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
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E k’abo! Welcome to Ibadan!
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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
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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
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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
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144 million population35,000 medical doctors<500 pathologistsPer capita (p.c.) income $300Health budget $50 p.c.
6
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
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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
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MeningiomaWAMJ 1963; 12:251-263
3 meningiomas
2 astrocytomas
2 pituitary adenomas
1 pinealoma
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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.
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WAMJ 1963; 12:251-263Case reported as ependymoma
15 year old male with fibrosarcoma of thigh with lung metastases and dura based intracranial tumour
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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%)
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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
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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
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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
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Sahabi, 2008
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Gender distribution among tumour groups
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Pilocytic astrocytomaSahabi, 2008
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Gemistocytic astrocytomaSahabi, 2008
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Anaplastic astrocytomaSahabi, 2008
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OligodendrogliomaSahabi, 2008
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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
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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 - - - -
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Meningioma- secretorySahabi, 2008
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Meningioma- transitionalSahabi, 2008
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CraniopharyngiomaSahabi, 2008
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Metastatic CNS neoplasmsSahabi, 2008
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Metastatic choriocarcinomaSahabi, 2008
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Lagos University Teaching Hospital
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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%.
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CraniopharyngiomaAwelimobor, 2011
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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
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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)
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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
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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
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Glioblastoma- cytology, Frozen section and permanent section
Awelimobor, 2011
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Pituitary adenoma- cytology and frozen sectionAwelimobor, 2011
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Meningioma- cytology, Frozen section and permanent section
Awelimobor, 2011
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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)
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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.
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LIST OF REFERENCES
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Thanks for listening!Have a safe trip home!O d’abo!