Population-based incidence and survival of central nervous system (CNS) malignancies in Girona (Spain) 1994–2005

The global prevalence of primary central nervous system tumors: a systematic review and meta-analysis

BACKGROUND

Primary central nervous system (CNS) tumors are a heterogeneous group of neoplasms, including benign and malignant tumors. Since there are many heterogeneities in the prevalence reported in previous studies on this type of tumor, this study was performed to determine the overall prevalence of different primary CNS tumors.

METHOD

The study was conducted as a systematic review and meta-analysis by searching international databases, including PubMed, Scopus, Science Direct, Web of science, and the Google Scholar search engine until August 2020. After transferring the studies to information management software (EndNote) and eliminating duplicate studies, the remaining studies were reviewed based on inclusion and exclusion criteria according to three stages of primary and secondary evaluation and qualitative evaluation. Comprehensive Meta-Analysis software, Begg, Mazumdar, and I² tests were used for data analysis, publication bias analysis, and heterogeneity analysis, respectively.

RESULTS

After performing the systematic review steps, 80 studies were included for final analysis. Based on 8 studies, the prevalence of brain tumors was 70.9%. Also, studies on 7 other studies showed that the prevalence of spinal tumors was 12.2%. A review of 14 studies showed that the prevalence of neuroepithelial tumors was 34.7%. The analysis of 27 studies reported a prevalence of glioma tumors of 42.8%. Analyses performed on other studies showed that the prevalence of pituitary adenomas was 12.2%, embryonal tumors 3.1%, ependymal tumors 3.2%, meningiomas 24.1%, glial tumors 0.8%, astrocytic 20.3%, oligodendroglial 3.9%, glioblastoma 17.7%, schwannoma 6.7%, medulloblastoma 7.7% and Polycystic astrocytomas 3.8%.

CONCLUSION

As a result, it can be stated that brain tumors are the most common type of primary CNS tumors. It was also observed that tumors involving neuroepithelial cells are more common in patients than other types of tumors.

Epidemiology of Glioblastoma Multiforme-Literature Review

Glioblastoma multiforme (GBM) is one of the most aggressive malignancies, with a median overall survival of approximately 15 months. In this review, we analyze the pathogenesis of GBM, as well as epidemiological data, by age, gender, and tumor location. The data indicate that GBM is the higher-grade primary brain tumor and is significantly more common in men. The risk of being diagnosed with glioma increases with age, and median survival remains low, despite medical advances. In addition, it is difficult to determine clearly how GBM is influenced by stimulants, certain medications (e.g., NSAIDs), cell phone use, and exposure to heavy metals.

Voxel-level analysis of normalized DSC-PWI time-intensity curves: a potential generalizable approach and its proof of concept in discriminating glioblastoma and metastasis

OBJECTIVE

Standard DSC-PWI analyses are based on concrete parameters and values, but an approach that contemplates all points in the time-intensity curves and all voxels in the region-of-interest may provide improved information, and more generalizable models. Therefore, a method of DSC-PWI analysis by means of normalized time-intensity curves point-by-point and voxel-by-voxel is constructed, and its feasibility and performance are tested in presurgical discrimination of glioblastoma and metastasis.

METHODS

In this retrospective study, patients with histologically confirmed glioblastoma or solitary-brain-metastases and presurgical-MR with DSC-PWI (August 2007-March 2020) were retrieved. The enhancing tumor and immediate peritumoral region were segmented on CE-T1wi and coregistered to DSC-PWI. Time-intensity curves of the segmentations were normalized to normal-appearing white matter. For each participant, average and all-voxel-matrix of normalized-curves were obtained. The 10 best discriminatory time-points between each type of tumor were selected. Then, an intensity-histogram analysis on each of these 10 time-points allowed the selection of the best discriminatory voxel-percentile for each. Separate classifier models were trained for enhancing tumor and peritumoral region using binary logistic regressions.

RESULTS

A total of 428 patients (321 glioblastomas, 107 metastases) fulfilled the inclusion criteria (256 men; mean age, 60 years; range, 20-86 years). Satisfactory results were obtained to segregate glioblastoma and metastases in training and test sets with AUCs 0.71-0.83, independent accuracies 65-79%, and combined accuracies up to 81-88%.

