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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 12  |  Issue : 1  |  Page : 26-31

Clinical study, evaluation, and management of cases of intracranial tumors admitted at Acharya Vinoba Bhave Rural Hospital, Sawangi (Meghe)


1 Department of Surgery, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India
2 Department of Neurosurgery, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India

Date of Web Publication25-Jul-2017

Correspondence Address:
Parag Jaipuriya
Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_17_17

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  Abstract 

Background: The introduction of modern neuro-imaging techniques, as well as various environmental factors, has been changing the incidence and the proportions of the types of clinically diagnosed intracranial tumours. Common presenting symptoms include headache, seizures, and altered mental status. Radiological investigations like MRI and CT helps in defining the extent and type of tumour, histopathology is often required to confirm the diagnosis. Treatment depends on the histology diagnosis which may be surgical resection, radiation therapy or chemotherapy. The aim of this study was to assess the clinical presentation, radiological evaluation and outcome after primary management of cases of intracranial tumours in central India. Materials and Methods: 62 cases of primary intracranial tumours who were admitted at AVBRH (Acharya Vinoba Bhave Rural Hospital), Sawangi(Meghe), Wardha were studied between August 2013 to August 2015. Results: The age group most frequently affected was 41-60 years (51.61%), mean age was 46.62±13.79 years. Astrocytomas (50%) were the most common intracranial tumour. Males (53.23%) were more frequently affected than females (46.77%) with male to female ratio as 1.13:1. Headache (48.38%) was the most common presenting symptom followed by vomiting (45.16%). Cerebral lobe (45.16%) was the most commonly affected site followed by convexity (16.12%).The sensitivity of CT scan and MRI scan were 83.33% and 87.71% respectively. All cases were surgically treated. 87.09% patients improved, 9.67% patients deteriorated and mortality was 3.23%. Conclusion: There seems to be an apparent increase in registration of brain tumours in recent years, which may well reflect the changing awareness and improved diagnostic facilities. The study shows highest frequency of tumours in the middle age group. The most common presenting symptom is headache followed by vomiting and neurological deficit. CT and MRI are useful modalities in diagnosing the intracranial tumours. Histopathology is still the gold standard for diagnosing the intracranial tumours and its types. Surgical treatment forms one of the main modality of treatment . Most of the cases show improvement after surgical management.

Keywords: Acharya Vinoba Bhave Rural Hospital, computed tomography, magnetic resonance imaging


How to cite this article:
Jaipuriya P, Yeola (Pate) M, Iratwar S, Mahakalkar CC, Chandankhede A. Clinical study, evaluation, and management of cases of intracranial tumors admitted at Acharya Vinoba Bhave Rural Hospital, Sawangi (Meghe). J Datta Meghe Inst Med Sci Univ 2017;12:26-31

How to cite this URL:
Jaipuriya P, Yeola (Pate) M, Iratwar S, Mahakalkar CC, Chandankhede A. Clinical study, evaluation, and management of cases of intracranial tumors admitted at Acharya Vinoba Bhave Rural Hospital, Sawangi (Meghe). J Datta Meghe Inst Med Sci Univ [serial online] 2017 [cited 2019 May 21];12:26-31. Available from: http://www.journaldmims.com/text.asp?2017/12/1/26/211576


  Introduction Top


The term “brain tumors” refers to a mixed group of neoplasm originating from intracranial tissues and the meninges with degrees ranging from benign to aggressive. Each type of tumor has its own biology, treatment, and prognosis and each is likely to be caused by different risk factors. Even “benign” tumors can be lethal due to their site in the brain, their ability to infiltrate locally, and their propensity to transform to malignancy. This makes the classification of brain tumors a difficult science and creates problems in describing the epidemiology of these conditions. Public perception generally fails to distinguish between different tumor subtypes, and although treatments and prognosis may vary, the functional neurological consequences are frequently similar.[1]

Primary central nervous system (CNS) tumors represent 2% of estimated new cancers occurring in adults. Gliomas are the most common type of primary intracranial neoplasm making up to 35%–50% of the tumors.[1] While there are minor variations in the incidences in series reported from different centers of the world, the difference is not significant.[2] A cross-sectional study conducted for a period of 3 years in Kolkata in India, on intracranial malignancies reported the common occurrence of astrocytomas (36.8%) and glioblastoma multiforme (7.9%) of all CNS tumors.[3]

No studies have been conducted/documented in the recent years in this part of the country to determine the frequency as well as the trends and management of primary intracranial neoplasms. Hence, there is a felt need for such a study in this part of the subcontinent. The study correlated several clinical variables such as age, sex, frequency, clinical features, radiological evaluation, and primary management of the tumors. The aim and objective of this study were to assess the clinical presentation, radiological, and pathological correlation and to study the outcome in terms of improvement, deterioration, and death after surgical management of cases of intracranial tumors.


