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A survey of 790 cases of astrocytoma
Original articles A survey of 790 cases of astrocytoma Xue Qing-cheng,
Pu Pei-yu, Yang Yu-shan, and Shen Chang-hong
Introduction Summary
According to local epidemiological surveys from six big cities in China, including Beijing, Shanghai and Guangzhou, the point prevalence rate of brain tumour was 32 per 100,000 inhabitants ‘. Brain tumour was the cause of death in 1.25% of all patients with fatal malignancies reported in China from 1974 till 1978, and was at the 10th place in order of frequency *. From January 1961 to April 1986,3269 Eases of brain tumour, pathologically verified, were treated at the Department of Neurosurgery, Tianjin Medical College Hospital. The histopathological diagnosis is summarized in Table 1. As shown, tumours of neuroglial origin were by far the most common primary brain turnouts, comprising 45.7% of the total. Meningiomas ranked secondly on the survey. Congenital tumour, pituitary tumour, nerve-sheath tumour, metastatic tumour, and vascular tumour occurred in descending order of frequency. For the classification of neuroglial tumours, we adopted Kernohan’s grading system in which astrocytoma and astroblastoma were classified as astrocytoma grade I and II respectively, and glioblastoma as astrocytoma grade II and IV. The frequency of each type of glioma is presented in Table 2. Benign astrocytoma (grade I and II) was the most common type of glioma. Malignant astrocytomas or glioblastoma (grade III
Address for correspondence and reprint requests: Xue Qing-cheng, Tianjin Neurological Institute. Tianjin, China
790 cases of cerebral astrocytoma. which consisted of 181 cases of astrocytoma grade I, 282 cases of grade II, and 327 cases of grade III-IV, histopathologically verified, are presented. The sex and age distribution, topographical distribution of the tumours, and clinical manifestations are analyzed. A total of 862 operations were performed, and 69 cases (8.6%) were operated on more than twice for recurrence. The operative mortality was 7.7%. 179 of the survivors following operation received a combined treatment with radiotherapy and/or chemotherapy. Based on the follow-up study of 170 cases, the factors which may correlate with the length of survival, are discussed. Key words: astrocytoma, follow-up study.
results of treatment,
1
and IV) were second in frequency. The incidence of ependymoma, oligodendroglioma and medulloblastoma rank in decreasing order, although in our series the incidence of oligodendroglioma and medulloblastoma are relatively low as compared to other series reported Z..l. In this paper we present 790 out of 1194 cases of astrocytoma with complete clinical data eligible for analysis.
Dept. of Neurosurgery,
Tianjin
Medical
College Hospital.
Accepted 17.4.89 Clin Neurol
Neurosurg
1990. Vo1.92-I
27
1. Histopathological
Table
diagnosis in 3269 cases of brain
Table 2. Histopathological
diagnosis of 14Yhcase\ 01 glioma.
tumours Type of tumour Type of tumour
n
“0
Neuroglial
1496
45.7 IX.6
Astrocytoma tum,!ur
Meningioma
608
Congenital turnour* Pituitary tumour
264 2SY
Nerve-sheath
232 IX? I25
3.x
tumour
Metastatic
tumour
Malignant
tumour tumour 19
Total
3269
craniopharyngioma.
w!
7.1 2.9
7.1
Medulloblastoma
27
1.8
5.h
Choroid
35 7
1.7 0.j
Y3
6.2
plexus papilloma
Unclassified
0.6
14%
Total
cholesteatoma,
chordoma
In supratentorial tumours, the frontal lobe was most commonly involved. The second site of predilection was the temporal lobe. There was a considerable number of cases in which two or three lobes were involved. Among the infratentorial tumours astrocytomas of the cerebellar hemisphere or vermis were most frequently seen. Malignancy of astrocytomas in relation to patient’s age and tumour location There were 181 cases of astrocytoma grade I, 282 cases of grade II and 327 cases of grade III/IV in this series. On the average, the patient’s age at the time of first admission was 28.3 years, 32.8 years and 39.8 years for the respec-
Table 4. Topographical
“‘/0
Temporal lobe Parietal lobe Occipital
Y
4x
IO- IY 20 - 2’)
123 127
6.0 IS.0
30 - 39
166
21.1
40 - 49
1x2
23.0
50 - 59
116
14.7
60 - 69 70 - 7’)
26 2
3.3 0.3
16.0
lobe
10tJ.O
of 790 cases of astrocy-
2 or 3 lobes involved
2.51
31.8
I.51 42
1Y.I
3
0.4
l7h
22.3
5.3
Thalamus
19
2.4
Lateral of 3rd ventricle
I6
2.0
h 3
0.8 0.4
Suprasellar region Optic nerve lnfrulentorial Cerebellar
hemisphere
Vermis 4th ventricle Cerebellopontine
28
distribution
toma
Supmemorial Frontal lobe
of 790 cases of astrocytoma
790
IOO.0
100.0
Topographical distribution In our series 667 (84.4%) out of a total of 790 astrocytomas were situated above the tentorium and 123 cases (15.6%) were infratentorial. The ratio between supratentorial and infratentorial astrocytomas was 5.4: 1. The topographical distribution of astrocytomas is shown in Table 4.
n
plioma
2.5
In our series 524 cases were male and 266 cases female, the ratio of 2:l thus indicates a definite preponderance of males. The age distribution is shown in Table 3. The youngest case was one and half years old, while the eldest was 73 years. There was a predilection for the 30-49 age group.
