Surgically Treated Brain Tumors: A Retrospective Case Series of 10,009 Cases at a

Single Institution
Young-Hoon Kim
1,2
, Sang Woo Song
1,2
, Ji Yeoun Lee
1,3
, Jin Wook Kim
1,2
, Yong Hwy Kim
1,2
, Ji Hoon Phi
1,3
,
Chul-Kee Park
1,2
, Jeong Eun Kim
1,2
, Seung-Ki Kim
1,3
, Sun Ha Paek
1,2
, Chun Kee Chung
1,2
, Kyu-Chang Wang
1,3
,
Dong Gyu Kim
1,2
, Hee-Won Jung
1,2
INTRODUCTION
The rst successfully operated brain tumor
case was described in 1774 by Louis, a lead-
ing French surgeon (2). The outstanding
achievement of Cushing with successful
brain tumor surgery in the early 1900s
opened a new era of the surgical treatment
of braintumors (37). Withthe development
of neurosurgical techniques and diagnostic
tools, brain tumor surgery has become a
representative part of neurosurgery.
InJanuary 1957, the Department of Neuro-
surgery separated from the Department of
Surgery at Seoul National University Hospital
(SNUH) (8, 16, 18, 24, 26). The rst craniot-
omy at SNUH for an intracranial tumor was
performed on September 7, 1957, by Profes-
sor Bo Sung Sim; the procedure included
gross total resection of a right temporal con-
vexitymeningiomainayoungmalepatient. In
1973, Professor Kil Soo Choi performed the
rst microsurgery at SNUHfor abraintumor.
In 1977, the transsphenoidal approach was
performedat SNUHfor pituitary tumors. The
rst stereotactic brain biopsy at SNUH for a
thalamic glioma was performed in 1983. In
1985, Seoul National University Childrens
Hospital (SNUCH) was founded adjacent to
SNUH, and pediatric brain tumor surgery
subsequently was performed in the Division
of Pediatric Neurosurgery at SNUCH (7, 16).
Intracranial neuroendoscopic facilities were
installed in operating rooms in 1994 to rein-
force existing clinical capabilities (16). As
brain tumor surgery was developing, the in-
troduction of computed tomography (CT) in
1977 and magnetic resonance imaging (MRI)
in 1988 provided great opportunities for the
diagnosis of and successful surgical out-
comes in brain tumors.
During the period 19572009, 10,009
brain tumor surgeries were performed in
the Department of Neurosurgery at SNUH
and SNUCH. The purpose of this article is
to analyze these 10,009 cases descriptively
and to evaluate the chronologic trends in
brain tumor surgery at this institution.
METHODS
Inclusion Criteria
Between January 1957 and December 2009,
15,665 patients underwent neurosurgical
procedures for intracranial mass lesions in
the Department of Neurosurgery of Seoul Na-
tional University College of Medicine. We
have included only histologically proved bra-
in tumor cases performed at SNUH and
SNUCH. Cases from Seoul National Univer-
sity Boramae Hospital and Seoul National
University Bundang Hospital, which are the
OBJECTIVE: To evaluate the chronologic trends in brain tumor surgery at a
single institution over 53 years (19572009).
METHODS: Data were collected from medical records and documents (eg,
daily records, surgical notes, or electronic databases) preserved in the library of
the Department of Neurosurgery, Seoul National University College of Medicine.
RESULTS: During the period 19572009, 10,009 brain tumors were surgically
treated. Glial tumor (25.2%) was the most frequently reported histologic category.
Meningioma and pituitary adenoma accounted for 17.5% and 17.1% of the
histologies. In children <20 years old, astrocytoma (16.7%), embryonal tumor
(16.2%), and germ cell tumor (11.9%) were the most common histologies. The
chronologic trend for changes in proportions of individual brain tumor surgeries
showed that cases of glioma have gradually increased since the 1980s, whereas
cases of benign extra-axial tumors, including meningioma, sellar tumor, and
schwannoma, have decreased. This trend implies that the presurgical diagnosis
of glioma has increased owing to modern imaging technologies, and alternative
treatment options, such as radiosurgery or observation, have been more fre-
quently applied over time to benign extra-axial tumors. Simultaneously, the
surgical management of lymphoma and metastatic tumor has increased gradu-
ally.
