Indian data on central nervous tumors: A summary of published work

Infrastructural Barriers to Neurosurgical Care of Brain Tumors in Low- and Middle-Income Countries: A Systematic Review

BACKGROUND

Appropriate surgical infrastructure is important for improving patient outcomes. However, low- and middle-income countries (LMICs) often struggle to provide adequate brain tumor surgery due to fractured infrastructure. This study aims to identify and evaluate barriers to surgical care infrastructure for brain tumors in LMICs.

METHODS

A comprehensive literature search was conducted from inception to October 20, 2022, using PubMed, Scopus, CINAHL, and Google Scholar. Inclusion criteria were studies that focused on surgical care of brain tumors in terms of infrastructure in low-resource settings. Studies were excluded if they did not focus on surgical care or were not conducted in LMIC. Data was extracted and analyzed qualitatively.

RESULTS

A final analysis of 39 studies showed significant barriers: 66% had poor operating room infrastructure, 32% lacked specialized care centers and imaging facilities, 26% faced long-distance travel issues, 13% had poor public health infrastructure, and 11% had poor referral pathways and lacked advanced diagnostic facilities. Additionally, 3% had an uneven distribution of quality centers and inadequate ward capacity. Proposed strategies include cross-border collaboration (29%), optimizing existing resources (29%), improving referral pathways (7%), resource sharing within hospitals, and acquiring surgical devices through donations (7%).

CONCLUSIONS

The review highlights key barriers in infrastructure while providing effective neurosurgical care to brain tumors in LMICs. To overcome these challenges, targeted strategies need to be implemented by stakeholders, policymakers, and health ministries.

Follow-Up Care for Brain Tumors in Low- and Middle-Income Countries: A Systematic Review of Existing Challenges and Strategies for the Future

BACKGROUND AND OBJECTIVES

Brain tumors have a poor prognosis and a high death rate. Sufficient aftercare is necessary to enhance patient results. But follow-up care provision is fraught with difficulties in low- and middle-income countries (LMICs), where a variety of variables can impede access to care. Therefore, our systematic review aimed to identify challenges to follow-up care for brain tumors and possible solutions in LMICs.

METHODS

A thorough search of the literature was performed from the beginning until October 20, 2022, using Google Scholar, PubMed, Scopus, and CINAHL. Studies focusing on the aftercare of brain tumors in LMICs met the inclusion criteria. Two reviewers used the National Surgical, Obstetric, and Anesthesia Plan categories to identify themes, extract relevant data, and evaluate individual articles. After being discovered, these themes were arranged in Microsoft Excel to make reporting and comprehension simpler.

RESULTS

A total of 27 studies were included in the review. Among the studies included, the most frequently cited barriers to follow-up care were financial constraints (54%), long-distance travel (42%), and a lack of awareness about the importance of follow-up care (25%). Other challenges included preference for traditional or alternative medications (4%) and high treatment costs (8%). Proposed strategies included implementing mobile clinics (20%), establishing a documentation system (13%), and educating patients about the importance of follow-up care (7%).

CONCLUSION

In LMICs, several issues pertaining to personnel, infrastructure, service delivery, financing, information management, and governance impede the provision of follow-up treatment for patients with brain tumors. As established by the suggested techniques found in the literature, addressing these issues will necessitate concurrent action by stakeholders, legislators, health ministries, and government agencies.

Epidemiology of glioblastoma in Pakistan: a secondary analysis of the Pakistan Brain Tumor Epidemiology Study (PBTES)

PURPOSE

The incidence and outcomes of glioblastoma (GBM) patients in Pakistan remain unassessed owing to a lack of cancer registries and the absence of population-based studies. For any specific population-based oncological intervention, epidemiology must be studied. Therefore, this study aims to examine the epidemiological characteristics of glioblastoma patients in Pakistan, as part of a secondary analysis of a nationwide epidemiological study.

METHODS

Data comprising of sociodemographic, tumor and treatment characteristics of 2750 patients from the Pakistan Brain Tumor Epidemiology Study were extracted and analyzed for cases between January 1, 2019, and December 31, 2019. Chi-square tests identified outcome and treatment differences. Data analysis was performed using SPSS version 26.

RESULTS

A total of 260 GBM cases were analyzed, with a mean diagnosis age of 45 years. Males accounted for 68.8%. Most patients were from a middle- (39.6%) or lower-income (42.7%) socioeconomic background and received care from a public institution (63.8%). GBM tumors were mainly located in the frontal lobe with similar proportions of right and left laterality. A median distance of 119 km was traveled for oncological care, and the mean time to surgery from the initial radiological diagnosis was 72 days. Gross total resection was achieved in 47.3% of first surgeries, with 23 reoperations for recurrence. At the end of the study period, 33% of the GBM cohort was recorded as alive with 47% being lost to follow-up.

CONCLUSION

Our analysis is the first population-based analysis of GBM in Pakistan. This epidemiologic study can serve as a basis for future research in etiology, treatment, and outcomes for glioblastoma in the Pakistani population.

IPD-Brain: An Indian histopathology dataset for glioma subtype classification

The effective management of brain tumors relies on precise typing, subtyping, and grading. We present the IPD-Brain Dataset, a crucial resource for the neuropathological community, comprising 547 high-resolution H&E stained slides from 367 patients for the study of glioma subtypes and immunohistochemical biomarkers. Scanned at 40x magnification, this dataset is one of the largest in Asia, specifically focusing on the Indian demographics. It encompasses detailed clinical annotations, including patient age, sex, radiological findings, diagnosis, CNS WHO grade, and IHC biomarker status (IDH1R132H, ATRX and TP53 along with proliferation index, Ki67), providing a rich foundation for research. The dataset is open for public access and is designed for various applications, from machine learning model training to the exploration of regional and ethnic disease variations. Preliminary validations utilizing Multiple Instance Learning for tasks such as glioma subtype classification and IHC biomarker identification underscore its potential to significantly contribute to global collaboration in brain tumor research, enhancing diagnostic precision and understanding of glioma variability across different populations.

Study of Molecular Markers in Glioma and Their Association with Clinicopathological Features

CONTEXT

Central nervous system tumors are a major cause of morbidity and mortality worldwide. The most prevalent type of primary brain tumor is glioma. The exploration of significant genetic, epigenetic, and transcriptional abnormalities has not only improved our understanding of glioma pathogenesis but has also revealed that these molecular alterations can serve as useful diagnostic markers for more precise classification and are linked to better treatment response and prognosis. Hence, incorporating molecular markers into routine tumor classification is a major priority in modern glioma diagnostics.

AIM

The aim is to assess the mutation status of isocitrate dehydrogenase (IDH)-1, alpha-thalassemia/mental retardation syndrome X-linked (ATRX), and tumor protein 53 in glioma, and look for their association with various clinicopathological features.

METHODOLOGY

A single-center prospective cohort study, where all biopsies of glioma (January 2019 to July 2020) were evaluated, and immunohistochemistry was performed to assess the expression of IDH-1, ATRX, p53, and Ki-67 index. The data were analyzed using IBM SPSS-24 software.

