The diagnosis and management of cerebral gliomas are challenging. The goal of this study was to evaluate the pattern of cerebral gliomas at the General Hospital Douala, Cameroon. A retrospective study was carried out over a period of 10 years. Non-glial lesions were not included. Data were analyzed with Epi info version 7.2.2.6 (Microsoft, Seattle, USA). 220 cases of brain tumors, comprising 56 gliomas (25.46% of all brain tumors) were managed during the study period. The mean age of the patients was 42.93 ± 16.90 years. 35 cases (62.5%) were males. Patients over 15 years of age represented 91.07% (n = 51) of the cases. The most frequent presenting complaints were headache and vomiting with 52 cases (92.86%) and 47 cases (83.93%) respectively. Brain computed tomography was done for all patients. The most frequent histological type was astrocytoma with 22 cases (39.29%) followed by glioblastoma with 20 cases (35.71%). The most performed surgical technique was partial removal with 33 cases (58.93%), followed by open biopsy with 14 cases (25.00%). Radiotherapy was administered to 54 patients (96.43%). The outcome ranged from full recovery in 8 cases (14.29%), recovery with persisting symptoms, in 15 cases (26.79%) and death in 26 cases (46.43%). Seven patients (12.50%) were lost to view. In this series, cerebral gliomas affected most often adult males. Most of them presented with signs of raised intracranial pressure. The outcome was poor with 46.43% of patients dying before 2 years after diagnosis.
A tumor is a growth or “lump” made of cells that have begun to grow in an unusual way [
CG are considered as primary brain tumors, meaning that they originate from cells in the brain [
The incidence of glial tumors in the United States of America is estimated to be about 11.2 cases per 100,000 persons annually. In France, the incidence of glial tumors annually is estimated to be about 7 cases per 100,000 persons-year for adults and 5 cases per 100,000 persons-year for children. The incidence of glial tumors in Northern Africa is estimated to be about 5 per 100,000 persons and in Sub-Saharan Africa, 0.8 cases per 100,000 persons [
In Cameroon as a whole, very little study has been carried out on BGs. However, studies carried out by Enow Orock et al. [
Clinically, the general presentation of brain tumors depends on the location, size of the tumor, and growth rate of the neoplasm [
The management of glial tumors has evolved over the years in developed countries, with more sophisticated minimal invasive (stereotactic mass spectrometry, radio-neurosurgery) and post-invasive (immunohistochemistry) techniques other than those found in less developed countries being used. In less developed countries, modern techniques available include; radiological imaging and pathological examination of the tumor mass. For radiological imaging, Brain CT scan and Magnetic Resonance Imagery are usually used.
The management of cerebral gliomas is multidisciplinary and disciplines involved include; neurosurgery, medical oncology, radiotherapy, medical imaging, neurologist and pathologists. The management of BG depends on the type of glioma and the grade of the tumor [
This study was done in order to have a better understanding of cerebral gliomas in our setting.
It was a cross-sectional retrospective review of cerebral gliomas cases managed at the General Hospital Douala (GHD), Cameroon, over a period of ten years from January 2008 to December 2017.
Selection criteria were as follows: patients of any age with a definite diagnosis of cerebral glioma (CG) confirmed by pathological analysis. Available imaging and pathology data were mandatory for inclusion in the study. Patients treated for non-glial cerebral lesions and those with incomplete medical files were not included. The study had agreement from the institutional ethical committee.
Data were collected from patients’ medical files at neurosurgery, neurology, oncology, radiology, radiotherapy and pathology units.
Variables such as age, gender, profession, marital status, previous exposure to ionizing radiations, history of traumatic brain injury, brain surgery, family history of CG, and exposure to pesticides were thoroughly reviewed. Clinical manifestations with thorough and concise neurological examination were collected, imaging data, pathology results, and management procedures (medical treatment, surgical procedure, radiation therapy and chemotherapy) also were gathered and analyzed. The pre and post-treatment Karnofsky [
The statistical analysis was done with the software SPSS 20.0 for Windows® [Microsoft, Seattle, USA]. The Fisher and the Chi-square tests were used. The statistical significance was set for p value < 0.05.
During the study period, 20,610 patients were hospitalized in the surgery and oncology units, 220 (1.07%) of them were treated for brain tumors, 56 (25.46%) of these brain tumors were confirmed as gliomas on pathology. Amongst patients with CG, 35 (62.5%) were males and 21 (37.5%) were females. Their mean age was 42.93 ± 16.90 years.
