During the study period 45 patients were admitted in the neurosurgical department with brain tumors. We excluded 1 patient with secondary brain tumor, 1 patient with no histopathological diagnosis and type of surgery undertaken, and we also excluded 4 patients who did not undergo surgical intervention (they were referred to another center) (see figure 1).
39 patients with primary brain tumors (PBTs) underwent surgery between 2019 and 2020. We determined the distribution of PBTs as shown in tables 1 and 2. Tumors predominantly originated from the frontal lobe (30.8%) and most were of neuroepithelial origin (59%). No difference was found in occurrence between the right and left-brain hemispheres.
Table 1
Patient characteristics
Clinicopathological parameter
|
Frequency, n (%)
|
Clinicopathological parameter
|
Frequency, n (%)
|
Gender
|
Male
|
21 (53.8)
|
Adjuvant treatment
|
Yes
|
11 (31.4)
|
|
Female
|
18 (46.2)
|
|
No
|
14 (28.6)
|
Residency
|
Urban
|
24 (61.5)
|
|
Unknown
|
3 (8.6)
|
|
Rural
|
15 (38.5)
|
|
Not required
|
11 (31.4)
|
Tumor location
|
Parietal lobe
|
3 (7.7)
|
Pre-op KPS
|
<70
|
30 (83.3)
|
|
Frontal lobe
|
12 (30.8)
|
|
>70
|
6 (16.7)
|
|
Temporal lobe
|
5 (12.8)
|
Post-op KPS
|
<70
|
23 (60.5)
|
|
Brainstem
|
2 (5.1)
|
|
>70
|
15 (39.5)
|
|
Cerebellum
|
2 (5.1)
|
1 year mortality
|
Yes
|
13 (33.3)
|
|
Ventricle
|
5 (12.8)
|
|
No
|
21 (53.8)
|
|
Sphenoid
|
5 (12.8)
|
|
Unknown
|
5 (12.8)
|
|
Sellar turcica
|
2 (5.1)
|
Surgical extent
|
GTR
|
10 (25.6)
|
|
Other
|
3 (7.8)
|
|
STR
|
26 (66.7)
|
|
|
|
|
CSF diversion
|
3 (7.7)
|
Adjuvant treatment include radiotherapy and chemotherapy. ‘Not required’ under adjuvant treatment means the patient’s tumor histology did not require chemotherapy and/or radiotherapy. Those labeled ‘Unknown’ under adjuvant treatment means they were lost to followup after surgical therapy though they were supposed to undergo some form of adjuvant therapy. KPS – Karnofsky performance status; GTR – gross tumor resection; STR subtotal tumor resection; CSF – cerebrospinal fluid.
Table 2
Histological diagnosis by gender and age group
|
Gender (%)
|
Age in years (%)
|
|
WHO Class
|
Male
|
Female
|
0-17
|
18-39
|
40-59
|
60-79
|
Total (%)
|
Neuroepithelial tumors
|
16 (59.6)
|
7 (30.4)
|
6 (26.1)
|
7 (30.4)
|
3 (13)
|
7 (30.4)
|
23 (59)
|
Medulloblastoma
|
2
|
0
|
2
|
0
|
0
|
0
|
2
|
Glioblastoma
|
7
|
4
|
2
|
1
|
2
|
6
|
11
|
Glioma
|
1
|
1
|
2
|
0
|
0
|
0
|
2
|
Diffuse astrocytoma
|
3
|
2
|
0
|
3
|
1
|
1
|
5
|
Anaplastic astrocytoma
|
1
|
0
|
0
|
1
|
0
|
0
|
1
|
Pilocytic astrocytoma
|
1
|
0
|
0
|
1
|
0
|
0
|
1
|
Pineal tumor
|
1
|
0
|
0
|
1
|
0
|
0
|
1
|
Craniopharyngioma
|
0
|
3
|
3
|
0
|
0
|
0
|
3 (7.7)
|
Meningioma
|
2 (20)
|
8 (80)
|
1 (10)
|
2 (20)
|
5 (50)
|
2 (20)
|
10 (25.6)
|
Lymphomas
|
1
|
0
|
0
|
1
|
0
|
0
|
1 (2.56)
|
Hypervascular schwannoma
|
1
|
0
|
0
|
1
|
0
|
0
|
1 (2.56)
|
Hemangioblastoma
|
1
|
0
|
1
|
0
|
0
|
0
|
1 (2.56)
|
Total
|
21 (53.8)
|
18 (46.2)
|
11 (28.2)
|
11 (28.2)
|
8 (20.5)
|
9 (23.1)
|
39
|
WHO – World Health Organization.