RESULTS

Immunohistochemistry was performed in 123 consecutive cases of glioma. IDH-1 mutation was noted in 54 (43.9%) cases and these patients frequently presented with "seizures" (P = 0.006). The expression was maximum in World Health Organization (WHO) grade 2 tumors (65.4%) (P < 0.001), with the highest frequency in oligodendrogliomas (100% in WHO grade 2 and 3). Furthermore, these tumors showed lower proliferative indices (P = 0.001). ATRX mutation was noted in 59 (48%) and p53 overexpression was noted in 76 (61.8%) cases. These mutations were significantly associated with astrocytic phenotype (P = 0.03).

CONCLUSIONS

Molecular characterization of glioma is an important step in modern glioma diagnostics and immunohistochemistry can play an important role. IDH-1 mutation is commonly observed in adults, frontal lobe location, patients presenting with seizures, and WHO grade 2 tumors with the highest frequencies in oligodendrogliomas. ATRX and p53 can be used as surrogate markers for tumors of astrocytic lineage.

Therapeutic potentials and targeting strategies of quercetin on cancer cells: Challenges and future prospects

BACKGROUND

Every cell in the human body is vital because it maintains equilibrium and carries out a variety of tasks, including growth and development. These activities are carried out by a set of instructions carried by many different genes and organized into DNA. It is well recognized that some lifestyle decisions, like using tobacco, alcohol, UV, or multiple sexual partners, might increase one's risk of developing cancer. The advantages of natural products for any health issue are well known, and researchers are making attempts to separate flavonoid-containing substances from plants. Various parts of plants contain a phenolic compound called flavonoid. Quercetin, which belongs to the class of compounds known as flavones with chromone skeletal structure, has anti-cancer activity.

PURPOSE

The study was aimed at investigating the therapeutic action of the flavonoid quercetin on various cancer cells.

METHODS

The phrases quercetin, anti-cancer, nanoparticles, and cell line were used to search the data using online resources such as PubMed, and Google Scholar. Several critical previous studies have been included.

RESULTS

Quercetin inhibits various dysregulated signaling pathways that cause cancer cells to undergo apoptosis to exercise its anticancer effects. Numerous signaling pathways are impacted by quercetin, such as the Hedgehog system, Akt, NF-κB pathway, downregulated mutant p53, JAK/STAT, G1 phase arrest, Wnt/β-Catenin, and MAPK. There are downsides to quercetin, like hydrophobicity, first-pass effect, instability in the gastrointestinal tract, etc., because of which it is not well-established in the pharmaceutical industry. The solution to these drawbacks in the future is using bio-nanomaterials like chitosan, PLGA, liposomes, and silk fibroin as carriers, which can enhance the target specificity of quercetin. The first section of this review covers the specifics of flavonoids and quercetin; the second section covers the anti-cancer activity of quercetin; and the third section explains the drawbacks and conjugation of quercetin with nanoparticles for drug delivery by overcoming quercetin's drawback.

CONCLUSIONS

Overall, this review presented details about quercetin, which is a plant derivative with a promising molecular mechanism of action. They inhibit cancer by various mechanisms with little or no side effects. It is anticipated that plant-based materials will become increasingly relevant in the treatment of cancer.

A cross-shaped terahertz metamaterial absorber for brain cancer detection

The article presents, for the first time, a terahertz metamaterial absorber (TMA) designed in the shape of a cross consisting of four orthogonally positioned horn-shaped patches in succession, to detect brain cancer cells. The design exhibits the property of mu-negative material, indicating magnetic resonance. The proposed TMA has achieved an impressive absorption rate of 99.43% at 2.334 THz and a high Q-factor of 47.15. The sensing capability has been investigated by altering the refractive index of the surrounding medium in the range of 1.3 to 1.48, resulting in a sensitivity of 0.502 THz/RIU. The proposed TMA exhibits complete polarization insensitivity, highlighting this as one of its advantageous features. The adequate sensing capability of the proposed TMA in differentiating normal and cancerous brain cells makes it a viable candidate for an early and efficient brain cancer detector. This research can be the foundation for future research on using THz radiation for brain cancer detection.

Pilomyxoid Astrocytoma Presenting With Developmental Regression: A Case Report

Pilomyxoid astrocytoma (PMA) is a subtype of pilocytic astrocytoma (PA). PMA tends to exhibit a more aggressive course compared to PA. We present a case of a two-year-old male with a PMA in the suprasellar region who presented with developmental regression, loss of previously attained milestones such as the ability to hold his neck, walk, and talk, along with hypotonia in all four limbs. Serum cortisol and thyroid-stimulating hormone (TSH) levels were measured to rule out endocrine disturbances and were within normal limits. Magnetic resonance imaging (MRI) of the brain showed a solid lesion in the suprasellar region, extending into the pituitary and interpeduncular fossae, compressing the pituitary gland, and effacing the third ventricle, causing cerebrospinal fluid (CSF) flow obstruction and lateral ventricle dilation. The tumor appears hypointense on T1 and hyperintense on T2, with fluid-attenuated inversion recovery (FLAIR), peripheral contrast enhancement, and no calcification, consistent with PMA. The CSF analysis was negative for malignant cells. Histopathological examination revealed monomorphous bipolar and spindle cells in an angiocentric pattern with a myxoid background, without rosenthal fibers, mitoses, or eosinophilic granular bodies, consistent with PMA but not seen in PA. Immunohistochemistry showed strong positivity for glial fibrillary acidic protein (GFAP) and S100, with a Ki-67 index of 3-4%, indicating a low-grade tumor. The preferred treatment is surgical resection, but due to the tumor's deep location and potential long-term neurological effects, the parents opted against surgery. A ventriculoperitoneal shunt was placed to alleviate CSF flow, following which the child showed mild improvement in symptoms. Treatment of nonresectable astrocytomas was controversial, but gross total surgical resection offers better disease control. Chemotherapy is for patients with recurrence or where total resection of the tumor is not possible, and radiotherapy, though the long-term disease control is good, has a variable visual outcome.

A Comprehensive Review on the Role of MRI in the Assessment of Supratentorial Neoplasms: Comparative Insights Into Adult and Pediatric Cases

Magnetic resonance imaging (MRI) is a critical diagnostic tool in assessing supratentorial neoplasms, offering unparalleled detail and specificity in brain imaging. Supratentorial neoplasms in the cerebral hemispheres, basal ganglia, thalamus, and other structures above the tentorium cerebelli present significant diagnostic and therapeutic challenges. These challenges vary notably between adult and pediatric populations due to differences in tumor types, biological behavior, and patient management strategies. This comprehensive review explores the role of MRI in diagnosing, planning treatment, monitoring response, and detecting recurrence in supratentorial neoplasms, providing comparative insights into adult and pediatric cases. The review begins with an overview of the epidemiology and pathophysiology of these tumors in different age groups, followed by a detailed examination of standard and advanced MRI techniques, including diffusion-weighted imaging (DWI), perfusion-weighted imaging (PWI), and magnetic resonance spectroscopy (MRS). We discuss the specific imaging characteristics of various neoplasms and the importance of tailored approaches to optimize diagnostic accuracy and therapeutic efficacy. The review also addresses the technical and interpretative challenges unique to pediatric imaging and the implications for long-term patient outcomes. By highlighting the comparative utility of MRI in adult and pediatric cases, this review aims to enhance the understanding of its pivotal role in managing supratentorial neoplasms. It underscores the necessity of age-specific diagnostic and therapeutic strategies. Emerging MRI technologies and future research directions are also discussed, emphasizing the potential for advancements in personalized imaging approaches and improved patient care across all age groups.