Total
32.5 44
Sex and age
o-
47.3
Oligodendroglioma
Patients and material
Age
79.X
708 106
etc.
Table 3. Age distribution
II
grade III-IV Ependymoma
x.1 7 0
83
Others
x Including
II04
I&
Pincaloma
unclassified Vascular
grade
“,,
II
Brain stem
angle
56
7.1
48 I7
6.1 2.2
I
0. I
I
0.
I
Table 5. Tumour
grade
in relation
Age
o- 9 IO - 19 20 - 29 30-39 40-49 50 - 59 60 - 69 70 - 79 Total
to age and location
III/IV
subt
Infratentorial Grade I II
5 28 45 58 57 38 5 0
8 32 49 60 87 61 18 I
I8 71 113 152 174 II2 25 2
17 29 8 8 2 I I 0
I1 I7 5 5 5 3 0 0
2 6 I I I 0 0 0
30 52 I4 14 8 4 I 0
236
316
667
66
46
II
I2
Supratentorial Grade I II
5 I1 I9 34 30 I3 2 1
II5
III/IV
subt
subt = subtotal
tive groups. It seems that the higher the malignancy of the astrocytoma, the elder the age of onset would be. The grade of astrocytomas in relation to age distribution and tumour location is shown in Table 5. Among the subtentorial astrocytomas gfade I was far more common, especially in patients under the age of 20 years, whereas astrocytoma grade III/IV was predominant among the supratentorial group, most of them occurring at the 4th to 6th decades. Duration of symptoms
At the time of the diagnosis, the average duration of symptoms in patients with astrocytoma grade I, II, and II/IV were 23.6,22.9, and 10.9 months, respectively. There was no significant difference between the duration of symptoms in patients with astrocytoma grade I and II. But they were longer than in astrocytomas grade III/IV. Clinical manifestations
The most frequent initial symptom with astrocytomas was headache (61%). Next were seizures (18%). Irrespective of infra- or supratentorial location, symptoms and signs due to intracranial hypertension were most often seen. Epileptic seizures as well as hemiparesis or hemiparalysis were more common in patients with supratentorial astrocytomas, while in the infratentorial astrocytomas ataxia and nystagmus were more frequent. In our series, a considerable number of cases had disturbance of consciousness, such as drow-
siness, confusion, disorientation and coma, at the time of admission and approximately half of them presented typical signs of herniation at the tentorium of the foramen magnum. Diagnostic studies
Of 338 cases plain skull roentgenography showed in 223 cases (66%) evidence of raised intracranial pressure. Pathological calcification could be found only in 28 (8%) cases, most of them (19 out of 28cases) frontal. Pathologically, they were astrocytoma grade I (9 cases), grade II (11 cases) and grade III/IV (8 cases). Pathological calcification thus could be seen not only in the benign, but also in the malignant astrocytomas. In 648 cases admitted before 1981, traditional ventriculography and cerebral angiography were utilised as standard diagnostic procedures. Since 1981, instead of traditional diagnostic studies, CT scanning has become available in our neurosurgical clinics as the diagnostic procedure of choice. However, cerebral angiography was also needed occasionally for investigating the blood supply of tumours or for the differential diagnosis with respect to meningiomas. CT scanning was satisfactory for the localisation of brain tumours. In 142 cases of astrocytoma we studied with CT scanning, the accuracy for identifying astrocytomas amounted up to 89%. Without contrast enhancement, nonanaplastic astrocytomas usually appeared on the CT scan as low density or isodense lesions, whereas astrocytomas grade III/IV tended to be lesions of high density or of mixed high and low density, 29
Table 6. The results of operation
Improved
No change
Worse
Death
Total
69-i X0.8
4x 5.6
10 1.2
IO7 12.J
X26
Gross total excision Subtotal excision Greater part excision Partial excision Biopsy
Total in %
if necrosis and cystic changes occurred. In addition, contrast enhancement in astrocytomas grade III/IV was more marked as compared to the low grade tumours. Both non-anaplastic and anaplastic astrocytomas may have a ring-Iike enhancement. However, the solid type of en-
hancement was rather common in high grade astrocytomas. Treatment and results Operative excision was the treatment of first choice for astrocytomas. Radiotherapy and che-
Fig. 1. a. Postoperative CTscan of a case of right frontal astrocytoma grade 1. b. CTscan aftger 1stcourse of intra-arterial BCNU treatment. The tumor shadow reduced in size. c. CT scan after 3rd course of intra-arterial chemotherapy. the tumor shadow became much smaller. d. CT scan after 4th course of intra-arterial chemotherapy. The tumor shadow couldn’t be visualized.