The most common presenting complaint were headache, vomiting, and motor weakness while altered consciousness, hemiparesis, and papilledema were the most common physical examination findings.
Able to carry on normal activity and to work; no special care needed. | 100 | Normal no complaints; no evidence of disease. |
---|---|---|
90 | Able to carry on normal activity; minor signs or symptoms of disease. | |
80 | Normal activity with effort; some signs or symptoms of disease | |
Unable to work; able to live at home and care for most personal needs; varying amount of assistance needed. | 70 | Cares for self; unable to carry on normal activity or to do active work. |
60 | Requires occasional assistance, but is able to care for most of his personal needs. | |
50 | Requires considerable assistance and frequent medical care. | |
Unable to care for self; requires equivalent of institutional or hospital care; disease may be progressing rapidly | 40 | Disabled; requires special care and assistance. |
30 | Severely disabled; hospital admission is indicated although death not imminent. | |
20 | Very sick; hospital admission necessary; active supportive treatment necessary. | |
10 | Moribund; fatal processes progressing rapidly. | |
0 | Dead |
COMPLAINT | FREQUENCY | PERCENT |
---|---|---|
Headache Vomiting Hemiparesis Seizures Vision disturbance Behavioral impairment Aphasia Vertigo Equilibrium disorder Hypoacousia Dysphonia | 52 47 37 21 12 11 11 8 4 4 1 | 92.86% 83.93% 66.07% 37.50% 21.43% 19.64% 19.64% 14.29% 7.14% 7.14% 1.79% |
PHYSICAL FINDINGS | FREQUENCY | PERCENT |
Altered consciousness Hemiparesis Papillary edema Hyper-reflexia Diminished visual acuity Cognitive disorder Aphasia Diplopia Memory disorder Co-ordination disorder Cranial nerve palsy Abnormal gait Hypo-aesthesia Exophthalmos | 48 37 33 19 14 13 9 9 7 7 7 5 3 1 | 85.71% 66.07% 58.93% 33.93% 25.00% 23.21% 16.07% 16.07% 12.50% 12.50% 12.50% 8.93% 5.36% 1.79% |
Symptoms and signs of intracranial hypertension were the mostcommonclinical manifestations.
A brain CT scan was done for all patients and some had brain MRI. A space occupying lesion was confirmed in all cases.
All patients had symptomatic treatment. It consisted in analgesics in all cases with paracetamol given alone or in combination to 50 patients, pregabalin to 32 and tramadol to 11. Corticosteroids were given to 54 patients consisting in oral or IV methyl-prednisolone in 53 cases. Anticonvulsants were given to 38 patients, phenobarbital was given alone or in combination to 18 patients, and sodium valproate toten. All patients had a surgical procedure. It consisted to open biopsy in 14 cases, partial resection in 41 cases, and total removal in only one case. Five patients had additional ventriculoperitoneal shunt for associated obstructive hydrocephalus. Fifty four (96.43%) patients underwent radiation therapy after surgery. The dosage of radiation with respect to histological nature ranged from 10 to 60 Grays.
BRAIN CT SCAN FINDING | FREQUENCY | PERCENTAGE |
---|---|---|
LOCATION OF LESION. Left side Right side Frontal lobe Parietal lobe Temporal lobe Occipital lobe Posterior fossa NUMBER OF LESIONS. Isolated lesion Multiple lesions LESION SURROUNDINGS. Irregular Circumscribed DENSITY OF LESION. Hypodense lesions Isodense lesions Hyperdense lesions ASSOCIATED SIGNS. Perilesional edema Shifting Necrosis Hydrocephalus Calcification | 33 23 28 16 09 08 10 41 12 46 07 50 04 01 46 41 27 25 20 | 58.93% 41.07% 50.00% 28.57% 16.07% 14.29% 17.86% 73.21% 21.43% 82.14% 12.50% 89.30% 07.14% 01.79% 82.14% 73.21% 48.21% 44.64% 35.71% |
CT: computed tomography. Most gliomas were located on the left cerebral hemisphere and the frontal lobe was the most common site involved. The CT scans showed hypodense lesions surrounded with edema in most of the cases.