Challenges to Early Detection of Brain Tumors in Low- and Middle-Income Countries: A Systematic Review

OBJECTIVE

While early diagnosis of brain tumors is essential for improving prognoses, several challenges prevent early diagnosis of these illnesses in low- and middle-income countries (LMICs). The objective of this systematic review is to identify and evaluate the barriers and challenges to early detection of brain tumors in LMICs, as well as to propose potential solutions.

METHODS

A thorough search of the literature was carried out with the aid of multiple databases, including Google Scholar, CINAHL, PubMed, and Scopus. Studies focusing on the early detection of brain tumors in low- and middle-income countries met the inclusion criteria for this review. Articles were screened independently by 2 reviewers. National Surgical, Obstetric, and Anesthesia plan framework was used to extract relevant data and develop themes. Microsoft Excel was then used to arrange and analyze these themes.

RESULTS

Out of 21 articles included in the final analysis, notable challenges to early detection of brain tumors included healthcare providers' lack of awareness of early signs and symptoms of brain tumors (21%), limited diagnostic facilities (38%), misdiagnosis by healthcare providers (33%), and financial constraints (46%). Potential strategies for addressing these barriers and challenges include educating healthcare providers on early warning signs (50%), improving the early referral system (25%) and establishing local clinical guidelines (19%).

CONCLUSIONS

Significant barriers to early detection persist in LMICs. Collaboration between stakeholders, legislators, health ministries, and governmental organizations is essential for developing and implementing focused interventions, such as establishment of referral pathways and specialized centers, adapting guidelines to local cultural contexts and raising public and professional awareness.

Exosome-Based Macromolecular neurotherapeutic drug delivery approaches in overcoming the Blood-Brain barrier for treating brain disorders

Delivering drugs to the brain is a complex challenge in medical research, particularly for disorders like Alzheimer's and Parkinson's. The blood-brain barrier restricts the entry of many therapeutic molecules, hindering their effectiveness. Nanoparticles, a potential solution, face issues like toxicity and limited approvals. A new avenue explores the use of small extracellular vesicles (sEVs), i.e., exosomes, as natural carriers for drug delivery. sEVs, tiny structures below 150 nm, show promise due to their minimal immune response and ability to precisely deliver drugs. This review focuses on the potential of sEVs-based drug delivery systems for treating neurological disorders, brain cancers, and other brain-related issues. Notably, bioengineered sEVs-carrying therapeutic compounds exhibit promise in early studies. The unique features of sEVs, such as their small size and natural properties, position them as candidates to overcome challenges in drug delivery to the brain. Ongoing clinical trials and research into sEVs behavior within the body further highlight their potential for revolutionizing drug delivery and addressing complex brain conditions.

The Spectrum of Central Nervous System Tumors at a Tertiary Care Center Primarily Serving a Rural Population

Background Central nervous system (CNS) tumors cause significant mortality and morbidity in all age groups. There was no data about the histological spectrum of all CNS tumors in the tertiary care center serving primarily the rural population of Uttar Pradesh. Aims and objectives The present study aimed to describe the histopathological spectrum of all CNS tumors reported in a rural tertiary care center at Saifai, Uttar Pradesh. It also aimed to provide an overview of the descriptive epidemiology of CNS tumors. Material and methods This was a retrospective, cross-sectional study. The study duration was three years. A total of 115 cases of CNS tumors were studied during that period. Cases were classified according to their histological types, and results were analyzed. Results The most common histological group was neuroepithelial tumors, with 53 cases (46.08%). This group had 36 cases of astrocytic tumors (31.3%), three cases of oligodendroglial tumors (2.6%), five cases of oligoastrocytic tumors (4.34%), five cases of ependymal tumors (4.34%), and four cases of embryonal tumors (3.47%). The second most common tumor was meningeal tumors, with 32 cases (27.82%). The male/female ratio (M/F) ratio was 0.7. Females were found to be more affected by almost all histologic categories. Most meningiomas (89.6%) were of World Health Organization (WHO) grade I (26 cases out of 29). Astrocytic tumors showed WHO grade I, II, III, and IV tumors in two cases (5.5%), twelve cases (33.3%), four cases (11.1%), and eighteen cases (50%), respectively. In the younger age group (0-20 years), ependymoma and medulloblastoma were most common, followed by pilocytic astrocytoma and schwannoma. Conclusion In this region, neuroepithelial tumors were seen more commonly than meningioma. Females were found to be more affected by CNS tumors. This study has provided relevant data, which can be used for research and better patient management. Further studies with the incorporation of advanced radiological investigation and immunohistochemistry have been recommended.

Role of Permeability Surface Area Product in Grading of Brain Gliomas using CT Perfusion

Purpose  The aim of this study was to evaluate the role of permeability surface area product in grading brain gliomas using computed tomography (CT) perfusion Materials and Methods  CT perfusion was performed on 33 patients with brain glioma diagnosed on magnetic resonance imaging. Of these, 19 had high-grade glioma and 14 had low-grade glioma on histopathological follow-up. CT perfusion values were obtained and first compared between the tumor region and normal brain parenchyma. Then the relative values of perfusion parameters were compared between high- and low-grade gliomas. Cut-off values, sensitivity, specificity, and strength of agreement for each parameter were calculated and compared subsequently. A conjoint factor (permeability surface area product + cerebral blood volume) was also evaluated since permeability surface area product and cerebral blood volume are considered complimentary factors for tumor vascularity. Results  All five perfusion parameters namely permeability surface area product, cerebral blood volume, cerebral blood flow, mean transit time, and time to peak were found significantly higher in the tumor region than normal brain parenchyma. Among these perfusion parameters, only relative permeability surface area product and relative cerebral blood volume were found significant in differentiating high- and low-grade glioma. Moreover, relative permeability surface area product was significantly better than all other perfusion parameters with highest sensitivity and specificity (97.74 and 100%, respectively, at a cut-off of 9.0065). Relative permeability surface area product had a very good agreement with the histopathology grade. The conjoint factor did not yield any significant diagnostic advantage over permeability surface area product. Conclusion  Relative permeability surface area product and relative cerebral blood volume were helpful in differentiating high- and low-grade glioma; however, relative permeability surface area product was significantly better than all other perfusion parameters. Grading brain gliomas using relative permeability surface area product can add crucial value in their management and prognostication; hence, it should be evaluated in the routine CT perfusion imaging protocol.