  Materials and Methods Top


This prospective observational study included 62 cases of newly diagnosed intracranial tumors of both sex and of any age group, who were admitted in a tertiary health care center - Acharya Vinoba Bhave Rural Hospital (AVBRH) attached to Jawaharlal Nehru Medical College which comes under Datta Meghe Institute of Medical Sciences University. Metastatic intracranial tumors were excluded from the study. The study was conducted from August 2013 to August 2015. After a detailed history, complete general and systemic examination, provisional diagnosis of intracranial tumors was done. Diagnosis was supported with the help of investigations such as computed tomography (CT) brain and magnetic resonance imaging (MRI) brain. Along with the various other diagnostic investigations, patients were subjected to various routine investigations. After complete evaluation, management was planned by surgical modality. The suspected tumor tissue was sent for histopathology for confirmation of diagnosis. After operative intervention, those patients who required further adjuvant therapy such as radiotherapy were referred to other centers as radiotherapy facility is not available in our institute at present. Patients were assessed preoperatively and postoperatively at the end of 1 month. The outcome was measured in terms of improvement, deterioration, and death by comparing the (Karnofsky Performance Status Scale (KPS scale).[4],[5] Statistical analysis was done using descriptive and inferential statistics using Chi-square test and sensitivity analysis. The software used in the analysis was SPSS 17.0 version (SPSS Inc, Chicago) and GraphPad Prism 5.0 and P< 0.05 was considered as level of significance.


  Observations and Results Top


Of the 62 cases of primary intracranial tumors that were received during the study period, astrocytomas were the most frequent comprising 50% of cases [Table 1]. The other tumors were meningiomas (33.87%), schwannomas (8.06%), pituitary adenomas (6.45%), and medulloblastomas (1.61%) in the decreasing order of frequency [Table 1].
Table 1: Frequency distribution of intracranial tumors (n=62)

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The tumors occurred at all ages with a range of 12 years to 75 years. The mean age of intracranial tumors was 46.62 ± 13.79 years. The average age for the different intracranial tumor types was as shown in [Table 2]. The highest frequency in age-specific distribution was seen in the 41–60 years age group (51.61%) followed by 19–40 years age group (27.41%) [Table 3].
Table 2: Age distribution of intracranial tumors

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Table 3: Age-specific distribution of intracranial tumors

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Using Chi-square test, statistically significant association was found between the intracranial tumors and its age-specific distribution (χ2 = 38.06, P= 0.000).

In general, among all the tumors, males (53.23%) were affected more than females (46.77%). Sex distribution in astrocytomas, medulloblastomas, meningiomas, pituitary adenomas, and schwannomas were as shown in [Table 4].
Table 4: Sex distribution of intracranial tumors

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Using Chi-square test, no significant association was found between the intracranial tumors and its gender distribution (χ2 = 8.67, P= 0.070).

The most common presenting symptom was headache (48.38%). The next frequent clinical features were vomiting (45.16%), motor weakness (43.54%), and cranial nerve involvement (43.54%) [Table 5].
Table 5: Distribution of clinical features associated with intracranial tumors

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The tumors occurred most often in the cerebral lobes (45.16%) [Table 6]. The second most commonly involved site after cerebral lobes was convexity which was the site of tumors of meningiomas [Table 6].
Table 6: Site distribution of intracranial tumors

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CT was done in 30 cases and MRI was done in 57 cases, and the correlation of CT (Z = 12.24, S) diagnosis and MRI (Z= 20.17, S) diagnosis with histopathology was found to be statistically significant. The sensitivity of CT and MRI scan was 83.33% and 87.71%, respectively [Table 7].
Table 7: Correlation of computed tomography and magnetic resonance imaging with histopathology

