Epidemiology of primary central nervous system neoplasms. I. Mortality from primary central nervous system neoplasms in Minnesota.
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The incidence rates of primary nervous system neoplasms in 5 districts (large administrative units) of Western Poland with a relatively homogeneous health care system but some contrasts in economic activity, as well as in 224 communes (smallest administrative units) located within these 5 districts, with a total population of 3,097,000 were estimated on the appointed day (31.12.79). Testing the hypothesis, assuming a homogeneous distribution of nervous system neoplasms over the region under investigation, that the incidence rates were distributed as a Poisson variable has revealed a focal distribution of these tumours; in 15 communes the frequency was higher than 9.0 and deviated from the remainder in the 5% right tail of the distribution. The main conclusion from the presented results was that tumours of the nervous system, of which 90% were intracranially located, may occur in clusters or foci, and this could prove to be of clinical as well as statistical import.
Classic histopathologic study revealed a series of highly treasured criteria for diagnosing central and peripheral nervous system neoplasms. The advent of immunohistochemistry galvanized further improvements in the accuracy of diagnostic neurooncologic pathology, and moreover, enriched our understanding of tumor histogenesis. Now with the tremendous technical advances in immunodetection and the commercial availability of high-quality monoclonal and polyclonal antibodies, the potential for first-rate diagnostic assessment is available to practically every laboratory, regardless of how small or remotely located. Intensive immunohistochemical analysis of nervous system neoplasms has taught us that neuroectodermal cells have a limited repertoire of highly redundant antigenic phenotypes and that neoplastic cells usually mimic their non-neoplastic immature or fully differentiated counterparts. These observations led to the concept that a panel of antibodies ought to be used to identify the "immuno-gestalt" of tumors, because it is often difficult if not impossible to subcategorize the tumors on the basis of a single immunohistochemical determination. The ensuing tour through the immunodiagnostic neurooncology summarizes approximately 10 years of original work in this field. I have attempted to provide consensus opinions, and whereever appropriate, highlight dissenting arguments. The salient immunohistochemical features of most nervous system tumors also are summarized in tabular form to facilitate diagnostic considerations at your own institutions.
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Current data indicate that mortality for primary malignant nervous system neoplasms (NSNs) provides a fairly accurate index of incidence. Average annual age- and sex-specific death rates among whites for primary malignant NSNs in the 48 contiguous United States from 1940 through 1975 showed a marked cohort effect among the elderly of either sex. For white men aged 60 through 64 years, mortality increased steadily from 5.3 per 100,000 per year for those born in 1880 to 16.1 per 100,000 per year for the 1910 cohort. No definite cohort effect was seen in the young. The increase in mortality could be due to better diagnosis and more complete case ascertainment for deaths due to primary malignant NSNs, but further studies are required to distinguish a real from an artifactual increase in mortality.
The authors report of 3 observations of the familiar incidence of the central nervous system neoplasms. In the first case it was brain astrocytoma in 2 brothers, in the second case is was man with the meningioma of falx cerebri and his sister with capillary hemangioma of the cerebellum, in the third case it was a woman with astrocytoma of the left temporal lobe and her brother with medulloblastoma. The authors are of the opinion that it was only coincidence in all three cases.
To determine whether nervous system neoplasms are associated with primary malignancies elsewhere, we studied the frequency of multiple primary tumous in patients in whom at least one of the primary tumors was within the nervous system. The patients were Conneticut residents with tumors diagnosed between 1935 and 1964. Of 135 patients, 130 had two primary tumors, four had three primary tumors, and one had four primary tumors. Only with multiple primary tumors involving the brain and breast did the number of observed cases significantly exceed the number of expected cases; eight patients who had a meningioma associated with a breast cancer accounted for this excess. Patients with breast cancer presenting with signs or symptoms of an intracranial neoplasm should be carefully evaluated, for the intracranial lesion may be a potentially curable meningioma.