Table 7. Results of follow-up study in 170 cases Alive
Dead grade I 3-
(tmonths 1 year 2years 3 years 4 years 5 years 10 years 15 years 20 years 20 years
Total
8 6
11
III/IV
17 8 3 3
25
I 1
3 1
14 4 1
1 1 1 1
1
18
37
motherapy were used as adjuvant therapeutic measures in some patients. A total of 862 operations were performed in our series. Sixty nine cases (8.6%) were operated cm more than twice for recurrent astrocytomas and in one case the treatment even comprised 5 interventions. There were 15 cases with astrocytomas grade I, 30 with astrocytoma grade II and 30 cases with astrocytomas grade IIUIV. The results of operation are presented in Table 6. In some recurrent cases, the turnout-s showed increased anaplasia. On reoperation, among 1.5 cases of recurrent astrocytoma grade I, it evolved into grade II in 5 cases (33%) into grade III/IV in 3 cases (20%). Sii (20%) out of 30 recurrent astrocytoma grade II evolved into grade III/IV at recurrence. Among the deceased, 67 cases died directly of the operation which included 16 cases of astrocytoma grade I, 20 cases of astr~ytoma grade II and 31 cases of astrocytoma grade III/IV. The operative mortality rate was 7.7%. The average age of the cases who died of the operation was 40 years. Prior to the operative treatment their performance status graded by the Karnofsky rating scale was all less than 60, of which 37 cases ranged between 10-30. A majority of these cases had alteration of consciousness, while their lesions diffusely involving more than two lobes, could only partially be removed. They did not show any clinical improvement and died within 2 weeks after operation. Following operation, 179 of the survivors re-
48
grade I
II
IIIlIV 4 1
4 3 1 2 2 1 5 3 4 1
4 2 3
1
23
33
11
9 1 3 4 2 5
2 1 1 1
ceived a combined treatment of radiotherapy and chemotherapy. In our series BCNU was the most commonly used chemotherapeutic agent. See figure I a-d In rare occasions, CCNU, Bleomycin, Mithramycin and Cisplatin were used. These agents were administered intravenously or by the intracarotid route. Follow-up study 170 cases, including as~~ytoma grade I (41 cases), grade II (70 cases) and grade IIUIV (59 cases) were followed for 3 months to 25 years. 103 out of 170 cases died; 67 cases are still alive. The result of the follow-up is shown in Table 7. One case with cerebellar astrocytoma grade I and 3 cases with astrocytomas grade II in the cerebellar hemisphere and in the frontal and temporal lobes, are still alive after 25,20,24 and 24 years respectively. Four cases with astrocytomas grade III/IV which were situated in the fronto-parietal, frontal, parietal and parieto-occipital lobes survived more than 5 years. One patient is still alive for 18 years. Discussion According to the data of 3269 cases with brain tumours confirmed histologically, the incidence of neuroglial tumour (45.7%) was the highest one. This figure approaches reports by other centres in China2-4. In most of the series reported, glioblastoma constituted nearly half of all gliomas or 15-20% of brain tumours4.6 , In our series, however, astrocytomas grade I and II 31
were more common than astrocytomas
grade
mas, the latter comprised 32.5% of the gliomas and 10% of the brain turnouts as a whole. The
of the 33 cases were treated by operative resection alone. In most cases the tumour mass was totally or subtotally removed. It indicates the importance of extensive resection in prolonging
predominance
survival
III/IV.
The former comprised
confirmed
of low grade by the report Institute
brain
they reported,
counted
astrocytomas
issued
Neurosurgical tumours
47.3% of the glio-
in 1985. In 9063 cases of astrocytomas
for 47% of the gliomas.
tomas only constituted In addition,
old with a peak incidence
ac-
while glioblas-
13.7%.