Psychiatric presentation in undiagnosed intracranial space-occupying lesions: A case series

Intracranial space-occupying lesions (SOLs) account for about 5-10 deaths per 100,000 in India. They present with physical symptoms such as headache, nausea, vomiting, and weakness; neurological symptoms such as seizures, and focal neurological deficit; and behavioral changes manifesting as depression (15-20%), anxiety (30-50%), psychosis (<5%), and personality changes (16-76%). Therefore, it is necessary to do an appropriate general, neurological, and behavioral examination for proper diagnosis and management. A series of four cases who reported to psychiatric outpatient with behavioural complaints and no focal neurological deficits were reported. The most common presentation of SOLs is seizure, headache, vomiting, and loss of consciousness. Along with this complaint, some patients may present with abnormal behavior. However, it is very rare for a SOL to present solely with psychiatric or behavioral complaints. Therefore, it becomes imperative to keep a close watch on the symptoms and send for timely investigations.

Utility of Diffusion Tensor Imaging in Assessing Corticospinal Tracts for the Management of Brain Tumors: A Cross-Sectional Observational Study

Introduction Intra-axial brain tumors are a significant health problem and present several diagnostic and treatment challenges. Conventional magnetic resonance imaging (MRI) has posed several limitations, such as the inability to delineate the detailed anatomy of fibers in structures like the brainstem and the inability to accurately judge the extent of tumor infiltration. Diffusion tensor imaging (DTI), based on the concepts of isotropic and anisotropic diffusion, is capable of visualizing and segmenting white fiber bundles in high detail and providing crucial information about tumor boundaries, extent, neighboring tracts, and more. This information can be very useful in initial non-invasive diagnosis, preoperative tumor grading, biopsy planning, surgical planning, and prognosis. Methods and materials This is a cross-sectional observational study in a tertiary care setup, conducted over a one-year period. The study was performed in Seth Gordhandas Sunderdas Medical College (Seth G.S. Medical College) and King Edward VII Memorial Hospital (K.E.M. Hospital), a tertiary care hospital located in Mumbai, India. Fiber tractography was performed and was used to visualize the corticospinal tracts passing through the length of the brainstem. Changes in the degree of infiltration, destruction, and displacement of the corticospinal tracts were observed carefully. Adult patients who were diagnosed with brain tumors, willing to participate in the study, and capable of providing written informed consent prior to study registration were included. The DTI findings along with information from other investigations were used to decide the best course of management for each case. Results The study included 30 participants with a mean age of 46.0 ± 17.1 years, 63.3% and 37.7% being male and female, respectively. According to the lesion's location, the pons was found to be the most often affected area in 23.33% of cases, followed by the temporo-parietal region (13.3%) and the frontal region (13.3%). These lesions had heterogenous enhancement in 63.3% of the instances and homogeneous enhancement in 36.7% of the cases, according to a contrast study. According to their consistency, the lesions were further divided into two categories: solid lesions, which were present in 66.7% of instances, and cystic lesions, which were present in 90% of cases. Results from the diffusion tensor technique revealed that infiltration accounted for 40.0% of cases, displacement for 76.7%, and loss of white fiber tracts for 20.0%. DTI findings were significantly associated with the type of planned management and with the presence of post-management neurological deficit. Conclusion DTI played a complementary role in the assessment of tumors and can be used to improve surgical planning and therapeutic decision making. Preservation of corticospinal tracts is vital to prevent motor impairment. Availability of qualitative data with the depiction of corticospinal tracts in a three-dimensional projection and their relation with the brain tumors by DTI greatly helps in preoperative decision making and surgical approach.

Baseline neurocognitive dysfunction is ubiquitous in intrinsic brain tumors- results from a large Indian cohort of patients and analysis of factors associated with domain-specific dysfunction

Background

Neurocognitive function (NCF) before surgery is an important marker of baseline performance in patients with brain tumors. Increasingly, neurocognitive deficits (NCD) have been demonstrated in a high proportion of patients. Selection bias (patient, tumor, and surgical procedure related) may influence the prevalence and type of domains involved in patients with gliomas.

Methods

We evaluated baseline NCF in a consecutive cohort of intra-axial tumors in Indian patients (n = 142). A comprehensive battery evaluating five domains - attention & executive function (EF), memory, language, visuospatial function and visuomotor abilities was used. Deficits were categorized as severe and mild-moderate. Factors associated with severe NCD were evaluated.

Results

Severe NCD was present in 90% of the patients, 70% of them having affection of at least 2 domains. Attention-EF, memory and visuomotor speed were most affected. 132 underwent surgery (69 awake, 63 under general anesthesia - GA). The awake cohort had younger patients with lower grade gliomas and more left sided tumors. Multi-domain dysfunction was seen almost equally in awake/GA groups as well as left/right sided tumors. On multivariate analysis, older age, lower educational status and larger tumor volume adversely affected NCF in many of the domains. Only language dysfunction was location specific (temporal lobe tumors) though not laterality (left/right) specific.

Conclusions

NCD were seen in a large majority of cases before surgery, including those undergoing awake surgery. Language may be affected even in tumors in the non-dominant hemisphere. Attention-EF and memory are most affected and need to be factored in while assessing patient performance intraoperatively during awake surgery as well as tailoring rehabilitative measures subsequently.

A Foreground Prototype-Based One-Shot Segmentation of Brain Tumors

The potential for enhancing brain tumor segmentation with few-shot learning is enormous. While several deep learning networks (DNNs) show promising segmentation results, they all take a substantial amount of training data in order to yield appropriate results. Moreover, a prominent problem for most of these models is to perform well in unseen classes. To overcome these challenges, we propose a one-shot learning model to segment brain tumors on brain magnetic resonance images (MRI) based on a single prototype similarity score. With the use of recently developed few-shot learning techniques, where training and testing are carried out utilizing support and query sets of images, we attempt to acquire a definitive tumor region by focusing on slices containing foreground classes. It is unlike other recent DNNs that employed the entire set of images. The training of this model is carried out in an iterative manner where in each iteration, random slices containing foreground classes of randomly sampled data are selected as the query set, along with a different random slice from the same sample as the support set. In order to differentiate query images from class prototypes, we used a metric learning-based approach based on non-parametric thresholds. We employed the multimodal Brain Tumor Image Segmentation (BraTS) 2021 dataset with 60 training images and 350 testing images. The effectiveness of the model is evaluated using the mean dice score and mean IoU score. The experimental results provided a dice score of 83.42 which was greater than other works in the literature. Additionally, the proposed one-shot segmentation model outperforms the conventional methods in terms of computational time, memory usage, and the number of data.

The Influence of Ethnicity on Survival from Malignant Primary Brain Tumours in England: A Population-Based Cohort Study

BACKGROUND

In recent years, the completeness of ethnicity data in the English cancer registration data has greatly improved. Using these data, this study aims to estimate the influence of ethnicity on survival from primary malignant brain tumours.

METHODS

Demographic and clinical data on adult patients diagnosed with malignant primary brain tumour from 2012 to 2017 were obtained (n = 24,319). Univariate and multivariate Cox proportional hazards regression analyses were used to estimate hazard ratios (HR) for the survival of the ethnic groups up to one year following diagnosis. Logistic regressions were then used to estimate odds ratios (OR) for different ethnic groups of (1) being diagnosed with pathologically confirmed glioblastoma, (2) being diagnosed through a hospital stay that included an emergency admission, and (3) receiving optimal treatment.

