pathology of brain tumors the subregional experience
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PATHOLOGY OF BRAIN TUMOURS - THE SUBREGIONAL
EXPERIENCEE.E.U. AKANG, MBBS
Professor of Pathology, University of Ibadan, NigeriaConsultant Pathologist, Department of Pathology, University
College Hospital, Ibadan, Nigeria
CLINICAL NEUROSCIENCE REVIEW CONFERENCEAUGUST 8 - 10, 2011
IBADAN, NIGERIA
E k’abo! Welcome to Ibadan!
Introduction 1• Central nervous system (CNS) tumours
are a diverse group of neoplasms• Each neoplasm has distinctive biology,
treatment and prognosis• High-grade CNS neoplasms are among
the most aggressive and intractable types of cancer
Introduction 2•Cancer is the leading cause of death in developed and the 2nd most common cause in developing nations•Age-standardised mortality rates for CNS tumours is 3.6 in developed and 2.9 per 100,000 in developing nations
Historical background•CNS tumours were believed to be rare in native Africans up until half a century ago•Expanding general/specialist medical services have led to increasing recognition of CNS tumours•Most of the early reports from the sub region have been clinical neurosurgery series
144 million population35,000 medical doctors<500 pathologistsPer capita (p.c.) income $300Health budget $50 p.c.
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307 million population814,000 medical doctors* *How many of these are Nigerians?20,000 pathologists*Per capita (p.c.) income $39,000Health budget $2,250 p.c. 6
Early studies in Africa•Necropsy-based studies were the 1st reports of CNS tumours in tropical Africa•Strachan, 1934- South Africa- less common in Bantus than other races•Davies, 1957- 6 gliomas among 2162 PMs- not uncommon•Jackson & Okubadejo, 1963- well-illustrated report of 13 CNS tumours among 3489 PMs- uncommon
MeningiomaWAMJ 1963; 12:251-263
3 meningiomas
2 astrocytomas
2 pituitary adenomas
1 pinealoma
WAMJ 1963; 12:251-263Case reported as medulloblastoma
14 yr F- left frontal lobe mass
Could this be a PNET or an anaplastic astrocytoma?
3 cases of medulloblastoma- 14 yr F- frontal lobe; 30 yr M- Lt thalamus, cerebellum and midbrain; 4 yr F- basal ganglia and optic n.
WAMJ 1963; 12:251-263Case reported as ependymoma
15 year old male with fibrosarcoma of thigh with lung metastases and dura based intracranial tumour
Later studiesOdeku & Janota 1967- 3 yrs after establishment of Neurosurgery at UCH, Ibadan- “not so rare”48 intracranial masses 44 neoplasms; neurogenous neoplasms (47.7%), meningiomas (22.9%), sellar region (15.9%)
Ohaegbulam et al 1980- 43 intracranial neoplasms from EnuguGliomas (23.2%), sellar region (20.9%), meningioma (18.6%)
Other early African studies• Kasili et al 1971- Kenya 97 intracranial tumours; gliomas 45%, meningiomas
28%• Collomb et al 1973- Senegal187 intracranial neoplasms and 33 inflammatory
masses Gliomas, meningiomas, sellar region tumours• Sorour et al 1973- EgyptTwo series 291 clinical and 377 autopsyGliomas, meningiomas- high incidence
Ibadan- 1980-1997East Afr Med J 2000; 77:1-5
Olasode et al 2000- 2nd and 3rd generations of Ibadan neurosurgeons210 histologically confirmed CNS neoplasms- 135 (64.3%) adults & 75 (35.7%) childrenGliomas most common, followed by metastases (choriocarcinoma and Burkitt’s lymphoma)Sellar region tumours predominate in children
Ibadan- 1991-2007Sahabi 2008- 3rd generation of Ibadan neurosurgeonsProgressive increase in CNS tumour rates356 histologically confirmed CNS neoplasms- 264 (74.2%) adults & 92 (25.8%) childrenGliomas most common, followed by meningiomas. Female predominance in meningiomas; Reduced metastases, with decline in choriocarcinoma
Sahabi, 2008
Gender distribution among tumour groups
Pilocytic astrocytomaSahabi, 2008
Gemistocytic astrocytomaSahabi, 2008
Anaplastic astrocytomaSahabi, 2008
OligodendrogliomaSahabi, 2008
Meningiomas-Sahabi, 2008
HISTOLOGICAL TYPES
HISTOLOGICAL SUBTYPES
WHO GRADETOTAL
I II III
Meningioma
Secretory 3 0 0 3Anaplastic 0 0 7 7Atypical 0 3 0 3Angiomatous 2 0 0 2Psammomatous 5 0 0 5Meningothelial 21 0 0 21Fibroblastic 8 0 0 8Transitional 45 0 0 45
Mesenchymal tumours Haemangiopericytoma 0 3 1 4
Other Haemangioblastoma 3 0 0 3TOTAL 87 6 8 101
Odebode et al, 2002Unpublished observations
Morphological variants
Nigeria(1972)N=38
Nigeria (2002)N=60
Turkey (1997)N=203
S’Arabia (1996)N=131
Canada (1983)N=114
USA (1982)N=51
Norway (1974)N=256
Transitional - 55 19 23 42.1 37.3 6Meningothelial 44.7 26.6 30.5 34 34.2 35.3 52
Psammomatous 23.7 1.7 7 3 - 9.8 -Fibrous 7.9 1.7 26 23 20.2 7.8 14Angiomatous 5.3 1.7 3.5 5 0.9 - 5
Mixed patterns 18.4 - - - - - 23
Sclerosing - - - 10.7 - - -
Chordoid - - - 0.8 - - -
Hemangiopericytoma - 8.3 - - - - -
Papillary - - - - - 9.8 -
Anaplastic - 5.0 13 - 2.6 - -
Atypical - - 1 - - - -
Meningioma- secretorySahabi, 2008
Meningioma- transitionalSahabi, 2008
CraniopharyngiomaSahabi, 2008
Metastatic CNS neoplasmsSahabi, 2008
Metastatic choriocarcinomaSahabi, 2008
Lagos University Teaching Hospital
LAGOS- 2001-2011Awelimobor 2011- 1st and 2nd generation of Lagos neurosurgeonsProgressive increase in CNS tumour rates110 CNS neoplasms- 76.4% adults & 23.6% childrenMeningioma (30.9%), pituitary adenoma (20%) and astrocytic tumours (19%). Metastases in 3.5%.
CraniopharyngiomaAwelimobor, 2011
PAEDIATRIC CNS NEOPLASMS 1
• Age standardised incidence rates for childhood CNS neoplasms is 25-40 per 106 in developed countries and <15 per 106 in developing nations• Due partly to under ascertainment
and partly to racial factors
PAEDIATRIC CNS NEOPLASMS 2IBADAN•Aghadiuno et al- 89 CNS neoplasms (1960-1982)- Astrocytoma, medulloblastoma, ependymoma and oligodendroglioma•Olasode- astrocytoma, craniopharyngioma and medulloblastoma•Overall increase with fewer Burkitt’s casesENUGU- Izuora et alCraniopharyngioma (38%), astrocytoma and medulloblastoma (14% each)
PAEDIATRIC CNS NEOPLASMS 3
• Karkouri et al reviewed 542 CNS neoplasms in Morrocco
• Astrocytoma and medulloblastoma were most common
• Emphasised the need for population based registry to assess true burden of these neoplasms
INTRAOPERATIVE CONSULTATIONA primary role of pathologist in patient management-Gross examination-Frozen section-CytologyAwelimobor 2011- 100% concordance rate between cytological and frozen section diagnosis, as well as between frozen section and routine paraffin embedded tissue diagnosis
Glioblastoma- cytology, Frozen section and permanent section
Awelimobor, 2011
Pituitary adenoma- cytology and frozen sectionAwelimobor, 2011
Meningioma- cytology, Frozen section and permanent section
Awelimobor, 2011
COMPARISON OF SELECTED AFRICAN SERIESTUMOUR TYPES
Ibadan 1957-1969N = 116*
Ibadan 1980-1990
N = 210
Ibadan 1991-2007
N = 356
Lagos 2001-2010
N = 110
Senegal 1960-1971
N = 187
Kenya 1968-1971
N = 97
Egypt 1956-1962N = 315*
Astro 15 (12.9) 53 (25.3%) 88 (24.7%) 21 (19.1%) 64 (34.2%) 33 (34%) 99 (31.4%)
Oligo 1 (0.9) 8 (3.8) 8 (2.2) 1 (0.9) 0 (0) 0 (0) 5 (1.6)
Ependymal 6 (5.2) 1 (0.5) 11 (3.1) 3 (2.7) 6 (3.2) 5 (5.2) 28 (8.9)
Choroid 0 (0) 0 (0) 1 (0.3) 2 (1.8) 3 (1.6) 1 (1) 3 (9.5)
Neuronal/Glial
0 (0) 0 (0) 8 (2.2) 0 (0) 0 (0) 0 (0) 0 (0)
Pineal 5 (4.3) 0 (0) 2 (0.6) 1 (0.9) 0 (0) 1 (1) 13 (4.1)
Embryonal 6 (5.2) 8 (3.8) 25 (7) 5 (4.5) 5 (2.7) 4 (4.1) 15 (4.8)
Cranial nerve
1 (0.9) 0 (0) 1 (0.3) 1 (0.9) 4 (2.1) 3 (3.1) 27 (8.6)
Meningeal 19 (16.4) 24 (11.4) 104 (29.2) 37 (33.6) 35 (15.9) 24 (24.7) 75 (23.8)
Lymphoma
0 (0) 0 (0) 1 (0.3) 0 (0) 0 (0) 0 (0) 0 (0)
Germ cell 2 (1.7) 3 (1.4) 1 (0.3) 0 (0) 0 (0) 0 (0) 0 (0)
Sellar region
24 (20.7) 55 (26.1) 78 (21.9) 31 (28.2) 14 (7.5) 13 (13.4) 28 (8.9)
Metastatic 21 (18.1) 48 (23) 31 (8.7) 5 (4.5) 26 (13.9) 10 (10.3) 14 (4.4)
CONCLUDING REMARKS•Pathologists in the sub region faces enormous challenges in terms of diagnostic facilities•Biologic characteristics of CNS neoplasms in developing countries have been discussed •Expansion of adult/pediatric neurologic/neurosurgical facilities requires increased sophistication of routine laboratory diagnostic methods•This can be facilitated by training and research linkages between centers in developing and developed countries.
LIST OF REFERENCES
Thanks for listening!Have a safe trip home!O d’abo!