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  Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 53  |  Issue : 4  |  Page : 562-565
 

Pediatric brain tumors: An analysis of 5 years of data from a tertiary cancer care center, India


1 Department of Radiation Oncology, Madras Medical College, Chennai, Tamil Nadu; Department of Radiation Oncology, Amrita Institute of Medical Sciences, Amrita University, Kochi, Kerala, India
2 Department of Radiation Oncology, Madras Medical College, Chennai, Tamil Nadu, India

Date of Web Publication21-Apr-2017

Correspondence Address:
R Madhavan
Department of Radiation Oncology, Madras Medical College, Chennai, Tamil Nadu; Department of Radiation Oncology, Amrita Institute of Medical Sciences, Amrita University, Kochi, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijc.IJC_66_17

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 » Abstract 

BACKGROUND: Pediatric brain tumors are the most common solid tumors in children and a leading cause of mortality and morbidity in children worldwide. Even though there are enough data about the epidemiology of pediatric brain tumors in western population, there are only a few reports from developing countries like India. AIMS: To study the epidemiological patterns of brain tumors in children, to study the patterns of care, and to assess the treatment response. MATERIALS AND METHODS: A retrospective epidemiological approach is used. The records of children <18 years registered in our department from August 2006 to July 2011 diagnosed as primary brain tumors are selected. Data regarding age, sex, site of the tumor, clinical features, histology, treatment plan, and treatment response are collected. The World Health Organization classification of neoplasms was adopted. RESULTS: Of 250 cases, females (57%) slightly outnumbered males. The present study revealed that astrocytoma (52%) is the most common brain tumor in childhood. Surgery was the main modality of treatment. Chemotherapy was given to 16% of patients. Even though radiation therapy was offered to 74% of patients, only 42% completed radiotherapy. There was subjective clinical improvement in 68% of patient population after treatment. CONCLUSIONS: This is the second study from Tamil Nadu that deals with epidemiology of brain tumors. Multimodality management including surgery, chemotherapy, and radiation therapy remains the cornerstone in the management of pediatric brain tumors.


Keywords: Epidemiology, pediatric brain tumors, radiotherapy


How to cite this article:
Madhavan R, Kannabiran B, Nithya A, Kani J, Balasubramaniam P, Shanmugakumar S. Pediatric brain tumors: An analysis of 5 years of data from a tertiary cancer care center, India. Indian J Cancer 2016;53:562-5

How to cite this URL:
Madhavan R, Kannabiran B, Nithya A, Kani J, Balasubramaniam P, Shanmugakumar S. Pediatric brain tumors: An analysis of 5 years of data from a tertiary cancer care center, India. Indian J Cancer [serial online] 2016 [cited 2020 Jul 14];53:562-5. Available from: http://www.indianjcancer.com/text.asp?2016/53/4/562/204783



 » Introduction Top


Pediatric brain tumors are the most common solid tumors in children and a leading cause of mortality and morbidity in children worldwide.[1],[2] Even though there are enough data about the epidemiology of pediatric brain tumors in western population, there are only a few reports from developing countries like India. According to the Indian Council of Medical Research, National Cancer Registry data, the incidence of pediatric brain tumors ranges from 0% to 2.11%.[3] In a recent multi-institutional study from seven prestigious tertiary care centers spread across India, pediatric central nervous system tumors accounted for on an average of 14.8% (10%–21%) of total intracranial tumors.[4] In India, in the absence of a comprehensive population-based national cancer registry, we depend on local hospital-based registries for assessing the incidence of pediatric brain tumors. Hence, more and more institutional data are required to assess the actual disease load in India. These data are also essential for developing proper infrastructure among various cancer centers spread across India and will provide insight into geographical variation in subtypes and biology of these tumors. The main objective of the present study is to assess the epidemiological patterns of brain tumors in children, to study the patterns of care, and to assess the treatment response in our institute.


 » Materials and Methods Top


This is a retrospective, observational study. The medical records of children <18 years registered in our department from August 2006 to July 2011 diagnosed as primary brain tumors were retrieved from medical records library. The Institutional Ethics Committee consent was obtained before collecting the data from medical records. Data regarding age, sex, site of the tumor, clinical features, histology, treatment given, and response to treatment were collected and analyzed. The treatment response was assessed clinically based on resolution of neurological symptoms since repeat imaging results were not available in the medical records of majority of patients. The World Health Organization (WHO) classification of brain tumors in 2007 was adopted.[5] The results obtained were compared with available Indian data and western literature.


