intra-cranial space occupying lesions

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INTRA-CRANIAL SPACE OCCUPYING LESIONS
A MORPHOLOGICAL ANALYSIS
M. EJAZ BUTT, SAEED A. KHAN, NASEER A. CHAUDRHY AND G. R. QURESHI
Department of Pathology, Postgraduate Medical Institute, Lahore - Pakistan
The purpose of this study was to provide preliminary data on morphological patterns of intracranial space occupying lesions (ICSOL) in central Punjab province. This is a cross-sectional
prospective study on 100 consecutive cases of intra-cranial space occupying lesions admitted to
both the neurosurgery units of Lahore General Hospital, Lahore, Pakistan. The biopsy materials
were examined histologically using paraffin sections. Eighty nine (89) patients had neoplasms,
while eleven (11) had non-neoplastic lesions. Neuroepithelial tumours comprised 41% of all the
neoplasms, followed by meningiomas being 23%, schwannomas 11% and metastatic tumours
6%. Males were affected slightly more than females (1.17:1). Tuberculomas constituted 3% of the
lesions. It was concluded that age and sex distribution were generally comparable to the other
published literature. Similarly neuroepithehal tumours formed majority of the lesions. However
meningiomas had a higher frequency as compared to the western literature; moreover
tuberculomas should also be considered in the differential diagnosis of such lesions in this part
of the world.
INTRODUCTION
The term “Intra-cranial space occupying lesion” is
defined as any neoplasm, benign or malignant, primary or secondary, as well as any inflammatory or
parasitic mass lying within the cranial cavity1. The
list also includes haematomas,2 different types of
cysts,3,4 and vascular malformations5,1,6. Space
occupying primary tumours of the central nervous
system and its coverings account for about 9% of
all the primary neoplasms of the human body.
Among the intracranial space occupying tumours,
those of central neurogenic origin claim priority in
number and complexity. These are the tumours
derived from parenchymatous neuroepithelial elements of central nervous system excluding the
microglia; and they are widely credited to account
for 40-50% of all the intra-cranial space occupying
tumours7,8. Systemic study of tumours of the central nervous system began when Baily and Cushing started their studies in the early 1920’s. Over
the past three decades, many reports suggested
that both incidence and pattern of intracranial
neoplasia are subject to considerable geographic
and racial variations. Knowledge of the regional
peculiarities of these lesions, may, therefore, help
in identifications of possible risk factors and also
in establishing measures for an improved
diagnosis, treatment and outcome. No accurate
statistics reporting the morphological pattern of
intracranial space occupying lesions were available
in the province of Punjab. Therefore, it was
decided to study the morphological pattern of
intracranial space occupying lesions in this part of
the world.
MATERIALS AND METHODS
A total of 100 cases of intracranial space occupying
lesions (ICSOLS) were collected from both the
neurosurgery wards of the Lahore General
Hospital Lahore, between the period from
September 1999 to April 2000. As these are the
oldest, the biggest and very busy neurosurgical
units of the province, hence the patient population
was fairly equally representative of the province of
Punjab. The patients were of all age groups and
belonged to both sexes. All cerebral neoplasms in
this study were grouped according to the
classification of the World Health Organization9.
Each patient had at least one cranial tomographic
scan (CT) and was found having a space occupying
lesion in the cranium. The gross examination of
the biopsy specimens was performed. They were
collected in, 10% buffered formalin as fixative.10,11.
All the specimens were dehydrated, cleared,
impregnated and embedded in suitable medium to
facilitate their cutting. The tissue sections were
Biomedica Vol. 21 (Jan. – Jun., 2005)
32
M. EJAZ BUTT, SAEED A. KHAN, NASEER A. CHAUDRHY et al
stained with haematoxylin and eosin following the
method of Harris haemotoxylin12,13.
number and percentage of different histological
types of this group are shown in Table 4.
RESULTS
Table 3: Distribution of 89 cases of neoplastic
Intra-cranial space occupying lesions.