CONCLUSION

This proof-of-concept study presents a different perspective on brain MR DSC-PWI evaluation by the inclusion of all time-points of the curves and all voxels of segmentations to generate robust diagnostic models of special interest in heterogeneous diseases and populations. The method allows satisfactory presurgical segregation of glioblastoma and metastases.

KEY POINTS

• An original approach to brain MR DSC-PWI analysis, based on a point-by-point and voxel-by-voxel assessment of normalized time-intensity curves, is presented. • The method intends to extract optimized information from MR DSC-PWI sequences by impeding the potential loss of information that may represent the standard evaluation of single concrete perfusion parameters (cerebral blood volume, percentage of signal recovery, or peak height) and values (mean, maximum, or minimum). • The presented approach may be of special interest in technically heterogeneous samples, and intrinsically heterogeneous diseases. Its application enables satisfactory presurgical differentiation of GB and metastases, a usual but difficult diagnostic challenge for neuroradiologist with vital implications in patient management.

Geographical variation in malignant and benign/borderline brain and CNS tumor incidence: a comparison between a high-income and a middle-income country

Purpose

There is large variability in reported incidence rates of primary brain/CNS tumors across the world, with mostly higher rates in higher-income countries. The aim was to compare malignant and benign brain/CNS tumor incidence between Zurich (Switzerland), a high-income country, and Georgia, a lower middle-income country.

Methods

For the period March 2009 to February 2012, we extracted the following tumors based on topography according to ICD-O3: C70.0–C72.9, and C75.1 (pituitary gland). Data were categorized into histology groups based on the WHO 2007 histological classification. Age-standardized rates per 100,000 person-years were calculated by subgroups.

Results

We included 1104 and 1476 cases of primary brain/CNS tumors for Zurich and Georgia, respectively. Mean age of patients was significantly lower in Georgia compared to Zurich (50.0 versus 58.3 years). Overall age-standardized incidence rates for malignant and benign brain/CNS tumors were 10.5 (95% CI 9.9–11.0) for Georgia and 23.3 (95% CI 21.9–24.7) for Zurich with a ratio of benign to malignant tumors of 1.656 for Georgia and 1.946 for Zurich. The most frequent histology types were meningiomas in both regions, followed by glioblastomas in Zurich, but pituitary tumors in Georgia.

Conclusion

Age-adjusted incidence rates of brain/CNS tumors were considerably higher in Zurich compared to Georgia, both for benign and malignant tumors, which is in line with other studies reporting higher rates in high-income than in low- and middle-income countries. The frequency distribution may be related to differences in diagnosing techniques and the population age structure.

Electronic supplementary material

The online version of this article (10.1007/s11060-020-03595-5) contains supplementary material, which is available to authorized users.

Trends in the Management Paradigms of Intracranial Meningioma

Objective  Intracranial meningiomas are the most common primary brain tumor. Treatment paradigms have evolved over time. There are limited number of population-based studies that examine this modern evolution. Here, we describe the trends of management of intracranial meningiomas using a national database. Methods  The data were obtained from the National Cancer Database for the years 2004 to 2015, the collected variables included: patients' age, gender, insurance type, income, comorbidity score, the tumor size and grade, and treatment modality (observation, surgery, radiotherapy, or combination therapy). We performed statistical analyses to detect association between unique variables and outcomes. In addition, we performed mortality analyses for various treatment modalities. Results  A total of 199,096 patients with a diagnosis of intracranial meningioma were included, the majority of patients were white females, mean age of 61 years, and half of the tumors were ≤ 3 cm. Observation was the most commonly used management modality followed by surgical resection, radiotherapy, and combination therapy. For the entire time period, there was an increased use of observation as a primary management method. Predictors of mortality included increased age, larger tumor size, higher tumor grade, treatment at a community hospital, and higher comorbidity scores. Conclusion  Population-based studies of intracranial meningiomas are uncommon; our study is one of the few reports that examine the changes in the modern management paradigms of meningioma in the United States over time. Additionally, we shed light on the factors that affected survival of patients with this condition.

