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Signs and surgical tactics in continued growth of gliomas of supratentorial localization in children
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Ashrapov Jamshid Raufovich, Republican Scientific Center of Neurosurgery and Tashkent Medical Academy, Ministry of Public Health of the Republic of Uzbekistan E-mail: [email protected]
Signs and surgical tactics in continued growth of gliomas of supratentorial localization in children
Abstract: This work is devoted to pediatric neuro-oncology. The analysis of examination and treatment of 55 patients with continued growth of brain supratentorial gliomas is presented. Based on the study, diagnostic criteria and surgical treatment tactics for patients with continued growth of supratentorial gliomas have been determined. Keywords: continued growth, brain tumors, central nervous system, pediatric age.
Introduction. According to data from cancer registries in European countries and the USA, tumors of the central nervous system (CNS) occupy the second place among all cancers in children [1, 35-39]. Malignant types are the most frequent, like anaplastic astrocytomas, ependymomas, and glioblastomas [3, 53-63; 2, 30].
There are several studies devoted to continued growth of CNS tumors in children. In the literature over past 10-15 years, there is no consensus about the frequency of tumors of continued growth with different histostructure in children [6, 319-331; 4, 40-51].
According to several authors, in a group with tumor clinical manifestations, terms of continued growth were significantly shorter than in a group with radiographic (X-ray) signs. While identification early and late periods of the appearance of continued tumor growth, most of the early periods were determined clinically; this difference maintained even after the distribution of nosology, and there were no statistically significant differences between age, gender and race. Patients with large volume of surgical interventions prevailed in a group with radiographic (X-ray) detection of prolonged tumor growth [7, 4135-4140; 5, 1273-1280].
Macedoni-Luksic et al. (2003) in a retrospective long-term study of history cases of 61 patients, who underwent surgical treatment, could observe the nature of neurological abnormalities associated by continued growth or recurrence of hemispheric tumors [8, 89-101].
However, according to Minn et al. (2001), a factor of extent of surgical resection ofthe tumor becomes to be ofgreat importance for forecasting the possibility of further tumor growth [7, 4135-4140].
The most significant prognostic factor for survival is the extent of surgical resection. This factor can be changed unlike other factors, such as the differentiation of tumor cells, X-ray therapy, and age of the patient. Race and gender, according to the researchers, probably, do not play such a huge role, but, as has been reported, correlated with survival rate [10, 16-26; 9, 138-150].
Rozumenko et al. (2006) reported that surgical tactics plays the important role in life expectancy of patients and improving the quality of life [4, 40-51]. According to Butowski et al. (2006), clinical manifestation of hypertension syndrome with tendency to
progression, appearance and aggravation of focal neurological deficit, the pattern of tumor progression on brain CT and MRI in the form of mass-effect, displacement of structures in the midline, signs of decay and hemorrhage in the tumor are the indications for reoperation in hemispheric tumors with prolonged growth. Along with this, the absence of effect of conservative treatment is an indication for surgical intervention as well [5, 1273-1280].
The purpose of study was to analyze data of patients with assessment of the informative value of brain CT and MRI in determining surgical tactics for brain supratentorial gliomas with continued growth.
Materials and methods
In the Centre of Neurosurgery of Tashkent city, we carried out analysis of data of 55 patients (28 boys and 27 girls), who had been diagnosed and treated for glial tumors with continued growth of supratentorial localization during the period 2010-2014. The age of children ranged from 2 to 17 years. The diagnosis was made based on clinical-neurological and instrumental examinations. For determining and selecting surgical tactics for gliomas with continued growth, brain CT was used in 30 (54.5 %) patients and brain MRI with and without contrast enhancement was used in 25 (45.5 %) patients, respectively. The degree of radicality was assessed by the program "Calculation ofvolume of tumors".
Results and discussion
Re-appearance of intracranial hypertension (60 %) and/or increase of symptoms of epileptic syndrome (25 %) and focal neurological deficit (15 %) were clinical signs of continued tumor growth. Later on, further growth of tumor was confirmed by additional studies using different methods (brain CT or MRI).