CONCLUSIONS: This article describes the largest series of chronologic analysis
of brain tumor surgeries conducted at a single institution and reects the longitudinal
trends by treatment option in incidences of selected brain tumors.
Key words
Brain tumor surgery
Seoul National University Childrens Hospital
Seoul National University Hospital
Abbreviations and Acronyms
CNS: Central nervous system
CT: Computed tomography
EMR: Electronic medical record
MRI: Magnetic resonance imaging
SNUCH: Seoul National University Childrens
Hospital
SNUH: Seoul National University Hospital
From the
1
Department of Neurosurgery, Seoul
National University College of Medicine, Seoul,
Korea;
2
Department of Neurosurgery, Seoul National
University Hospital, Seoul, Korea; and
3
Division of Pediatric
Neurosurgery, Seoul National University Childrens
Hospital, Seoul, Korea
To whom correspondence should be addressed:
Hee-Won Jung, M.D., Ph.D. [E-mail: hwnjung@snu.ac.kr]
Citation: World Neurosurg. (2011) 76, 6:555-563.
DOI: 10.1016/j.wneu.2011.04.032
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/$ - see front matter 2011 Elsevier Inc.
All rights reserved.
PEER-REVIEW REPORTS
WORLD NEUROSURGERY 76 [6]: 555-563, DECEMBER 2011 www.WORLDNEUROSURGERY.org 555
afliated hospitals of SNUH, were excluded.
Patients with scalp mass lesions and infec-
tiousdiseasessuchasparagonimiasis, neuro-
cysticercosis, tuberculosis, and other brain
abscesses were also excluded. Finally, we ex-
cluded all radiosurgically treated brain tu-
mors. Included in this study were 10,009
cases.
Data Acquisition
Data were collected from the medical re-
cords and from documents (eg, daily re-
cords, surgical notes, and electronic data-
bases) preserved in the library of the
Department of Neurosurgery, Seoul Na-
tional University College of Medicine (8, 16,
25). To obtain the clinical data from pa-
tients with brain tumors before the elec-
tronic medical records (EMR) system was
introduced, we investigated the surgical re-
cords and patient lists of the department,
the charts andimaging data, andthe annual
reports. We acquired the full clinical and
pathologic data from the EMR system for
patients who had undergone surgery since
Figure 1. (A) Annual cases of brain tumor surgery in the Department of
Neurosurgery at Seoul National University Hospital (SNUH) and Seoul
National University Childrens Hospital (SNUCH) from 19572009. (B)
Histologic distribution of all brain tumor surgeries at SNUH and SNUCH (N
10,009).
PEER-REVIEW REPORTS
YOUNG-HOON KIM ET AL. BRAIN TUMOR SURGERY: 10,009 CASES
556 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2011.04.032
2003. Pathologic diagnoses were con-
rmed from the formal pathologic reports
in either the charts or the EMR system. We
categorized all brain tumors into nine cate-
gories, including glioma, nonglial neuro-
epithelial tumor, schwannoma, meningeal
tumor, lymphoma, germ cell tumor, sellar
tumor, metastatic tumor, and other tumors
by the 2007 World Health Organization
classication of tumors of the central ner-
vous system (CNS) (34). Gliomas were de-
nedas astrocytic tumors, oligodendroglial
tumors, oligoastrocytic tumors, ependymal
tumors, choroid plexus tumors, or other
glial tumors. Nonglial neuroepithelial tu-
mors included neuronal or mixed neuro-
glial tumors, pineal parenchymal tumors,
and embryonal tumors such as medullo-
blastoma. Schwannomas included all tu-
mors of cranial andparaspinal nerves. Men-
ingeal tumors consisted of meningiomas,
hemangioblastomas, and other mesenchy-
mal tumors (4). Pituitary adenomas and
craniopharyngiomas were categorized as
sellar tumors.
Statistical Analysis
All data were presented as the meanstan-
dard error. We used Student t test of contin-
uous data and Fisher exact test for compar-
isonof the categorical data betweengroups.