Increasing incidence of central nervous system (CNS) tumors (2000-2012): findings from a population based registry in Gironde (France)

BACKGROUND

Although some countries have observed a stabilization in the incidence of CNS, an increasing incidence has been reported from multiple studies. Recent observations point out to the heterogeneity of incidence trends according to histological subtypes, gender and age-groups. Using a high-quality regional CNS tumor registry, this article describes the trends of CNS tumor incidence for main histological subtypes, including benign and malignant tumors, in the French department of Gironde from 2000 to 2012.

METHODS

Crude and age-standardized incidence rates were calculated globally, by histological subtypes, malignant status, gender and age groups. For trends, annual percent changes (APC) were obtained from a piecewise log-linear model.

RESULTS

A total of 3515 CNS tumors was registered during the period. The incidence of overall CNS tumors was 19/100000 person-years (8.3/100000 for neuroepithelial tumors and 7.3/100000 for meningeal tumors). An increased incidence of overall CNS tumors was observed from 2000 to 2012 (APC = + 2.7%; 95%-confidence interval (CI): 1.8-3.7). This trend was mainly explained by an increase in the incidence of meningiomas over the period (APC = + 5.4%, 95%-CI: 3.8-7.0). The increased incidence rate of CNS tumors was more pronounced in female and in older patients even though the incidence rate increased in all age groups.

CONCLUSIONS

Part of the temporal variation may be attributed to improvement in registration, diagnosis and clinical practices but also to changes in potential risk factors. Thus, etiological studies on CNS tumors are needed to clarify this rising trend.

Descriptive epidemiology of primary malignant and non-malignant central nervous tumors in Spain: Results from the Girona Cancer Registry (1994-2013)

BACKGROUND

Systematic registration of non-malignant central nervous system (CNS) tumors is a rare practice among European cancer registries. Thus, the real burden of all CNS tumors across Europe is underestimated. The Girona Cancer Registry provides here the first data on CNS tumor incidence and survival trends in Spain for all histological types, including malignant and non-malignant tumors.

METHODS

Data on all incident cases of primary CNS tumors notified to the Girona population-based cancer registry from 1994 to 2013 (n=2,131) were reviewed. Incidences rates (IRs) were standardized to the 2013 European population and annual percentage changes (EAPC) were estimated using a piecewise log linear model. 1- and 5-year observed (OS) and relative survival (RS) were also calculated. Results were expressed by sex, age-group, histological subtype and behavior.

RESULTS

The overall IR was 16.85 and increased across the period of study (EAPC=+2.2%). The proportion and IRs of malignant (50.2%; IR=9.35) and non-malignant cases (49.8%; IR=9.14) were similar; however, non-malignant tumors were more frequent in women (sex ratio=0.63). The most frequently reported histologies were meningioma (27.6%; IR=5.11) and glioblastoma (22.2%; IR=4.15), which also accounted for the highest and lowest 5-year RS (80.2%; 3.7%, respectively). Globally, 5-year RS was lower in men (42.6% vs. 58.3%, respectively) and in the elderly (64.9% for 0-14years vs. 23.0% for >74years).

CONCLUSION

This study presents a comprehensive overview of the epidemiology of malignant and non-malignant CNS primary tumors from the well-established region-wide Girona Cancer Registry (1994-2013). Incidence rates were recovered for all histologies. Survival is still dramatically associated to both age and histological subtype.

Cost-effectiveness analysis of the bevacizumab-irinotecan regimen in the treatment of primary glioblastoma multiforme recurrences

The purpose of the present study was to calculate the cost-effectiveness of the inclusion of the bevacizumab (BVZ) + irinotecan (CPT-11) regimen in the second-line of treatment for primary glioblastoma multiforme. A retrospective cohort study with a control group was performed in which the cost-effectiveness of a course of chemotherapy was calculated based on survival time and the incremental cost between the two lines of treatment. A total of 77 patients were included, 36 of who formed the BVZ/CPT-11 cohort. The median survival time for the non-BVZ control cohort was 13.23 months [95% confidence interval (CI), 11.79-14.68], while for the BVZ/CPT-11 treatment cohort, the median survival time was 17.63 months (95% CI, 15.38-19.89). Overall, each year of life gained for each patient treated with BVZ/CPT-11 would cost €46,401.99. These results demonstrate the effectiveness of the BVZ/CPT-11 combination, but its incremental cost compared with other lines of treatment or the best care available does not appear to be acceptable for public health systems in the current situation of budgetary adjustments.

