|Year : 2018 | Volume
| Issue : 4 | Page : 175-182
Retrospective analysis of intracranial and intraspinal space-occupying lesions at a tertiary care center: A 5-Year study
Meena B Patil, Manjiri N Karandikar
Department of Pathology, Bharati Vidyapeeth (Deemed to be University) Medical College, Pune, Maharashtra, India
|Date of Web Publication||16-Apr-2019|
Dr. Meena B Patil
Flat No. 8, Surya Apartment, Kohinoor Colony, Sahakarnagar No. 2, Pune - 411 009, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Incidence of central nervous system (CNS) tumors is 2% of all malignancies. Low-grade tumors progress to high-grade tumors. CNS is a common site for metastasis from other organs. Aims: The aim is to study the incidence of various lesions in light of the World Health Organization (WHO) classification of tumors of the CNS, 2016, and to study relevant statistics. Objectives: The objective of this study is to provide an overview of intracranial and intraspinal space-occupying lesions at a single tertiary care referral center. Materials and Methods: A total of 124 cases were studied. Intraoperative diagnosis was desired in 70 cases. The final diagnoses in all the cases were made by routine histopathology. Results: Neoplastic lesions comprised 83.88%, including metastatic tumors, while 16.12% were nonneoplastic. Classification and grading of CNS tumors was done according to the WHO, 2016. Astrocytic tumors constituted the largest category. Incidence was more in females than males and in the fifth and sixth decades of life. Conclusion: This study highlights histological diversity of CNS tumors in adults and children. The most common destructive but nonneoplastic lesions such as infections/abscesses, infarcts, and cysts can be diagnosed, by crush cytology and frozen section for the definitive management.
Keywords: Astrocytoma, central nervous system tumors, crush cytology, frozen section
|How to cite this article:|
Patil MB, Karandikar MN. Retrospective analysis of intracranial and intraspinal space-occupying lesions at a tertiary care center: A 5-Year study. J Datta Meghe Inst Med Sci Univ 2018;13:175-82
|How to cite this URL:|
Patil MB, Karandikar MN. Retrospective analysis of intracranial and intraspinal space-occupying lesions at a tertiary care center: A 5-Year study. J Datta Meghe Inst Med Sci Univ [serial online] 2018 [cited 2019 Jul 20];13:175-82. Available from: http://www.journaldmims.com/text.asp?2018/13/4/175/256212
| Introduction|| |
Central nervous system (CNS) tumors are not very common. However, the incidence of CNS tumors has rapidly increased over the past few years., The incidence of CNS tumors in India ranges from 5 to 10 per 100,000 population with an increasing trend and accounts for 2% of all malignancies., This substantial increase in the diagnosis of CNS tumors is mostly attributed to advances in neuroimaging technology. Some of the most important intraoperative diagnoses in neurosurgery are the diagnoses of nonneoplastic lesions because patients with such lesions often do not benefit from resection. The most common destructive but nonneoplastic lesions that mimic neoplasia clinically and radiologically are infections/abscesses, infarcts, and plaques of demyelinating diseases such as multiple sclerosis.,,
The objective of this study is to provide an overview of CNS tumors in a tertiary hospital setup. The aim was to study the incidence of various lesions in light of the World Health Organization (WHO) classification of tumors of the CNS, 2016, and to study relevant statistics. In developing countries like India, due to lack of complete registration of newly diagnosed cancer cases with local registries, the exact tumor burden of such diseases goes unnoticed and is underestimated. Hospital-based prevalence data, therefore, form the basis for estimating the disease load.
In the present study, the spectra of the CNS tumors were different in the pediatric and adult age groups. In adults, astrocytic tumors and tumors of the meninges were more common. In children, astrocytic tumors and embryonic tumors took the lead. The data collected are further analyzed in the following paper.
| Materials and Methods|| |
A retrospective study of biopsy specimens received at the Department of Pathology, Bharati Vidyapeeth Deemed University Medical College and Hospital, Pune, from January 2007 to December 2011 was carried out. A total of 124 biopsy specimens of intracranial and intraspinal space-occupying lesions (SOLs) were received. In 70 specimens, an intraoperative diagnosis was desired. In all the specimens, crush cytology and frozen section were done. The rest of the specimen was submitted for routine histopathology. Routine tissue processing was done, and the slides were stained with hematoxylin and eosin (H and E). Histological classification and grading of these tumors was done as per the WHO classification of tumors of the CNS, 2016. The incidence of the tumors over a 5-year period and the distribution based on age, sex, and location were analyzed.
| Results|| |
The study was conducted for a 5-year period in which 124 cases of intracranial and intraspinal SOLs were studied. Out of 124 cases clinically diagnosed as intracranial SOLs, 104 cases showed neoplastic lesions while 20 cases were nonneoplastic.
The various symptoms noted were headache, nausea, vomiting, slurring of speech, blurring of vision, diplopia, seizures, weakness of limbs, and paraparesis. Duration of symptoms in 108 cases was <6 months, and in 16 cases, it was >6 months.
