Malignant central nervous system tumors among adolescents and young adults (15-39 years old) in 14 Southern-Eastern European registries and the US Surveillance, Epidemiology, and End Results program: Mortality and survival patterns

The Molecular Landscape of Primary CNS Lymphomas (PCNSLs) in Children and Young Adults

Pediatric brain tumors are often noted to be different from their adult counterparts in terms of molecular features. Primary CNS lymphomas (PCNSLs) are mostly found in elderly adults and are uncommon in children and teenagers. There has only been scanty information about the molecular features of PCNSLs at a young age. We examined PCNSLs in 34 young patients aged between 7 and 39 years for gene rearrangements of BCl2, BCL6, CCND1, IRF4, IGH, IGL, IGK, and MYC, homozygous deletions (HD) of CDKN2A, and HLA by FISH. Sequencing was performed using WES, panel target sequencing, or Sanger sequencing due to the small amount of available tissues. The median OS was 97.5 months and longer than that for older patients with PCNSLs. Overall, only 14 instances of gene rearrangement were found (5%), and patients with any gene rearrangement were significantly older (p = 0.029). CDKN2A HD was associated with a shorter OS (p < 0.001). Only 10/31 (32%) showed MYD88 mutations, which were not prognostically significant, and only three of them were L265P mutations. CARD11 mutations were found in 8/24 (33%) cases only. Immunophenotypically, the cases were predominantly GCB, in contrast to older adults (61%). In summary, we showed that molecular findings identified in the PCNSLs of the older patients were only sparingly present in pediatric and young adult patients.

Total diagnostic interval in children with brain tumours in a middle-income country: national experience from Serbia

PURPOSE

The aim was to evaluate the total diagnostic interval (TDI) and presenting complaints in children with brain tumours in Serbia.

METHODS

This study retrospectively analysed 212 children aged 0-18 years newly diagnosed with brain tumours in two tertiary centres from mid-March 2015 to mid-March 2020 covering virtually all children with brain tumours in Serbia. TDI was calculated as the difference between the date of diagnosis and the date of symptom onset presented as a median in weeks. This variable has been evaluable for 184 patients.

RESULTS

Overall TDI was 6 weeks. TDI was significantly longer in patients with low-grade tumours (11 weeks) than in patients with high-grade tumours (4 weeks). Children with the most frequent complaints (headache, nausea/vomiting and gait disturbance) were more likely to be diagnosed sooner. Patients with a single complaint had significantly longer TDI (12.5 weeks) contrasted to patients with multiple complaints (5 weeks).

CONCLUSION

TDI with a median of 6 weeks is similar to other developed countries. Our study supports the view that low-grade tumours will present later than high-grade tumours. Children with the commonest complaints and children with multiple complaints were more likely to be diagnosed sooner.

Global survival trends for brain tumors, by histology: analysis of individual records for 556,237 adults diagnosed in 59 countries during 2000-2014 (CONCORD-3)

BACKGROUND

Survival is a key metric of the effectiveness of a health system in managing cancer. We set out to provide a comprehensive examination of worldwide variation and trends in survival from brain tumors in adults, by histology.

METHODS

We analyzed individual data for adults (15-99 years) diagnosed with a brain tumor (ICD-O-3 topography code C71) during 2000-2014, regardless of tumor behavior. Data underwent a 3-phase quality control as part of CONCORD-3. We estimated net survival for 11 histology groups, using the unbiased nonparametric Pohar Perme estimator.

RESULTS

The study included 556,237 adults. In 2010-2014, the global range in age-standardized 5-year net survival for the most common sub-types was broad: in the range 20%-38% for diffuse and anaplastic astrocytoma, from 4% to 17% for glioblastoma, and between 32% and 69% for oligodendroglioma. For patients with glioblastoma, the largest gains in survival occurred between 2000-2004 and 2005-2009. These improvements were more noticeable among adults diagnosed aged 40-70 years than among younger adults.

CONCLUSIONS

To the best of our knowledge, this study provides the largest account to date of global trends in population-based survival for brain tumors by histology in adults. We have highlighted remarkable gains in 5-year survival from glioblastoma since 2005, providing large-scale empirical evidence on the uptake of chemoradiation at population level. Worldwide, survival improvements have been extensive, but some countries still lag behind. Our findings may help clinicians involved in national and international tumor pathway boards to promote initiatives aimed at more extensive implementation of clinical guidelines.