Glioblastoma was the most commonly diagnosed tumor subtype (28.2%), followed by meningioma (25.6%). However, among females, meningioma was the most common tumor subtype (44.4%) followed by glioblastoma (22.2%). Among males, glioblastoma was the most common tumor subtype (33.3%), followed by diffuse astrocytoma (14.3%).
Neuroepithelial tumors were more common in adults than in children (73.9% vs 26.1%, respectively), whereas craniopharyngiomas occurred exclusively in pediatrics. Meningiomas were also seen mostly in adults than in pediatrics (90% vs 10%, respectively). The most common meningioma seen was meningotheliomatous meningioma (60%).
Presentation and Outcomes
Three patients had no KPS recorded pre-operatively. Headache and focal neurological deficits were the most common presenting symptoms (56.4% and 51.3% respectively), others being; gait disturbances (17.9%), visual disturbances (17.9%), convulsions (12.8%), vomiting (10.3%) and altered level of consciousness (10.3%). Most patients (83.3%) had a preoperative KPS score of less than 70.
Postoperatively, complications included; focal neurological deficit (n=9, 23.1%), new onset convulsions (n=2, 5.1%), pseudo-meningocele (n=2, 5.1%), pneumocephalus (n=1, 2.6%), difficulty in breathing (n=1, 2.6%) and persistent vomiting (n=1, 2.6%). Postoperatively, 60.5% of the patients had a KPS score of less than 70.
5 patients (12.8%) were lost after initial surgical management, 33.3% (13 patients) had died by 1 year post op and 53.8% (21 patients) were still alive one year after the initial surgery for tumor resection. Of the 13 patients that had died, 4 died within the first 30 days post-surgical intervention, 4 patients died between 2- and 6-months post-surgery and 5 died more than 6 months post-surgery.
Patient age, gender, tumor histology, preoperative KPS score, residency, reception of adjuvant treatment and type of surgery done, were analyzed for survival/mortality prediction. Those that were found to be statistically significant (p-value <0.05) were; type of surgery done (p-value 0.005) and receiving adjuvant treatment (p value 0.007) (see table 3).
Rates by age
Among adults (18years of age and above), 11 (39.3%) were 18-39years of age, 8 (28.6%) being 40-59years and 9 (32.1%) were 60-79years. Pediatric patients ranged from 2years to 17years.
All children seen had a pre-operative KPS score of < 70, while among adults, 83.3% had a pre-operative KPS score of <70 (mostly in those 60-79years of age, 88.9%). Poor post-surgery KPS score (< 70) was also highest in the pediatric population (80% of pediatrics) and those aged 60-79years of age (55.6% of adults).
Overall, mortality rates were slightly higher in adults compared to pediatric population (7 of 13 deaths occurred in adults - 53.8%). Among adults, mortality rates were highest in those 40-59 years of age (42.9% mortality by age group; 42.9% of all adult mortality), followed closely by those aged 60-79 years of age (37.5% mortality by age group; 42.9% of all adult mortality). Those aged 18-39 years of age had the lowest mortality overall (11.1% per age group; 14.2% of all adult mortality).
