Biomedica Vol. 21 (Jan. – Jun., 2005)

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INTRA-CRANIAL SPACE OCCUPYING LESIONS A MORPHOLOGICAL ANALYSIS

M. EJAZ BUTT, SAEED A. KHAN, NASEER A. CHAUDRHY AND G. R. QURESHI

Department of Pathology, Postgraduate Medical Institute, Lahore - Pakistan

The purpose of this study was to provide preliminary data on morphological patterns of intra-cranial space occupying lesions (ICSOL) in central Punjab province. This is a cross-sectional prospective study on 100 consecutive cases of intra-cranial space occupying lesions admitted to both the neurosurgery units of Lahore General Hospital, Lahore, Pakistan. The biopsy materials were examined histologically using paraffin sections. Eighty nine (89) patients had neoplasms, while eleven (11) had non-neoplastic lesions. Neuroepithelial tumours comprised 41% of all the neoplasms, followed by meningiomas being 23%, schwannomas 11% and metastatic tumours 6%. Males were affected slightly more than females (1.17:1). Tuberculomas constituted 3% of the lesions. It was concluded that age and sex distribution were generally comparable to the other published literature. Similarly neuroepithehal tumours formed majority of the lesions. However meningiomas had a higher frequency as compared to the western literature; moreover tuberculomas should also be considered in the differential diagnosis of such lesions in this part of the world.

INTRODUCTION The term “Intra-cranial space occupying lesion” is defined as any neoplasm, benign or malignant, pri-mary or secondary, as well as any inflammatory or parasitic mass lying within the cranial cavity1. The list also includes haematomas,2 different types of cysts,3,4 and vascular malformations5,1,6. Space occupying primary tumours of the central nervous system and its coverings account for about 9% of all the primary neoplasms of the human body. Among the intracranial space occupying tumours, those of central neurogenic origin claim priority in number and complexity. These are the tumours derived from parenchymatous neuroepithelial ele-ments of central nervous system excluding the microglia; and they are widely credited to account for 40-50% of all the intra-cranial space occupying tumours7,8. Systemic study of tumours of the cen-tral nervous system began when Baily and Cus-hing started their studies in the early 1920’s. Over the past three decades, many reports suggested that both incidence and pattern of intracranial neoplasia are subject to considerable geographic and racial variations. Knowledge of the regional peculiarities of these lesions, may, therefore, help in identifications of possible risk factors and also in establishing measures for an improved diagnosis, treatment and outcome. No accurate

statistics reporting the morphological pattern of intracranial space occupying lesions were available in the province of Punjab. Therefore, it was decided to study the morphological pattern of intracranial space occupying lesions in this part of the world.

MATERIALS AND METHODS A total of 100 cases of intracranial space occupying lesions (ICSOLS) were collected from both the neurosurgery wards of the Lahore General Hospital Lahore, between the period from September 1999 to April 2000. As these are the oldest, the biggest and very busy neurosurgical units of the province, hence the patient population was fairly equally representative of the province of Punjab. The patients were of all age groups and belonged to both sexes. All cerebral neoplasms in this study were grouped according to the classification of the World Health Organization9. Each patient had at least one cranial tomographic scan (CT) and was found having a space occupying lesion in the cranium. The gross examination of the biopsy specimens was performed. They were collected in, 10% buffered formalin as fixative.10,11. All the specimens were dehydrated, cleared, impregnated and embedded in suitable medium to facilitate their cutting. The tissue sections were

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stained with haematoxylin and eosin following the method of Harris haemotoxylin12,13.

RESULTS In a total of 100 cases of intracranial space occupying lesions, 54 cases were males and 46 were females, having a male / female ratio of 1.17:1 as shown in Tables 1,2. Of all the 100 cases, 18 cases were found below the age of twenty, while maximum number of cases (28) were found in the third decade. Thirteen cases were seen in 3rd decade, and 14 in 4th decade. A steep rise in the number of cases in the sixth decade was noticed i.e, 20 cases. These observations are depicted in Table 2.

Table 1: Distribution of 100 cases of intra-

cranial space occupying lesions.