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All the patients of intracranial tumors were surgically treated. In this study, all patients of gliomas were of astrocytoma type only. Astrocytomas, meningiomas, schwannomas, and medulloblastomas were operated by craniotomy approach. Pituitary adenoma was operated by transcranial transsphenoidal approach. All intracranial tumor patients underwent either gross total resection, near total resection, or subtotal resection [Table 8]. Of the 62 patients of intracranial tumors, twenty patients (32.25%) were referred for radiotherapy or chemotherapy [Table 9].
Table 8: Type of surgical resection of intracranial tumors

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Table 9: Adjuvant therapy for intracranial tumors

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Using Chi-square test, statistically significant association was found between the intracranial tumors and its type of resection (χ2 = 116.10, P< 0.0001) [Table 8].

Of the 62 patients (100%) of intracranial tumors, 87.09% improved, 9.67% deteriorated, and mortality was 3.23% [Table 10].
Table 10: Outcome of the patients of intracranial tumors

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Using Chi-square test, statistically significant association was found between intracranial tumors and its outcome after surgical management (χ2 = 195.50, P< 0.0001) [Table 10].


  Discussion Top


This was a prospective study which evaluated the demographic profile, clinical features, and radiological and pathological correlation and to see the outcome after primary management of cases of intracranial tumors. Sixty-two cases studied in our study showed the following salient features.

The most common tumor in our study at AVBRH was astrocytomas which comprised 50% of all intracranial tumors [Table 1]. Studies conducted by Jalali and Datta in Mumbai, Ghosh et al. at Kolkata, and by Baldi et al. in France, also found astrocytomas as the most common intracranial tumor.[3],[6],[7] The second most common tumor in our study was meningiomas with 33.87% [Table 1]. In a study by Baldi et al. in France and by Ghosh et al. on intracranial tumors, meningiomas were the second most frequent tumor.[3],[7] The third most common intracranial tumor was schwannomas which constituted 8.06% of all intracranial tumors [Table 1] which is in accordance with a study conducted by Mehrazin et al. in Iran.[8] The fourth most common intracranial tumor in our study was pituitary adenomas which constituted 6.45% of all brain tumors [Table 1]. In a prospective study by Jalali and Datta at Tata Memorial Hospital in Mumbai, pituitary adenomas were the second most common tumor with 8.38%.[6] There was a single case of medulloblastoma in our study at AVBRH which constituted 1.61% of all intracranial tumors [Table 1]. It was seen in 0–18-year age group [Table 3]. In a prospective study by Jalali and Datta at Tata Memorial Hospital, medulloblastomas were the third most common type with 7.16%. Maximum frequency of medulloblastomas (78.72%) occurred in 0–18-year age group.[6]

The mean age of intracranial tumors in our study at AVBRH was 46.62 ± 13.79 years. In a study by Mehrazin et al. in Iran on intracranial tumors, mean age of intracranial tumors was 33.9 ± 18.1 years.[8] The difference in mean age in our study and study at Iran may be due to less number of cases in our study and environmental factors. In our study, the most commonly affected age group was 41–60 years and comprised 51.61% of all tumors [Table 3]. In a prospective study by Jalali and Datta at Tata Memorial Hospital in Mumbai, the most commonly affected age group was 19–40 years which comprised 36.3%.[6] The difference probably reflecting the environmental influences on the occurrence of these tumors in the metropolitan city like Mumbai.

In general, among all the intracranial tumors, males (53.23%) were more affected than females (46.77%) [Table 4]. In a prospective study by Jalali and Datta at Tata Memorial Hospital in Mumbai, among all the brain tumors, males (60.21%) were more affected than females (39.8%).[6] A study by Mehrazin et al. in Iran on intracranial tumors also showed more number of male patients (55.4%) as compared to females (44.6%).[8]

The most common presenting symptom individually or in association with other symptoms was headache (48.38%). The next frequent clinical features included vomiting (45.16%), motor weakness (43.54%), and cranial nerves involvement (43.54%) [Table 5]. Buckner et al.,[9] Valentinis et al.,[10] and Forsyth and Posner [11] also described headache as the most common presenting symptom in brain tumor, which is in accordance with our study. Thus, it can be concluded that headache is the most common presenting symptom in cases of intracranial tumors.