DOSAGE (Gray) | FREQUENCY | PERCENTAGE |
---|---|---|
Glioblastoma. 30 - 39 Gy 40 - 49 Gy 50 - 59 Gy >60 Gy Astrocytoma. 20 - 29 Gy 30 - 39 Gy 50 - 59 Gy >60 Gy Oligodendroglioma. 10 - 19 Gy 20 - 29 Gy 30 - 39 Gy 50 - 59 Gy Ependymoma. 10 - 19 Gy 20 - 29 Gy 50 - 59 Gy | 5 1 10 3 4 1 10 6 1 1 2 7 1 1 1 | 26.32% 5.26% 52.63% 15.79% 19.05% 4.76% 47.62% 28.57% 9.09% 9.09% 18.18% 63.64% 33.33% 33.33% 33.33% |
Gy: Grays. Most patients received whole brain irradiation of 50 to 59 Grays.
SCORE | FREQUENCY | PERCENT |
---|---|---|
Astrocytoma 40 60 70 80 90 100 Oligodendroglioma 50 80 90 100 Ependymoma 60 80 100 Glioblastoma 30 40 50 60 70 80 | 2 5 3 3 4 5 2 2 5 2 1 1 1 4 4 5 1 5 1 | 9.09% 22.73% 13.64% 13.64% 18.18% 22.73% 18.18% 18.18% 45.45% 18.18% 33.33% 33.33% 33.33% 20.00% 20.00% 25.00% 5.00% 25.00% 5.00% |
The pretreatment Karnofsky performance scores were strongly bond with type of gliomas and the subsequent outcome.
The aim of this study was to have a global view on brain gliomas patterns and management in our setting. The limitations of this study were as follows: it was retrospective cross-sectional analysis, therefore, gathering of data was not perfect; immunochemistry was not available and accurate categorization of lesions such as astrocytomas was not feasible.
Gliomas represent more than 80% of primary brain tumors [
Cerebral gliomas represented 25% of brain tumors managed at our hospital. Astrocytomas accounted for 75% of these gliomas. The results of this series showed that, astrocytomas other than GBM was the most frequent age-adjusted histological type with 22 cases (39.29%), followed by grade IV astrocytoma or GBM with 20 cases (35.71%), oligodendrogliomas with 11 cases (19.64%) and ependymomas were less frequent with 3 cases (5.36%) recorded. GBM was most frequent in patients between 50 and 59 years with 7 cases (35.00%) followed by the 40 to 49 years age group with 5 cases (25.00%). These results are similar to those reported in other studies. Astrocytomas were most frequent in patients between 50 and 69 years with 10 cases (40.00%). Oligodendrogliomas were most frequent in patients between 30 to 39 years. Ependymomas were seen in patients aged less than 30 or above 60. Studies carried out in the U.S.A in 2011 showed that, the age-adjusted rate per 100,000 persons-year for glioblastoma is 3.19 compared with 0.12 for anaplastic oligodendrogliomas and 0.11 for protoplasmic/fibrillary astrocytomas [
This series also showed that the age-adjusted frequency of cerebral gliomas was higher in males with a frequency of 35 cases (62.5%) against 21 cases (37.5%) in females, (SR, 1.5:1). In males, the 4th and 6th decades were the most involved with nine (25.71%) and seven cases (20.00%) respectively. In females, the most frequent age groups were 5th and 6th decades (28.27%; and 23.81% of cases). Astrocytomas and GBM were the most common gliomas both in males and females in the present study. In 2005; the estimated worldwide incidence of cerebral gliomaswas 3.7 per 100,000 persons-year in males and 2.6 per 100,000 person-years in females [
Developed countries tend to have higher rates (incidence rate of 5.8 per 100,000 persons-year for men and 4.1 per 100,000 persons-year for females), than less developed countries (incidence rate of 3.0 per 100,000 persons-year for males and 2.1 per 100,000 persons-year for females) possibly reflecting less access to modern medical facilities [
The most common presentation of brain tumors is progressive neurologic deficit (68%), usually motor weakness (45%). Patients with primary brain tumors can present with generalized or focal signs and symptoms [
In this series, the most frequent presenting complaints were, headache (92.86%), vomiting (83.93%), hemiparesis (66.07%) and seizures (37.50% of cases). Moderately frequent symptoms included; vision disturbances (21.43%), behavioral impairment (19.64%) and vertigo (14.29%). Less frequent symptoms were; equilibrium imbalance with (7.14%), hypoacousia (7.14%) and dysphonia (1.79%). Signs of raised ICP were present in most patients including: altered state of consciousness, 48 cases (85.71%); headache, 52 cases (92.86%); vomiting, 47 cases (83.93%); and vision disorders such as papilledema, 33 cases (58.93%), diminished visual acuity, 14 cases (25.00%), and diplopia, 9 cases (16.07%).