Prognostic role of IDH mutations in gliomas: a meta-analysis of 55 observational studies

Background

IDH (Isocitrate dehydrogenase) mutations occur frequently in gliomas, but their prognostic impact has not been fully assessed. We performed a meta-analysis of the association between IDH mutations and survival in gliomas.

Methods

Pubmed and EMBASE databases were searched for studies reporting IDH mutations (IHD1/2 and IDH1) and survival in gliomas. The primary outcome was overall survival (OS); the secondary outcome was progression-free survival (PFS). Hazard ratios (HR) with 95% confidence interval (CI) were determined using the Mantel-Haenszel random-effect modeling. Funnel plot and Egger's test were conducted to examine the risk of publication bias.

Results

Fifty-five studies (9487 patients) were included in the analysis. Fifty-four and twenty-seven studies investigated the association between IDH1/2 mutations and OS/PFS respectively in patients with glioma. The results showed that patients possessing an IDH1/2 mutation had significant advantages in OS (HR = 0.39, 95%CI: 0.34–0.45; P < 0.001) and PFS (HR = 0.42, 95% CI: 0.35–0.51; P < 0.001). Subgroup analysis showed a consistent result with pooled analysis, and patients with glioma of WHO grade III or II-III had better outcomes.

Conclusions

These findings provide further indication that patients with glioma harboring IDH mutations have improved OS and PFS, especially for patients with WHO grade III and grade II-III.

Descriptive epidemiology and risk factors of primary central nervous system tumors: Current knowledge

Although comparisons are difficult due to differences in methodologies, the annual incidence rates of central nervous system (CNS) tumors range from 8.5 to 21.4/100,000 population according to cancer registries, with a predominance of neuroepithelial tumors in men and meningiomas in women. An increase in the incidence of CNS tumors has been observed during the past decades in several countries. It has been suggested that this trend could be due to aging of the population, and improvements in diagnostic imaging and healthcare access, but these factors do not explain differences in incidence by gender and histological subtypes. Several etiological hypotheses related to intrinsic (sociodemographic, anthropometric, hormonal, immunological, genetic) and exogenous (ionizing radiation, electromagnetic fields, diet, infections, pesticides, drugs) risk factors have led to analytical epidemiological studies to establish relationships with CNS tumors. The only established environmental risk factor for CNS tumors is ionizing radiation exposure. However, for other risk factors, studies have been inconsistent and inconclusive due to systematic differences in study design and difficulties in accurately measuring exposures. Thus, the etiology of CNS tumors is complex and may involve several genetic and/or environmental factors that may act differently according to histological subtype.

Temporal evolution of brain cancer incidence in the municipalities of Navarre and the Basque Country, Spain

BACKGROUND

Brain cancer incidence rates in Spain are below the European's average. However, there are two regions in the north of the country, Navarre and the Basque Country, ranked among the European regions with the highest incidence rates for both males and females. Our objective here was two-fold. Firstly, to describe the temporal evolution of the geographical pattern of brain cancer incidence in Navarre and the Basque Country, and secondly, to look for specific high risk areas (municipalities) within these two regions in the study period (1986-2008).

METHODS

A mixed Poisson model with two levels of spatial effects is used. The model also included two levels of spatial effects (municipalities and local health areas). Model fitting was carried out using penalized quasi-likelihood. High risk regions were detected using upper one-sided confidence intervals.

RESULTS

Results revealed a group of high risk areas surrounding Pamplona, the capital city of Navarre, and a few municipalities with significant high risks in the northern part of the region, specifically in the border between Navarre and the Basque Country (Gipuzkoa). The global temporal trend was found to be increasing. Differences were also observed among specific risk evolutions in certain municipalities.

CONCLUSIONS

Brain cancer incidence in Navarre and the Basque Country (Spain) is still increasing with time. The number of high risk areas within those two regions is also increasing. Our study highlights the need of continuous surveillance of this cancer in the areas of high risk. However, due to the low percentage of cases explained by the known risk factors, primary prevention should be applied as a general recommendation in these populations.