The most common site for intracranial tumors was cerebral lobes (45.16%) followed by convexity (16.12%) [Table 6]. In a prospective study by Jalali and Datta at Tata Memorial Hospital in Mumbai, they found cerebral lobe as the most common site involved.[6]

CT or MRI scan or both were done in cases of intracranial tumors before any intervention for evaluation of the type of tumor and its location. Of the total 62 cases, CT was done in 30 cases and MRI was done in 57 cases, and the correlation of CT (Z= 12.24, S) diagnosis and MRI (Z= 20.17, S) diagnosis with histopathology was found to be significant. The sensitivity of CT and MRI scan in our study was 83.33% and 87.71%, respectively [Table 7]. In an experimental case series study by Taghipour Zahir et al., (2011) sensitivity of CT was 83% and sensitivity of MRI was 92%,[12] the difference may be due to less number of cases in this study. Thus, it can be concluded that CT and MRI are sensitive investigations in diagnosing the intracranial tumors.

All 62 cases in our study underwent surgical treatment. Astrocytomas, meningiomas, schwannomas, and medulloblastoma were operated by craniotomy approach. Pituitary adenomas were operated by transcranial transsphenoidal approach. All cases of schwannomas were operated by retrosigmoid approach. All patients underwent either gross total resection, near total resection, or subtotal resection [Table 8]. In our study, all glioma cases were of astrocytoma type. There were 12 cases of low-grade gliomas and 19 cases of high-grade gliomas. Of 12 cases of low-grade gliomas, 11 (91.66%) cases underwent gross total resection and 1 (8.33%) case underwent near total resection. Of 19 cases of high-grade gliomas, 8 (42.11%) cases underwent gross total resection, 9 (47.37%) cases underwent near total resection, and 2 (10.53%) case underwent subtotal resection [Table 8].

Of the 62 patients of intracranial tumors, 54 (87.09%) patients improved after surgical management. P value was <0.0001, which was statistically significant [Table 10]. In a study by Hervey-Jumper and Berger and by Sanai and Berger, they concluded that survival of patients with both low- and high-grade gliomas is enhanced with maximal tumor resection.[13],[14] In a study by Marosi et al. and Whittle et al. on meningiomas, they found that surgical excision is the standard treatment in meningioma.[15],[16] In a retrospective study by Lee and team, they concluded that surgical removal should be the standard management for acoustic tumors, particularly for large and medium tumors, and can be accomplished with acceptable complication rates.[17] In one study by Jagannathan and team, they concluded that for most pituitary adenomas, transsphenoidal resection remains the mainstay of treatment.[18] Thus, it can be concluded that surgery remains the main modality of treatment for intracranial tumors and as much tumor as feasible should be resected without compromising on functional status so as to improve the overall survival of patients.

According to KPS scores calculated on preoperative day and postoperatively at the end of 1 month, improvement occurred in 87.09% patients, deterioration in 9.67% patients, and mortality in 3.23% patients [Table 10]. In one study by Sawaya et al. on neurosurgical outcomes after 4 weeks of operation, they found that 58% patients showed no change, 32% improved, and 9% patients deteriorated.[19] In another study by Kim et al. in 2009, they found that at the end of 1 month after craniotomy, 83% patients improved and 17% patients deteriorated.[20]


  Conclusion Top


An apparent increase in registration of brain tumors in recent years reflects the changing awareness and improved diagnostic facilities. The study shows the highest frequency of tumors in the middle age group. Astrocytomas are being the most common intracranial tumor. The tendency of male predominance is seen in overall intracranial tumors. The most common presenting symptom is headache, followed by vomiting and neurological deficit. CT scan and MRI scan are useful modalities in diagnosing the intracranial tumors. Histopathology is still the gold standard for diagnosing the intracranial tumors and its types. Surgical treatment forms one of the main modality of treatment in cases of intracranial tumors. Most of the cases show improvement after surgical management.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
McKinney PA. Brain tumours: Incidence, survival, and aetiology. J Neurol Neurosurg Psychiatry 2004;75 Suppl 2:ii12-7.  Back to cited text no. 1
    
2.
Dastur DK, Lalitha VS, Ramamurthy B. Pathology of intracranial tumours. In: Ramamurthy B, Tandon PN, editors. Textbook of Neurosurgery. 2nd ed., Vol. II. New Delhi: B.I. Churchill Livingstone; 1996. p. 804-48.  Back to cited text no. 2
    