Survival rates (at one-year post-operatively) were lowest in the pediatric population (40% survival rates by age group; 19% overall), compared to adults (70.8% overall). Those aged 18-39 years of age, had the best survival rates (38.1% overall; 80% by age group).
Rates by sex
Of the PBTs diagnosed, males accounted for 21 cases (53.8%) and females 18 cases (46.2%). Rates of tumor diagnoses was higher among males for all tumor subtypes except for meningioma and craniopharyngioma that showed female predominance (table 2).
Being female was associated with poor KPS score both pre-operatively (88.2% vs 78.9% in males) and post-operatively (70.6% vs 52.4% in males). Mortality was however highest among males (61.5% overall; 47.1% mortality rate by gender) than in females (38.5% overall; 29.4% mortality rate by gender). Overall survival rates at one year were higher in females (57.1%) as compared to males (42.9%) (table 3).
Table 3
Factors associated with mortality/survival after PBTs intervention.
Patient Characteristics
|
Study sample
(N=39), n(%)
|
Survived
(n=21, 53.8%), n (%)
|
Mortality
(n=13, 33.3%), n (%)
|
P value
|
Age
|
0-17
|
11 (28.2)
|
4
|
6
|
0.191
|
19-39
|
11 (28.2)
|
8
|
1
|
40-59
|
8 (20.5)
|
4
|
3
|
60-79
|
9 (23.1)
|
5
|
3
|
Gender
|
Male
|
21
|
9
|
8
|
0.33
|
Female
|
18
|
12
|
5
|
Histology
|
Neuroepithelial tumor
|
20
|
8
|
9
|
0.19
|
Meningioma
|
10
|
8
|
2
|
Others
|
9
|
5
|
2
|
Pre-op KPS
|
>70
|
6
|
4
|
1
|
0.474
|
<70
|
30
|
17
|
9
|
Residence
|
Rural
|
15
|
7
|
5
|
0.926
|
Urban
|
24
|
14
|
8
|
Adjuvant treatment
|
Yes
|
11
|
6
|
5
|
0.007
|
No
|
14
|
3
|
7
|
Type of resection
|
GTR
|
10
|
6
|
2
|
0.005
|
STR
|
26
|
15
|
9
|
Diversion
|
3
|
0
|
3
|
KPS – Karnofsky performance status; GTR – gross tumor resection; STR subtotal tumor resection; CSF – cerebrospinal fluid.
Rates by geographic distribution
Most of our patients came from an urban setting (61.5%). 13 out of 14 patients from a rural setting presented with a poor KPS score (92.8%), this is different as compared to those from an urban setting whereby 77.2% (17 out of 22) presented with a poor KPS score. There was no difference noted in those who received adjuvant treatment between rural and urban residents. There was also no difference observed among those who were lost to follow-up between rural and urban residents. No difference was found in post-operative mortality between those from rural or urban setting.
Treatment
10 of our patients (25.6%) underwent gross tumor resection, 26 (66.7%) underwent subtotal tumor resection, and 3 (7.7%) underwent diversion procedures alone. A total of 7 patients underwent CSF diversion procedures as either VPS (5 patients) or ETV (2 patients). Four of the six patients who underwent diversion procedures subsequently underwent tumor resection.
Adjuvant treatment as chemotherapy and/or radiotherapy was required in 71.8% (28) of the patients. However, 13 patients (33.3%) refused further treatment after surgery, 4 (10.3%) patients died before or shortly after starting adjuvant treatment. Only 11 patients (28.2%) of the 28 that required adjuvant therapy underwent adjuvant treatment.
Those who underwent gross tumor resection (GTR) had better survival at one year (75% survival rates) compared to those who underwent subtotal tumor resection (62.5%). Those who underwent diversion procedures alone, had the worst outcome (100% mortality at one year). Similarly, those who underwent adjuvant treatment (as chemotherapy and/or radiotherapy) had the best survival rates (54.5% one-year survival rates) as compared to those who did not undergo adjuvant treatment (30% one-year survival rates).