Ependymomas in Children and Adults

Ependymomas account for approximately 5% of all CNS tumors in adults and around 10% in the pediatric population. Contrary to traditional theories supporting that ependymomas arise from ependymal cells, recent studies propose radial glial cells as the cells of origin. In adults, half of the ependymomas arise in the spinal cord, whereas in the pediatric population, almost 90% of ependymomas are located intracranially. Most of the ependymomas are usually low-grade tumors except anaplastic variants and some cases of RELA-fusion-positive ependymomas, a molecular variant consisting the most recent addition to the 2016 World Health Organization (WHO) classification. Of note, the recently described molecular classification of ependymomas into nine distinct subgroups appears to be of greater clinical utility and prognostic value compared to the traditional histopathological classification, and parts of it are expected to be adopted by the WHO in the near future. Clinical manifestations depend on the location of the tumor with infratentorial ependymomas presenting with acute hydrocephalus. Gross total resection should be the goal of treatment. The prognostic factors of patients with ependymomas include age, grade, and location of the tumor, with children with intracranial, anaplastic ependymomas having the worst prognosis. In general, the 5-year overall survival of patients with ependymomas is around 60-70%.

The Significance of MGMT Promoter Methylation Status in Diffuse Glioma

A single-institution observational study with 43 newly diagnosed diffuse gliomas defined the isocitrate dehydrogenase 1 and 2 (IDH1/2) gene mutation status and evaluated the prognostic relevance of the methylation status of the epigenetic marker O6-methylguanine-DNA methyltransferase (MGMT). Younger patients (<50 years) with surgically resected glioma and temozolomide (TMZ) adjuvant chemotherapy were associated with better prognosis, consistent with other studies. The methylation status depends on the chosen method and the cut-off value determination. Methylation-specific PCR (MSP) established the methylation status for 36 glioma patients (19 (52.8%) positively methylated and 17 (47.2%) unmethylated) without relevancy for the overall survival (OS) (p = 0.33). On the other side, real-time methylation-specific PCR (qMSP) revealed 23 tumor samples (54%) that were positively methylated without association with OS (p = 0.15). A combined MSP analysis, which included the homogenous cohort of 24 patients (>50 years with surgical resection and IDH1/2-wildtype diffuse glioma), distinguished 10 (41.6%) methylated samples from 14 (58.4%) unmethylated samples. Finally, significant correlation between OS and methylation status was noticed (p ≈ 0.05). The OS of the hypermethylated group was 9.6 ± 1.77 months, whereas the OS of the unmethylated group was 5.43 ± 1.04 months. Our study recognized the MGMT promoter methylation status as a positive prognostic factor within the described homogenous cohort, although further verification in a larger population of diffuse gliomas is required.

Global variation in young adult central nervous system tumor incidence by region, age, and sex from 1988 to 2012

BACKGROUND

Central nervous system (CNS) tumors result in tremendous morbidity and mortality. Incidence of CNS tumors in young adults is less studied. It is unknown how young adult CNS tumor incidence has changed globally in recent decades.

METHODS

We used Cancer Incidence in Five Continents (CI5) data (1988-2012) to estimate incidence rates (IR), average annual percent change in incidence (AAPC; 95% confidence intervals [95% CI]), and male-to-female incidence rate ratios (IRR; 95% CI) by six histologies and age at diagnosis (20-29years, 30-39years). Tumors were classified as astrocytic, medulloblastoma, ependymal, oligodendroglial, meninges, and other embryonal. Geographic regions were defined using the United Nations Statistics Division geoscheme.

RESULTS

There were 78,240 CNS tumor cases included. 20-29-year-old (yo) rates were lower than 30-39 yo in most regions for astrocytic, oligodendroglial and ependymal tumors. Globally, astrocytic tumor incidence decreased (20-29 yo AAPC: - 0.70; 95% CI: - 1.32, - 0.08) while incidence increased for oligodendroglial (20-29 yo AAPC: 3.03; 95% CI: 1.57-4.51; 30-39 yo AAPC: 2.67; 95% CI: 0.79-4.58), ependymal (20-29 yo AAPC: 1.16; 95% CI: 0.31-2.03; 30-39 yo AAPC: 2.29; 95% CI: 1.14-3.46), medulloblastoma (30-39 yo AAPC: 0.6; 95% CI: 0.04-1.24) and tumors of the meninges (20-29 yo AAPC: 1.55; 95% CI: 0.04-3.07). There was a 20-40% male incidence excess in all histologies except for meninge tumors (30-39 yo IRR: 0.71; 95% CI: 0.61, 0.84).