The CNS lesions showed a slight female predominance (males – 56 and female – 68). Astrocytoma was more common in males whereas meningioma was more common in females. For craniopharyngioma, pituicytoma, medulloblastoma, and primitive neuroectodermal tumor, the male: female ratio was 1:1.
Age distribution seen in our study revealed that tumors were more common in the age group of 41–50 years (n = 27), followed by 51–60 years (n = 26). The youngest patient was 18 months old while the oldest patient was 75 years of age. Tumors had predilection for cerebral hemisphere in pediatric as well as adult patients [Table 1].
|Table 1: Distribution of lesions according to site in different age groups|
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The age group from 0 to 10 years showed the presence of 21 cases of neoplastic lesions, among which astrocytoma and medulloblastoma were maximum. The age group of 41–50 years showed 26 neoplastic lesions with predominance of meningioma and astrocytoma [Table 2].
We observed that out of 104 neoplastic lesions, Grade I lesions were the most common (n = 56), followed by Grade II lesions (n = 23) [Table 3].
|Table 3: Grading of primary central nervous system tumors according to the World Health Organization classification of central nervous system tumors, 2016|
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Among the CNS tumors, 88% presented as intracranial lesions and only 12% were intraspinal lesions. Among the nonneoplastic lesions, 75% were detected as intracranial lesions and 25% as intraspinal lesions.
Correlation of crush cytology, frozen section, and routine paraffin-embedded sections was done in 70 cases. The results were as follows: 61 turned out to be neoplastic lesions while 9 were nonneoplastic lesions.
Eight cases showed correlation between cytology, frozen section, and routine H and E in nonneoplastic lesions while one case did not correlate [Table 4]a.
Sixty cases showed correlation between cytology, frozen section, and routine H and E in neoplastic lesions while one case did not correlate [Table 4]b.
The different nonneoplastic lesions found during the study were arachnoid cyst, brain abscess, epidermoid cyst, cerebral infarct, mucocele, and tuberculoma [Table 5].
Causes of errors of interpretation
The tissue sent for intraoperative diagnosis did not represent the actual lesion. The presence of multinucleate giant cells, spindle-shaped cells, and lymphocytes posed a diagnostic problem between a tuberculoma and a pleomorphic xanthoastrocytoma (PXA).
There was no case beyond 50 years of age in nonneoplastic group.
| Discussion|| |
The incidence of CNS tumors in India ranges from 5 to 10 per 100,000 population with an increasing trend and accounts for 2% of malignancies., Tumors of CNS account for 20% of all cancers of childhood. About 70% of childhood CNS tumors arise in the posterior fossa.
A considerable number of tumors in adults arise within the cerebral hemisphere above the tentorium.
The relative frequency of various intracranial tumors is different in adults and in children. In both the adults and children, the most common intracranial tumor is an astrocytoma [Figure 3]a, [Figure 3]b, [Figure 3]c, [Figure 3]d, [Figure 3]e, [Figure 3]f, [Figure 3]g, [Figure 3]h, [Figure 3]i. Second in frequency are meningeal tumors [Figure 2]a, [Figure 2]c, [Figure 2]f, [Figure 2]h in adults and embryonal tumors in children. Tumors of cranial and paraspinal nerves are mostly Schwnnomas [Figure 1]b and are seen in adults.
|Figure 1: (a) Medulloblastoma, (b) schwannoma, (c) papillary tumor of pineal region, (d) metastatic clear cell carcinoma, (e) metastatic adenocarcinoma, (f) choroid plexus papilloma, (g) ependymoma, (h) astroblastoma, (i) astroblastoma-GFAP positive|
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|Figure 2: (a) Meningioma, (b) pineocytoma, (c) meningeal hemangiopericytoma, (d) primitive neuroectodermal tumor, (e) craniopharyngioma, (f) clear cell meningioma, (g) pituitary adenoma, (h) atypical meningioma, (i) hemangioblastoma|
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|Figure 3: (a) Pleomorphic xanthoastrocytoma, (b) diffuse fibrillary astrocytoma, (c) glioblastoma, (d) Rosenthal fiber-rich astrocytoma, (e) oligodendroglioma, (f) pilocytic astrocytoma, (g) gemistocytic astrocytoma, (h) giant cell glioblastoma, (i) pilomyxoid astrocytoma|
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The distinction between benign and malignant lesions is less evident in the CNS as compared to other organs. Brain tumors are graded on the basis of their histological characteristics from Grade I to IV, according to the WHO grading system providing an approximate prognostic guide. In our study, maximum lesions were Grade I.