3.
Ghosh A, Sarkar S, Begum Z, Dutta S, Mukherjee J, Bhattacharjee M, et al. The first cross sectional survey on intracranial malignancy in Kolkata, India: Reflection of the state of the art in Southern West Bengal. Asian Pac J Cancer Prev 2004;5:259-67.  Back to cited text no. 3
    
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Cherny N, Fallon M, Kaasa S, Portenoy RK, Currow DC. Oxford Textbook of Palliative Medicine. New Delhi: Oxford University Press; 1993. p. 109.  Back to cited text no. 4
    
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O'Toole DM, Golden AM. Evaluating cancer patients for rehabilitation potential. West J Med 1991;155:384-7.  Back to cited text no. 5
    
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Jalali R, Datta D. Prospective analysis of incidence of central nervous tumors presenting in a tertiary cancer hospital from India. J Neurooncol 2008;87:111-4.  Back to cited text no. 6
    
7.
Baldi I, Gruber A, Alioum A, Berteaud E, Lebailly P, Huchet A, et al. Descriptive epidemiology of CNS tumors in France: Results from the Gironde Registry for the period 2000-2007. Neuro Oncol 2011;13:1370-8.  Back to cited text no. 7
    
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Mehrazin M, Rahmat H, Yavari P. Epidemiology of primary intracranial tumors in Iran, 1978-2003. Asian Pac J Cancer Prev 2006;7:283-8.  Back to cited text no. 8
    
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Buckner JC, Brown PD, O'Neill BP, Meyer FB, Wetmore CJ, Uhm JH. Central nervous system tumors. Mayo Clin Proc 2007;82:1271-86.  Back to cited text no. 9
    
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Valentinis L, Tuniz F, Valent F, Mucchiut M, Little D, Skrap M, et al. Headache attributed to intracranial tumours: A prospective cohort study. Cephalalgia 2010;30:389-98.  Back to cited text no. 10
    
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Forsyth PA, Posner JB. Headaches in patients with brain tumors: A study of 111 patients. Neurology 1993;43:1678-83.  Back to cited text no. 11
    
12.
Taghipour Zahir SH, Rezaei Sadrabadi M, Dehghani F. Evaluation of diagnostic value of CT scan and MRI in brain tumors and comparison with biopsy. Iran J Ped Hematol Oncol 2011;1:121-5.  Back to cited text no. 12
    
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Hervey-Jumper SL, Berger MS. Role of surgical resection in low- and high-grade gliomas. Curr Treat Options Neurol 2014;16:284.  Back to cited text no. 13
    
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Sanai N, Berger MS. Operative techniques for gliomas and the value of extent of resection. Neurotherapeutics 2009;6:478-86.  Back to cited text no. 14
    
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Marosi C, Hassler M, Roessler K, Reni M, Sant M, Mazza E, et al. Meningioma. Crit Rev Oncol Hematol 2008;67:153-71.  Back to cited text no. 15
    
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Whittle IR, Smith C, Navoo P, Collie D. Meningiomas. Lancet 2004;363:1535-43.  Back to cited text no. 16
    
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Lee SH, Willcox TO, Buchheit WA. Current results of the surgical management of acoustic neuroma. Skull Base 2002;12:189-95.  Back to cited text no. 17
    
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Jagannathan J, Kanter AS, Sheehan JP, Jane JA Jr., Laws ER Jr. Benign brain tumors: Sellar/parasellar tumors. Neurol Clin 2007;25:1231-49, xi.  Back to cited text no. 18
    
19.
Sawaya R, Hammoud M, Schoppa D, Hess KR, Wu SZ, Shi WM, et al. Neurosurgical outcomes in a modern series of 400 craniotomies for treatment of parenchymal tumors. Neurosurgery 1998;42:1044-55.  Back to cited text no. 19
    
20.
Kim SS, McCutcheon IE, Suki D, Weinberg JS, Sawaya R, Lang FF, et al. Awake craniotomy for brain tumors near eloquent cortex: Correlation of intraoperative cortical mapping with neurological outcomes in 309 consecutive patients. Neurosurgery 2009;64:836-45.  Back to cited text no. 20
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]



 

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