|Year : 2011 | Volume
| Issue : 2 | Page : 299-306
|Frequency of central nervous system tumors in delta region, Egypt
Khaled R Zalata1, Dina A El-Tantawy1, Azza Abdel-Aziz1, Abdel-Wahab M Ibraheim2, Ahmed H Halaka3, Hasan H Gawish4, Mohamed Safwat2, Nabil Mansour2, Mohammad Mansour2, Abdelhadi Shebl1
1 Department of Pathology, Mansoura University, Mansoura, Egypt
2 Department of Neurosurgery, Mansoura University, Mansoura, Egypt
3 Department of Neurosurgery, Elhekma Hospital, Mansoura, Egypt
4 Department of Neurosurgery, Zagazeg University, Egypt
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|Date of Web Publication||27-May-2011|
| Abstract|| |
Introduction and Aim of Work: Central nervous system (CNS) tumors represent a major public health problem, and their epidemiological data in Egypt have been rather incomplete except for some regional reports. There are no available frequency-based data on CNS tumors in our locality. The objective of this study was to estimate the frequency of CNS tumors in east delta region, Egypt. Materials and Methods: The data were collected during the 8-year period from January 1999 to December 2007 from Pathology Department, Mansoura University, and other referred pathology labs. Examination of HandE stained sections from retrieved paraffin blocks were done in all cases for histopathologic categorization of C.N.S. tumors. Immunohistochemical studies were applied to confirm final histopathologic diagnosis in problematic cases. Results: Intracranial tumors represented 86.7% of cases in comparison to only 13.3% for spinal tumors. Gliomas were the CNS tumors of the highest frequency (35.2%), followed by meningioma (25.6%), pituitary adenoma (11.6%) and nerve sheath tumors (6.6%). 10.25% of tumors were of children <15 years. Conclusion: This study provides the largest series of the relative frequency of CNS tumors in Delta region in Egypt till now and may help to give insight into the epidemiology of CNS tumors in our locality.
Keywords: Brain, Egypt, glioma, meningioma, spinal cord, tumors
|How to cite this article:|
Zalata KR, El-Tantawy DA, Abdel-Aziz A, Ibraheim AWM, Halaka AH, Gawish HH, Safwat M, Mansour N, Mansour M, Shebl A. Frequency of central nervous system tumors in delta region, Egypt. Indian J Pathol Microbiol 2011;54:299-306
|How to cite this URL:|
Zalata KR, El-Tantawy DA, Abdel-Aziz A, Ibraheim AWM, Halaka AH, Gawish HH, Safwat M, Mansour N, Mansour M, Shebl A. Frequency of central nervous system tumors in delta region, Egypt. Indian J Pathol Microbiol [serial online] 2011 [cited 2019 Aug 21];54:299-306. Available from: http://www.ijpmonline.org/text.asp?2011/54/2/299/81607
| Introduction|| |
Central nervous system (CNS) tumors are rare constituting about 1-2% of all human neoplasms.  They are however quite heterogeneous, vary widely by site of origin and morphologic features, growth potential, and extent of invasion.  CNS tumors are the second most common overall and the most common solid tumors in the pediatric population.  Approximately, 25% of all cancer-related mortalities in pediatric population occur due to CNS tumors.  These tumors represent a major public health problem as they bear unfavorable clinical prognosis merely by their localization. 
Characterizing the different forms and range of CNS neoplasms in different regions serves as a major guide that may provide etiological clues to some tumor types.  Descriptive studies characterize the frequency of brain tumors with respect to demographic data of patients affected, such as their age, sex, and geographic region. Analytic epidemiologic studies compare the risk of brain tumors in relation to certain demographic characteristics.  These are also used in setting up both clinical and basic research protocols, and allow the evaluation of the medical practices of an area or of the entire country and harmonize the healthcare of patients affected by CNS neoplasms. 