A group of main risk factors for occurrence of continued growth ofbrain tumors of supratentorial localization in children included surgery radicality (total operation in 41.8 % of cases), malignancy grade of neoplasms (56.3 % were anaplastic), tumor localization, its location in the medial parts ofhemisphere and expansion to the neighboring lobe and subcortical structures (61.8 %). The totality of removal was calculated by the program "Calculation of tumor volume".
Section 5. Medical science
Table 1. - Relationship between continued tumor growth and radicality degree of surgical intervention
Surgery radicality degree Frontal lobe Temporal lobe Parietal lobe Medial structures Occipital lobe Total
Abs % Abs % Abs % Abs % Abs % Abs
Total 4 16.6 6 25 5 20.8 2 8.7 6 25 23
Subtotal 4 19.0 4 19.0 5 23.8 7 31.86 2 9.5 22
Partial and biopsy 1 10 2 20 1 10 5 50 1 10 10
Total 9 100 12 100 11 100 14 100 9 100 55
Table 2. - The distribution of tumors by anaplasia degree, depending on localization
Histological type Frontal lobe Temporal lobe Parietal lobe Medial structures Occipital lobe Total
Abs % Abs % Abs % Abs % Abs % Abs
Benign 4 16.6 5 20.8 5 20.8 6 25 4 16.6 24
Anaplastic 5 16.1 7 22.6 6 19.3 8 25.8 5 16.1 31
Total 9 100 12 100 11 100 14 100 9 100 55
Table 1 shows that in 55 children, who later revealed continued growth of tumors, mainly underwent subtotal resection, partial removal and biopsy (58.2 %). 24 (43.6 %) patients had histologically benign tumors, 31 (56.3 %) ones had anaplastic types (Table 2). Anaplastic tumors were more likely located in the medial brain structures.
According to brain CT and MRI, re-appearance of tumor lesion or increase in size, depending on surgery radicality are the signs of continued tumor growth. The presence of perifocal edema and dislocation of midline structures indicate the progression of tumor growth.
By CT data, the average tumor size was approximately 4.5 ± 1.5 cm., tumor lesion had clear boundaries in 13 (52 %) patients, and indistinct boundaties in 12 (48 %) patients, in most cases of heterogeneous structure. X-ray density (HU) in the continued growth changed as hypodensive lesions in 11 (44 %) patients with gliomas of typical structure and in 6 (24 %) patients with anaplastic gliomas. Hyperdensive lesions were noted in 5 (20 %) patients with malignant gliomas. Isodensive lesions were observed in 3 (12 %) of cases with malignant gliomas as well. Continued growth of gliomas, containing cysts, observed in 12 cases. The accumulation of contrast agent in the continued growth of gliomas increased in 1.5-2.0 times.
According to brain MRI, in continued tumor growth, the average diameter was 5.5 ± 1.0 cm., with heterogeneous nature. Isodensive lesions were revealed in 13 (43.3 %) patients that was more
typical for low-grade gliomas. Hypodensive lesions were marked in 17 (56.7 %) patients with anaplastic forms of continued growth of gliomas. Continued growth of tumor with solid-cystic component was noted in 14 observations.
Choice of surgical tactics for patients with continued growth of supratentorial brain gliomas should be based on data regarding the histological type of tumor, tumor expansion, involvement of neighboring brain structures, and nature of growth. Infiltrative growth was noted in 26 observations, nodular growth in 29 cases, vascularization of tumor, presence of hemorrhage were detected in 14 cases, indicating increased vascularization and time between primary tumor removal and continued growth. Thus, surgical approach should be determined by the clinical-instrumental pattern.
Conclusions
1. Surgical tactics for continued growth of supratentorial brain gliomas largely depends on the results of comprehensive clinical-neurological examination, CT and MRI diagnostic studies.
2. We have developed a program "Calculation of tumor volume", which was used to accurately determine the degree of radicality of surgical intervention.
3. Manifestations of neurological symptoms is of great value and alertness for physicians and must be considered for further conducting a comprehensive examination, including CT and MRI of the brain.
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