P 0.05 was considered statistically signif-
icant. All analyses were performed using
the SPSS statistical software package (ver-
sion 17.0.1, 2008; SPSS, Chicago, Illinois,
USA).
RESULTS
Overview of Brain Tumor Surgery at
Seoul National University Hospital and
Seoul National University Childrens
Hospital
The annual number of brain tumor surger-
ies performed at SNUH and SNUCH in-
creased slowly until the late 1970s and then
showed a rapid increase from the early
1980s (Figure 1A). Demographic data from
the 10,009 cases are summarizedinTable 1.
There were 5023 (50.2%) male patients and
4986 (49.8%) female patients. The median
age of all patients was 40 years old (range
088 years old). There were 2143 pediatric
cases (019 years old) of brain tumor sur-
gery, and adult cases (20 years old) ac-
counted for 7866 cases (78.6%). The spe-
cic distribution based on patient age is
shown in Table 1. Incidence of brain tumor
surgery reached its peak in the fth decade
of life (4150 years old). Of 10,009 cases of
brain tumor surgery, the number of trans-
cranial surgeries was 7421 (74.1%), the
number of transsphenoidal surgeries was
1562 (15.6%), the number of endoscopic
surgeries was 124 (1.2%), the number of
stereotactic biopsies was 727 (7.3%), and
the number of openbiopsies was 175(1.7%)
(Table 1).
Of 10,009 cases, 2799 cases (28.0%) cor-
responded to malignant tumors, and 7210
cases (72.0%) corresponded to benign tu-
mors. The distributionby histopathology of
all brain tumor surgeries at SNUH and
SNUCH is shown in Table 1 and in Figure
1B. In this study, the broad category neuro-
epithelial tumor represented 32.3% of all
brain tumor surgeries. The distribution by
specic histology for neuroepithelial tu-
mors including gliomas (25.2%) is illus-
tratedinthe smaller circular graphinFigure
1B. Astrocytomas and glioblastomas com-
bined accounted for about 55%of neuroep-
ithelial tumors. The second most frequent
histologic category was sellar tumors
(21.1%), including pituitary adenomas
(17.1%) and craniopharyngiomas (4.0%),
followed by meningeal tumors (20.4%), in-
cluding meningiomas (17.5%), hemangio-
blastomas (1.6%), and other mesenchymal
tumors (1.3%) (Table 1 and Figure 1B).
Table 1. Demographic Data from
10,009 Cases
Variables Value
Total 10,009
Sex
Male 5023 (50.2%)
Female 4986 (49.8%)
Age
Median (range) 40 years (088)
09 years 1085 (10.8%)
1019 years 1058 (10.6%)
2029 years 1163 (11.6%)
3039 years 1609 (16.1%)
4049 years 2023 (20.2%)
5059 years 1721 (17.2%)
6069 years 1102 (11.0%)
70 years 248 (2.5%)
Methods
Transcranial surgery 7421 (74.1%)
Transsphenoidal surgery 1562 (15.6%)
Endoscopic surgery 124 (1.2%)
Stereotactic biopsy 727 (7.3%)
Open biopsy 175 (1.7%)
Pathologic diagnosis
Neuroepithelial tumor
Glioblastoma 787 (7.9%)
Astrocytoma 979 (9.8%)
Oligodendroglioma 425 (4.2%)
Oligoastrocytoma 51 (0.5%)
Ependymoma 169 (1.7%)
Choroid plexus tumor 47 (0.5%)
Uncertain glioma 64 (0.6%)
Nonglial neuroepithelial
tumor
Neuronal or mixed
neuroglial tumor
239 (2.4%)
Tumors of the pineal
region
51 (0.5%)
Embryonal tumor 424 (4.2%)
Schwannoma
Vestibular schwannoma 552 (5.5%)
Others 182 (1.8%)
Meningeal tumor
Meningioma 1753 (17.5%)
Continues
Table 1. Continued
Variables Value
Hemangioblastoma 157 (1.6%)
Other mesenchymal
tumor
130 (1.3%)
Lymphoma and
hematopoietic
neoplasm
218 (2.2%)
Germ cell tumor 307 (3.1%)
Sellar tumor
Pituitary adenoma 1711 (17.1%)
Craniopharyngioma 405 (4.0%)
Metastatic tumor 324 (3.2%)
Other tumors 1034 (10.3%)
PEER-REVIEW REPORTS
YOUNG-HOON KIM ET AL. BRAIN TUMOR SURGERY: 10,009 CASES
WORLD NEUROSURGERY 76 [6]: 555-563, DECEMBER 2011 www.WORLDNEUROSURGERY.org 557
F
i
g
u
r
e
2
.
