or located in fourth ventricle and medulla oblongata.

a sex ratio of 1.6 [7]. But in another Moroccan study about two cities, Rabat and Casablanca, the authors found on 542 patients that 51.8% were males and 48.2% were females [8]. In Cameroon (Center of Africa) cerebral tumors in children represented 35.29% of all cerebral tumors. The average age was 9 years, and they found 47.62% of males against 52.38% of females [4]. Broalet et al. (Ivory Coast) found a frequency of 15.74% with a sex ratio of 0.5 [5]. In our case series, we found 7 females against 4 males.

Clinical aspects

Ten on eleven patients of our series have intracranial hypertension (Table 1). Mbonda, E. et al. [4] in Cameroon found intracranial hypertension in 88% of cases. Ndubuisi et al. [9] in Nigeria found in a series of 54 cases from 2006 to 2007 (one year) that a significant proportion of cases presented an advanced disease. They found that 48% of patients had an alteration of the level of consciousness and more than 70% with a definite focal deficit.

Topography

About location of the lesion, Barnholtz-Sloan et al. [2] in a study about pediatric brain tumors in Non-Hispanics, Hispanics, African Americans and Asians; the majority of the tumors were infratentorial in each racial group (57% of Non-Hispanics, 47% of Hispanics, 55% of African Americans and 53% of Asians). Hazmiri et al. [7] in Morocco found the same results (infratentorial tumors in 61.53% of cases). Some authors like Broalet et al. (Ivory Coast) found a majority of supratentorial tumors, 54.38% [5]. In our case series, we found six cases of infratentorial tumors and five of supratentorial location. Globally, there is no difference between these locations in the literature, but the difference is found depending on the age of patients: before three years old, supratentorial tumors are predominant and between three and eleven years old, tumors of posterior fossa are predominant; after this step, there is no difference about location [10] [11].

Histology

In the United States of America, the previous study showed that African Americans had the highest proportion of medulloblastoma. Actually, Barnholtz-Sloan et al. found that the Hispanics and Asians had the highest proportions of these tumors. Hispanics, African Americans, and Asians had higher proportions of astrocytoma, high-grade tumors compared to Non-Hispanics [2].

In Morocco (North of African continent), astrocytoma and medulloblastoma accounted for 46.32% (29.41% and 16.91%, respectively) in the study of Hazmiri et al. [7]. In another study, also in Morocco, Karkouri et al. [8] found 34.5% for medulloblastoma, followed by pilocytic astrocytoma (17.3%) and diffuse astrocytoma grade 2 (12.5%). The difference between these two studies can be explained by methodology about the selection of patients (cases ranged until 19 years old in the first group and until 15 years old in the second). Near the Republic of Congo, in Cameroon; astrocytoma was the most frequent type in histology, in 45.23% of cases [4]. The same result was found in the Ivory Coast (astrocytoma) for 19% of cases [5]. In our study, only three cases had histology.

Treatment

Surgery represents the initial treatment for the majority of pediatric brain tumors. The surgical resection that is as extensive as possible is important for long-term survival with most tumors [3].

Pilocytic astrocytoma is generally circumscribed and slow-growing tumors. They are commonly located within the cerebellar hemispheres. When complete tumor excision is achieved, there is no need for another therapy, and complete surgical resection is curative. When total resection is not possible without damage to eloquent structures of the brain, chemotherapy or radiotherapy can be used for the residual and recurrent tumors [3] [12] [13]. With the introduction of neuro-navigation systems, functional brain mapping and cortical mapping, the lesions located in eloquent brain areas become more accessible for surgical resection with minimal morbidity [3] [13].

Medulloblastomas are undifferentiated embryonal neuroepithelial tumors of the cerebellum. Complete resection should be performed at 74.6%. Brainstem infiltration could be one of the major reasons for the high incidence of subtotal excision. Standard therapy consists of total surgical resection followed by radiation to the entire craniospinal axis and or chemotherapy [3] [13] [14]. Some patients might require a ventricular shunt or third ventriculostomy prior to the resection of the tumor, and the majority of them will have a resolution of the hydrocephalus after tumor resection. Cerebellar mutism syndrome is one post-surgical complication characteristically developing after surgery of posterior fossa [13].

The understanding of tumorigenesis, molecular growth pathways, and immune mechanisms in the pathogenesis of these tumors has ushered in a new era in cancer therapeutics. Some biologic agents tested in pediatric clinical settings have demonstrated promise, with a consequent antitumor activity in preclinical studies. Regarding some barriers to long-term success, most of these novel biologic agents exhibit cytostatic activity and therefore may need to be combined with conventional chemotherapy and radiotherapy [15] [16].

In our context of work, total resection of the tumor can be performed for cerebellar pilocytic astrocytoma. But the difficulty of to manage the surgical treatment of pediatric brain tumors is characterized by poor working conditions regarding possibilities of brain mapping because the neuro-navigation system is not available. Also, there was no possibility of radiotherapy in Congo, during the period of study. This situation contributes to explain a case of recurrence of medulloblastoma after a surgical resection estimated at 90%.

Evolutionary

About some sub-Saharan series, postoperative with complementary treatment follow up is characterized by satisfying evolution in 15% of cases, global mortality around 22% and, postoperative mortality estimated at 7%, survival at 1 and 5 years were 56% and 47% respectively [5] [17]. Also, pediatric brain tumors survivors at 5 years have an increased endocrine disease, psychiatric disorders, cognitive and developmental disorders [18] [19]. Most of this morbidity can be attributed to direct neurological damage to the developing brain caused by the tumor, surgery, toxicity of chemotherapy and effects of irradiation. Generally, children treated at a young age and those who receive the most intensive therapy are more likely to develop late effects [20].

Limitation of the study

This was a retrospective study, limited in the collection of data from perioperative aspects and evolutionary during hospitalization (blood loss, duration of intervention, anesthetics parameters). The size of this case series was limited at patients admitted in the neurological unit of the surgical department. It was important to verify if all cases of brain tumors admitted in the pediatric department were addressed for neurosurgical management.

5. Conclusion

The epidemiological profile of pediatric brain tumors has been poorly described in Sub-Saharan countries. Their diagnosis can be improved by more access to CT-scan and MRI. Intracranial hypertension is the most common clinical presentation. The majority of these tumors are infratentorial. Histological data are dominated by low-grade astrocytoma and medulloblastoma. Surgical resection that is as extensive as possible is important for long-term survival, but the quality of life after surgery depends on postoperative morbidity, chemotherapy and radiotherapy toxicities. In our context, to organize a multidisciplinary team to manage these cases, including pediatrician, radiologist, neurosurgeon, and oncologist is needed to improve the management of pediatric brain tumors. Histological data and the possibilities of chemotherapy and radiotherapy are imperatively needed.

Cite this paper
Mbaki, H. , Boukassa, L. , Ngackosso, O. , Bambino, S. , Thouassa, G. and Kala, R. (2020) Treatment of Pediatric Brain Tumors in Brazzaville (Congo) about a Case Series. Open Journal of Modern Neurosurgery, 10, 27-35. doi: 10.4236/ojmn.2020.101004.
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