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The "ideal" classification of pediatric brain tumors will depend on a full characterization of pathologic variables and their influence on prognosis. Currently available information about these variables remains incomplete, even for traditional histologic and cytologic features, and certainly for those studied by the newer methods that will continue to appear. In light of the multiplicity and specialized nature of some of the techniques that are or will become available, it is suggested that specific pediatric central nervous system neoplasms be targeted for study by groups of pathologists according to a protocol that delegates specific studies to specific individuals. In light of the large number of cases required, as well as the need to control for effects of different treatments, such studies are most readily done within the framework of large cooperative clinical trials. Such organizations provide the mechanism to test the biologic significance of pathologic findings that can then be used in the ideal classification.
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Proliferating cell nuclear antigen (PCNA) is a cell-cycle-regulated protein, which can be demonstrated in routinely fixed specimens. Studies on various tissues, cell cultures and neoplasms have shown that PCNA labelling index (LI) correlates with flow cytometry, tritiated thymidine LI, bromodeoxyuridine (BrdU) incorporation and Ki67 LI. PCNA LI may have prognostic value in various neoplasms. The present study concerns PCNA immunostaining in a series of neuroglial tumours. We demonstrate that there is a relation between PCNA LI and histological grade, and between PCNA LI and reported thymidine LI, BrdU LI and Ki67 LI. Pleomorphic xanthoastrocytomas and low-grade astrocytomas had the lowest LI, whereas metastases of small cell lung cancer and medulloblastomas had the highest LI. Glioblastomas sometimes showed a certain degree of intratumoral heterogeneity of distribution of immunostained cells. Intratumoral heterogeneity underscores the critical importance of representative sampling of central nervous system neoplasms for kinetic studies. As expected, PCNA LI are somewhat higher than tritiated thymidine LI, BrdU LI and Ki67 LI because PCNA is a marker of G1, S, G2 and M-phases of the cell cycle and not of S-phase only. In addition, because of its long half-life, PCNA may be detected immunohistochemically in cells that have recently left the cell cycle. The immunohistochemical evaluation of PCNA LI is easy to perform on routinely processed material, allowing retrospective studies. PCNA LI may be a useful tool in grading gliomas. However, its prognostic value must be validated by comparing PCNA LI with the follow-up of the neoplasms, and possibly with the responsiveness to anti-proliferative therapy.
An epidemiologic survey of central nervous system (CNS) neoplasms in Central Finland revealed a total of 367 neoplasms, 298 of which were diagnosed during 1975-82, the remaining being diagnosed earlier. Histological verification was available in 83% of intracranial and 90% of intraspinal neoplasms. 14% of the intracranial neoplasms diagnosed during 1975-82 were found incidentally at autopsy. Metastases corresponded to 18% of all CNS neoplasms. Age- and sex-adjusted annual incidence rates for primary and metastatic intracranial neoplasms were 12.3 and 3.4/100,000, and for intraspinal neoplasms 1.3 and 0.7/100,000, respectively. The total incidence of all CNS neoplasms was 17.7/100,000/year. Of the different types of intracranial neoplasms, meningiomas were more frequent among women than among men with a ratio of 8:1; metastases were more common among men with a ratio of 2.5:1. For primary intracranial neoplasms, point prevalences (January 1, 1983) were 65.9/100,000 and intraspinal neoplasms 9.1/100,000. The corresponding period prevalences for 1982 were 73.7 and 9.5/100,000.
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The hospitalizations and hospital deaths due to nervous system tumours were analysed on the basis of statistical cards filled in hospitals in a random sample of 10% of patients hospitalized in all Polish hospitals in the years 1979-1981 and 1986-1988. An evident rise was observed in the frequency of these hospitalizations and a less evident rise in the number of hospital deaths with a decrease of the hospital deaths caused by nervous system tumours. In the analysed time periods the greatest number of hospitalizations was in the age group 40-59 years, and deaths in the age group over 60 years. Hospitalization and hospital deaths indices were higher for urban population and males.
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The evaluation of cerebrospinal fluid (CSF) requires adaption of basic cytopathologic principles to the specific neoplasms that involve the central nervous system (CNS). In this review, general criteria for detecting malignant cells in CSF are presented. The incidence and cytologic characteristics of specific metastatic tumors that involve CSF are reviewed, and the incidence, pathogenesis and natural history of meningeal carcinomatosis are discussed. The role of cytopathology in the detection and management of primary CNS tumors is presented. Emphasis is placed on the cytologic characteristics of individual types of primary brain tumors and the application of fine needle aspiration biopsy to intracranial lesions.