Sex Groups

Male Female Total

Neoplastic Lesions 48 41 89

Non-neoplastic Lesions 6 5 11

Total 54 46 100

Table 2: Age and Sex distribution of 100 cases of

intra-cranial space occupying lesions.

Sex* Age group (years)

Male Female Total

1. 0 – 9 3 2 5

2. 10 – 19 8 5 13

3. 20 – 29 14 14 28

4. 30 – 39 6 7 13

5. 40 – 49 5 9 14

6. 50 – 59 13 7 20

7. 60 – 69 14 46 100

*No significant difference between males and females for all age groups (P > 0.05).

Table 1 shows, that of all the 100 cases of ICSOLs, 89 cases were intracranial neoplasms. Among the 89 neoplasms, 48 were in males and 41 cases were in females. Male / Female ratio in case these of neoplasms was counted as 1.17:1. Table-3 shows that neuroepithelial tumours ranked No. 1 with the highest number of cases. Meningiomas were second in frequency schwannomas and metastatic tumours ranked third and fourth respectively in frequency. Neuroepithelial tumours were the most common intracranial neoplasms and comprised of 41% of the total (Figure 1). The

number and percentage of different histological types of this group are shown in Table 4.

Table 3: Distribution of 89 cases of neoplastic

Intra-cranial space occupying lesions.

Sex Types of Tumor

Male Female Total (%)

1. Neuro-epithelial Tumours

26 15 41 (41%)

2. Meningiomas 7 16 23 (23%)

3. Nerve sheet tumours (Schwa-nnomas)

4 7 11 (11%)

4. Primary adenomas

1 1 2 (2%)

5. Vascular Tumours

1 0 1 (1%)

6. Arterio-venous malformation

1 0 1 (1%)

7. Extension from regional Tumours

2 0 2 (2%)

8. Metastatic Tumours

4 2 6 (6%)

9. Germ cell Tumours

1 0 1 (1%)

10. Lymphomas 1 0 1 (1%)

Total 48 41 89 (89%)

Table 4: Relative frequency of the different types

of neuro-epithelial tumours.

Sex Types of Tumor

Male Female Total (%)

1. Benign Astrocytomas

15 4 19 (46.3%)

2. Anaplastic Astrocytomas

6 3 9 (21.9%)

3. Glioblastomas Multiforme

2 4 6 (14.6%)

4. Ependymomas 1 1 2 (4.8%)

5. Oligoden-drogliomas

0 2 2 (4.8%)

6. Medullo-blastomas

1 0 1 (2.4%)

7. Choroid plexus papilloma

1 0 1 (2.4%)

8. Mixed Tumour 1 0 1 (2.4%)

Total 26 15 41 (100%)

In a total 41 cases, 19 were benign astrocy-tomas and 15 cases were malignant astrocytomas. These astrocytomas collectivity accounted for 82.8% of the total neuroepithelial tumours. M/F ratio was 1.17:1. Meningiomas constituted 23% of

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Choroid plexus papilloma 2.4%

Mixed tumors 2.4%

Medulloblastoma 2.4%Oligodendroglioma

4.8%

Glioblastoma Multiforme 14.8%

Ependymoma 4.8%

Anaplastic Astrocytomas

21.9%

Benign Astrocytomas

46.3%

Table 5: Distribution of 11 cases of non-neo-

plastic Intra-cranial space occupying lesions.

Sex Types of Lesion

Male Female Total (%)

1. Tuberculoma 2 1 3 (3%)

2. Fungal Infection 2 0 2 (2%)

3. Cysts 0 2 2 (2%)

4. Haemorrhages 2 0 2 (2%)

5. Cholesteatoma 0 1 1 (1%)

6. Chronic infection 0 1 1 (1%)

Total 6 5 11 (11%)

Chrohic Chronic

infection 9%

Choleste-atoma 9%

Haemorrh-ages 18%

Cysts 18%

Fungal Infection

18%

Tubercul-omas 27%

Fig. 2: Distribution of 11 cases of non-neoplastic Intra-cranial space occupying lesions.

the total neoplasms and were the second most common type. Females were affected almost twice as often as males. As a result meningiomas were the commonest intracranial neoplasms of the females. These occurred exclusively in the middle and higher age groups with maximum incidence during fourth and fifth decades. Among the 11 cases of non-neoplastic intracranial masses, there

were 3 tuberculomas, two fungal granulomas, two cysts, two haemorrhages and cholesteatoma and chronic infection one each as shown in Table 5 and Figure 2.