CONCLUSIONS

Incidence of oligodendroglial and ependymal tumors increased globally in 20-39 yo suggesting better diagnoses or changes in risk factors. Males had a higher incidence of CNS tumors for most tumors studied and in most regions.

Molecular landscape of IDH-wildtype, H3-wildtype glioblastomas of adolescents and young adults (AYA)

OBJECTIVE

We aimed to characterise glioblastomas of adolescents and young adults (AYA) that were IDH wildtype (wt) and H3 wildtype (wt).

MATERIALS AND METHODS

Fifty such patients (aged 16-32) were studied by methylation profiling, targeted sequencing and targeted RNA-seq.

RESULTS

Tumours predominantly clustered into three methylation classes according to the terminology of Capper et al. (2018): (anaplastic) PXA (21 cases), GBM_midline (15 cases) and glioblastoma RTK/mesenchymal (7 cases). Two cases clustered with ANA_PA, 4 cases with LGG classes and 1 with GBM_MYCN. Only fifteen cases reached a calibrated score >0.84 when the cases were uploaded to DKFZ Classifier. GBM_midline-clustered tumours had a poorer overall survival (OS) compared to the PXA-clustered tumours (p=0.030). LGG-clustered cases had a significantly better survival than GBM_midline-clustered tumours and glioblastoma RTK/mesenchymal-clustered tumours. Only 13/21 (62%) of PXA-clustered cases were BRAF V600E mutated. Most GBM_midline-clustered cases were not located in the midline. GBM_midline-clustered cases were characterized by PDGFRA amplification/mutation (73.3%), mutations of mismatch repair genes (40.0%), and all showed H3K27me3 and EZH1P loss, and an unmethylated MGMT promoter. Across the whole cohort, MGMT promoter methylation and wildtype TERT promoter were favourable prognosticators. Mismatch repair gene mutations were poor prognosticators and together with methylation class and MGMT methylation, maintained their significance in multi-variate analyses. BRAF mutation was a good prognosticator in the PXA-clustered tumours.

CONCLUSION

Methylation profiling is a useful tool in the diagnosis and prognostication of AYA glioblastomas and the methylation classes have distinct molecular characteristics. The usual molecular diagnostic criteria for adult IDHwt glioblastoma should be applied with caution within the AYA age group.

Can inflammasomes promote the pathophysiology of glioblastoma multiforme? A view about the potential of the anti-inflammasome therapy as pharmacological target

Glioblastoma multiforme (GBM) is a malignant brain tumor with one of the worst general survivorship cases among the existing neoplasia. This aggressiveness is due to its complex molecular heterogeneity, immunohistochemistry and genetics. The current therapeutic approach brings little contribution to the improvement of the survival of the patients. Due to that, new forms of treatment have been explored, one of them being immunotherapy. In this aspect, the inflammasome pathway, which induces inflammation and immunosuppressive tumor response, contributing to the progression of the tumor, seems to be a new alternative to improve the treatment efficacy and the survival of the patients.

The incidence of major subtypes of primary brain tumors in adults in England 1995-2017

Background

Primary brain tumors are a complex heterogenous group of benign and malignant tumors. Reports on their occurrence in the English population by sex, age, and morphological subtype and on their incidence are currently not available. Using data from the National Cancer Registration and Analysis Service (NCRAS), the incidence of adult primary brain tumor by major subtypes in England will be described.

Methods

Data on all adult English patients diagnosed with primary brain tumor between 1995 and 2017, excluding spinal, endocrinal, and other CNS tumors, were extracted from NCRAS. Incidence rates were standardized to the 2013 European Standard Population. Results are presented by sex, age, and morphological subtype.

Results

Between 1995 and 2017, a total of 133 669 cases of adult primary brain tumor were registered in England. Glioblastoma was the most frequent tumor subtype (31.8%), followed by meningioma (27.3%). The age-standardized incidence for glioblastoma increased from 3.27 per 100 000 population per year in 1995 to 7.34 in men in 2013 and from 2.00 to 4.45 in women. Meningioma incidence also increased from 1.89 to 3.41 per 100 000 in men and from 3.40 to 7.46 in women. The incidence of other astrocytic and unclassified brain tumors declined between 1995 and 2007 and remained stable thereafter.