 » Results Top


A total of 250 cases of primary pediatric brain tumors were registered in our department from August 2006 to July 2011. Of 250 cases, females (57%) slightly outnumbered males. The present study revealed that astrocytoma (52%) is the most common brain tumor in childhood. Other common tumors include medulloblastoma (21.6%), followed by ependymoma (10.4%), oligodendroglioma (6%), and craniopharyngioma (3.6%). The percentage of various histologic types is given in [Table 1]. The various histologic subtypes of astrocytoma are given in [Figure 1]. Four cases of pilocytic astrocytoma and two cases of optic nerve glioma were part of Type 1 neurofibromatosis. Two cases of subependymal giant cell astrocytoma were associated with tuberous sclerosis. Among oligodendrogliomas, 53.3% were anaplastic, whereas among ependymomas, only 11.5% were anaplastic in nature. During analysis, it was found that 52% of tumors were supratentorial in location.
Table 1: Percentage of various histologic types of brain tumors

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Figure 1: Type of astrocytomas

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The cases were subdivided into three age groups, 0–5 years, 6–10 years, and 11–18 years. On analysis, there were 107 patients (42.8%) in 11–18 years group, followed by 91 patients (36.4%) in 6–10 years group and 52 patients (20.8%) in 0–5 years group. In 0–5 and 11–18 years of age group, females outnumbered males [Figure 2]. The percentage of various types of brain tumors in each age group is given in [Table 2],[Table 3],[Table 4]. Medulloblastoma was the most common histology in 0–5 years age group, whereas in 6–10 and 11–18 years age groups, astrocytoma was the predominant histologic type. Craniopharyngioma was most common in 11–18 years age group.
Figure 2: Age and sex distribution

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The two most common clinical symptoms at diagnosis were headache and vomiting. The clinical symptoms at presentation in the order of decreasing frequency are listed in [Table 5]. In 48% of cases, ventriculoperitoneal shunt surgery was performed as initial treatment to reduce raised intracranial pressure. Surgery was the main modality of treatment. The types of surgery performed are given in [Figure 3]. Chemotherapy was given to 16% of patients. Even though radiation therapy was offered to 74% of patients, only 42% completed radiotherapy. About 32% of patients defaulted for radiotherapy. Radiotherapy was deferred in 18% of patients and they were kept on follow-up. In 8% of patient population, radiation therapy was postponed and chemotherapy was offered since they were <3 years of age. There was subjective clinical improvement in 68% of patient population after treatment.
Table 2: Percentage of various histologic types of brain tumors in 0-5 age group

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Table 3: Percentage of various histologic types of brain tumors in 6-10 age group

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Table 4: Percentage of various histologic types of brain tumors in 11-18 age group

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Table 5: Clinical symptoms at presentation

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Figure 3: Type of Surgery

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 » Discussion Top


Pediatric brain tumors are a heterogeneous group of neoplasms which varies in their cell of origin, clinical features, treatment strategies, and clinical outcomes. Even though significant advances are made in the management of many other pediatric malignancies, especially hemato-oncology, pediatric brain tumors still pose a tough challenge to oncologists worldwide. In our present epidemiological study, we used the WHO classification of brain tumors in 2007. The major limitation of this classification is that it uses only the cell of origin and not any genetic mutations which significantly influence the outcomes. We still went ahead with WHO classification 2007 because, in majority of cases, immunohistochemistry or mutation analysis was not possible due to paucity of resources. Various epidemiological studies about pediatric brain tumors across the world use different age limits. We used 18 years as the upper limit in the present study because the previous large multi-institutional Indian study took 18 years as the cutoff age.

The two most common clinical features in the present study were headache and vomiting. Headache may be a symptom of functional disorders in older children, whereas in infants, it may indicate an underlying organic disease.[6] The parents and physicians can sometimes attribute vomiting to gastrointestinal disorders. Parents notice that their child is irritable most often, but they attribute these symptoms to other causes. This may be dangerous especially when the diagnosis is delayed. Diagnosis was mainly based on radiology and biopsy. In 12% of cases, biopsy was not possible due to diffuse infiltrative nature of brainstem gliomas. Immunohistochemistry was not done in majority of cases due to paucity of resources.

In western population, it was found that astrocytomas and medulloblastomas are the two most common brain tumors in children. These tumors are the most common tumors in our study too. Various studies from Asian centers also confirm these data. Another interesting observation is that ependymoma is the third most common childhood brain tumor in various Western studies from Germany,[7] Canada,[8] Sweden,[9] and Morocco.[10] In the present study too, ependymoma is the third most common brain tumor. On the contrary, craniopharyngioma is the third most common tumor in various Asian studies from Korea,[11] Beijing,[12] Japan,[13] and also in a large multi-institutional study from India. The table comparing data from various countries is given in [Table 6] and [Table 7]. Another interesting finding is that the incidence of oligodendroglioma which is a rare tumor in most of these studies is quite high in our study (6%). This is in tune with the Beijing study which also had higher percentage of oligodendrogliomas (6.2%).
Table 6: Comparisons of percentage of types of pediatric brain tumors from various countries of West with our study

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Table 7: Comparisons of percentage of types of pediatric brain tumors from various Asian countries with our study

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Multimodality approach including surgery, chemotherapy, and radiotherapy is the cornerstone in the management of childhood brain tumors.[14] The completeness of surgical excision usually determines the outcome of treatment. The consensus guideline published by Bhat et al. provides detailed outline regarding the diagnosis, treatment, and follow-up of childhood brain tumors. This consensus document was prepared after a National Consultation on Pediatric Brain Tumors held in Delhi on November 6, 2008. In our present study, surgery was deferred in 16% of patients in view of diffuse infiltrative nature of brainstem disease or due to poor performance status of patients. In children <3 years of age, radiation therapy was postponed and chemotherapy was given. Radiation was not given for older children with poor performance status too.