it has been reported
tomas usually occurred
was
by the Beijing
in patients
It has been
reported
in some glioblastomas
plete resection
of the tumour
tion combined
with radiotherapy
that glioblas-
tient with a parieto-occipital totally
grade
III/IV, 159 cases were under. and 168 cases (51.4%) over the age of 40. There is no statistically significant difference of incidence of glioblastoma between these two age groups. In general, astrocytoma grade III/IV are rarely seen below the tentorium, if it occurred infratentorially, the brain stem was the common site. In our series, 11 cases of astrocytoma grade III/IV occurred below the tentorium. Of which, 9 cases were situated in the cerebellum, one in the brain stem and one in the fourth ventricle. All but two were children and juveniles between 5-17 years old. The preoperative course was shorter, mostly less than 4 months. As the clinical presentation is concerned, it was found that regardless of the grading and location of the astrocytomas. the symptoms and signs of intracranial hypertension were the most common. Next were epileptic seizures. It occurred more often in supratentorial astrocytomas, especially in the low grade astrocytomas. The incidence of epilepsy in patients with astrocytoma grade I. II and III/IV was 47%, 3 1% , and 24% respectively. No correlation could be found between the incidence of motor dysfunction and the grade of malignancy of astrocytomas. However, in the patients with low grade astrocytomas motor dysfunction usually presented as hemiparesis or monoparesis. while in the patients with astrocytomas or monoparesis, while in the patients with astrocytomas grade III/IV severe paralysis of extremities more often occurred. Among the 170 cases with astrocytomas we followed, 33 cases survived longer than 5 years. Besides the 6 cases which were treated in combination with chemotherapy or radiotherapy, 27
if a com-
or a subtotal
resec-
is performed”.
with long survivals.
over 40 years
at 48-52 years (4-6). In
that a curt
In our series. there were a few cases of astrocytoma grade III/IV
our series, of 327 cases with astrocytoma
32
time.
may be expected
removed
still alive after
and receiving 1X years.
One pa-
glioblastoma chemotherapy
It indicates
subis
that under
appropriate circumstances, with more complete resection of the tumour. the prognosis of glioblastoma may me improved in some cases. Moreover. the more extensive the tumour is excised, the more the tumour burden is reduced and the effects of adjuvant therapy such as radiotherapy or chemotherapy may be enhanced. For example, with intracarotid BCNU chemotherapy, we found that its effect was closely related to the extent of tumour resection. Based on the clinical data of 20 cases which survived longer than 10 years, the factors which may correlate with the length of survival are as follows: 1. Age: our data showed that the younger patients tend to survive longer than the older. Most of the patients with long term survival in this series were children en juveniles. The average age of the group was 23.5 years. Three of them. aged 10. 10 and 13 years. with cerebellar astrocytoma grade I and II were treated only by excision of the greater part of the tumour. but they have survived for 20. 18 and 11 years. Obviously this favourable effect may in part reflect some difference in the histopathological type of the tumours for this special age group. For example, the most benign and slowly growing cerebellar astrocytomas are quite common in children. 2. The grading and localisation of astrocytomas: the degree of anaplasia of astrocytomas is one of the factors most determining survival. In our series, except for two patients with astrocytoma grade III/IV who survived longer than 10 years, all patients with long term survivals had astrocytomas grade I or II, of which, 6 cases with localisation in the cerebellum, and the remainder in the frontal, temporal or occipital lobes.
These locations are the most accesible to surgery, allowing a total resection of the tumour. 3. Preoperative performance status: the length of survival may be related to the patient’s performance status before the operation. The preoperative performance status graded by Karnofsky rating scale in most cases with long term survivals ranged between 60-90. 4. The modality of treatment: most of the patients with late onset and long term survival were treated by total removal of the tumour or subtotal resection combined with chemotherapy and radiotherapy. References '
z
ZHONGCHENG et al. Epidemiologic study of major neurologic diseases in the urban population of six cities in China. Chinese J Neurosurg 1985:1:2-8. Hu.4NciwENoiNo et al. Statistical analysis of central nervous system tumors in China. J Neurosurg 1982;56:55564.
WANG
Beijing Neurosurgical Institute: pathological analysis of 9063 cases of intracranial tumors. Chinese J Neurosurg 1985;1:9-14. BUTLER AB. Classification and biology of brain tumours. In: Youmans JR, ed. Neurological Surgery, ~01.5, 2nd ed. Philadelphia: WB Saunders Company, 1982:2659759. MACCABE JJ. Glioblastoma. In: Vinken PJ, Bruyn GW, eds. Handbook of Clinical Neurology Vol.18. Amsterdam: North Holland Publishing 1973:49-71. BUCY PC el al. Cerebral glioblastomas can be cured. Neurosurgery 1985:16:714-7. FEUN LG et al. Phase I trial of intracarotid BCNU and cisplatin in patients with malignant intracerebral tumors. Cancer Drug Delivery 1984;1:239-45. GREENBERG HS eral. Intra-arterial BCNU chemotherapy for the treatment of malignant gliomas of the central nervous system: A preliminary report. Cant Treat Rep 1981;65:803-10. GREENBERG HS etal. Intra-arterial BCNU chemotherapy for treatment of malignant gliomas of the central nervous system. J Neurosurg 1984;61:423-9. FEUN LG era/. Intracarotid infusion of cis-diammine dichloroplatinum in the treatment of recurrent malignant brain tumors. Cancer 1984:54:794-9. KAPP JP, VANCE RB. Supraophthalmic carotid infusion for recurrent glioma. J Neuro-oncology 1985;3:5-11.