P
r
o
p
o
r
t
i
o
n
o
f
m
a
l
i
g
n
a
n
t
t
u
m
o
r
s
i
n
c
h
i
l
d
r
e
n
a
n
d
a
d
u
l
t
s
a
n
d
h
i
s
t
o
l
o
g
i
c
d
i
s
t
r
i
b
u
t
i
o
n
i
n
c
h
i
l
d
r
e
n
(
0

1
9
y
e
a
r
s
o
l
d
)
a
n
d
i
n
a
d
u
l
t
s
(

2
0
y
e
a
r
s
o
l
d
)
.
PEER-REVIEW REPORTS
YOUNG-HOON KIM ET AL. BRAIN TUMOR SURGERY: 10,009 CASES
558 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2011.04.032
Distribution of Brain Tumor Surgery by
Histology and Age
The proportion of malignant tumors in pe-
diatric cases (019 years old; n 2143
[38%]) was statistically signicantly (P
0.001) higher than the proportion in adult
cases (20 years old; n 7866 [25%]).
Figure 2 shows the distribution of brain
tumor surgeries by histology in children
and adults. The most common histology in
pediatric brain tumor surgery was astrocy-
toma (16.7%), followed by embryonal tu-
mors, such as medulloblastomas (16.2%),
germcell tumors (11.9%), andsellar tumors
including craniopharyngiomas (11.5%).
The proportions of nonglial neuroepithelial
tumors and germ cell tumors in pediatric
brain tumor surgery (22.4% and 11.9%)
were signicantly (P 0.001) higher than
the proportions in adults (3.0% and 0.7%).
Of brain tumor surgeries performed at
SNUHand SNUCH, embryonal tumors, in-
cluding medulloblastoma, were the most
common histology in younger children
(09 years old); pituitary adenomas were
the most common histology in young
adults (2039 years old); and meningiomas
were the most common histology in older
adults (40 years old). Astrocytomas and
germ cell tumors were the most common
histologies in older children 1014 years
old (astrocytomas) and 1519 years old
(germ cell tumors) (Table 2).
Figure 3 shows the age distribution of
brain tumor surgeries by selected histolo-
gies. The surgical incidences of glioblas-
toma, oligodendroglioma, schwannoma,
and meningioma peaked inpatients intheir
40s, and the surgical incidences of lym-
phoma and metastatic brain tumor peaked
in patients in their 50s (lymphoma) and 60s
(metastatic brain tumor). Incidence of sellar
tumor peakedinpatients intheir 30s. Surger-
ies for embryonal tumor, including medullo-
blastoma, and germ cell tumor were per-
formed most frequently in children.
Distribution of Brain Tumor Surgery by
Histology and Sex
Incidence ratios by sex (male-to-female) of
selected histologies are presented in Figure
4. The surgical incidence for germ cell tu-
mors was 2.8 times greater in males than in
females. Similar patterns were found for
other histologies, with incidences higher in
males, especially for most neuroepithelial
tumors, hemangioblastoma, lymphoma,
craniopharyngioma, and metastatic brain
tumors. Incontrast, incidences of meningi-
oma, schwannoma, and pituitary adenoma
were higher in females than in males.
Chronologic Data
Table 3 shows the chronologic data of sur-
gical methods at SNUH and SNUCH. At
SNUH and SNUCH, the transsphenoidal
approach was introduced in 1977, stereo-
tactic surgery was introduced in 1983, and
endoscopic procedures were introduced in
1994. These minimally invasive procedures
replaced the conventional transcranial ap-
proach as time passed. Over the years, the
proportion of patients 60 years old has
increased gradually from 1.9% in 1960s to
17.1% in 2000s.