In a total of 100 cases of intracranial space
occupying lesions, 54 cases were males and 46
were females, having a male / female ratio of 1.17:1
as shown in Tables 1,2. Of all the 100 cases, 18
cases were found below the age of twenty, while
maximum number of cases (28) were found in the
third decade. Thirteen cases were seen in 3rd
decade, and 14 in 4th decade. A steep rise in the
number of cases in the sixth decade was noticed
i.e, 20 cases. These observations are depicted in
Table 2.
Table 1: Distribution of 100 cases of intracranial space occupying lesions.
Groups
Neoplastic Lesions
Non-neoplastic Lesions
Total
Sex
Total
Male
Female
48
41
89
6
5
11
54
46
100
Sex
Total
(%)
15
41
(41%)
7
16
23
(23%)
4
7
11
(11%)
1
1
2
(2%)
5. Vascular
Tumours
1
0
1
(1%)
6. Arterio-venous
malformation
1
0
1
(1%)
7. Extension from
regional Tumours
2
0
2
(2%)
8. Metastatic
Tumours
4
2
6
(6%)
9. Germ cell
Tumours
1
0
1
(1%)
Types of Tumor
Male
Female
26
2. Meningiomas
3. Nerve sheet
tumours (Schwannomas)
4. Primary
adenomas
1. Neuro-epithelial
Tumours
10. Lymphomas
Table 2: Age and Sex distribution of 100 cases of
intra-cranial space occupying lesions.
Age group (years)
Sex*
Total
Male
Female
1.
0–9
3
2
5
2.
10 – 19
8
5
13
3.
20 – 29
14
14
28
4.
30 – 39
6
7
13
5.
40 – 49
5
9
14
6.
50 – 59
13
7
20
7.
60 – 69
14
46
100
*No significant difference between males and females for all
age groups (P > 0.05).
Table 1 shows, that of all the 100 cases of
ICSOLs, 89 cases were intracranial neoplasms.
Among the 89 neoplasms, 48 were in males and 41
cases were in females. Male / Female ratio in case
these of neoplasms was counted as 1.17:1. Table-3
shows that neuroepithelial tumours ranked No. 1
with the highest number of cases. Meningiomas
were second in frequency schwannomas and
metastatic tumours ranked third and fourth
respectively in frequency. Neuroepithelial tumours
were the most common intracranial neoplasms
and comprised of 41% of the total (Figure 1). The
Biomedica Vol. 21 (Jan. – Jun., 2005)
Total
1
0
1
(1%)
48
41
89
(89%)
Table 4: Relative frequency of the different types
of neuro-epithelial tumours.
Types of Tumor
Sex
Total
(%)
4
19
(46.3%)
6
3
9
(21.9%)
2
4
6
(14.6%)
Male
Female
1. Benign
Astrocytomas
15
2. Anaplastic
Astrocytomas
3. Glioblastomas
Multiforme
4. Ependymomas
1
1
2
(4.8%)
5. Oligodendrogliomas
0
2
2
(4.8%)
6. Medulloblastomas
1
0
1
(2.4%)
7. Choroid plexus
papilloma
1
0
1
(2.4%)
8. Mixed Tumour
1
0
1
(2.4%)
26
15
41
(100%)
Total
In a total 41 cases, 19 were benign astrocytomas and 15 cases were malignant astrocytomas.
These astrocytomas collectivity accounted for
82.8% of the total neuroepithelial tumours. M/F
ratio was 1.17:1. Meningiomas constituted 23% of
33
INTRA-CRANIAL SPACE OCCUPYING LESIONS
Oligodendroglioma
4.8%
Medulloblastoma
2.4%
Choroid plexus
papilloma 2.4%
Mixed tumors 2.4%
Ependymoma 4.8%
Glioblastoma
Multiforme 14.8%
Benign
Astrocytomas
46.3%
Anaplastic
Astrocytomas
21.9%
Table 5: Distribution of 11 cases of non-neoplastic Intra-cranial space occupying
lesions.
