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Primary malignant brain tumors have been a cause of increasing concern in the last several years. There has been a steady rise in the incidence of primary brain tumors, with an almost 25 percent increase during the last two decades, perhaps due to improved detection with neuroradiological imaging. y , y Although the incidence of some tumors such as lung cancer has declined, and improvements in therapy have increased survival for other tumors such as breast cancer, the incidence of brain tumors continues to increase. Just as important as the rise in incidence is the fact that the need for treatment of these neoplasms is urgent because they afflict the young in disproportionate numbers, significantly affecting their chances of living productive lives.

According to statistics gathered by the American Cancer Society, 17,900 new cases of central nervous system (CNS) tumors were diagnosed in 1996, involving approximately 10,400 men and 7500 women (..Tab!,ยง..4S.:!. ). More than half of these cases were malignant gliomas. In children, brain tumors are the most common solid tumor and are second only to leukemias in overall incidence. For comparison, during 1996 there were 185,700 cases of breast cancer and 27,600 cases of leukemia.

Early studies date back centuries to descriptions or drawings of lethal brain tumors discovered at autopsy. In 1828, John Ambercrombie published the first pathological descriptions of brain tumors in his monograph Pathological and Practical Research on Disease of the Brain and Spinal Cord. The first acknowledged resection of a brain tumor was performed in London in 1884, after Hughes Bennett provided sufficient clinical localization to permit Rickham Godlee to perform a craniotomy. Even then, doctors were quick to announce their findings in the lay press, and a report documenting the operation was published in The London Times a mere 21 days following the procedure. Formal reports of the operation were later published in the medical literature. The first monograph on brain tumors was prepared 4 years later by Sir Byron Bramwell.

Pathological criteria for the diagnosis of primary brain tumors remained under study and was controversial for almost a century. Even at the turn of the century, surgeons complained bitterly that a lack of precise pathological criteria hindered diagnosis. Fedor Krause, in his three-volume Surgery of the Brain and Spinal Cord (1912), described several successful tumor surgical procedures in which the neuropathologist was either unable or unwilling to venture a diagnosis. Bailey and Cushing published the first modern treatise on brain tumors and pathological description in 1932. Previously, they had histologically defined and coined the term medulloblastoma.y Use of this term to refer to a blue cell tumor of the posterior fossa continues to spark debate. [4

In the first half of this century, Cushing continued to develop and refine the techniques of neurosurgical removal and localization, including angiography and pneumoencephalography. Greg Walter described the first use of electroencephalography for tumor localization in 1936. Improvements in radiotherapy and chemotherapy[5| during the second half of this century marked the emergence of neuro-oncology as a truly multidisciplinary field. In the 21st century, analysis of the biological markers and genetic behavior of these tumors is expected to advance our ability to treat effectively this most difficult class of cancers.

TABLE 46-1 -- FREQL

ENCY OF PR

MARY CNS TLMORS

Children (0-14 Years)

Adults (215 Years)

Type

Percentage

Type

Percentage

Glioblastoma

20

Glioblastoma

50

Astrocytoma

21

Astrocytoma

10

Ependymoma

7

Ependymoma

2

Oligodendroglioma

1

Oligodendroglioma

3

Medulloblastoma

24

Medulloblastoma

2

Neuroblastoma

3

Neurilemmoma

2

Neurilemmoma

1

Pituitary adenoma

4

Craniopharyngioma

5

Craniopharyngioma

1

Meningioma

5

Meningioma

17

Teratoma

2

Pinealoma

1

Pinealoma

2

Hemangioma

2

Hemangioma

3

Sarcoma

1

Sarcoma

1

Others

5

Others

5

Total

100

Total

100

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