Figure 5 shows the chronologic data in
terms of pathologic diagnosis for brain tu-
mor surgeries at SNUH and SNUCH. Gli-
oma, meningioma, and sellar tumors have
been the most common histologic groups
since 1957. In the 1960s, the proportions of
meningioma and glioma were higher than
that of sellar tumors, whereas the propor-
tions of glioma and sellar tumor were
higher in the 1970s than that of meningi-
oma. Since the 1980s, the proportionof sur-
gical cases of glial tumor has increased
from 21.8% to 26.4%, whereas the propor-
tions of meningioma, sellar tumor, and
schwannoma have decreased gradually.
From the 1960s to the 2000s, the propor-
tions of nonglial neuroepithelial tumors
(from 1.0% to 7.6%), metastatic brain tu-
mors (from 1.0% to 3.6%), lymphomas
(from 0% to 3.1%), and germ cell tumors
(from 1.0% to 3.5%) gradually increased.
The histologic distribution by specic
age group showed the distinct characteris-
tics seen in Figure 6. In pediatric brain tu-
mor surgery (019 years old), the propor-
tion of glial tumor surgery decreased over
time, whereas the proportion of nonglial
neuroepithelial tumor surgery increased
from the 1960s to the 2000s. In the young
adult group (2039 years old), sellar tumor
was the most frequent histology until the
1990s. The proportionof glioma tumor sur-
gery in younger adults has increased since
the 1960s andreachedits highest level inthe
2000s. By contrast, the proportions of me-
ningioma and schwannoma have decreased
gradually in young adults. Brain tumor sur-
geries were performed most frequently at
SNUHand SNUCHonpatients 4059 years
old. In this middle-aged group, meningio-
mas, gliomas, and sellar tumors were the
most common histologies. The proportion
of metastatic tumors in the middle-aged
group increased gradually. In the oldest age
group (60 years old), which saw increas-
ing incidence and proportion of brain tu-
mor surgeries from the 1960s to the 2000s,
the proportion of lymphoma has increased
distinctively since the 1980s.
DISCUSSION
Cases of Brain Tumor Surgery at Seoul
National University Hospital and Seoul
National University Childrens Hospital
Since the 1980s, the number of annual cases
of brain tumor surgeries has increased
Table 2. Most Common Brain Tumor Surgery by Age
Age (years) Most Common Histology
Second Most
Common Histology
04 Embryonal/medulloblastoma Astrocytoma
59 Embryonal/medulloblastoma Astrocytoma
1014 Astrocytoma Germ cell tumor
1519 Germ cell tumor Astrocytoma
2029 Pituitary adenoma Astrocytoma
3039 Pituitary adenoma Meningioma
4049 Meningioma Pituitary adenoma
5059 Meningioma Pituitary adenoma
6069 Meningioma Pituitary adenoma
70 Meningioma Glioblastoma
PEER-REVIEW REPORTS
YOUNG-HOON KIM ET AL. BRAIN TUMOR SURGERY: 10,009 CASES
WORLD NEUROSURGERY 76 [6]: 555-563, DECEMBER 2011 www.WORLDNEUROSURGERY.org 559
more rapidly than before the 1980s (Figure
1A). The advent of new imaging technolo-
gies, such as brain CT and MRI, was the
most important cause of this increase. Until
brainCTwas introducedinclinical services,
brain tumor surgery and related diagnostic
procedures were extremely limited. The in-
troduction and clinical use of brain CT and
MRI at SNUHand SNUCHin the late 1970s
and 1980s led to a notable increase in the
number of brain tumor surgeries. The pre-
cise detection and evaluation of intracranial
mass lesions caused the number of inter-
ventions for brain tumors and their success
rates to increase. In addition, the introduc-
tion of new operative technologies such as
transsphenoidal surgery (1977) and stereo-
tactic surgery (1983), the recruitment of
subspecialized faculty, and the increased
number of operating rooms subsequent to
the founding of SNUCH induced a rapid
increase after the 1980s in the number of
brain tumor surgeries performed at SNUH
and SNUCH (5).
The most common histologies at
SNUH and SNUCH (7, 14, 28) were gli-
oma, meningioma, and sellar tumor.
