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Shakir M, Khowaja AH, Shariq SF, Irshad HA, Tahir I, Rae AI, Hamzah R, Gupta S, Park KB, Enam SA. Workforce Challenges for the Neurosurgical Care of Brain Tumors in Low- and Middle-Income Countries: A Scoping Review. World Neurosurg 2024:S1878-8750(24)01057-X. [PMID: 38925244 DOI: 10.1016/j.wneu.2024.06.098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2024] [Accepted: 06/18/2024] [Indexed: 06/28/2024]
Abstract
Limited neurosurgical workforces remain one of the critical problems experienced in low resource settings. Therefore, our study aims to explore and summarize the key challenges to neurosurgical care of brain tumors in terms of workforce in LMICs. A comprehensive literature search was conducted using Scopus, PubMed, CINAHL, and Google Scholar from inception to October 20, 2022. All extracted data were screened independently by 2 reviewers and thematically analyzed. We found and screened 3764 articles, of which 33 studies were included in our final analysis as per our inclusion criteria. Among the studies included, 33% highlighted the limited number of neurosurgeons, 39% emphasized the absence of specialized surgical teams, 7% pointed out a shortage of nursing staff, and 4% noted suboptimal anesthesia teams. The study uncovered the need for improved training programs in neuro-oncology (32%) and neuro-anesthesia (3%), as well as improved collaboration (32%), and multidisciplinary team structures (15%), are essential for tackling these workforce challenges and improving patient outcomes. It is crucial to implement targeted interventions and policy changes to address the barriers to the workforce in providing effective neurosurgical care to patients with brain tumors in developing countries. This might entail capacity building and training programs for healthcare professionals. Policymakers should consider allocating resources and funding for workforce development and making neurosurgical care a priority in healthcare plans.
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Affiliation(s)
- Muhammad Shakir
- Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan.
| | | | | | | | - Izza Tahir
- Medical College, Aga Khan University, Karachi, Pakistan
| | - Ali I Rae
- Department of Global Health and Social Medicine, Program for Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Radzi Hamzah
- Department of Global Health and Social Medicine, Program for Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Saksham Gupta
- Department of Global Health and Social Medicine, Program for Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Kee B Park
- Department of Global Health and Social Medicine, Program for Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Syed Ather Enam
- Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan.
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Girardi F, Allemani C, Coleman MP. Worldwide Trends in Survival From Common Childhood Brain Tumors: A Systematic Review. J Glob Oncol 2019; 5:1-25. [PMID: 31682549 PMCID: PMC6882508 DOI: 10.1200/jgo.19.00140] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2019] [Indexed: 11/30/2022] Open
Abstract
PURPOSE The histology of brain tumors determines treatment and predicts outcome. Population-based survival reflects the effectiveness of a health care system in managing cancer. No systematic review of worldwide variation and time trends in survival from brain tumors in children is currently available. PATIENTS AND METHODS We considered longitudinal, observational studies comprising children diagnosed with intracranial astrocytic or embryonal tumors. We searched six electronic databases from database inception to September 30, 2018, using complex search strategies. The outcome measure was 5-year survival, estimated through a time-to-event analysis. This study is registered with PROSPERO, number CRD42018111981. RESULTS Among 5,244 studies, we identified 47 eligible articles that provided 228 survival estimates. Only five studies were entirely or partially conducted in low-income or middle-income countries. Five-year survival from embryonal tumors increased from 37% in 1980 to approximately 60% in 2009. Although survival for medulloblastoma improved substantially (from 29% to 73% during 1959-2009), survival for primitive neuroectodermal tumors wavered over time (1973-2009) and between countries. Five-year survival from astrocytoma changed very little over the 27 years between 1982 and 2009 (from 78% to 89%). Interpretation of the literature was made difficult by the heterogeneity of study designs. CONCLUSION Survival has improved for embryonal tumors, but little change has been observed for astrocytic tumors. We found a striking gap in knowledge about survival from childhood brain tumor subtypes in middle-income and low-income countries, where half of these tumors are diagnosed. Larger studies are needed, including in under-represented countries and based on standardized data collection, to provide up-to-date survival estimates.