The nonneoplastic lesions [Figure 4]a, [Figure 4]b, [Figure 4]c, [Figure 4]d, [Figure 4]e encountered in the study were arachnoid cysts, brain abscess, epidermoid cysts, cerebral infarcts, mucocele, meningomyelocele, and tuberculoma.
|Figure 4: (a) Epidermoid cyst, (b) meningomyelocele, (c) brain abscess, (d) brain infarct, (e) arachnoid cyst|
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Out of 124 cases in our study, 104 lesions were neoplastic and the remaining 20 lesions were nonneoplastic. The comparison of our findings with other studies in terms of neoplastic and nonneoplastic lesions is shown in [Table 6].
|Table 6: Comparison of Nonneoplastic & Neoplastic lesions with other studies,,|
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Astrocytic tumors being the most common lesion found in this study, it is worthwhile analyzing the cases of astrocytoma using various parameters as shown in [Table 7].
|Table 7: Analysis of cases of Astrocytomas using parameters as site, age & sex|
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Although most of the lesions were seen in the same age groups and the same sites as described in the literature, there were some unusual findings which have been highlighted in the following paragraphs.
Pilocytic astrocytoma [Figure 3]f which is a childhood tumor occurring in the posterior fossa was found in a 55-year-old female, in the parietal lobe.
There has been a lot of debate over the grading of pilomyxoid astrocytoma [Figure 3]i and whether it is an entity distinct from pilocytic astrocytoma. We would like to put on record that there was recurrence of pilomyxoid astrocytoma in a 5-year-old girl.
Biological behavior of PXA depends on the extent of resection and the number of mitotic figures. Five or more mitoses/10 hpf is a bad prognostic indicator. The case of recurrent PXA in the study group did not show increased mitosis.
Although cerebral Glioblastoma [Figure 3]c can occur at any age, they are most frequent after 50 years of age, but a few cases may occur in younger age group as is the occurrence of a glioblastoma at 18 years of age in this study.
When there are a large number of monstrous tumor giant cells in a glioblastoma, it is termed as Giant cell glioblastoma [Figure 3]h. Giant-cell glioblastoma is much firmer in consistency and are localized due to the presence of intercellular reticulin. A case of giant-cell glioblastoma was seen with a history of recurrence in a 57-year-old male.
A case of astroblastoma [Figure 1]h was seen in a 26-year-old female patient. Whether astroblastoma is a distinct clinicopathological entity was not clear for a long time. The WHO classification of the CNS tumors, 2016, has included astroblastoma in “other glioma” group and has been allotted Grade II.
[Table 8] highlights differences between astroblastoma and Ependymoma [Figure 1]g, [Figure 1]h, [Figure 1]i.
A case of intracranial SOL in a 57-year-old male was diagnosed as keratoma with extra-axial spread to the base of the brain. He was having a past history of tympanoplasty.
Papillary tumour of the pineal region [Figure 1]c is a rare entity. This tumor was introduced in the WHO classification 2007 for the first time and is thought to derive from specialized ependymocytes of the subcommissural organ. Local recurrence is known to occur, and our case was a recurrent tumor after the previous surgery 2 years back.
Pineal parenchymal tumor of intermediate differentiation (PPTID) was seen in a 25-year-old female with a history of recurrence after 3 years. She presented with metastases in thoracic and lumbosacral spinal regions. This is a rare event. PPTID was recognized in the 2007 WHO classification as a new pineal parenchymal neoplasm intermediate in malignancy (WHO Grades II and III) between pineocytoma (Grade I) and pineoblastoma (Grade IV). It occurs at all ages, from childhood to adult life, with a peak incidence in early adults. PPTIDs are more aggressive than pineocytomas and commonly present with local infiltration and distant cerebrospinal fluid dissemination.
Another case of PPTID was an 8-year-old female who presented as a posterior fossa tumor.
[Table 9] shows the details of pineal parenchymal tumors:
The secondary involvement of the CNS by direct extension or hematogenous metastasis is a common complication of systemic cancer and a phenomenon that frequently prompts diagnostic as well as a palliative neurosurgical intervention.
[Table 10] shows the details of metastatic lesions, and the frontal lobe of the cerebral hemisphere was the common site for metastasis.
As this study is a single-center series, the data in this study may not represent the national epidemiological data of CNS tumors. This study may help in monitoring disease patterns and changing trends. The data from this study may provide valuable information regarding CNS tumor spectrum for future research and planning.
| Conclusion|| |
The present study highlights the histological diversity in CNS tumors in both, adult and pediatric age groups. A retrospective epidemiological review of brain tumors is particularly important for future research because it can demonstrate the changes in the tumor spectrum of a population. It can reveal possible risk factors. Further multicentric studies need to be conducted to have substantial data for use in future.
Crush cytology is useful in diagnosing gliomas, medulloblastomas, and pituicytomas but has a limited role in the diagnosis of schwannomas, meningiomas (fibroblastic), and craniopharyngiomas as they are resistant to smear. Frozen sections are useful in differentiating low-grade astrocytomas from normal brain and reactive gliosis and are helpful in diagnosing craniopharyngiomas.
Correlation of clinical and radio imaging findings and with crush cytology and frozen sections must be done during intraoperative diagnosis.,,
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]