Since the 1980s, the proportion of surger-
ies for glial tumors (17) has increased (30,
35), whereas the proportions of surgeries
for meningiomas (22) and sellar tumors
have decreased (Figure 5). Glioma repre-
sents a broad spectrum of glial tumors
(29). The initial treatment of choice for
glioma has been surgery in most cases
because of the indispensable requirement
of histologic diagnosis, whereas in cases
of meningioma or pituitary adenoma, al-
ternative treatment options, such as ra-
diosurgery or observation, have become
available. The increase in surgical treat-
ment of glioma has been greatly due to the
increased presurgical diagnosis that has
come about as a result of advances in
modern imaging technologies.
The increases in proportions of meta-
static brain tumor (20) and lymphoma (21)
were caused by the increasing number of
elderly patients, owing to improvements in
primary cancer control andincreases inlon-
gevity and survival (Figures 5 and 6). Meta-
static brain tumors and lymphomas are the
representative brain tumors in elderly pa-
tients (Figure 3). Although metastatic brain
tumor was the leading intracranial tumor in
terms of overall incidence (10), the true in-
cidence of metastatic tumor was underesti-
mated in this report because most patients
with metastatic brain tumor tend to un-
dergo radiosurgery or radiotherapy without
biopsy.
The most common sites of germ cell tu-
mors are the sellar areas and pineal glands
(6, 9, 12, 27, 31). The introduction of endo-
scopic surgery and stereotactic surgery has
resulted in an increase in the number of
cases of germcell tumors fromthe 1980s to
the 1990s (Figure 5). The increase in non-
glial neuroepithelial tumors can be ex-
plained in terms of medulloblastomas (38)
and neuronal or mixed neuroglial tumors
(Figure 5). The advent of new diagnostic
criteria for glioneuronal tumors (36) and
neurocytoma (15, 19, 23, 33, 34) has caused
Figure 3. Age distribution of brain tumor surgeries by selected histologies.
PEER-REVIEW REPORTS
YOUNG-HOON KIM ET AL. BRAIN TUMOR SURGERY: 10,009 CASES
560 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2011.04.032
an increase in neuronal and mixed neuro-
glial tumors.
Characteristics of Brain Tumor Surgery
at Seoul National University Hospital and
Seoul National University Childrens
Hospital
The present study was compared with other
statistical reports concerning databanks
andregistries of CNS tumors to evaluate the
characteristics of our brain tumor series (1,
3, 11, 13, 32). Direct comparisons were lim-
ited because the subjects in our series were
braintumor surgery cases, whereas the sub-
jects of the other reports were patients with
primary CNS tumors. However, the ten-
dency of distribution in our brain tumor se-
ries could be estimated.
In the reports of the Korean Central Can-
cer Registry in 2005, 5692 patients in Korea
diagnosed with primary CNS tumors were
enrolled (32). In other words, the reports
reect the overall incidences of primary
CNS tumors in Korea in 2005, whereas the
present study reects the operative cases of
brain tumors at a single institution over 53
years. The female-to-male ratio of overall
incidences of primary CNS tumors (1.43)
was higher than that in our surgical cases
(0.99). The proportions of meningioma
and schwannoma in primary CNS tumors
(30.6% and 11.1%) were relatively higher
than the proportions in our surgical cases
(17.5% and 7.3%). The differences may be
caused by radiosurgery or observation as
primary treatment options for meningioma
and schwannoma, which occurred more
commonly in females than in males. Con-
versely, the proportions of glial tumors and
sellar tumors (17.7%and15.8%) were lower
compared with our surgical cases (25.2%
and 21.1%). In pediatric cases, there was no
signicant difference of histologic propor-
tions between overall incidence and brain
tumor surgery. This phenomenon suggests
that most pediatric patients diagnosed with
CNS tumors underwent surgical interven-
tions.
The most signicant characteristic in his-
tologicdistributioninKoreaincludingour in-
stitution was a relatively lower proportion of
glioblastoma, the most common malignant
primary brain tumor. The proportion of glio-
blastoma in Western countries (eg, 17.1% in
the United States (1) and 23.9%inFrance (3))
was higher than that in Korea (eg, 5.9% in
incidences (32) and 7.9%in our series). Con-
versely, the incidences of other common his-
tologies, including meningiomas and pitu-
itary adenomas, were similar among nations.