Hemiparesis was present 37 cases (66.07%) with exaggerated deep tendon reflexes in 19 (33.93%) of them. Co-ordination was impaired in 12.50% of the patients, 8.93% had abnormal gait, 14.29% a vertigo, 23.21% cognitive impairment, 16.07% had aphasia, and the cranial nerves were involved in 12.50% of the cases.
According to a study carried out at the National Hospital for Neurology and Neurosurgery at Queen Square London, on a large case record review of initial symptoms experienced by 653 glioma patients between 1955 and 1975 found that patients presented with neurological problems such as seizures (54%), headache (71%), mental change (52%), and hemiparesis (43%) by the time of diagnosis [
The scope of neuroradiology tumor imaging has continued to evolve, within the past decades imaging has moved from indirect diagnosis of lesion using cerebral angiography to precise lesion localization using multi planar CT scan or MRI and to lesion diagnosis using stereotactic mass spectrometry which can reveal a lesion’s molecular composition [
The presentation of the lesion on imagery depends on the imaging technique used and the histological nature of the tumor [
In this series, the brain CT scan was done in all patients, but only few did MRI. This is because the CT scan is, cheaper and more readily available in our setting. The brain CT scan findings were as follows: the left hemisphere was involved in 58.93% of cases, and the frontal lobe in 50.00%. The lesions were isolated in 73.21%. The contours were irregular in 82.14%. The gliomas were hypo-dense in 89.30%, with surrounding edema in 82.14% of the cases, brain shifting was present in 73.21% and necrosis in 48.21%. Most low grade gliomas are hypo intense on T1WI MRI, and T2WI shows high signal changes that extend beyond the tumor volume. Most low-grade gliomas do not enhance on CT or MRI, although up to 40% do; some malignant gliomas do not enhance. Glioblastoma multiforme typically shows ring enhancement on CT, with low density necrotic center, and enhancing ring corresponding to tumor cells.
The management of cerebral gliomas has many aspects which include: symptoms relief, tissue diagnosis, restoring cerebrospinal fluid flow and decompressing adjacent neural structures, radiation therapy and chemotherapy. Non-surgical alternatives such as radiosurgery can be contemplated when an invasive procedure is precluded [
Symptomatic treatment is achieved by medications such as corticosteroids, analgesics, anti-epileptics and anxiolytics.
The tissue diagnosis can be made after surgical techniques such as open or stereotactic biopsy, partialor gross total resection. Gross total removal of the lesion provides the best clinical outcomes. When risk of surgery is too high or if gross total resection cannot be performed, consideration for chemotherapy and radiotherapy can be given [
Chemotherapy regimens usually consist of a specific number of cycles given over a set period of time. The main hindrance to effective chemotherapy use for gliomas is the blood brain barrier which prevents most drugs from getting to the brain parenchyma. However, some drugs still go through the blood-brain barrier. These drugs include: nitrosoureas such as carmustine or, lomustine, nimustine; alkylating (methylating) agents like temozolomide and procarbazine; carboplatin and cispaltin; nitrogen mustards as cyclophosphamide, isofamide and cytoxan; and vinca alkaloids such as Vincristine, vinblastine, paclitaxel; and so on.
The chemotherapy regimens used for treatment of CG are well established and usually begin with PCV (Procarbazine, CCNU and Vincristine). Temozolomide, a chemotherapy agent administered per os can also be used in the place of PCV. Its advantages are that it is easy to administer, it has lesser adverse effects and it is very efficient [
Concerning radiotherapy, the dose of irradiation for intracranial tumors varies (50 to 60 Grays given in a period of 5 to 6 weeks, divided as 2 Grays per session and 5 sessions per week). This dosage can however be modified with respect to the histological type [
The management of a patient with cerebral glioma depends on the histological nature of the tumor, the age of the patient and the Karnofsky score [
The options for managing a low-grade glioma include surgery and radiotherapy, either alone or combined [
The options for managing high-grade gliomas include surgery, radiotherapy and chemotherapy usually two or three combined [
The surgical techniques usually used include biopsy, shunting, incomplete or complete resection of the lesion.