RESULTS

After an adjustment for known prognostic factors and factors potentially affecting access to healthcare, patients with an Indian background (HR 0.84, 95% CI 0.72-0.98), Any Other White (HR 0.83, 95% CI 0.76-0.91), Other Ethnic Group (HR 0.70, 95% CI 0.62-0.79), and Unknown/Not Stated Ethnicity (HR 0.81, 95% CI 0.75-0.88) had better one-year survivals than the White British Group. Individuals with Unknown ethnicity are less likely be diagnosed with glioblastoma (OR 0.70, 95% CI 0.58-0.84) and less likely to be diagnosed through a hospital stay that included an emergency admission (OR 0.61, 95% CI 0.53-0.69).

CONCLUSION

The demonstrated ethnic variations associated with better brain tumour survival suggests the need to identify risk or protective factors that may underlie these differences in patient outcomes.

Imaging Recommendations for the Diagnosis, Staging, and Management of Adult Brain Tumors

Neuroimaging plays a pivotal role in the clinical practice of brain tumors aiding in the diagnosis, genotype prediction, preoperative planning, and prognostication. The brain tumors most commonly seen in adults are extra-axial lesions like meningioma, intra-axial lesions like gliomas and lesions of the pituitary gland. Clinical features may be localizing like partial seizures, weakness, and sensory disturbances or nonspecific like a headache. On clinical suspicion of a brain tumor, the primary investigative workup should focus on imaging. Other investigations like fundoscopy and electroencephalography may be performed depending on the clinical presentation. Obtaining a tissue sample after identifying a brain tumor on imaging is crucial for confirming the diagnosis and planning further treatment. Tissue sample may be obtained by techniques such as stereotactic biopsy or upfront surgery. The magnetic resonance (MR) imaging protocol needs to be standardized and includes conventional sequences like T1-weighted (T1W) imaging with and without contrast, T2w imaging, fluid-attenuated axial inversion recovery, diffusion-weighted imaging (DWI), susceptibility-weighted imaging, and advanced imaging sequences like MR perfusion and MR spectroscopy. Various tumor characteristics in each of these sequences can help us narrow down the differential diagnosis and also predict the grade of the tumor. Multidisciplinary co-ordination is needed for proper management and care of brain tumor patients. Treatment protocols need to be adapted and individualized for each patient depending on the age, general condition of the patient, histopathological characteristics, and genotype of the tumor. Treatment options include surgery, radiotherapy, and chemotherapy. Imaging also plays a vital role in post-treatment follow-up. Sequences like DWI, MR perfusion, and MR spectroscopy are useful to distinguish post-treatment effects like radiation necrosis and pseudoprogression from true recurrence. Radiological reporting of brain tumor images should follow a structured format to include all the elements that could have an impact on the treatment decisions in patients.

Neuro-Ophthalmic Manifestations of Intracranial Space Occupying Lesions in Adults

Objectives

The purpose of this study is to evaluate the epidemiology, neuro-ophthalmic, and clinical characteristics of intracranial space occupying lesions (ICSOLs) in adult patients.

Methods

All patients above 16 years presenting with brain tumors confirmed by magnetic resonance imaging and treated surgically in our institute were included in this study. Epidemiology of the patients along with neurological and ophthalmic manifestation was evaluated.

Results

A total of 252 patients were included in the study ranging from 18 years to 79 years. Supratentorial location was more common than infratentorial location. The most common neurological symptom in our study was headache followed by seizures. Ophthalmic manifestations were present in (73.4%) of patients. The most common visual symptoms and signs were visual loss, strabismus, papilledema, and visual field defects. The most common histopathological diagnosis seen in our study was meningiomas followed by high-grade gliomas.

Conclusion

Ocular signs and symptoms can be considered as a window to the brain through which ICSOLs can be detected. The most common neurological manifestation of ICSOL in our study was headache with or without true localizing signs and symptoms. More frequently, these patients present to an ophthalmologist before a neurosurgeon with related ocular manifestations. Hence, through our study, we emphasize the importance of a detailed ophthalmological examination in these patients which can aid in early diagnosis and prompt management of such lesions.

Accurate Brain Tumor Detection Using Deep Convolutional Neural Network

Detection and Classification of a brain tumor is an important step to better understanding its mechanism. Magnetic Reasoning Imaging (MRI) is an experimental medical imaging technique that helps the radiologist find the tumor region. However, it is a time taking process and requires expertise to test the MRI images, manually. Nowadays, the advancement of Computer-assisted Diagnosis (CAD), machine learning, and deep learning in specific allow the radiologist to more reliably identify brain tumors. The traditional machine learning methods used to tackle this problem require a handcrafted feature for classification purposes. Whereas deep learning methods can be designed in a way to not require any handcrafted feature extraction while achieving accurate classification results. This paper proposes two deep learning models to identify both binary (normal and abnormal) and multiclass (meningioma, glioma, and pituitary) brain tumors. We use two publicly available datasets that include 3064 and 152 MRI images, respectively. To build our models, we first apply a 23-layers convolution neural network (CNN) to the first dataset since there is a large number of MRI images for the training purpose. However, when dealing with limited volumes of data, which is the case in the second dataset, our proposed “23-layers CNN” architecture faces overfitting problem. To address this issue, we use transfer learning and combine VGG16 architecture along with the reflection of our proposed “23 layers CNN” architecture. Finally, we compare our proposed models with those reported in the literature. Our experimental results indicate that our models achieve up to 97.8% and 100% classification accuracy for our employed datasets, respectively, exceeding all other state-of-the-art models. Our proposed models, employed datasets, and all the source codes are publicly available at: (https://github.com/saikat15010/Brain-Tumor-Detection).

Association of ABO Blood Group Antigen and Neurological Tumors

Background Various risk factors for tumors such as smoking, alcohol consumption, diet, and radiation, etc., were already identified. ABO blood group antigens are also present on epithelia, endothelia, and neurons. Recent evidence suggested the role of ABO antigens in the pathogenesis of certain malignancies.

Materials and Methods A retrospective observational study was conducted in a tertiary care neurosurgical center in North India from January 2016 to December 2018. The hospital information system was used to obtain patient information while the blood center information system was used to collect blood group information. Brain tumors were majorly divided into cavernoma, glioma, meningioma, neuroma, pituitary adenoma, schwannoma, and others.

Results We found a total of 1,970 patients with brain tumors admitted during our study period. Most patients had glioma (33.55%), followed by pituitary adenoma (20.05%) and neuroma (2.23%). B blood group individuals had more prevalence of cavernoma, glioma, meningioma, pituitary adenoma, schwannoma, and others followed by O, A, and AB. Only association of O blood group with neuroma tumor was found statistically significant.

Conclusions Our patient population had blood group distribution similar to our general population and no significant association was observed by blood group antigens and brain tumors. Although neuroma was significantly associated with blood group O but the prevalence of neuroma in our patient population is very low hence large sample study is required to draw a firm conclusion regarding this association.