Conclusion

Part of the increase in the incidence of major subtypes of brain tumors in England could be explained by advances in clinical practice including the adoption of new diagnostic tools, classifications and molecular testing, and improved cancer registration practices.

Global Trends in Survival From Astrocytic Tumors in Adolescents and Young Adults: A Systematic Review

Background

Brain tumors represent an important cause of cancer-related death in adolescents and young adults. Most are diagnosed in low-income and middle-income countries. We aimed to conduct the first, to our knowledge, systematic review of time trends and geographical variation in survival in this age group.

Methods

We included observational studies describing population-based survival from astrocytic tumors in patients aged 15-39 years. We queried 6 electronic databases from database inception to December 31, 2019. This review is registered with PROSPERO, number CRD42018111981.

Results

Among 5640 retrieved records, 20 studies fulfilled the inclusion criteria. All but 1 study focused on high-income countries. Five-year survival from astrocytoma (broad morphology group) mostly varied between 48.0% and 71.0% (1973-2004) without clear trends or geographic differences. Adolescents with astrocytoma had better outcomes than young adults, but survival values were similar when nonmalignant tumors were excluded. During 2002-2007, 5-year survival for World Health Organization grade I-II tumors was in the range of 72.6%-89.1% in England, Germany, and the United States but lower in Southeastern Europe (59.0%). Five-year survival for anaplastic astrocytoma varied between 39.6% and 55.4% (2002-2007). Five-year survival from glioblastoma was in the range of 14.2%-23.1% (1991-2009).

Conclusions

Survival from astrocytic tumors remained somewhat steady over time, with little change between 1973 and 2009. Survival disparities were difficult to examine, because nearly all the studies were conducted in affluent countries. Studies often adopted the International Classification of Childhood Cancer, which, however, did not allow to accurately describe variation in survival. Larger studies are warranted, including underrepresented populations and providing more recent survival estimates.

Cancer incidence and mortality trends in young adults in Metropolitan Lima young adults, 1990-2012

Aims

The purpose of this research was to calculate and compare standardised incidence and mortality ratios in young adults, based on the data published by the population-based cancer registry of Metropolitan Lima.

Method

A secondary analysis was carried out on the data published by the population-based cancer registry of Metropolitan Lima in its last five volumes. Calculating the standardised incidence ratio, in accordance with the World Health Organization’s standard population, was done using the direct method, and the annual percentage change was calculated using the Joinpoint Regression Program.

Results

From 1990 to 2012, 12,380 new cases of cancer in young adults between the ages of 20 and 49 were reported in Metropolitan Lima. The neoplasms with the highest standardised incidence ratio in the young adult male group were testicular cancer, brain and nervous system cancer, stomach cancer, non-Hodgkin’s lymphoma and bowel cancer. The neoplasms with the highest standardised mortality ratio for this group were stomach cancer, brain and nervous system cancer, non-Hodgkin’s lymphoma, tracheal cancer, bronchial and lung cancer and liver cancer. The neoplasms with the highest standardised incidence ratio in the young adult female group were breast cancer, cervical cancer, thyroid cancer, ovarian cancer and brain and nervous system cancer. The neoplasms with the highest standardised mortality ratio for this group were breast cancer, cervical cancer, stomach cancer, brain and nervous system cancer and non-Hodgkin’s lymphoma.

Conclusions

Young adults represent a highly unique group, characterised by little diagnostic suspicion, distribution and aggressiveness of the neoplasms that occur in them. Assessing and reporting incidence and mortality ratios in this age group can contribute to decision making.

Gliomatosis Cerebri Among Children and Adolescents: An Individual-Patient Data Meta-analysis of 182 Patients

BACKGROUND

Gliomatosis cerebri is a rare but fatal widespread infiltrating central nervous system tumor. We aimed to describe diagnostic and prognostic features of gliomatosis cerebri among children and adolescents.

METHODS

We conducted a systematic literature review for published case reports and case series on patients with histologically confirmed gliomatosis cerebri and extracted data on an individual patient level for those aged 0-18 years. Multivariable Cox proportional hazard models were fit for overall survival.