Clinicopathological findings and five year survival rates for patients with central nervous system tumors in Yazd, Iran

BACKGROUND

The incidence rate of brain tumors has increased more than 40% in the past 20 years, especially in adults. We aimed to study the clinical and pathological findings of central nervous system (CNS) tumor patients and to evaluate their 5 year survival rates.

MATERIALS AND METHODS

The archives of all patients with CNS tumors in 6 health care centers in Yazd, Iran, from 2006 to 2013, were studied. Patients data were extracted using a checklist which included age, sex, date of reference and diagnosis, date of death, clinical signs, radiography findings, pathology report, size and location of tumor, patient treatment and grade of tumor.

RESULTS

A total of 306 patient records were studied in the 8 year period. The most prevalent type of tumor was astrocytoma (n=113, 36.9%). The frequency of almost all tumor types was statistically higher in male patients (p=0.025). In most cases surgery with radiotherapy was the treatment of choice (49.3%). The most frequent symptom reported was headache (in 60.8% of patients) followed by convulsions (15.7%). Most of the tumors were located in the right hemisphere (46.1%) and the frontal and parietal lobe (26% and 12%, respectively). Radiography findings displayed edema with a nonhomogeneous lesion in majority of the patients (87%). The survival fraction of the patients with malignant tumors decreased over time (0.807 in the first year and 0.358 at the end of the 5th year).

CONCLUSIONS

Astrocytoma was the more common CNS tumor with male predominance. Overall survival rates of malignant tumors decreased over time and this was in relation with tumor grade.

Incidence rates of the primary brain tumours in Georgia--a population-based study

BACKGROUND

To determine the incidence rate and to describe other basic epidemiological data of primary brain tumours in a population-based study in Georgia, performed between March 2009 and March 2011.

METHODS

Active case ascertainment was used to identify brain tumour cases by searching neuroradiology scan reports and medical records from all participating medical institutions, covering almost 100% of the neurooncology patients in the country.

RESULTS

A total of 980 new cases were identified during the two-year period. For a population of almost 4.5 million, the overall annual incidence rate was 10.62 per 100,000 person-years, age-standardized to the year 2000 US population (ASR). Non-malignant tumours constituted about 65.5% of all tumours. Males accounted for 44% and females for 56% of the cases. Among classified tumours, age-standardized incidence rates by histology were highest for meningiomas (2.65/100,000), pituitary adenoma (1.23/100,000) and glioblastomas (0.51/100,000). ASR were higher among females than males for all primary brain tumours (10.35 vs. 9.48/100,000) as well as for main histology groups except for neuroepithelial, lymphomas and germ cell tumours.

CONCLUSIONS

The annual incidence rate of all primary brain tumours in Georgia, though comparable with some European registry data, is low in comparison with the 2004-2005 Central Brain Tumor Registry of the United States (CBTRUS) database, which may reflect variations in reporting and methodology. The higher percentage of unclassified tumours (37.8%) probably also affects the discrepancies between our and CBTRUS findings. However, the most frequently reported tumour was meningioma with a significant predominance in females, which is consistent with CBTRUS data.

Should we continue temozolomide beyond six cycles in the adjuvant treatment of glioblastoma without an evidence of clinical benefit? A cost analysis based on prescribing patterns in Spain

PURPOSE

The standard adjuvant treatment for glioblastoma is temozolomide concomitant with radiotherapy, followed by a further six cycles of temozolomide. However, due to the lack of empirical evidence and international consensus regarding the optimal duration of temozolomide treatment, it is often extended to 12 or more cycles, even in the absence of residual disease. No clinical trial has shown clear evidence of clinical benefit of this extended treatment. We have explored the economic impact of this practice in Spain.

MATERIALS AND METHODS

Spanish neuro-oncologists completed a questionnaire on the clinical management of glioblastomas in their centers. Based on their responses and on available clinical and demographic data, we estimated the number of patients who receive more than six cycles of temozolomide and calculated the cost of this extended treatment.