31-Phosphorus Magnetic Resonance Spectroscopy in Evaluation of Glioma and Metastases in 3T MRI

Background:  31-Phosphorus magnetic resonance spectroscopy (31-P MRS) has excellent potential for clinical neurological practice because of its noninvasive in-vivo assessment of cellular energy metabolism and the indirect evaluation of the phospholipid composition of the cell membrane, intracellular pH, and intracellular Mg2+ concentration.

Purpose:  The aim of this study was to evaluate the metabolic characteristics of glioma and metastases using 31-P MRS and assess utility to differentiate both.

Study Type:  Prospective study.

Population:  Fifteen consecutive patients with brain tumor.

Field Strength/Sequence:  Three-tesla magnetic resonance imaging/three-dimensional MRS imaging sequence.

Statistical Tests:  Unpaired sample t -test, and one-way analysis of variance with Tukey's post-hoc test.

Results:  Significantly decreased values of phosphomonoesters/inorganic phosphate (PME/Pi) in the tumor group (1.22 ± 0.72) compared with controls (2.28 ± 1.44) with a p -value of 0.041 were observed. There is a significant decrease in phosphocreatine (PCr)/Pi values (energy demand) in the tumor group (2.76 ± 0.73) compared with controls (4.13 ± 1.75) with a p -value of 0.050. Significant increase in Pi/adenosine triphosphate (ATP) was noted in tumor group (0.28 ± 0.09) compared with controls (0.22 ± 0.08) with p -value 0.049. Among tumor group, PME/PCr values were significantly decreased in gliomas (0.35 ± 0.17) than metastasis (0.58 ± 0.23) compared with controls with a p -value of 0.047. A significant decrease in PME/ATP was noted in gliomas (0.25 ± 0.12) than metastasis (0.41 ± 0.14) compared with controls with a p -value of 0.034. The tumor group exhibits alkaline pH (7.12 ± 0.10) compared with the normal parenchyma (7.04 ± 0.06) with a significant p -value of 0.025. Glioma and metastasis could not be differentiated with pH. However, the perilesional edema of glioma shows alkaline pH (7.09 ± 0.06) and metastasis shows acidic pH (7.02 ± 0.05) with a significant p -value of 0.030.

Conclusion:  Our study provides new insight into the cellular constituents and pH of gliomas and metastases and results were significant in differentiation between these two. However, due to the additional high expense, it is available as a research tool in very few institutions in India.

Developing a Radiomics Signature for Supratentorial Extra-Ventricular Ependymoma Using Multimodal MR Imaging

Rationale and Objectives: To build a machine learning-based diagnostic model that can accurately distinguish adult supratentorial extraventricular ependymoma (STEE) from similarly appearing high-grade gliomas (HGG) using quantitative radiomic signatures from a multi-parametric MRI framework.

Materials and Methods: We computed radiomic features on the preprocessed and segmented tumor masks from a pre-operative multimodal MRI dataset [contrast-enhanced T1 (T1ce), T2, fluid-attenuated inversion recovery (FLAIR), apparent diffusion coefficient (ADC)] from STEE (n = 15), HGG-Grade IV (HGG-G4) (n = 24), and HGG-Grade III (HGG-G3) (n = 36) patients, followed by an optimum two-stage feature selection and multiclass classification. Performance of multiple classifiers were evaluated on both unimodal and multimodal feature sets and most discriminative radiomic features involved in classification of STEE from HGG subtypes were obtained.

Results: Multimodal features demonstrated higher classification performance over unimodal feature set in discriminating STEE and HGG subtypes with an accuracy of 68% on test data and above 80% on cross validation, along with an overall above 90% specificity. Among unimodal feature sets, those extracted from FLAIR demonstrated high classification performance in delineating all three tumor groups. Texture-based radiomic features particularly from FLAIR were most important in discriminating STEE from HGG-G4, whereas first-order features from T2 and ADC consistently ranked higher in differentiating multiple tumor groups.

Conclusions: This study illustrates the utility of radiomics-based multimodal MRI framework in accurately discriminating similarly appearing adult STEE from HGG subtypes. Radiomic features from multiple MRI modalities could capture intricate and complementary information for a robust and highly accurate multiclass tumor classification.

Role of Extracellular Vesicles in Glioma Progression: Deciphering Cellular Biological Processes to Clinical Applications

Glioma predominantly targets glial cells in the brain and spinal cord. There are grade I, II, III, and IV gliomas with anaplastic astrocytoma and glioblastoma multiforme as the most severe forms of the disease. Current diagnostic methods are limited in their data acquisition and interpretation, markedly affecting treatment modalities, and patient outcomes. Circulating extracellular vesicles (EVs) or "magic bullets" contain bioactive signature molecules such as DNA, RNA, proteins, lipids, and metabolites. These secretory "smart probes" participate in myriad cellular activities, including glioma progression. EVs are released by all cell populations and may serve as novel diagnostic biomarkers and efficient nano-vehicles in the targeted delivery of encapsulated therapeutics. The present review describes the potential of EV-based biomarkers for glioma management.

Hypoxia and Microvascular Alterations Are Early Predictors of IDH-Mutated Anaplastic Glioma Recurrence

Simple Summary

Anaplastic gliomas (AGs) are considered the most common and aggressive primary brain tumors of young adults with inevitable recurrence and treatment failure. The aim of this study was to investigate whether the imaging biomarkers of hypoxia, microvascular architecture and neovascularization activity can be of assistance to detect pathophysiological changes in the early developmental stages of isocitrate-dehydrogenase (IDH) mutated AG recurrence. We evaluated 142 physiological magnetic resonance imaging follow-up examinations as a part of the conventional magnetic resonance imaging (MRI) protocol in 60 AG patients after standard therapy. Physiological MRI biomarkers showed intensifying local tissue hypoxia 250 days prior to radiological recurrence with following upregulation of neovascularization activity 50 to 70 days later. Integration of physiological MRI in the monitoring of AG patients may be of clinical significance to make personalized decision of early tumor recurrence without an additional delay for multimodal therapy.

Abstract

Anaplastic gliomas (AG) represents aggressive brain tumors that often affect young adults. Although isocitrate-dehydrogenase (IDH) gene mutation has been identified as a more favorable prognostic factor, most IDH-mutated AG patients are confronted with tumor recurrence. Hence, increased knowledge about pathophysiological precursors of AG recurrence is urgently needed in order to develop precise diagnostic monitoring and tailored therapeutic approaches. In this study, 142 physiological magnetic resonance imaging (phyMRI) follow-up examinations in 60 AG patients after standard therapy were evaluated and magnetic resonance imaging (MRI) biomarker maps for microvascular architecture and perfusion, neovascularization activity, oxygen metabolism, and hypoxia calculated. From these 60 patients, 34 patients developed recurrence of the AG, and 26 patients showed no signs for AG recurrence during the study period. The time courses of MRI biomarker changes were analyzed regarding early pathophysiological alterations over a one-year period before radiological AG recurrence or a one-year period of stable disease for patients without recurrence, respectively. We detected intensifying local tissue hypoxia 250 days prior to radiological recurrence which initiated upregulation of neovascularization activity 50 to 70 days later. These changes were associated with a switch from an avascular infiltrative to a vascularized proliferative phenotype of the tumor cells another 30 days later. The dynamic changes of blood perfusion, microvessel density, neovascularization activity, and oxygen metabolism showed a close physiological interplay in the one-year period prior to radiological recurrence of IDH-mutated AG. These findings may path the wave for implementing both new MR-based imaging modalities for routine follow-up monitoring of AG patients after standard therapy and furthermore may support the development of novel, tailored therapy options in recurrent AG.