Chemotherapy is indicated in low grade gliomas (grade I and II) in case of a residual of the initial tumor.
Chemotherapy is recommended for all patients with high-grade gliomas (grade III and IV). It should begin at the same time as radiotherapy and continue for six months after radiotherapy.
In this series, all the patients received symptomatic treatment with analgesics, corticosteroids, anti-epileptics. The most frequent surgical technique performed was partial resection, followed by open biopsy. This can be explained by the fact that gliomas are usually infiltrating and complete resection usually impossible and risky, therefore radiotherapy is usually required after partial removal and biopsy. Patients with CSF obstruction had ventricular-peritoneal shunting besides tumor resection. Radiotherapy was administered to 96.43% of the patients. The dosage of radiation with respect to histological nature ranged from 10 to 60 Grays. The dosage of radiation varied from the norm because of avoidance of adverse effects of radiotherapy such as necrosis and cerebral atrophy which are difficult to manage in resource limited environments.
The outcome of glioma patients depends on the interval between onset and treatment, the histological nature of the tumor and the treatment administered. The independent factors that statistically affect longevity are: patient age, histological features and performance status at presentation. The patient age is the most significant prognosticator, younger patients having better outcomes [
In the present series, of the eight (14.29%) patients who recovered fully, five of them (62.50%) had astrocytomas. For 15 patients who recovered partially, 14 (93.33%) had low-grade astrocytomasor oligodendrogliomas with 7 cases each. It is noticeable that most patients with astrocytomas and oligodendrogliomas had high performance (Karnofsky) scores at presentation. For the 26 patients who died, 18 had GBM and the remainders anaplastic astrocytomas. These patients also presented with the lowest performance scores. No death was recorded in patients with low-grade gliomas no matter the histologic type. Therefore, we can conclud that the outcome of our patients was strongly influenced by the tumor type and neurological status before treatment.
Lamborn et al. [
According to results of a study published by the Clinical Oncology Society of Australia in 2011, in people with low-grade oligodendrogliomas, median survival time after diagnosis was seven years. This means that half of these people survive for more than seven years. For people with high-grade oligodendrogliomas, median survival time after diagnosis was 11 - 14 months. This means that half of these people survive for more than 14 months [
The prevalence of cerebral gliomas for brain tumors managed at the General Hospital Douala was 25.46%. Nine patients out of ten were adults, two-thirds were males. Most patients presented with intracranial hypertension and headache, altered consciousness, and vomiting were the most frequent clinical manifestations. Brain CT scanning was the most accessible imaging tool and it was done in all patients. Symptomatic treatment was administered to most patients and consisted in analgesics in all cases, corticosteroids in all but two cases, and anti-epileptics in two-thirds of the patients. All patients were operated most often for histological diagnosis purpose. The most performed surgical procedure was partial resection of the tumor. External beam whole brain irradiation was administered to all but two patients. Seventy-five per cent of the gliomas were astrocytomas, and glioblastoma (grade IV astrocytoma) was the most common type. The prognosis was poor since almost half of the patients died before two years after the diagnosis. All deaths concerned patients with glioblastomas or anaplastic astrocytomas, and death prevalence in patients with GBM was 90%. The prognosis was strongly correlated with the histologic type, the grade of the glioma and the pre-treatment Karnofsky performance score which in turn was bond with the nature of the neoplasm. Patients with grade IV and grade III gliomas had the poorest performance scores at presentation and the worst outcome after treatment.
We thank Miss NDIMBA Erica for her help with the corrections.
The authors declare no conflicts of interest regarding the publication of this paper.
Ndoumbe, A., Motah, M., Ikango, B.J., Moumi, M., Fewou, A. and Sone, A.M. (2018) Cerebral Gliomas Patterns at the General Hospital of Douala, Cameroon. Open Journal of Modern Neurosurgery, 8, 389-405. https://doi.org/10.4236/ojmn.2018.84035
GHD: General Hospital Douala.
IV: Intravenous.
CSF: Cero-Spinal Fluid.
CG: Cerebral Glioma.
GBM: Glioblastoma Multiforme.
ICP: Intracranial Pressure.
CT: Computed Tomography.
MRI: Magnetic Resonance Imaging.
WHO: World Health Organization.
USA: United States of America.