DISCUSSION Despite some limiting factors in this study, the analysis shows that these 100 cases of ICSOLs share several features common with other published series. Both age and sex distribution lie within the estimated ranges in the other reports. In this study, brain tumours occurred mostly during the third and sixth decades of life. In com-parison to that most series reported from Asian countries,14,3,15,5,1,16,17 brain tumours occurred mos-tly during fourth decade of life, in Western count-ries during the fifth and sixth decades of life18,19,20. This could be due to the differrrent age characteri-stics of the populations as well as different case ascertainment in the two country groups, with a higher rate of autopsies in the latter.

The percentage of pediatric brain tumours, oc-curring below the age of twenty years, in the pre-sent series was18% as compared with13% in Saudi Arabia1, 10.0% in United States,21 16.8% in India22, 18.6% in China,5 28.4% in Thailand23. This figure seems to be related to the size of the pediatric population in each country. The most common tumours in pediatric group were astrocy-tomas, followed by medulloblastomas, in line with other published reports24,25. The male to female ratio of 1.17:1 in the present 100 cases corresponds to an overall male / female ratio ranging from 1:1 to 1:626,27,28,29,30,31,32. i. e. more males that females develop brain tumours.

As in all other series tumours of the neuroepi-thelial origin were also in the present study, the most frequent type of intracranial neoplasms except in a study reported from Nigeria,33 where

Fig. 1: Distribution of 41 cases of Neuro-epithelial tumors

34 M. EJAZ BUTT, SAEED A. KHAN, NASEER A. CHAUDRHY et al

Biomedica Vol. 21 (Jan. – Jun., 2005)

metastatic tumours ranked first followed by glial tumours in frequency. As regards age distribution of tumours, neuroepithelial tumours occurred at a significantly younger age (P<0.01) in this study (Table 6).

Table 6: Range and mean age in neuroepithelial

tumors & non-neuroepithelial tumors.

Age (Years) Lesion

Number of cases Range Mean ±±±± SD

Neuro- epithelial Tumours

41 (41%) 9-60 29.34 ± 14.10

Non-Neuro- epithelial tumours

48 (48%) 1-65 *38.26 ± 15.89

*p < 0.01 as compared to neuroepithelial tumors

These finding are comparable to that of Jamjoom1, who also reported that majority of the neuroepthelial tumours were found in a younger age. Two cases of pleomorphic xanthoastrocy-tomas were also in line with reported six cases from India34 .

Photo 1: Photomicrograph of a Pleomorphic Xantho-astrocytoma (H & E x 100).

The relative frequency of meningiomas in this series of 100 intra-cranial space occupying neo-plasms was 23% which is higher than the rates reported from Western and Asian countries. Jamjoom1 from Saudi Arabia showed 28% meningiomas in the Saudi population. This view is supported by the findings of Chowdhry35 who rep-orted a ratio of 26% for the meningiomas in a small series of 54 intracranial tumours from the Eastern province of Saudi Arabia. Also statistics about meningiomas from KFSH36 showed a high proportion of meningiomas in Saudi Arabia as compared to our study in the central Punjab. A report from JPMC Karachi37 analyzed 13.7% meni-ngiomas, which is a fairly low incidence as com-pared to our study. The meningiomas have a clear

preponderance of females over males in our study, which is in agreement with majority of the other studies.

Photo 2: Photomicrograph of a Meningioma showing Psammoma Bodies (H & E x 100).

The relative incidence of malformative tumo-urs in this series was markedly below the rates re-ported from Japan, Thailand and China but within the comparable ranges given by most Western series. The ratio of secondary brain tumours in the present series is near the limits estimated in the other series. Unexpectedly, the incidence of cere-bral tuberculomas in the present series is less than the rates reported from India and Saudi Arabia14,15,1 and more than the other series from Kuwait, Germany and France38,39,40. Thus in conclusion, this study has highlighted the relative frequency of different intracranial space occupying lesions in the central Punjab Province.

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