Optimal dose of bevacizumab in recurrent glioma

Background:

Recurrent gliomas have a dismal prognosis. They can be treated with re-surgery and re-irradiation. Bevacizumab as a single agent or in combination with chemotherapy is an alternative treatment option. However, in our country, a considerable proportion of patients cannot afford the approved 10 mg/kg dose.

Objective:

This study was aimed at evaluating the efficacy of low-dose bevacizumab in recurrent gliomas.

Methods:

Patients with recurrent gliomas presenting to our Neuro-Medical Oncology unit between July 1, 2015, and November 30, 2018, were retrospectively analyzed. The patients were divided into two groups, those treated with ≤5 mg/kg of bevacizumab (low dose) and those treated with >5–10 mg/kg (standard dose) of bevacizumab. The status of isocitrate dehydrogenase (IDH) and O[6]-methylguanine-DNA methyltransferase was recorded. The primary endpoint of the study was overall survival (OS), and the secondary endpoints were progression-free survival (PFS) and adverse events.

Results:

A total of 68 patients were treated with bevacizumab, of which 23 (33.8%) received the low-dose regimen. At a median follow-up of 26.2 months, there was no difference in the median PFS (low-dose group: 3.60 months; 95% confidence interval [CI], 2.5–7.47 vs. standard-dose group: 3.67 months; 95% CI, 2.17–4.53) (P= 0.18) and median OS (low-dose group: 7.33 months; 95% CI, 3.97–9.10 vs. standard-dose group: 5.47 months; 95% CI, 4.67–6.2) (P= 0.27). In addition, the adverse events were not significantly different between the two groups.

Conclusion:

Low-dose bevacizumab may be effective in the treatment of recurrent gliomas and should be compared with standard dose in prospective randomized studies.

Return to work in survivors of Primary Brain Tumours treated with Intensity Modulated Radiotherapy

MINI: Primary Brain Tumour survivors usually have significant morbidity, especially cognitive and neurological dysfunction. Return to pre-diagnosis work can be an important QoL indicator and outcomes measure in these patients. We did a retrospective study to assess return to work amongst the patients who underwent radiotherapy at our centre.

BACKGROUND

Primary brain tumour (PBT) survivors have a high burden of morbidity. Return to work (RTW) is an important survivorship parameter and outcomes measure in these patients, especially in developing countries. This study was done to assess RTW after radiotherapy, reasons for no RTW, and relationship of RTW with treatment and patient factors.

PATIENTS AND METHODS

A single centre study was done amongst PBT patients. Baseline and treatment details, education, employment was assessed. RTW assessed as: time to RTW, full/ part-time, reasons for no RTW and RTW at 6 months post-therapy, and last follow up.

RESULTS

67 PBT patients with a median age of 42 years were assessed. Most common diagnosis was low grade glioma. Over 66% patients were illiterate, and 62% had semi-skilled and unskilled jobs, mostly agriculture. About 64.4% patients returned to employment in a median time of 3 months. At 6 months post-treatment 58.2% had a job, with only 42% working full-time. 'Limb weakness' (21.4%), followed by 'loss of job/ no job' (16.7%), 'fatigue'/ 'tiredness' (14.3%), 'poor vision/ diminished vision' (11.9%) were the common reasons for no RTW. The factors found to be significantly associated with return to work were younger age (p = 0.042), male sex (0.013), the absence of complications during radiotherapy (p = 0.049), part time job prior to diagnosis (p = 0.047), and early return to work after RT (p < 0.001).

CONCLUSION

Studies are needed to identify the barriers in re- employment and steps to overcome them in cancer patients.

Prognostic factors and outcomes in anaplastic gliomas: An institutional experience

Background:

There is lack of clear evidence and treatment guidelines for anaplastic gliomas (AGs) with very few studies focusing exclusively on these patients. The aim of the study was to analyze the clinical profile and survival in these patients.

Materials and Methods:

Patients of AGs treated with radiation and concurrent ± adjuvant chemotherapy from January 2010 to December 2015 were analyzed. Statistical analysis was done using SPSS version 20 software.

Results:

A total of 100 patients were included in the study. The median age was 35 years (range 6–68 years). Eighty-four patients had follow-up details and were included for survival analysis. The 5-year overall survival (OS) was 58%. Age, presentation with seizures, and focal neurological deficit were not found to significantly influence survival. The 5-year survival for oligodendroglioma and astrocytoma was 69% and 52%, respectively. Patients with Karnofsky Performance Score (KPS) of ≥70 had a significantly better 5-year OS (65%) as compared to those with KPS <70 (33%) (P = 0.000). The use of adjuvant temozolomide (TMZ) showed longer 5-year OS of 67.7% compared to 36% in patients who did not receive adjuvant chemotherapy (P = 0.018). Patients receiving both concurrent and adjuvant TMZ showed longer 5-year OS (68.5% vs. 40%, P = 0.010). Twenty-two patients had recurrence with average time to recurrence being 37 months. Fourteen patients underwent salvage surgery and two patients received reirradiation.

Conclusions:

OS significantly correlated with KPS and receipt of concurrent and adjuvant chemotherapy with TMZ. Therefore, adjuvant radiation with concurrent and adjuvant TMZ should be the standard of care for AGs.

Disentangling the therapeutic tactics in GBM: From bench to bedside and beyond

Glioblastoma multiforme (GBM) is one of the most common and malignant form of adult brain tumor with a high mortality rate and dismal prognosis. The present standard treatment comprising surgical resection followed by radiation and chemotherapy using temozolomide can broaden patient's survival to some extent. However, the advantages are not palliative due to the development of resistance to the drug and tumor recurrence following the multimodal treatment approaches due to both intra- and intertumoral heterogeneity of GBM. One of the major contributors to temozolomide resistance is O⁶ -methylguanine-DNA methyltransferase. Furthermore, deficiency of mismatch repair, base excision repair, and cytoprotective autophagy adds to temozolomide obstruction. Rising proof additionally showed that a small population of cells displaying certain stem cell markers, known as glioma stem cells, adds on to the resistance and tumor progression. Collectively, these findings necessitate the discovery of novel therapeutic avenues for treating glioblastoma. As of late, after understanding the pathophysiology and biology of GBM, some novel therapeutic discoveries, such as drug repurposing, targeted molecules, immunotherapies, antimitotic therapies, and microRNAs, have been developed as new potential treatments for glioblastoma. To help illustrate, "what are the mechanisms of resistance to temozolomide" and "what kind of alternative therapeutics can be suggested" with this fatal disease, a detailed history of these has been discussed in this review article, all with a hope to develop an effective treatment strategy for GBM.