RESULTS

Temozolomide treatment is continued for more than six cycles by 80.5 % of neuro-oncologists: 44.4 % only if there is residual disease; 27.8 % for 12 cycles even in the absence of residual disease; and 8.3 % until progression. Thus, 292 patients annually will continue treatment beyond six cycles in spite of a lack of clear evidence of clinical benefit. Temozolomide is covered by the National Health Insurance System, and the additional economic burden to society of this extended treatment is nearly 1.5 million euros a year.

CONCLUSIONS

The optimal duration of adjuvant temozolomide treatment merits investigation in a clinical trial due to the economic consequences of prolonged treatment without evidence of greater patient benefit.

Primary brain tumour epidemiology in Georgia: first-year results of a population-based study

A population-based cohort study was initiated in Georgia in March 2009 to collect epidemiologic data of malignant and non-malignant primary brain tumours. During the first year, 473 incident cases were identified. For a population of 4.3 million, the annual incidence rate was 10.25 per 100,000 inhabitants, age-standardized to the year 2000 US population. Non-malignant tumours constituted about 66 % of all tumours. Males accounted for 40 % and females for 60 % of the cases. Crude incidence rates by histology were highest for meningiomas (2.92/100,000), pituitary adenoma (1.16/100,000) and glioblastomas (0.64/100,000), which was in agreement with the frequency of reported histology: meningiomas--45.2 %, pituitary adenoma--18.0 % and glioblastomas--9.9 %. The age-standardized incidence rates were higher among females than males for all primary brain tumours (11.05 vs. 8.44/100,000) as well as for individual histologies except for glioblastoma and several other neuroepithelial tumours. Some differences compared with 2004-2005 Central Brain Tumor Registry of the United States data may be explained by a higher percentage of unclassified tumours (37 %) in our study. We suggest further studies to clarify the nature of this discrepancy.

Bevacizumab in glioblastoma multiforme

Bevacizumab is a humanized IgG1 monoclonal antibody that selectively binds with high affinity to human VEGF and neutralizes VEGF' s biologic activity. Malignant gliomas are characterized by extensive microvascular proliferation and produce VEGF. Preclinical data indicate that angiogenesis is essential for the proliferation and survival of malignant glioma cells. Promising response rates, progression-free survival rates at 6 months and median overall survival in patients with recurrent glioblastoma multiforme (GBM) have been reported with bevacizumab, both in retrospective analyses and in prospective Phase II studies. In the pivotal randomized but noncomparative Phase II trial, a non-negligible percentage of patients survived beyond 1 and 2 years after the start of bevacizumab administration. However, randomized Phase III trial data on bevacizumab in recurrent GBM are lacking. Currently, bevacizumab is being studied in combination with temozolomide and radiation in previously untreated GBM patients in two large randomized Phase III trials.

Survival of European patients with central nervous system tumors

We present estimates of population-based 5-year relative survival for adult Europeans diagnosed with central nervous system tumors, by morphology (14 categories based on cell lineage and malignancy grade), sex, age at diagnosis and region (UK and Ireland, Northern, Central, Eastern and Southern Europe) for the most recent period with available data (2000-2002). Sources were 39 EUROCARE cancer registries with continuous data from 1996 to 2002. Survival time trends (1988 to 2002) were estimated from 24 cancer registries with continuous data from 1988. Overall 5-year relative survival was 85.0% for benign, 19.9% for malignant tumors. Benign tumor survival ranged from 90.6% (Northern Europe) to 77.4% (UK and Ireland); for malignant tumors the range was 25.1% (Northern Europe) to 15.6% (UK and Ireland). Survival decreased with age at diagnosis and was slightly better for women (malignant tumors only). For glial tumors, survival varied from 83.5% (ependymoma and choroid plexus) to 2.7% (glioblastoma); and for non-glioma tumors from 96.5% (neurinoma) to 44.9% (primitive neuroectoderm tumor/medulloblastoma). Survival differences between regions narrowed after adjustment for morphology and age, and were mainly attributable to differences in morphology mix; however UK and Ireland and Eastern Europe patients still had 40% and 30% higher excess risk of death, respectively, than Northern Europe patients (reference). Survival for benign tumors increased from 69.3% (1988-1990) to 77.1% (2000-2002); but survival for malignant tumors did not improve indicating no useful advances in treatment over the 14-year study period, notwithstanding major improvement in the diagnosis and treatment of other solid cancers.