RESULTS

Following screening of 274 published studies, 182 gliomatosis cerebri patients (63% males) aged 0-18 years with individual-level data available were identified. The most common presenting symptoms were seizures (52%), focal motor deficits (36%), and headache (30%). Imaging showed bilateral hemisphere involvement in 60%, infratentorial infiltration in 39%, and a focal contrast-enhanced mass (type II gliomatosis cerebri) in 27% of cases. Anaplastic astrocytoma was the most common histologic subtype of pediatric gliomatosis cerebri, whereas MGMT promoter methylation, IDH1 mutations, and codeletion of 1p/19q were less common molecular aberrations, as compared to adult gliomatosis cerebri. In the multivariable analyses, age at diagnosis >4 years, extended central nervous system infiltration, coordination abnormalities, and cognitive decline were predictors of worse outcome. Conversely, IDH1 mutations were associated with prolonged overall survival. Chemotherapy and extended surgical resection were associated with improved outcome, whereas radiotherapy was not associated with overall survival and was inferior to chemotherapy alone.

CONCLUSION

Gliomatosis cerebri among children and adolescents presents distinct histopathologic and molecular features compared to adults. However, similar associations of chemotherapy, and, when feasible, extended surgical resection, with favorable outcomes were noted among the 2 age groups.

The role of medical registries, potential applications and limitations

Medical registries provide highly reliable data, challenged hierarchically only by randomized controlled trials. Although registries have been used in several fields of medicine for more than a century and a half, their key role is frequently overlooked and poorly recognized. Medical registries have evolved from calculating basic epidemiological data (incidence, prevalence, mortality) to diverse applications in disease prevention, early diagnosis and screening programs, treatment response, health care planning, decision making and disease control programs. Implementing, maintaining and running a medical registry requires substantial effort. Developing the registry represents a complex task and is one of the major barriers in widespread use of registries. Medical registries have potential to evolve to a next generation by taking benefit from recent semantic web technology developments. This paper is aimed at providing a summary of the basic information available on medical registries and to highlight the progress and potential applications in this field.

Incidence and survival of gliomatosis cerebri: a population-based cancer registration study

Gliomatosis cerebri (GC) comprises a rare widespread infiltrating growth pattern of diffuse gliomas. We explored the incidence patterns and survival rates of GC in a population-based registration sample from the Surveillance, Epidemiology and End, Results database (1973-2012). GC cases (n = 176) were identified based on their International Classification of Diseases in Oncology (ICD-O-3) morphology code (9381). We calculated age-adjusted incidence rates (AIR) and evaluated temporal trends. Survival was assessed with Kaplan-Meier curves and Cox regression models. The annual AIR of GC was 0.1/million. We noted increasing trends in the preceding registration years (1973-2002; annually, + 7%) and a tendency of clinical/radiological approaches to substitute the gold-standard histological assessment for diagnosis. GC was diagnosed in the entire age spectrum (range 1-98 years), but higher incidence rates (0.43/million) were noted among the elderly (≥ 65 years). A slight male preponderance was identified (male-to-female ratio: 1.4). Median overall survival was 9 months with a 5 year survival rate of 18%. Increasing age, primary tumor location not restricted to the cerebral hemispheres and rural residence at diagnosis were identified as negative prognostic factors, whereas receipt of radiotherapy, surgical treatment, race and method of diagnosis were not associated with outcome. This first comprehensive overview of GC epidemiology exemplifies the rarity of the disease, provides evidence for male preponderance and increased incidence among the elderly and shows lower survival rates compared to the published single center reports. Expansion of registration to histological and molecular characteristics would allow emergence of clinical prognostic factors at the population level.

Hodgkin's lymphoma and its association with EBV and HIV infection

Hodgkin's lymphoma (HL) constitutes a clonal expansion of what appears to be malignant B cells. Viruses are involved in its pathogenesis, such as the Epstein-Barr virus (EBV) and human immunodeficiency virus (HIV). Since these viral infections have been shown to play key roles in the pathogenesis of HL, countries with a prevalence of HIV and EBV represent interesting population targets to study the pathogenesis of HL, linking the evolution of the disease with viral infections. Usually, patients present with late stage disease often involving the bone marrow at the time of diagnosis. The present paper discusses the role of viral infection in African countries, as HL is considered to be a malignant disease characterized by an inflammatory reaction to an aberrant B cell clone that is well known as the Reed-Sternberg cell (HRS).