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Affiliation(s)
- Fabio Girardi
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Claudia Allemani
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Michel P. Coleman
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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Aboian MS, Kline CN, Li Y, Solomon DA, Felton E, Banerjee A, Braunstein SE, Mueller S, Dillon WP, Cha S. Early detection of recurrent medulloblastoma: the critical role of diffusion-weighted imaging. Neurooncol Pract 2018; 5:234-240. [PMID: 30402262 DOI: 10.1093/nop/npx036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background Imaging diagnosis of medulloblastoma recurrence relies heavily on identifying new contrast-enhancing lesions on surveillance imaging, with diffusion-weighted imaging (DWI) being used primarily for detection of complications. We propose that DWI is more sensitive in detecting distal and leptomeningeal recurrent medulloblastoma than T1-weighted postgadolinium imaging. Methods We identified 53 pediatric patients with medulloblastoma, 21 of whom developed definitive disease recurrence within the brain. MRI at diagnosis of recurrence and 6 months prior was evaluated for new lesions with reduced diffusion on DWI, contrast enhancement, size, and recurrence location. Results All recurrent medulloblastoma lesions demonstrated reduced diffusion. Apparent diffusion coefficient (ADC) measurements were statistically significantly lower (P = .00001) in recurrent lesions (mean=0.658, SD=0.072) as compared to contralateral normal region of interest (mean=0.923, SD=0.146). Sixteen patients (76.2%) with disease recurrence demonstrated contrast enhancement within the recurrent lesions. All 5 patients with nonenhancing recurrence demonstrated reduced diffusion, with a mean ADC of 0.695 ± 0.101 (normal=0.893 ± 0.100, P = .0027). While group 3 and group 4 molecular subtypes demonstrated distal recurrence more frequently, nonenhancing metastatic disease was found in all molecular subtypes. Conclusion Recurrent medulloblastoma lesions do not uniformly demonstrate contrast enhancement on MRI, but all demonstrate reduced diffusion. Our findings support that DWI is more sensitive than contrast enhancement for detection of medulloblastoma recurrence, particularly in cases of leptomeningeal nonenhancing disease and distal nonenhancing focal disease. As such, recurrent medulloblastoma can present as a reduced diffusion lesion in a patient with normal postgadolinium contrast MRI.
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Affiliation(s)
- Mariam S Aboian
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA
| | - Cassie N Kline
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of California San Francisco, San Francisco CA
| | - Yi Li
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA
| | - David A Solomon
- Department of Pathology, University of California San Francisco, San Francisco CA
| | - Erin Felton
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of California San Francisco, San Francisco CA
| | - Anu Banerjee
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA.,Department of Neurological Surgery, University of California San Francisco, San Francisco CA
| | - Steve E Braunstein
- Department of Radiation Oncology, University of California San Francisco, San Francisco CA
| | - Sabine Mueller
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of California San Francisco, San Francisco CA.,Department of Neurological Surgery, University of California San Francisco, San Francisco CA
| | - William P Dillon
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA
| | - Soonmee Cha
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA
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Grossman R, Ram Z. Posterior Fossa Intra-Axial Tumors in Adults. World Neurosurg 2015; 88:140-145. [PMID: 26743385 DOI: 10.1016/j.wneu.2015.12.066] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2015] [Revised: 12/21/2015] [Accepted: 12/22/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND The posterior fossa is the site of many types of tumors, and brain metastases are the most common malignancies in that location among adults. Other brain tumors, such as ependymomas, medulloblastomas, and juvenile pilocytic astrocytomas, mostly occur during childhood and are relatively rare in adults. Most primary malignant brain tumors, such as gliomas and lymphomas, tend to be located in the supratentorial compartment. METHODS This review summarizes prognostic factors, therapeutic management, and molecular data of intra-axial posterior fossa tumors in adults, including ependymomas, medulloblastomas, and pilocytic astrocytomas. RESULTS The literature on intra-axial posterior fossa tumors in adults relies mainly on limited retrospective clinical studies, and such studies employ a wide range of treatment approaches that are usually based on therapies developed specifically for children or for supratentorial brain tumors. CONCLUSIONS The clinical course and surgical outcome of adult patients with intra-axial brain tumors in the posterior fossa are summarized in this review. The prognostic factors and therapeutic management of patients with these tumors are controversial because of their rarity, their heterogeneity, and the lack of sufficient data in the literature.
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Affiliation(s)
- Rachel Grossman
- Department of Neurosurgery, Sackler Faculty of Medicine, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel.