There were no distinguishing characteristics
in the histologic distribution of our series in
terms of sex and age. In pediatric cases, the
proportion of astrocytoma in the United
States (24.8%) was higher than that of our
series (16.7%). However, the proportions of
germ cell tumor and craniopharyngioma in
theUnitedStates (3.9%and3.3%) werelower
than those of our study (11.9%and 8.3%).
Signicance and Limitations of Study
The current study is the largest series evalu-
ating the chronologic characteristics of
braintumor surgery at a single institutionin
Figure 4. Patterns by sex for selected histologies.
Table 3. Chronologic Analysis of Methodology of Brain Tumor Surgery at Seoul National University Hospital and Seoul National
University Childrens Hospital
1960s* 1970s 1980s 1990s 2000s Total
Transcranial 95 (91.3%) 301 (94.7%) 1245 (84.2%) 2450 (72.6%) 3330 (70.4%) 7421
Transsphenoidal 0 4 (1.3%) 214 (14.5%) 601 (17.8%) 743 (15.7%) 1562
Endoscopy 0 0 0 18 (0.5%) 106 (2.2%) 124
Stereotactic biopsy 0 0 4 (0.3%) 249 (7.4%) 474 (10.0%) 727
Open biopsy 9 (8.7%) 13 (4.1%) 16 (1.1%) 57 (1.7%) 80 (1.7%) 175
Total 104 318 1479 3375 4733 10,009
*The 1960s include years from 19571969.
PEER-REVIEW REPORTS
YOUNG-HOON KIM ET AL. BRAIN TUMOR SURGERY: 10,009 CASES
WORLD NEUROSURGERY 76 [6]: 555-563, DECEMBER 2011 www.WORLDNEUROSURGERY.org 561
Korea. We have shown the longitudinal
changes of brain tumor surgery at SNUH
and SNUCH. One-fth of brain tumor sur-
geries in Korea were performed at SNUH
andSNUCH. The trends inbraintumor sur-
geries inpractice canbe recognizedover the
long span of the modern neurosurgical era.
However, the real incidence rates of brain
tumors couldnot be presentedinthis report
because only the number of surgical cases
could be calculated. This study was not an
epidemiologic study for a large population
but rather a descriptive study in a single
institution. Updates in histologic diagnos-
tic criteria of brain tumors, especially neu-
roepithelial tumors (33, 34), should also be
adjusted for possible bias in this report.
CONCLUSIONS
We have reported the largest series of
chronologic analysis of braintumor surger-
ies at a single institution. There were
changes in trends of brain tumor surgeries
in terms of both technique and histologic
diagnosis at SNUH and SNUCH, and these
changes were presumed to be the results of
the transition of preferred treatment op-
tions, the development of newscientic ap-
proaches, and an aging society.
REFERENCES
1. Central Brain Tumor Registry of the United States:
Statistical report: primary brain tumors diagnosed
Figure 5. Chronologic changes in the proportions of selected histologies of all brain tumor surgeries
at Seoul National University Hospital and Seoul National University Childrens Hospital.
Figure 6. Chronologic changes in the proportions of selected histologies by patient ages: 019 years, 2039 years, 4059 years, and 60 years.
PEER-REVIEW REPORTS
YOUNG-HOON KIM ET AL. BRAIN TUMOR SURGERY: 10,009 CASES
562 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2011.04.032
in the United States in 2004-2005. Available at:
http://www.cbtrus.org. Accessed September 10,
2009.
2. Bakay L: Cruveilhier on meningiomas (1829-1842).
Surg Neurol 32:159-164, 1989.
3. Bauchet L, Rigau V, Mathieu-Daude H, Figarella-
Branger D, Hugues D, Palusseau L, Bauchet F, Fab-
bro M, Campello C, Capelle L, DurandA, Tretarre B,
Frappaz D, Henin D, Menei P, Honnorat J, Segnar-
bieux F: French brain tumor data bank: methodol-
ogy and rst results on 10,000 cases. J Neurooncol
84:189-199, 2007.