Impact of volume of irradiation on survival and quality of life in glioblastoma: a prospective, phase 2, randomized comparison of RTOG and MDACC protocols

BACKGROUND

Though conformal partial-brain irradiation is the standard adjuvant treatment for glioblastoma, there is no consensus regarding the optimal volume that needs to be irradiated. European Organisation for Research and Treatment of Cancer (EORTC) and The University of Texas MD Anderson Cancer Center (MDACC) guidelines differ from the Radiation Therapy Oncology Group (RTOG) in their approach toward peritumoral edema, whereas RTOG and MDACC guidelines differ from EORTC in the concept of boost phase. A scarcity of randomized comparisons has resulted in remarkable variance in practice among institutions.

METHODS

Fifty glioblastoma patients were randomized to receive adjuvant radiotherapy using RTOG or MDACC protocols. Apart from dosimetric and volumetric analysis, acute toxicities, recurrence patterns, progression-free survival (PFS), overall survival (OS), and quality of life (QoL) were compared using appropriate statistical tests.

RESULTS

Both groups were comparable with respect to demographic characteristics. Dosimetric analysis revealed significantly lower boost-phase planning treatment volumes and V60 Gy in the MDACC arm (chi-squared, P = .001 and .013, respectively). No significant differences were observed in doses with respect to organs at risk, acute toxicity, or recurrence patterns (chi-squared, P > .05). On the log-rank test, median PFS (8.8 months vs 6.1 months, P = .043) and OS (17 months vs 12 months, P = .015) were statistically superior in the MDACC group.Age, extent of resection, and proportion of whole brain receiving prescription dose were associated with improved PFS and OS on regression analysis. QoL of patients was significantly better in the MDACC group in all domains except cognitive, as assessed with the EORTC Quality of Life Questionnaire (QLQ-C30) and Brain Cancer Module (QLQ-BN20) (general linear model, P < .05).

CONCLUSIONS

Use of limited-margin MDACC protocol can potentially improve survival outcomes apart from QoL of glioblastoma patients, as compared with the RTOG protocol.

Is High Altitude an Emergent Occupational Hazard for Primary Malignant Brain Tumors in Young Adults? A Hypothesis

Introduction: Brain cancer accounts for approximately 1.4% of all cancers and 2.3% of all cancer-related deaths. Although relatively rare, the associated morbidity and mortality affecting young- and middle-aged individuals has a major bearing on the death-adjusted life years compared to other malignancies. Over the years, we have observed an increase in the incidence of primary malignant brain tumors (PMBTs) in young adults. This observational analysis is to study the prevalence and pattern of brain tumors in young population and find out any occupational correlation. Materials and Methods: The data were obtained from our tertiary care cancer institute's malignant diseases treatment center registry from January 2008 to January 2018. A total of 416 cases of PMBT were included in this study. Results: Our analysis suggested an overall male predominance with most PMBTs occurring at ages of 20–49 years. The glial tumors constituted 94.3% while other histology identified were gliosarcoma (1) gliomatosis cerebri (1), hemangiopericytoma (3), and pineal tumors (3). In our institute, PMBT constituted 1% of all cancers while 2/416 patients had secondary glioblastoma multiforme with 40% showing positivity for O-6-methylguanine-DNA-methyltransferase promoter methylation. Conclusions: Most patients belonged to a very young age group without any significant family history. A probable hypothesis could be excessive cosmic radiation exposure to persons staying at high altitude areas due to occupational exigencies for which in-depth case–control epidemiological studies are required to reach any conclusion.

99mTc-Methionine Hybrid SPECT/CT for Detection of Recurrent Glioma: Comparison With 18F-FDG PET/CT and Contrast-Enhanced MRI

OBJECTIVES

Posttherapy changes in treated glioma patients cannot be reliably differentiated from tumor recurrence. We evaluated the role of Tc-methionine SPECT/CT for the detection of recurrent glioma and compared the same with F-FDG PET/CT and contrast-enhanced MRI (CeMRI).

METHODS

Forty-four patients with histologically proven, previously treated glioma and clinical suspicion of recurrence were prospectively enrolled in the study. Of these 44 patients, 39 (28 male and 11 female subjects; age, 38.05 ± 9.7 years) underwent Tc-methionine SPECT/CT, F-FDG PET/CT, and CeMRI of the brain and were included for final analysis. Combination of repeat imaging, biopsy, and/or clinical follow-up (6-36 months) was taken as reference standard. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated. Diagnostic values among modalities were compared.

RESULTS

Positive predictive value and negative predictive value for Tc-methionine SPECT/CT, F-FDG PET/CT, and CeMRI were 95.6% and 56.2%, 92.3% and 61.5%, and 79.4% and 42.9%, respectively. Sensitivity and specificity for the 3 modalities were 75.9% and 90%, 82.8% and 80%, and 87.1% and 30%. Specificity of Tc-methionine SPECT/CT was significantly higher than that of CeMRI (P < 0.0001) but not of F-FDG PET/CT (P = 0.36). No significant difference was seen between the modalities for sensitivity and accuracy.

CONCLUSIONS

Tc-methionine is a promising tracer for detection of recurrent glioma. Diagnostic values of Tc-methionine SPECT/CT are similar to F-FDG, although it is more specific than CeMRI. So it may be used as a cost-effective alternative and also where PET/CT is not available.

Suppression of STAT3 NH2 -terminal domain chemosensitizes medulloblastoma cells by activation of protein inhibitor of activated STAT3 via de-repression by microRNA-21

Medulloblastoma (MB) is a malignant pediatric brain tumor with poor prognosis. Signal transducers and activators of transcription-3 (STAT3) is constitutively activated in MB where it functions as an oncoprotein, mediating cancer progression and metastasis. Here, we have delineated the functional role of activated STAT3 in MB, by using a cell permeable STAT3-NH₂ terminal domain inhibitor (S3-NTDi) that specifically perturbs the structure/function of STAT3. We have implemented several biochemical experiments using human MB tumor microarray (TMA) and pediatric MB cell lines, derived from high-risk SHH-TP53-mutated and MYC-amplified Non-WNT/SHH tumors. Treatment of MB cells with S3-NTDi leads to growth inhibition, cell cycle arrest, and apoptosis. S3-NTDi downregulated expression of STAT3 target genes, delayed migration of MB cells, attenuated epithelial-mesenchymal transition (EMT) marker expressions and reduced cancer stem-cell associated protein expressions in MB-spheres. To elucidate mechanisms, we showed that S3-NTDi induce expression of pro-apoptotic gene, C/EBP-homologous protein (CHOP), and decrease association of STAT3 to the proximal promoter of CCND1 and BCL2. Of note, S3-NTDi downregulated microRNA-21, which in turn, de-repressed Protein Inhibitor of Activated STAT3 (PIAS3), a negative regulator of STAT3 signaling pathway. Furthermore, combination therapy with S3-NTDi and cisplatin significantly decreased highly aggressive MYC-amplified MB cell growth and induced apoptosis by downregulating STAT3 regulated proliferation and anti-apoptotic gene expression. Together, our results revealed an important role of STAT3 in regulating MB pathogenesis. Disruption of this pathway with S3-NTDi, therefore, may serves as a promising candidate for targeted MB therapy by enhancing chemosensitivity of MB cells and potentially improving outcomes in high-risk patients.