| | - Zvi Ram
- Department of Neurosurgery, Sackler Faculty of Medicine, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
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Zhang ZY, Xu J, Ren Y, Li KKW, Ng HK, Mao Y, Zhong P, Yao Y, Zhou LF. Medulloblastoma in China: clinicopathologic analyses of SHH, WNT, and non-SHH/WNT molecular subgroups reveal different therapeutic responses to adjuvant chemotherapy. PLoS One 2014; 9:e99490. [PMID: 24932704 PMCID: PMC4059646 DOI: 10.1371/journal.pone.0099490] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 05/15/2014] [Indexed: 01/12/2023] Open
Abstract
Medulloblastoma (MB) is one of the most common primary central nervous system tumors in children. Data is lacking of a large cohort of medulloblastoma patients in China. Also, our knowledge on the sensitivity of different molecular subgroups of MB to adjuvant radiation therapy (RT) or chemotherapy (CHT) is still limited. The authors performed a retrospective study of 173 medulloblastoma patients treated at two institutions from 2002 to 2011. Formalin-fixed paraffin embedded (FFPE) tissues were available in all the cases and sections were stained to classify histological and molecular subgroups. Univariate and multivariate analyses were used to investigate prognostic factors. Of 173 patients, there were 118 children and 55 adults, 112 males and 61 females. Estimated 5-year overall survival (OS) rates for all patients, children and adults were 52%, 48% and 63%, respectively. After multivariate analysis, postoperative primary radiation therapy (RT) and chemotherapy (CHT) were revealed as favorable prognostic factors influencing OS and EFS. Postoperative primary chemotherapy (CHT) was found significantly improving the survival of children (p<0.001) while it was not a significant prognostic factor for adult patients. Moreover, patients in WNT subtype had better OS (p = 0.028) than others (SHH and Non-SHH/WNT subtypes) given postoperative adjuvant therapies. Postoperative primary RT was found to be a strong prognostic factor influencing the survival in all histological and molecular subgroups (p<0.001). Postoperative primary CHT was found significantly to influence the survival of classic medulloblastoma (CMB) (OS p<0.001, EFS p<0.001), SHH subgroup (OS p = 0.020, EFS p = 0.049) and WNT subgroup (OS p = 0.003, EFS p = 0.016) but not in desmoplastic/nodular medulloblastoma (DMB) (OS p = 0.361, EFS p = 0.834) and Non-SHH/WNT subgroup (OS p = 0.127, EFS p = 0.055). Our study showed postoperative primary CHT significantly influence the survival of CMB, SHH subgroup and WNT subgroup but not in DMB and Non-SHH/WNT subgroup of MB.
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Affiliation(s)
- Zhen-Yu Zhang
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Jian Xu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Yong Ren
- Department of Pathology, Wuhan General Hospital of Guangzhou Command, People's Liberation Army, Wuhan, China
| | - Kay Ka-Wai Li
- Department of Anatomical and Cellular Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Ho-Keung Ng
- Department of Anatomical and Cellular Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Ying Mao
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Ping Zhong
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Yu Yao
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Liang-Fu Zhou
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
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Romero-Rojas AE, Diaz-Perez JA, Raju S, Lozano-Castillo A. Neuroradiology and histopathology in two cases of adult medulloblastoma. Neuroradiol J 2014; 27:163-8. [PMID: 24750703 DOI: 10.15274/nrj-2014-10021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Accepted: 02/01/2014] [Indexed: 12/16/2022] Open
Abstract
Medulloblastoma (MB) is the most common central nervous system neoplasm in children and only rarely presents in the adult population. Recent molecular biology findings have characterized MB as a heterogeneous neoplasm distinguished by well-defined tumour subsets each with specific histologic and molecular features. Available immunohistochemical stains can now be used to differentiate the distinct molecular types of MB. This report analyzed the histopathologic and neuroradiologic features of two new cases of adult MB. Imaging studies in these patients revealed the morphological appearance of high-grade, well-circumscribed heterogeneous tumours with necrosis, located laterally within the posterior cranial fossa. Histopathology of resected samples demonstrated high-grade tumours (WHO grade IV) containing sheets of undifferentiated neural cells with high mitotic activity and evidence of necrosis. The histopathologic and molecular characteristics of these cases of MB are reviewed for potential applications in new molecular methods of imaging.
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Affiliation(s)
| | - Julio A Diaz-Perez
- Moores Cancer Center, University of California; San Diego, La Jolla, CA, USA - Department of Pathology, University of Santander; Bucaramanga, Colombia
| | - Sharat Raju
- Moores Cancer Center, University of California; San Diego, La Jolla, CA, USA
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Management of recurrent medulloblastoma in adult patients: a systematic review and recommendations. J Neurooncol 2013; 115:1-8. [PMID: 23877361 DOI: 10.1007/s11060-013-1206-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Accepted: 07/12/2013] [Indexed: 10/26/2022]
Abstract
Medulloblastoma accounts for almost one-third of pediatric central nervous system (CNS) cancers, but is very rare in the adult population. As a result, adult patients with medulloblastoma are often treated according to therapies developed for children with similarly staged disease at diagnosis, based on the assumption that adult and pediatric tumors have similar properties. The purpose of this review was to summarize the evidence and to make recommendations for the management of recurrent disease in adult patients with medulloblastoma. We conducted a systematic literature search to find publications addressing treatment of recurrent medulloblastoma in adults. Current treatment strategies for adult patients with relapsed medulloblastoma are based on the results of retrospective case series and published consensus recommendations, and include maximal safe re-resection where possible, combined with chemotherapy and/or re-irradiation. We describe the results of 13 publications involving 66 adult patients treated with high-dose chemotherapy (HDCT) plus stem cell transplantation for recurrent medulloblastoma. HDCT with stem cell transplantation may be a treatment option for a small proportion of adult patients who are unlikely to benefit from conventional chemotherapy and who are fit and have their disease recurrence contained within the CNS. Potential cases in which stem cell transplantation is being considered should be discussed at a multidisciplinary tumor board which includes involvement by hematologic oncologists and transplant specialists.