In our present study, the percentage of patients defaulted for radiation is quite high (32%). This reflects the inherent fear of parents about radiation therapy and the need for proper counseling about the benefits of a completely noninvasive treatment modality like radiation. In our present study, we could assess only the subjective improvement of patients at completion of treatment. Majority of patients defaulted after treatment and did not report for follow-up. This exposes the lacunae in our follow-up practices and the need to educate the parents about nature of illness and importance of further follow-up. Alternatively, various follow-up centers can be established at district level hospitals to tackle the logistics of patients from low socioeconomic background.


 » Conclusions Top


This study is an attempt to map the epidemiology of pediatric brain tumors from Tamil Nadu. This is the second study from Tamil Nadu that deals with epidemiology of brain tumors. The major limitation of the present study is that it is a single institution study and hence may not reflect the national statistics. More and more studies like this from various cancer centers across India help to project an epidemiological profile of Indian Pediatric brain tumors and thereby aid in developing national treatment protocols. Multimodality management including surgery, chemotherapy, and radiation therapy remains the cornerstone in the management of pediatric brain tumors. The study also reflects the need to strengthen the follow-up practices for providing the best possible care to our children.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 » References Top

1.
Baldwin RT, Preston-Martin S. Epidemiology of brain tumors in childhood – A review. Toxicol Appl Pharmacol 2004;199:118-31.  Back to cited text no. 1
    
2.
Magnani C, Aareleid T, Viscomi S, Pastore G, Berrino F; EUROCARE Working Group. Variation in survival of children with central nervous system (CNS) malignancies diagnosed in Europe between 1978 and 1992: The EUROCARE study. Eur J Cancer 2001;37:711-21.  Back to cited text no. 2
    
3.
Consolidated Report of Population Based Cancer Registries 2001-2004. National Cancer Registry Programme, Indian Council of Medical Research, Bangalore, India; December, 2006. Available from: http://www.icmr.nic.in/ncrp/report_pop_2001-04/cancer_p_based.htm. [Last accessed on 2016 Dec 23].  Back to cited text no. 3
    
4.
Jain A, Sharma MC, Suri V, Kale SS, Mahapatra AK, Tatke M, et al. Spectrum of pediatric brain tumors in India: A multi-institutional study. Neurol India 2011;59:208-11.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Louis DN, Ohgaki H, Wiestler OD, Cavenee WK, editors. World Health Organization Classification of Tumors of the Central Nervous System. Lyon: IARC; 2007.  Back to cited text no. 5
    
6.
Cohen BH. Headaches as a symptom of neurological disease. Semin Pediatr Neurol 1995;2:144-50.  Back to cited text no. 6
    
7.
Kaatsch P, Rickert CH, Kühl J, Schüz J, Michaelis J. Population-based epidemiologic data on brain tumors in German children. Cancer 2001;92:3155-64.  Back to cited text no. 7
    
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Kaderali Z, Lamberti-Pasculli M, Rutka JT. The changing epidemiology of paediatric brain tumours: A review from the hospital for sick children. Childs Nerv Syst 2009;25:787-93.  Back to cited text no. 8
    
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Hjalmars U, Kulldorff M, Wahlqvist Y, Lannering B. Increased incidence rates but no space-time clustering of childhood astrocytoma in Sweden, 1973-1992: A population-based study of pediatric brain tumors. Cancer 1999;85:2077-90.  Back to cited text no. 9
    
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Karkouri M, Zafad S, Khattab M, Benjaafar N, El Kacemi H, Sefiani S, et al. Epidemiologic profile of pediatric brain tumors in Morocco. Childs Nerv Syst 2010;26:1021-7.  Back to cited text no. 10
    
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Suh YL, Koo H, Kim TS, Chi JG, Park SH, Khang SK, et al. Tumors of the central nervous system in Korea: A multicenter study of 3221 cases. J Neurooncol 2002;56:251-9.  Back to cited text no. 11
    
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Zhou D, Zhang Y, Liu H, Luo S, Luo L, Dai K. Epidemiology of nervous system tumors in children: A survey of 1,485 cases in Beijing Tiantan hospital from 2001 to 2005. Pediatr Neurosurg 2008;44:97-103.  Back to cited text no. 12
    
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Makino K, Nakamura H, Yano S, Kuratsu J; Kumamoto Brain Tumor Group. Population-based epidemiological study of primary intracranial tumors in childhood. Childs Nerv Syst 2010;26:1029-34.  Back to cited text no. 13
    
14.
Bhat S, Yadav SP, Suri V, Patir R, Kurkure P, Kellie S, et al. Management of childhood brain tumors: Consensus report by the pediatric hematology oncology (PHO) chapter of indian academy of pediatrics (IAP). Indian J Pediatr 2011;78:1510-9.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]

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