33
Pu Pei-yu, Yang Yu-shan, and Shen Chang-hong
Introduction Summary
According to local epidemiological surveys from six big cities in China, including Beijing, Shanghai and Guangzhou, the point prevalence rate of brain tumour was 32 per 100,000 inhabitants ‘. Brain tumour was the cause of death in 1.25% of all patients with fatal malignancies reported in China from 1974 till 1978, and was at the 10th place in order of frequency *. From January 1961 to April 1986,3269 Eases of brain tumour, pathologically verified, were treated at the Department of Neurosurgery, Tianjin Medical College Hospital. The histopathological diagnosis is summarized in Table 1. As shown, tumours of neuroglial origin were by far the most common primary brain turnouts, comprising 45.7% of the total. Meningiomas ranked secondly on the survey. Congenital tumour, pituitary tumour, nerve-sheath tumour, metastatic tumour, and vascular tumour occurred in descending order of frequency. For the classification of neuroglial tumours, we adopted Kernohan’s grading system in which astrocytoma and astroblastoma were classified as astrocytoma grade I and II respectively, and glioblastoma as astrocytoma grade II and IV. The frequency of each type of glioma is presented in Table 2. Benign astrocytoma (grade I and II) was the most common type of glioma. Malignant astrocytomas or glioblastoma (grade III
Address for correspondence and reprint requests: Xue Qing-cheng, Tianjin Neurological Institute. Tianjin, China
790 cases of cerebral astrocytoma. which consisted of 181 cases of astrocytoma grade I, 282 cases of grade II, and 327 cases of grade III-IV, histopathologically verified, are presented. The sex and age distribution, topographical distribution of the tumours, and clinical manifestations are analyzed. A total of 862 operations were performed, and 69 cases (8.6%) were operated on more than twice for recurrence. The operative mortality was 7.7%. 179 of the survivors following operation received a combined treatment with radiotherapy and/or chemotherapy. Based on the follow-up study of 170 cases, the factors which may correlate with the length of survival, are discussed. Key words: astrocytoma, follow-up study.
results of treatment,
1
and IV) were second in frequency. The incidence of ependymoma, oligodendroglioma and medulloblastoma rank in decreasing order, although in our series the incidence of oligodendroglioma and medulloblastoma are relatively low as compared to other series reported Z..l. In this paper we present 790 out of 1194 cases of astrocytoma with complete clinical data eligible for analysis.
Dept. of Neurosurgery,
Tianjin
Medical
College Hospital.
Accepted 17.4.89 Clin Neurol
Neurosurg
1990. Vo1.92-I
27
1. Histopathological
Table
diagnosis in 3269 cases of brain
Table 2. Histopathological
diagnosis of 14Yhcase\ 01 glioma.
tumours Type of tumour Type of tumour
n
“0
Neuroglial
1496
45.7 IX.6
Astrocytoma tum,!ur
Meningioma
608
Congenital turnour* Pituitary tumour
264 2SY
Nerve-sheath
232 IX? I25
3.x
tumour
Metastatic
tumour
Malignant
tumour tumour 19
Total
3269
craniopharyngioma.
w!
7.1 2.9
7.1
Medulloblastoma
27
1.8
5.h
Choroid
35 7
1.7 0.j
Y3
6.2
plexus papilloma
Unclassified
0.6
14%
Total
cholesteatoma,
chordoma
In supratentorial tumours, the frontal lobe was most commonly involved. The second site of predilection was the temporal lobe. There was a considerable number of cases in which two or three lobes were involved. Among the infratentorial tumours astrocytomas of the cerebellar hemisphere or vermis were most frequently seen. Malignancy of astrocytomas in relation to patient’s age and tumour location There were 181 cases of astrocytoma grade I, 282 cases of grade II and 327 cases of grade III/IV in this series. On the average, the patient’s age at the time of first admission was 28.3 years, 32.8 years and 39.8 years for the respec-
Table 4. Topographical
“‘/0
Temporal lobe Parietal lobe Occipital
Y
4x
IO- IY 20 - 2’)
123 127
6.0 IS.0
30 - 39
166
21.1
40 - 49
1x2
23.0
50 - 59
116
14.7
60 - 69 70 - 7’)
26 2
3.3 0.3
16.0
lobe
10tJ.O
of 790 cases of astrocy-
2 or 3 lobes involved
2.51
31.8
I.51 42
1Y.I
3
0.4
l7h
22.3
5.3
Thalamus
19
2.4
Lateral of 3rd ventricle
I6
2.0
h 3
0.8 0.4
Suprasellar region Optic nerve lnfrulentorial Cerebellar
hemisphere
Vermis 4th ventricle Cerebellopontine
28
distribution
toma
Supmemorial Frontal lobe
of 790 cases of astrocytoma
790
IOO.0
100.0
Topographical distribution In our series 667 (84.4%) out of a total of 790 astrocytomas were situated above the tentorium and 123 cases (15.6%) were infratentorial. The ratio between supratentorial and infratentorial astrocytomas was 5.4: 1. The topographical distribution of astrocytomas is shown in Table 4.
n
plioma
2.5
In our series 524 cases were male and 266 cases female, the ratio of 2:l thus indicates a definite preponderance of males. The age distribution is shown in Table 3. The youngest case was one and half years old, while the eldest was 73 years. There was a predilection for the 30-49 age group.
Total
32.5 44
Sex and age
o-
47.3
Oligodendroglioma
Patients and material
Age
79.X
708 106
etc.
Table 3. Age distribution
II
grade III-IV Ependymoma
x.1 7 0
83
Others
x Including
II04
I&
Pincaloma
unclassified Vascular
grade
“,,
II
Brain stem
angle
56
7.1
48 I7
6.1 2.2
I
0. I
I
0.
I
Table 5. Tumour
grade
in relation
Age
o- 9 IO - 19 20 - 29 30-39 40-49 50 - 59 60 - 69 70 - 79 Total
to age and location
III/IV
subt
Infratentorial Grade I II
5 28 45 58 57 38 5 0
8 32 49 60 87 61 18 I
I8 71 113 152 174 II2 25 2
17 29 8 8 2 I I 0
I1 I7 5 5 5 3 0 0
2 6 I I I 0 0 0
30 52 I4 14 8 4 I 0
236
316
667
66
46
II
I2
Supratentorial Grade I II
5 I1 I9 34 30 I3 2 1
II5
III/IV
subt
subt = subtotal
tive groups. It seems that the higher the malignancy of the astrocytoma, the elder the age of onset would be. The grade of astrocytomas in relation to age distribution and tumour location is shown in Table 5. Among the subtentorial astrocytomas gfade I was far more common, especially in patients under the age of 20 years, whereas astrocytoma grade III/IV was predominant among the supratentorial group, most of them occurring at the 4th to 6th decades. Duration of symptoms
At the time of the diagnosis, the average duration of symptoms in patients with astrocytoma grade I, II, and II/IV were 23.6,22.9, and 10.9 months, respectively. There was no significant difference between the duration of symptoms in patients with astrocytoma grade I and II. But they were longer than in astrocytomas grade III/IV. Clinical manifestations
The most frequent initial symptom with astrocytomas was headache (61%). Next were seizures (18%). Irrespective of infra- or supratentorial location, symptoms and signs due to intracranial hypertension were most often seen. Epileptic seizures as well as hemiparesis or hemiparalysis were more common in patients with supratentorial astrocytomas, while in the infratentorial astrocytomas ataxia and nystagmus were more frequent. In our series, a considerable number of cases had disturbance of consciousness, such as drow-
siness, confusion, disorientation and coma, at the time of admission and approximately half of them presented typical signs of herniation at the tentorium of the foramen magnum. Diagnostic studies
Of 338 cases plain skull roentgenography showed in 223 cases (66%) evidence of raised intracranial pressure. Pathological calcification could be found only in 28 (8%) cases, most of them (19 out of 28cases) frontal. Pathologically, they were astrocytoma grade I (9 cases), grade II (11 cases) and grade III/IV (8 cases). Pathological calcification thus could be seen not only in the benign, but also in the malignant astrocytomas. In 648 cases admitted before 1981, traditional ventriculography and cerebral angiography were utilised as standard diagnostic procedures. Since 1981, instead of traditional diagnostic studies, CT scanning has become available in our neurosurgical clinics as the diagnostic procedure of choice. However, cerebral angiography was also needed occasionally for investigating the blood supply of tumours or for the differential diagnosis with respect to meningiomas. CT scanning was satisfactory for the localisation of brain tumours. In 142 cases of astrocytoma we studied with CT scanning, the accuracy for identifying astrocytomas amounted up to 89%. Without contrast enhancement, nonanaplastic astrocytomas usually appeared on the CT scan as low density or isodense lesions, whereas astrocytomas grade III/IV tended to be lesions of high density or of mixed high and low density, 29
Table 6. The results of operation
Improved
No change
Worse
Death
Total
69-i X0.8
4x 5.6
10 1.2
IO7 12.J
X26
Gross total excision Subtotal excision Greater part excision Partial excision Biopsy
Total in %
if necrosis and cystic changes occurred. In addition, contrast enhancement in astrocytomas grade III/IV was more marked as compared to the low grade tumours. Both non-anaplastic and anaplastic astrocytomas may have a ring-Iike enhancement. However, the solid type of en-
hancement was rather common in high grade astrocytomas. Treatment and results Operative excision was the treatment of first choice for astrocytomas. Radiotherapy and che-
Fig. 1. a. Postoperative CTscan of a case of right frontal astrocytoma grade 1. b. CTscan aftger 1stcourse of intra-arterial BCNU treatment. The tumor shadow reduced in size. c. CT scan after 3rd course of intra-arterial chemotherapy. the tumor shadow became much smaller. d. CT scan after 4th course of intra-arterial chemotherapy. The tumor shadow couldn’t be visualized.
Table 7. Results of follow-up study in 170 cases Alive
Dead grade I 3-
(tmonths 1 year 2years 3 years 4 years 5 years 10 years 15 years 20 years 20 years
Total
8 6
11
III/IV
17 8 3 3
25
I 1
3 1
14 4 1
1 1 1 1
1
18
37
motherapy were used as adjuvant therapeutic measures in some patients. A total of 862 operations were performed in our series. Sixty nine cases (8.6%) were operated cm more than twice for recurrent astrocytomas and in one case the treatment even comprised 5 interventions. There were 15 cases with astrocytomas grade I, 30 with astrocytoma grade II and 30 cases with astrocytomas grade IIUIV. The results of operation are presented in Table 6. In some recurrent cases, the turnout-s showed increased anaplasia. On reoperation, among 1.5 cases of recurrent astrocytoma grade I, it evolved into grade II in 5 cases (33%) into grade III/IV in 3 cases (20%). Sii (20%) out of 30 recurrent astrocytoma grade II evolved into grade III/IV at recurrence. Among the deceased, 67 cases died directly of the operation which included 16 cases of astrocytoma grade I, 20 cases of astr~ytoma grade II and 31 cases of astrocytoma grade III/IV. The operative mortality rate was 7.7%. The average age of the cases who died of the operation was 40 years. Prior to the operative treatment their performance status graded by the Karnofsky rating scale was all less than 60, of which 37 cases ranged between 10-30. A majority of these cases had alteration of consciousness, while their lesions diffusely involving more than two lobes, could only partially be removed. They did not show any clinical improvement and died within 2 weeks after operation. Following operation, 179 of the survivors re-
48
grade I
II
IIIlIV 4 1
4 3 1 2 2 1 5 3 4 1
4 2 3
1
23
33
11
9 1 3 4 2 5
2 1 1 1
ceived a combined treatment of radiotherapy and chemotherapy. In our series BCNU was the most commonly used chemotherapeutic agent. See figure I a-d In rare occasions, CCNU, Bleomycin, Mithramycin and Cisplatin were used. These agents were administered intravenously or by the intracarotid route. Follow-up study 170 cases, including as~~ytoma grade I (41 cases), grade II (70 cases) and grade IIUIV (59 cases) were followed for 3 months to 25 years. 103 out of 170 cases died; 67 cases are still alive. The result of the follow-up is shown in Table 7. One case with cerebellar astrocytoma grade I and 3 cases with astrocytomas grade II in the cerebellar hemisphere and in the frontal and temporal lobes, are still alive after 25,20,24 and 24 years respectively. Four cases with astrocytomas grade III/IV which were situated in the fronto-parietal, frontal, parietal and parieto-occipital lobes survived more than 5 years. One patient is still alive for 18 years. Discussion According to the data of 3269 cases with brain tumours confirmed histologically, the incidence of neuroglial tumour (45.7%) was the highest one. This figure approaches reports by other centres in China2-4. In most of the series reported, glioblastoma constituted nearly half of all gliomas or 15-20% of brain tumours4.6 , In our series, however, astrocytomas grade I and II 31
were more common than astrocytomas
grade
mas, the latter comprised 32.5% of the gliomas and 10% of the brain turnouts as a whole. The
of the 33 cases were treated by operative resection alone. In most cases the tumour mass was totally or subtotally removed. It indicates the importance of extensive resection in prolonging
predominance
survival
III/IV.
The former comprised
confirmed
of low grade by the report Institute
brain
they reported,
counted
astrocytomas
issued
Neurosurgical tumours
47.3% of the glio-
in 1985. In 9063 cases of astrocytomas
for 47% of the gliomas.
tomas only constituted In addition,
old with a peak incidence
ac-
while glioblas-
13.7%.
it has been reported
tomas usually occurred
was
by the Beijing
in patients
It has been
reported
in some glioblastomas
plete resection
of the tumour
tion combined
with radiotherapy
that glioblas-
tient with a parieto-occipital totally
grade
III/IV, 159 cases were under. and 168 cases (51.4%) over the age of 40. There is no statistically significant difference of incidence of glioblastoma between these two age groups. In general, astrocytoma grade III/IV are rarely seen below the tentorium, if it occurred infratentorially, the brain stem was the common site. In our series, 11 cases of astrocytoma grade III/IV occurred below the tentorium. Of which, 9 cases were situated in the cerebellum, one in the brain stem and one in the fourth ventricle. All but two were children and juveniles between 5-17 years old. The preoperative course was shorter, mostly less than 4 months. As the clinical presentation is concerned, it was found that regardless of the grading and location of the astrocytomas. the symptoms and signs of intracranial hypertension were the most common. Next were epileptic seizures. It occurred more often in supratentorial astrocytomas, especially in the low grade astrocytomas. The incidence of epilepsy in patients with astrocytoma grade I. II and III/IV was 47%, 3 1% , and 24% respectively. No correlation could be found between the incidence of motor dysfunction and the grade of malignancy of astrocytomas. However, in the patients with low grade astrocytomas motor dysfunction usually presented as hemiparesis or monoparesis. while in the patients with astrocytomas or monoparesis, while in the patients with astrocytomas grade III/IV severe paralysis of extremities more often occurred. Among the 170 cases with astrocytomas we followed, 33 cases survived longer than 5 years. Besides the 6 cases which were treated in combination with chemotherapy or radiotherapy, 27
if a com-
or a subtotal
resec-
is performed”.
with long survivals.
over 40 years
at 48-52 years (4-6). In
that a curt
In our series. there were a few cases of astrocytoma grade III/IV
our series, of 327 cases with astrocytoma
32
time.
may be expected
removed
still alive after
and receiving 1X years.
One pa-
glioblastoma chemotherapy
It indicates
subis
that under
appropriate circumstances, with more complete resection of the tumour. the prognosis of glioblastoma may me improved in some cases. Moreover. the more extensive the tumour is excised, the more the tumour burden is reduced and the effects of adjuvant therapy such as radiotherapy or chemotherapy may be enhanced. For example, with intracarotid BCNU chemotherapy, we found that its effect was closely related to the extent of tumour resection. Based on the clinical data of 20 cases which survived longer than 10 years, the factors which may correlate with the length of survival are as follows: 1. Age: our data showed that the younger patients tend to survive longer than the older. Most of the patients with long term survival in this series were children en juveniles. The average age of the group was 23.5 years. Three of them. aged 10. 10 and 13 years. with cerebellar astrocytoma grade I and II were treated only by excision of the greater part of the tumour. but they have survived for 20. 18 and 11 years. Obviously this favourable effect may in part reflect some difference in the histopathological type of the tumours for this special age group. For example, the most benign and slowly growing cerebellar astrocytomas are quite common in children. 2. The grading and localisation of astrocytomas: the degree of anaplasia of astrocytomas is one of the factors most determining survival. In our series, except for two patients with astrocytoma grade III/IV who survived longer than 10 years, all patients with long term survivals had astrocytomas grade I or II, of which, 6 cases with localisation in the cerebellum, and the remainder in the frontal, temporal or occipital lobes.
These locations are the most accesible to surgery, allowing a total resection of the tumour. 3. Preoperative performance status: the length of survival may be related to the patient’s performance status before the operation. The preoperative performance status graded by Karnofsky rating scale in most cases with long term survivals ranged between 60-90. 4. The modality of treatment: most of the patients with late onset and long term survival were treated by total removal of the tumour or subtotal resection combined with chemotherapy and radiotherapy. References '
z
ZHONGCHENG et al. Epidemiologic study of major neurologic diseases in the urban population of six cities in China. Chinese J Neurosurg 1985:1:2-8. Hu.4NciwENoiNo et al. Statistical analysis of central nervous system tumors in China. J Neurosurg 1982;56:55564.
WANG
Beijing Neurosurgical Institute: pathological analysis of 9063 cases of intracranial tumors. Chinese J Neurosurg 1985;1:9-14. BUTLER AB. Classification and biology of brain tumours. In: Youmans JR, ed. Neurological Surgery, ~01.5, 2nd ed. Philadelphia: WB Saunders Company, 1982:2659759. MACCABE JJ. Glioblastoma. In: Vinken PJ, Bruyn GW, eds. Handbook of Clinical Neurology Vol.18. Amsterdam: North Holland Publishing 1973:49-71. BUCY PC el al. Cerebral glioblastomas can be cured. Neurosurgery 1985:16:714-7. FEUN LG et al. Phase I trial of intracarotid BCNU and cisplatin in patients with malignant intracerebral tumors. Cancer Drug Delivery 1984;1:239-45. GREENBERG HS eral. Intra-arterial BCNU chemotherapy for the treatment of malignant gliomas of the central nervous system: A preliminary report. Cant Treat Rep 1981;65:803-10. GREENBERG HS etal. Intra-arterial BCNU chemotherapy for treatment of malignant gliomas of the central nervous system. J Neurosurg 1984;61:423-9. FEUN LG era/. Intracarotid infusion of cis-diammine dichloroplatinum in the treatment of recurrent malignant brain tumors. Cancer 1984:54:794-9. KAPP JP, VANCE RB. Supraophthalmic carotid infusion for recurrent glioma. J Neuro-oncology 1985;3:5-11.
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