Epidemiological data on CNS tumors as they occur in Egypt have been rather incomplete although there are some regional reports. In an epidemiological study done in the Egyptian National Cancer Institute, CNS neoplasms constitute about 3% of primary malignant tumors. They are the most common solid tumor in children. They are responsible for about 18% of malignant tumors and they represent the second most frequent cause of cancer-related mortality of children. 
In Delta region which includes four governorates, no statistical data were recorded on CNS tumors. In this study, we aimed to determine the relative frequency of CNS tumors in Delta region according to the revised WHO classification. 
| Materials and Methods|| |
This retrospective study was performed in Mansoura city which contains medical reference centers from the whole East Delta region. The data were collected during 8-year period from January 1999 to December 2007 from Pathology Department, Mansoura University, and other referred pathology labs. The data included age, gender, clinical data, neuro-radiological imaging details: site and number of lesions.
Examination of HandE stained sections from retrieved paraffin blocks were done in all cases by independent histopathologists for pathological typing of C.N.S. tumors. The classification and nomenclature used in the present study were those adopted by the revised WHO classification. 
Immunohistochemical stains were done for selected (problematic) cases to confirm final histopathologic diagnosis. The following monoclonal and polyclonal antibodies were used.
- Glial fibrillary acidic protein (GFAP): for assessment of the glial tumors.
- Synaptophysin: for neuronal tumors.
- S-100 protein: for tumors of a neuroectodermal origin.
- Leucocyte common antigen (LCA): for hemopoietic tumors.
- Epithelial membrane antigen (EMA): for tumors of an epithelial origin.
- Vimentin: for tumors of a mesodermal origin.
Immunohistochemical staining was applied as usual with application of Envision detection kit from Dako Corporation and DAB as chromogen.
Categorization of some histopathological entities was done for simplification of statistical data; Low- and high-grade oligodendrogliomas were grouped together as oligodendrogliomas. Mixed oligoastrocytoma was defined by the presence of a distinct and unequivocal astrocytic component. Subependymoma, myxopapillary, low- and high-grade ependymomas were grouped together as ependymomas. The diagnosis of primitive neuroectodermal tumor was made for neoplasms morphologically indistinguishable from medulloblastoma but located at other sites in the CNS.
Conventional meningioma, atypical, and malignant variants were all categorized as meningiomas. The benign cystic lesions included Rathke's cleft cyst, endodermal cyst, arachnoid cyst, dermoid and epidermoid cysts.th
"Others" category included neuroepithelial tumors of an uncertain origin (astroblastoma-polar spongioblastoma-gliomatosis), malignant melanoma, chordoma, paraganglioma, and atypical rhabdoid/teratoid tumor.
This study was based on retrospective analysis dealing with archival paraffin slides and blocks. It followed the ethical guidelines of 1975 declaration of Helsinki.
| Results|| |
The study included 1618 cases of CNS tumors, 847 (52.3%) male patients and 771 (47.7%) were females. The relative frequency of 1618 CNS tumors among Egyptians in delta region was demonstrated in [Figure 1].
Gliomas were the CNS tumors of the highest frequency (35.2%), followed by meningioma (25.6%), pituitary adenoma (11.6%), and nerve sheath tumors (6.6%).
There were 1524 cases of primary CNS tumors (94.2%) and 94 cases of metastatic origin (5.8%). Rare tumor entities encountered were: cysts (1.5%), pineal tumors (0.2%), choroid plexus tumors (0.3%), mixed glioma (0.4%), germ cell tumors (0.4%), and A-V malformations (0.5%).
Glioma and other neuroepithelial tumors (including choroid plexus tumors, embryonal tumors, ganglion cell tumors and parenchymal pineal tumors with one case of astroblastoma grouped in "others " category) constituted 42.8 % of primary CNS tumors (PCNST).
Gliomas (excluding other neuroepithelial tumors) accounted for only about one third of primary CNS tumors (37.3%). Astrocytic tumors were the most common CNS tumors and the most common glial tumors (79.4% of all gliomas) followed by ependymoma (11.4%) and oligodendroglioma (7.6%). Glioblastoma represented 38.3% of gliomas in this work while low-grade diffuse astrocytomas formed only 17.9% of gliomas.
Meningiomas formed the next most frequent histologic type in our study as it constituted 25.6% of all studied CNS tumors and 27.2% of primary CNS tumors, and the most common histologic subtype was meningothelial meningioma 31.8% [Figure 2].
The "others" group (0.9% of all cases), included neuroepithelial tumors of uncertain origin (astroblastoma-polar spongioblastoma-gliomatosis) (two cases; one astroblastoma and one gliomatosis), malignant melanoma (one case), chordoma (five cases), paraganglioma (six cases) and atypical rhabdoid/teratoid tumor (one case).
Age and Sex
As demonstrated in [Table 1] and [Table 2], CNS tumors seen in young age included embryonal tumors (73.8% of medulloblastomas were younger than 30 years), pilocytic astrocytoma (more than three quarter of cases (84.4%) were seen under 20 years of age), ependymomas, about two thirds (61.8%) were recorded in age less than 30 years, and craniopharyngiomas (45% of cases were noticed in patients less than 20 years).
|Table 2: Age distribution in decades in relation to different types of astrocytic tumors|
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Tumors in the older age group (more than 60 years) were: 81 cases astrocytomas (mainly glioblastoma), 73 cases meningiomas and 42 cases metastatic tumors.
Males constituted 52.3% of all cases. Females outnumbered males in the case of meningiomas and ganglion cell tumors, while males were more affected in other tumors including pituitary adenoma. On the other hand, the male:female ratio in nerve sheath tumors was equal [Table 3].
Intracranial tumors represented 86.7% of cases compared to 13.3% for spinal tumors. About 45.6% of all studied CNS tumors were located in the cerebral hemispheres. Frontal lobes were most frequently involved (more than 50% of all cerebral sites) followed by the tempro-parietal region.
The second site of predilection was the sella turcica (15.3% of all cases), where pituitary adenoma (186 cases), meningiomas (25 cases), and craniopharyngioma (16 cases) mostly occurred in such site. Rare sites included the pineal region, orbital region and others (clivus, glomus jugular, foramen magnum, brain stem, and cavernous sinus) [Table 4].
Cerebellar tumors included astrocytoma (41 cases) mainly pilocytic astrocytomas, embryonal tumors (38 cases), non-meningothelial mesenchymal tumors (mainly hemangioblastoma) (13 cases) and cysts (9 cases).
Cerebellopontine angle (CPA) lesions form 4.2% of intracranial sites grouped in our work. Schwannoma, meningioma, and cysts were the most common tumors occurring in such sites.
Primary spinal cord tumors (excluding metastatic tumors) in this work formed 10.9%. The most common primary spinal tumor in our publication was nerve sheath tumors (28%) followed by meningioma (22%) and gliomas (17.5%). Ependymomas in our work comprised 54.8% of all spinal gliomas.
Most astrocytomas had predilection for cerebral hemispheres except pilocytic astrocytomas where 44% of cases were located mainly in the cerebellar region. Spinal astrocytomas constituted only 3.1%, while 2% of all astrocytomas were multiple [Table 5].
|Table 5. Site distribution of the astrocytic tumors collected in this study|
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| Discussion|| |
Epidemiologic data on CNS tumors in our locality are rather incomplete. The present study attempted to estimate the frequency of CNS tumors in the population of the Delta region for the period between 2000 and 2007.
There are numerous epidemiologic studies of CNS tumors estimating the differences in the frequency between populations. ,, The current study represents the largest series of relative frequency of CNS tumors in our locality till now. The CNS tumors grouped in this work are coded according to recent publications. ,, and the classification system of the World Health Organization.  The relative frequencies (%) of CNS tumors in the current study were compared to that of some other worldwide publications [Table 6].
|Table 6: Comparison of the relative frequency (%) of CNS tumors with results of some other studies|
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To compare with Asian, ,, American,  and the Mexican series, , the frequency rates of CNS tumors in this study do not appear to deviate much from that reported. Glioma and other neuroepithelial tumors grouped in this work (including choroid plexus tumors, embryonal tumors and parenchymal pineal tumors) constituted 42.8% of primary CNS tumors (PCNST) which are lower than Wrensch et al,  where they constituted (49%) and Bauchet et al,  (55%), but higher than CBTRUS, 2005--2006  in which gliomas and other neuroepithelial tumors formed 40% of all PCNST tumors.
In our work, gliomas (excluding other neuroepithelial tumors) accounted for only about one third of PCNST (37.3%) This is lower than that recorded by Bauchet et al,  in which gliomas form about one half of all PCNST but approaches that of CBTRUS, (2005-2006)  where it formed 40%. Astrocytic tumors were the most common glial tumor (79.4% of all gliomas) followed by ependymoma (11.4%) and oligodendroglioma (7.6%). This differs from that reported by Suh et al,  where astrocytic tumors form 62.1% of gliomas followed by oligodendrogliomas (10.7%) then ependymoma. This also differs from CBTRUS, (2005--2006),  and Coudwell et al,  who stated that oligodendrogliomas are the most common glioma after glioblastoma and other astrocytomas. However, some other publications  were in agreement with ours in arranging ependymoma as the second most frequent glioma after astrocytomas followed by oligodendroglioma.
In this study, astrocytomas were the most common CNS tumors which goes with Louis et al,  and Suh et al,  who also reported glioblastoma as the most common glial tumors. Glioblastoma represented 38.3% of gliomas in the current work. This is lower than that of Swensen, and Kirsch,  who reported that glioblastoma constitutes 61% of all gliomas and CBTRUS, (2005--2006),  in which glioblastoma formed 50.7% of all gliomas.
Meningiomas are common CNS neoplasms, representing the second most common brain tumor in adults.  As for the frequency of meningiomas in relation to primary CNS tumors, ours was nearly the same as that of some American publications (27 %),  but lower than French publication (29%)  and higher than that of Japan (26.4%). 
Regarding frequency of meningioma in relation to all other CNS tumors, our results, 25.6%, were similar to some American publications  but higher than a Korean publication  where it formed 21.4% and Mexican publication  where it was 22%. On the other hand, it is lower than that of Singapore (35.2%). 
The frequency of atypical/malignant meningioma in this study represents 13.3% of all meningiomas which is higher than that reported by Swensen, and Kirsch,  (8%) and Das et al, B (9.2%). 
Pituitary tumors form the third frequent group of CNS tumors in our publication (11.6 %). This goes with Singapore series (11.8%),  but lower than Korean (19%)  and Mexican (24%)  and higher than Indian (8.3%)  and American publications (6.3%). 
Embryonal tumors in this work formed 3.8% which was lower than Indian publications (9% of all CNS tumors)  and higher than American (1.7%)  and Korean (2.7%). 
In the present study, the frequency of metastatic tumors (5.8%) appeared to be lower than that reported for metastases in Indian series (11.6%)  but it goes more or less with that of Korea (6.0%)  and higher than that of Mexico (4%). 
For all CNS tumors, the most common decade represented in our study was the sixth decade forming 21.7% of all cases The median age was 43 years which is comparable to that of Suh et al,  but lower than CBTRUS, (2004--2005)  (57 years) and (51 years). Children (<15 years) in our series were 166 cases (10.25%). This figure is higher than Korean series (8.5%)  and lower than those of China (19%). 
Embryonal tumors and choroid plexus tumors showed predilection for children in concordance with Pietsch et al,  and Kato et al,,  whereas pituitary adenoma, meningiomas, metastatic tumor, and nerve sheath tumors (mainly schwannoma) rarely affected this age group similar to Rosemberg and Fujiwara,  73.8% of medulloblastomas in our work were younger than 30 years, that corresponds to Levin et al. 
Median ages for brillary, anaplastic astrocytomas and glioblastoma in this work were, 44, 49, 57 respectively as compared to corresponding values of 33, 49, 62 years recorded in some American publications  and, 35, 36, 50 years in India.  The median age for pilocytic astrocytoma in this work was 13 years, as compared to corresponding values of 16 years recorded in India. 
45% of craniopharyngiomas were noticed in patients less than 20 years and 30% of cases were in patients under 10 years, this is somewhat higher than that of Japan in which only 22% of craniopharyngiomas were seen in children. 
CNS tumors are more common in males than in females. ,, In this study, males constituted 52.3% of all cases which is slightly higher than the females. In many publications, ,, females outnumbered males in four tumor types including meningiomas, pituitary adenoma, schwannoma, and cystic lesions. In other tumor types, there was a prevalence of male over female. In our study, this was true for all tumors but the male:female ratio in schwannoma was equal. This goes in agree with Surawicz et al,  stating that tumors of cranial and spinal nerves affect males and females almost equally. Pituitary tumors are also more seen in males and this copes with Indian series. 
CNS tumors commonly occur intracranially.  Intracranial tumors in this work form 86.7% of cases which was lower than other publications (93.5%),  (94.3%)  and (95%).  Diffuse astrocytomas and oligodendrogliomas have predilection for cerebral hemispheres in adults.  About 375 cases (79%) of all astrocytomas in this work were located in the cerebral hemispheres. While almost all cases of oligodendrogliomas were in the cerebral hemisphere.
In this study, about 47% of cases of meningiomas were cerebral and 30.4% of cases were dura based and this goes with Kleihues et al.  Meningiomas arising within the ventricular system constitute approximately 0.5-2% of all intracranial meningiomas.  However, the frequency in our series is slightly higher (3.7%).
Cerebellar tumors in this publication were: pilocytic astrocytomas, embryonal tumors, non-meningothelial mesenchymal tumors (mainly hemangioblastoma) and cysts which go with other publications. , Cerebellopontine angle (CPA) lesions account for 5-10% of all intracranial tumors  where it is slightly lower (4.2%) in our work. It is a common site for nerve sheath tumors (acoustic schwannoma), meningiomas, and cysts. , Our results were comparable to this statement. Schwannomas usually present as tumors of cerebellopontine angle or lumbosacral spinal region.  Most cases (about 85%) of nerve sheath tumors in our study were seen in these two sites.
Primary spinal cord tumors (excluding metastatic tumors) in this work formed 10.9% which is slightly higher than other publications in which it comprises 4-8%.  The most common primary spinal tumor in our publication was nerve sheath tumors (28%) followed by meningioma (22%) and gliomas (17.5%). This goes with Jalali and Datta,  but differs from Kate et al,  and Materljan et al,  as the most common histology types of primary spinal tumors in their publications were meningiomas followed by nerve sheath tumors and ependymoma. Spinal ependymomas in our work comprised 54.8% of all spinal gliomas which is similar to Rezai et al,  who stated that ependymomas form 30--60% of spinal intramedullary gliomas.
In conclusion, Gliomas were the CNS tumors of the highest frequency (35.2%), followed by meningioma (25.6%), then pituitary adenoma (11.6%). Males constituted 52.3% of all cases. 10.25% of tumors were in children less than 15 years of age. Intracranial tumors represented 86.7% of cases compared to 13.3% for spinal tumors. We believe that this effort would help in establishing the grounds for future epidemiologic studies that would, eventually, contribute to give insight into the epidemiology of CNS tumors in our locality.
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Department of Pathology, Mansoura University, Mansoura
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]
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