Sex
Types of Lesion
Total
(%)
1
3
(3%)
0
2
(2%)
0
2
2
(2%)
2
0
2
(2%)
5. Cholesteatoma
0
1
1
(1%)
6. Chronic infection
0
1
1
(1%)
6
5
11
(11%)
Male
Female
1. Tuberculoma
2
2. Fungal Infection
2
3. Cysts
4. Haemorrhages
Total
Chrohic
Chronic
infection
9%
Cholesteatoma 9%
Tuberculomas 27%
Haemorrhages 18%
Cysts 18%
Fungal
Infection
18%
Fig. 2: Distribution of 11 cases of non-neoplastic Intracranial space occupying lesions.
the total neoplasms and were the second most
common type. Females were affected almost twice
as often as males. As a result meningiomas were
the commonest intracranial neoplasms of the
females. These occurred exclusively in the middle
and higher age groups with maximum incidence
during fourth and fifth decades. Among the 11
cases of non-neoplastic intracranial masses, there
Fig. 1: Distribution of
41 cases of Neuroepithelial tumors
were 3 tuberculomas, two fungal granulomas, two
cysts, two haemorrhages and cholesteatoma and
chronic infection one each as shown in Table 5 and
Figure 2.
DISCUSSION
Despite some limiting factors in this study, the
analysis shows that these 100 cases of ICSOLs
share several features common with other
published series. Both age and sex distribution lie
within the estimated ranges in the other reports.
In this study, brain tumours occurred mostly
during the third and sixth decades of life. In comparison to that most series reported from Asian
countries,14,3,15,5,1,16,17 brain tumours occurred mostly during fourth decade of life, in Western countries during the fifth and sixth decades of life18,19,20.
This could be due to the differrrent age characteristics of the populations as well as different case
ascertainment in the two country groups, with a
higher rate of autopsies in the latter.
The percentage of pediatric brain tumours, occurring below the age of twenty years, in the present series was18% as compared with13% in Saudi
Arabia1, 10.0% in United States,21 16.8% in India22,
18.6% in China,5 28.4% in Thailand23. This figure
seems to be related to the size of the pediatric
population in each country. The most common
tumours in pediatric group were astrocy-tomas,
followed by medulloblastomas, in line with other
published reports24,25. The male to female ratio of
1.17:1 in the present 100 cases corresponds to an
overall male / female ratio ranging from 1:1 to
1:626,27,28,29,30,31,32. i. e. more males that females
develop brain tumours.
As in all other series tumours of the neuroepithelial origin were also in the present study, the
most frequent type of intracranial neoplasms
except in a study reported from Nigeria,33 where
Biomedica Vol. 21 (Jan. – Jun., 2005)
34
M. EJAZ BUTT, SAEED A. KHAN, NASEER A. CHAUDRHY et al
metastatic tumours ranked first followed by glial
tumours in frequency. As regards age distribution
of tumours, neuroepithelial tumours occurred at a
significantly younger age (P<0.01) in this study
(Table 6).
preponderance of females over males in our study,
which is in agreement with majority of the other
studies.
Table 6: Range and mean age in neuroepithelial
tumors & non-neuroepithelial tumors.
Age (Years)
Number
of cases
Range
Mean ± SD
Neuroepithelial Tumours
41 (41%)
9-60
29.34 ±
14.10
Non-Neuroepithelial tumours
48 (48%)
1-65
*38.26 ±
15.89
Lesion
*p < 0.01 as compared to neuroepithelial tumors
These finding are comparable to that of
Jamjoom1, who also reported that majority of the
neuroepthelial tumours were found in a younger
age. Two cases of pleomorphic xanthoastrocytomas were also in line with reported six cases
from India34 .
Photo 2: Photomicrograph of a Meningioma showing
Psammoma Bodies (H & E x 100).
The relative incidence of malformative tumours in this series was markedly below the rates reported from Japan, Thailand and China but within
the comparable ranges given by most Western
series.
The ratio of secondary brain tumours in the
present series is near the limits estimated in the
other series. Unexpectedly, the incidence of cerebral tuberculomas in the present series is less than
the rates reported from India and Saudi
Arabia14,15,1 and more than the other series from
Kuwait, Germany and France38,39,40. Thus in
conclusion, this study has highlighted the relative
frequency of different intracranial space occupying
lesions in the central Punjab Province.
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Photo 1: Photomicrograph of a Pleomorphic Xanthoastrocytoma (H & E x 100).
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