ghosh et al, Jalali and Datta and Patty also reported astrocytomas to be the 9. Jalali R, Datta D. Prospective analysis of incidence of commonest tumors in their respective studies. However central nervous system tumors presenting in a tertiary Das et al, Suh et al and Lee at al observed that cancer hospital from India. J Neurooncol 2008; 87: meningiomas made up the largest subgroup of their studies.among astrocytomas,glioblastoma were the 10. Rohringer M, Sutherland GR, Louw DF, et al. commonest (40.9%) similar to that observed by other Incidence and clinicopathological features of 14,16 workers. meningioma. Journal of Neurosurgery 1989 Nov; Meningiomas were the second commonest tumors (21 71(5): cases) constituting 19.8% of all CNS neoplasms. 11. Das A, Chapman C A T, Yap W M. Histological Similar observations were made by Iyengar and subtypes of symptomatic central nervous system Chandra, Wen-quing et al, Ahmed et al and Patty. tumours in Singapore. J Neurol Neurosurg Psychiatry 12 cases (11.3%) of pituitary adenomas were reported 2000; 68: similar to that reported by Das et al.ependymoma 12. Hadidy AM, Nadi MM, Ahmad TM, et al. constituted 4.5% of all CNS neoplasms which is Descriptive epidemiological analysis, MRI signals comparable to 4.3% and 3.96% incidence reported by intensity and histopathological correlations of 16 7 Ahmed et al and Jamal et al.medulloblastoma meningiomas. Neurosciences (Riyadh) 2010 Jan; constituted 3.8% of all CNS neoplasms which is 15(1):11-4. agreeable to 4.4% and 3.2% incidence reported by 13. Andrews NB, Ramesh R, Odjidja T.A prelimnary 16 8 survey of central nervous system tumors in Tema, Ahmed et al and Patty.Oligodendroglial tumors Ghana. West Afr J Med 2003 Jun; 22(2): represented 2.8% of the CNS neoplasms which is Torres LF, Almeida R, Avila S, et al. Brain tumours in similar to that reported by Jalali and Datta. CNS south Brazil: a retrospective study of 438 cases. Arq lymphoma constitutes.8 to 1.5 and in some series even 20 Neuropsiquiatr 1990 Sep;48(3): up to 6.6% are reported.we found CNS lymphoma to 15. Gelabert-Gonzalez M. Primary spinal cord tumours. be 1.89% of all tumors An analysis of a series of 168 patients. Rev Neurol 2007 Mar 1-15;44(5): References 16. Ahmed Z, Muzaffar S, Kayani N, et al Histological 1. Stewart BW, Kleihues P. Tumors of the nervous pattern of central nervous system neoplasms. J Pak system In: World Cancer report. IARC Press, Lyon, Med Assoc 2001 Apr; 51(4): France Ghosh A, Sarkar S, Begum Z, et al. The first cross 2. Iyenger B, Chandra K. The pattern of distribution of sectional survey on intracranial malignancy in tumors in the brain and spinal cord. Ind J Cancer 1974; Kolkata, India: reflection of the state of the art in 11: Southern West Bengal.Asian Pac J Cancer Prev 3. Lantos PL, Louis DN, Rosenblum MK, et al. Tumours 2004;Jul-Sep ;5(3): of the nervous system. In: Graham DI, Lantos PL, eds, th 18. Suh YL, Koo H, Kim TS, et al. Tumors of the central Greenfield's Neuropathology,7 ed., Arnold, London, nervous system in Korea: a multicentre study of cases. J Neurooncol 2002; 56: Preston-Martin S. Epidemiology of Primary CNS 19. Lee CH, Jung KW, Yoo H, et al. Epidemiology of neoplasms. Neurol Clin 1996; 14(2): primary brain and central nervous system tumors in 5. Louis DN, Ohgaki H, Weistler OD, et al. The 2007 Korea. J Korean Neurosurg Soc.2010 Aug; 48(2) WHO classification of Tumours of the Central : Nervous System. Acta Neuropathologica 2007 Aug; 20. Miller D, Hochberg FH, Harris NL, et al. Pathology 114(2): with clinical correlations of Primary Central Nervous 6. Wen-qing H, Shi-ju Z, Qing-sheng T,et al. Statistical System Non-Hodgkin's Lymphoma. Cancer analysis of central nervous system tumors in China. 1994;74: