Clinical review of pediatric pilocytic astrocytomas treated at a tertiary care hospital in Pakistan

Abstract Background: Pilocytic Astrocytoma (PA) is a common type of brain tumor in the pediatric population. They have a fairly good prognosis. This study describes PAs in detail, with a focus on the demographic factors, presenting features, management and prognosis, and aims, to identify the negative outcome predictors in our population, which can affect the course of the disease. This article will add to the understanding of PAs from a third world perspective. Methods: The Aga Khan University medical records (1995 – 2007) were reviewed, to study the clinical features, management, and outcome of patients (0 – 15 years) with Pilocytic Astrocytomas (PAs) in our population. After a thorough review of the medical records, all the PAs diagnosed on the basis of histopathology at our Pathology Laboratory, during this period, were included in the study. Results: Twenty-two patients were included with a mean age of 9.25 years. Male-to-female ratio was 1 : 1. The most common presenting feature was a sign of increased intracranial pressure. The most common location was the cerebellum followed by the cerebrum. Fifteen patients underwent maximum surgical resection. Three had recurrence, despite no residual tumor. There were 10 Intensive Care Unit (ICU) admissions and one inpatient mortality. Fifteen patients followed up in the clinic: Eight had recurrence and four underwent repeat surgery (three showed clinical improvement). Hydrocephalus was a predictor of ICU admission. Solid consistency was found to be a marker of recurrence. Conclusion: Pilocytic Astrocytomas are the most common pediatric brain tumors in our population, commonly located in the cerebellum. Complete resection is the best treatment option, but some tumors are aggressive and recurrence is not uncommon. The possible negative outcome predictors are age, source of admission, extent of resection, hydrocephalus, and solid consistency

Our Experience of Posterior Fossa Tumors Surgeries

Objective:  In Neurosurgery Unit III, Punjab Institute of Neurosciences, Lahore, we evaluated our posterior fossa tumor surgery results, complications, and surgical outcomes. Materials and Methods:  Between January 2017 and September 2021, 80 patients with posterior fossa tumors who underwent surgical excision at the Neurosurgery Department-III of the Punjab Institute of Neurosciences in Lahore were studied retrospectively. For each patient, the diagnosis was made clinically and confirmed radiologically and histopathologically. Results:  Males comprised 47 percent (37) of the 80 cases, while females made up 53 percent (43). The average age was 15 (with a range of 6 – 30 years). Medulloblastomas were the most frequent pathology in 25 patients (31%), followed by ependymomas in 21 patients (26%), pilocytic astrocytomas in 19 patients (24%), and hemangioblastomas in 7 individuals (8.8%). There were four cases of metastatic brain cancers (5%), two cases of choroid plexus papilloma (2.5%), one case of ganglioglioma (1.3%), and one case of Dermoid cyst (1.3%). In 90 percent of the cases (72 cases), gross total resection was obtained, while subtotal excision was performed in 10% of the cases (8 cases). The best results were seen in pilocytic astrocytoma surgery, followed by ependymoma surgery, whereas the worst results were seen in medulloblastoma surgery. Conclusion:  The surgical treatment of posterior fossa tumors still poses a significant challenge to neurosurgeons. Our experience shows that accepted results, complications, and surgical outcomes can be obtained by meticulous surgical techniques from previous clinical studies

Outcomes of Children With Low-Grade Gliomas in Low- and Middle-Income Countries: A Systematic Review

Purpose: Pediatric CNS tumors are increasingly a priority, particularly with the WHO designation of low-grade glioma (LGG) as one of six index childhood cancers. There are currently limited data on outcomes of pediatric patients with LGGs in low- and middle-income countries (LMICs). Methods: To better understand the outcomes of LGGs in LMICs, this systematic review interrogated nine literature databases. Results: The search identified 14,977 publications. Sixteen studies from 19 countries met the selection criteria and were included for data abstraction and analysis. Eleven studies (69%) were retrospective reviews from single institutions, and one (6%) captured institutional data prospectively. The studies captured a total of 957 patients with a median of 49 patients per study. Seven (44%) of the studies described the treatment modalities used. Of 373 patients for whom there was information, 173 (46%) had a gross total or near total resection, 109 (29%) had a subtotal resection, and 91 (24%) had only a biopsy performed. Seven studies, with a total of 476 patients, described the frequency of use of radiotherapy and/or chemotherapy in the cohorts: 83 of these patients received radiotherapy and 76 received chemotherapy. The 5-year overall survival ranged from 69.2% to 93.5%, although lower survival rates were reported at earlier time points. We identified limitations in the published studies with respect to the cohort sizes and methodologies. Conclusion: The included studies reported survival rates frequently exceeding 80%, although the ultimate number of studies was limited, pointing to the paucity of studies describing the outcomes of children with LGGs in LMICs. This study underscores the need for more robust data on outcomes in pediatric LGG

Complications Following Posterior Fossa Tumour Surgery in Children: Experience from a Tertiary Care Neurosurgical Facility in a Developing Country

Background: Posterior fossa tumours are the commonest childhood brain tumours with diverse clinical presentations, treatment modalities and postoperative outcomes. The literature has limited description of postoperative complications following surgery for these tumours. Objective: The aim of this study is to analyse the postoperative complications, which occur after PFT surgery in children. A brief overview of the in-hospital mortality and management of these complications presented. Materials and Methods: This is a retrospective chart review of children who were operated for PFTs. The occurrence of complications during the postoperative period was noted. Complications management, in-hospital mortality and overall survival was also recorded until the time of discharge. The complications are divided according to the modified Clavien-Dindo classification and outcome was stratified accordingly. Results: 79 (60.3%) males and 52 (39.7%) females with a mean age of 8.15 ± 3.3 years. The mean duration between symptoms onset and diagnosis was 35.3 ± 16.6 days. Overall, there were 53 (40.5%) cases of medulloblastoma, 40 (30.5%) cases of ependymoma, 34 (26.0%) cases of pilocytic astrocytoma and only 4 (3.1%) cases of atypical teratoid/rhabdoid tumours. Twenty-five (19.1%) patients developed hydrocephalous postoperatively. The most common complication was postoperative incisional CSF leak, which occurred in 17 (13.0%) patients. Wound infection was noted in 8 (6.1%) patients, eight (6.1%) of patients presented with cerebellar mutism, five (3.8%) patients had bleed in tumour bed, five (3.8%) patients had aspiration pneumonia and 7 (5.3%) patients developed hospital acquired pneumonia. The overall mean length of stay (LOS) was 5.4 ± 2.2 days (range: 3 – 12 days). The overall mortality rate was 9.9% (n = 13). Conclusion: The most common complication is the development of hydrocephalous, followed by cerebrospinal fluid leaks, cerebellar mutism, peri-tumour oedema, tumour bed haematoma and systemic complications such as meningitis, sepsis and postoperative pneumonia.&nbsp

Histopathological study of Gliomas and Evaluation of IDH – 1 Expression in Glioblastoma by Immunohistochemistry

INTRODUCTION: The recent WHO 2016 CLASSIFICATION OF CNS TUMORS incorporates molecular parameters for classification of gliomas. • Accordingly, all diffusely infiltrating gliomas (Grades II –IV) have been grouped together based on histopathological assessment and IDH – (Isocitrate dehydrogenase) mutation status. • IDH mutant, IDH wildtype- diffuse gliomas & glioblastomas are among the few new entities included in this classification. • Utility of assessment of IDH mutation status: • To identify reactive gliosis from gliomas in difficult cases. • To differentiate infiltrating and non infiltrative gliomas in adults. • IDH mutant gliomas are associated with better prognosis. • Can provide ground for novel treatment strategies targeting IDH mutations. AIMS AND OBJECTIVES: 1. To study the frequency of occurrence of gliomas in specimens received from Government Rajaji hospital, Madurai to the Department of pathology, Madurai Medical College. 2. To study the incidence in relation to age and sex in gliomas. 3. To study the histopathological classification of gliomas. 4. To analyse the expression of immunohistochemical marker Isocitrate dehydrogenase (IDH -1) in glioblastomas – utility in identifying glioblastomas with better prognosis. BACKGROUND OF STUDY: • Histopathological study to morphologically classify gliomas and to know the incidence of the same in a population of different age and sex. • Immunohistochemical marker study with IDH-1(R132H) as an independent predictor of better prognosis in gliobastomas. • Place of study: Madurai Medical College. • Study design: Prospective study. • Sample size: 50. INCLUSION CRITERIA: • Biopsy specimens of space occupying lesions (SOL) of brain EXCLUSION CRITERIA: • Benign tumors. • Neoplastic lesions other than gliomas. SUMMARY: In the present prospective study of 96 cases of brain SOLs, the following results were obtained: • Out of the 96 cases, 92% were neoplastic lesions and 97% were primary brain tumors. • Gliomas comprised of 50 cases out of the 96 brain SOLs and were the commonest among the primary CNS tumors. • Of the non glial tumors, meningiomas were the commonest constituting 28.2%. • The commonest glioma was glioblastoma accounting for 42%. • The most common age group affected by gliomas was 40-59 years with an overall frequency of 46% and the glioblastomas was 50 -59 years accounting for 38.1%. • Males had a definite sex predilection for both gliomas overall and glioblastomas specifically, accounting for 62% and 71.4% respectively. • The commonest location of all gliomas and glioblastomas in specific was the frontal lobe. • Unusual sites of distribution of gliomas were – corpus callosum and cerebellum. • The analysis of IDH1mutation showed IDH wild type glioblastomas as the most predominant, comprising 71.4% of the glioblastomas. The results were statistically significant with a p value of 0.0327 (p<0.05). • The most common sex affected in IDH1 mutant glioblastomas was male and the most common age group was 50-59 years. The results were statistically significant with a p value of 0.0464(p<0.05). • IDH wild type glioblastomas accounted for 26.7% of the seventh decade patients. • Frontal lobe was the predilected site for IDH1 mutant glioblastomas. The results were statistically significant with a p value of 0.028. • The analysis of EGFR mutation in all IDH wild type glioblastomas showed 40% positivity

Consensus guidelines for the management of primary supra-tentorial intraventricular tumour for low- and middle-income countries

Almost any primary or metastatic brain tumour can manifest in intraventricular (IV) locations. These tumours may either originate within the ventricular system or extend into the IV space through growth. Such neoplasms represent a broad spectrum, with supratentorial IV tumours forming a heterogeneous group. This group includes primary ependymal tumours, central neurocytomas, choroid plexus tumours, and notably, meningiomas, as well as a variety of non-neoplastic, benign, glial, and metastatic lesions that can secondarily invade the IV compartment. Often presenting with nonspecific symptoms, these tumours can lead to delayed medical attention. The diversity in potential diagnoses, combined with their deep and complex locations, poses significant management challenges. This paper aims to delineate optimal management strategies, underscoring the importance of multidisciplinary care, especially in settings with limited resources, to effectively navigate the complexities associated with treating intraventricular brain tumours. Keywords: Meningeal neoplasms, meningioma, neurocytoma, choroid plexus, neoplasms, intraventricular tumour, supratentorial tumours

An overview of central nervous system tumours

Central nervous system (CNS) tumours refer to tumours that occur in the tissues of the brain and/or spinal cord. These tumours arise as a result of abnormal growth of cells and may begin in different parts of the brain or spinal cord. There are many types of CNS tumours, which are further divided into subtypes. Despite decades of research conducted, CNS tumours remain among the deadliest of all cancers. It is most often challenging to treat these tumours, due to the risks involved, and biological characteristics associated with them. The classification, grading, and characterisation of CNS tumour plays a pivotal role in the management thereof. The current review provides an overview of CNS tumours, classification, grading and treatment, as well as their characterisation with specific focus on gliomas, ependymomas, oligodendrogliomas, meningiomas, medulloblastomas, schwannomas, gangliogliomas, and craniopharyngiomas.https://scimedjournal.org/index.php/SMJPharmacolog

Consensus guidelines for the management of brain stem and diffuse midline glioma for low- and middle-income countries

The understanding of brainstem gliomas and diffuse midline gliomas has significantly increased in the last decade. However, the management paradigm remains a dilemma. The critical location is the foremost factor dictating the outcome. Recent advancements in the field of neuro-oncology are pushing the boundaries of optimal care in the developed world nevertheless, the strategies in low- and middle-income countries (LMICs) need to be tailored according to the resources to improve outcome. The objective of these guidelines is to provide an algorithm-based management plan to cater challenges for healthcare providers in LMICs. Keywords: Algorithms, brain stem, glioma

A description of the profile of paediatric brain tumours in a tertiary neurosurgery service

Dissertation (MSc(Human Physiology))--University of Pretoria, 2024.Background Central nervous system (CNS) tumours are the most common form of solid tumours in children, leading to significant mortality and morbidity. In developing countries, survival rates for children with CNS tumours are lower than in developed nations. In South Africa, brain tumours account for 13% of paediatric cancers, yet local epidemiological data is scarce. No regional data exists for Steve Biko Academic Hospital in South Africa. Aim and Objectives This study aimed to describe the profile of paediatric brain tumours at Steve Biko Academic Hospital by examining patient demographics, histopathology, and imaging data. Methods This retrospective study reviewed medical records from the neurosurgery department at Steve Biko Academic Hospital. Data on patient demographics, tumour histopathology, and imaging from January 2019 to June 2023 were analysed to compile a comprehensive tumour profile. Results The study included 52 patients, with a male-to-female ratio of 1.74:1 and a mean age of 6.8 years. The highest tumour prevalence was in the 3–8-year age group. Infratentorial tumours were the most common. In descending order, the most prevalent tumour types were mixed glioma, medulloblastoma, astrocytoma, and ependymoma. Discussion The male predominance aligns with existing studies, potentially due to sex differences in brain development. The high incidence of infratentorial tumours may be linked to genetic susceptibility and rapid cell proliferation in this region. The common tumour types in this study all originate from highly prolific cells, contributing to an elevated risk of tumorigenesis. Conclusion The findings in this study, such as mean age, tumour location, and tumour prevalence, corroborate similar studies from Westernised countries. Understanding the epidemiology of paediatric brain tumours is vital for improving diagnosis, treatment, and healthcare policies. Regional data is essential for enhancing medical knowledge and improving patient outcomes. Keywords: Paediatric brain tumours, malignancy, cancer, supratentorial, infratentorial, posterior fossa glioma, medulloblastoma.PhysiologyMSc (Human Physiology)UnrestrictedFaculty of Health Science