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Balducci M, Chiesa S, Chieffo D, Manfrida S, Dinapoli N, Fiorentino A, Miccichè F, Frascino V, Anile C, Valentini V, De Bari B. The role of radiotherapy in adult medulloblastoma: long-term single-institution experience and a review of the literature. J Neurooncol 2011; 106:315-23. [PMID: 21805324 DOI: 10.1007/s11060-011-0665-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Accepted: 07/06/2011] [Indexed: 01/22/2023]
Abstract
Medulloblastoma (MB) occurs infrequently in adult patients and standard treatment is still controversial. We report our long-term, single-institution experience of adult MB and a review of the literature. We analysed adult patients with histologically proved MB treated by postoperative radiotherapy. Primary endpoints were local control (LC), disease-free survival (DFS), and overall survival (OS). Acute toxicity was reported according to CTC-NCI score vers. 3.0 and specific neuropsychological assessment analysis was performed to define late brain toxicity. From 1990-2008, 13 patients were treated by craniospinal (CSI, 12/13) or cranial irradiation (1/13, because of bad clinical conditions). Median follow up was 101 months (64-218). Complete radiological response was observed in 12/13 patients and a partial response in 1/13. Ten-year LC, OS, and DFS were 91, 76, and 84%, respectively. Two patients died because of local and spinal progression after 13 and 62 months. Acute G3 haematological toxicity (RTOG score) was observed for one patient only. The neuropsychological analysis did not reveal late toxicity related to brain radiotherapy. This experience confirms the efficacy and safety of radiotherapy in adult MB patients, resulting in very interesting 10-year LC and OS.
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Affiliation(s)
- M Balducci
- Bio-Images and Radiological Sciences Department, Radiotherapy Institute, Catholic University of Rome, 00168 Rome, Italy
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Minturn JE, Janss AJ, Fisher PG, Allen JC, Patti R, Phillips PC, Belasco JB. A phase II study of metronomic oral topotecan for recurrent childhood brain tumors. Pediatr Blood Cancer 2011; 56:39-44. [PMID: 21108437 DOI: 10.1002/pbc.22690] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND The prognosis for recurrent or refractory brain tumors in children is poor with conventional therapies. Topotecan is a topoisomerase I inhibitor with good central nervous system (CNS) penetration following oral administration. Increased efficacy of topotecan has been demonstrated with prolonged low-dose daily treatment in pre-clinical models. To investigate further this drug delivered orally in pediatric CNS malignancies, a phase II study in children with recurrent or refractory brain tumors was performed. PROCEDURE Patients ≤ 21 years of age at diagnosis with a recurrent, progressive, or refractory primary CNS malignancy and measurable disease, were eligible. Patients enrolled into four strata: ependymoma (N = 4), high-grade glioma (HGG) (N = 6), brainstem glioma (BSG) (N = 13), and primitive neuroectodermal tumor (PNET) (N = 8). Oral topotecan was administered once daily at a dose of 0.8 mg/m(2)/day for 21 consecutive days repeated every 28 days. Response and toxicity profiles were evaluated. RESULTS Twenty-six patients were evaluable (median age 9.2 years; 10 males). Two objective responses were observed in PNET patients with disseminated tumor at study entry. These two patients remain alive and in remission 7 and 9.5 years off study. Four other patients (two BSG, one PNET, and one HGG) had stable disease (median 4.6 months). The most common toxicities were hematologic. CONCLUSIONS Daily oral topotecan at a dose of 0.8 mg/m(2)/day can be safely administered to children with recurrent or refractory brain tumors. This regimen identified activity in recurrent PNET. The prolonged progression free survival (PFS) in two PNET patients justifies consideration of this regimen in more advanced clinical trials.
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Affiliation(s)
- Jane E Minturn
- Division of Oncology, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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