4. Cho BK, Chi JG, Wang KC, Chang KH, Choi KS:
Intracranial mesenchymal chondrosarcoma: a case
report and literature review. Childs Nerv Syst 9:295-
299, 1993.
5. Cho BK, Wang KC, Chang KH, Chi JG: Deep sylvian
meningioma in a child. Childs Nerv Syst 6:228-230,
1990.
6. Cho BK, Wang KC, Nam DH, Kim DG, Jung HW,
Kim HJ, Han DH, Choi KS: Pineal tumors: experi-
ence with 48 cases over 10 years. Childs Nerv Syst
14:53-58, 1998.
7. Cho KT, Wang KC, Kim SK, Shin SH, Chi JG, Cho
BK: Pediatric brain tumors: statistics of SNUH, Ko-
rea (1959-2000). Childs Nerv Syst 18:30-37, 2002.
8. Choi KS, Han DH, Kim HJ, Jung H-W, Wang K-C:
The History of the Department of Neurosurgery in
Seoul National University College of Medicine
(1957-1989). Seoul: E*Public; 1990.
9. Eom KY, Kim IH, Park CI, Kim HJ, Kim JH, Kim K,
Kim SK, Wang KC, Cho BG, Jung HW, Heo DS,
Kang HJ, Shin HY, Ahn HS: Upfront chemotherapy
and involved-eld radiotherapy results in more re-
lapses than extended radiotherapy for intracranial
germinomas: modication in radiotherapy volume
might be needed. Int J Radiat Oncol Biol Phys 71:
667-671, 2008.
10. Gavrilovic IT, Posner JB: Brainmetastases: epidemi-
ology and pathophysiology. J Neurooncol 75:5-14,
2005.
11. Hoffman S, Propp JM, McCarthy BJ: Temporal
trends in incidence of primary brain tumors in the
United States, 1985-1999. Neuro Oncol 8:27-37,
2006.
12. ImSH, Wang KC, KimSK, Lee YH, Chi JG, Cho BK:
Congenital intracranial teratoma: prenatal diagno-
sis and postnatal successful resection. Med Pediatr
Oncol 40:57-61, 2003.
13. Kaneko S, Nomura K, Yoshimura T, Yamaguchi N:
Trend of brain tumor incidence by histological sub-
types in Japan: estimation from the Brain Tumor
Registry of Japan, 1973-1993. J Neurooncol 60:61-
69, 2002.
14. Kang HS, Wang KC, Kim YM, Kim IO, Kim SK, Chi
JG, Cho BK: Choroid plexus carcinoma in an infant.
J Korean Med Sci 12:162-167, 1997.
15. Kim DG, Chi JG, Park SH, Chang KH, Lee SH, Jung
HW, Kim HJ, Cho BK, Choi KS, Han DH: Intraven-
tricular neurocytoma: clinicopathological analysis
of seven cases. J Neurosurg 76:759-765, 1992.
16. Kim DG, Chung YS, Park C-K, Chung CK, Kim S-K,
Paek SH, Son Y-J: The 50th Anniversary of the De-
partment of Neurosurgery inSeoul National Univer-
sity College of Medicine (1957-2007). Seoul: Acad-
emya; 2007.
17. KimDG, Han MH, Lee SH, Chi JG, Cho KJ, KimJH,
Choi KS, Han DH: MRI of intracranial sub-
ependymoma: report of a case. Neuroradiology 35:
185-186, 1993.
18. Kim DG, Kim HJ: The Department of Neurosurgery
at Seoul National University: past, present, and fu-
ture. Neurosurgery 48:919-928, 2001.
19. Kim DG, Kim JS, Chi JG, Park SH, Jung HW, Choi
KS, Han DH: Central neurocytoma: proliferative po-
tential and biological behavior. J Neurosurg 84:742-
747, 1996.
20. Kim DG, Lee SY, Chung SK, Park SK, Chun YK, Chi
JG: Brain metastasis frommyxobrosarcoma of the
heart. Acta Neurochir (Wien) 139:88-89, 1997.
21. Kim DG, Nam DH, Jung HW, Choi KS, Han DH:
Primary central nervous system lymphoma: variety
of clinical manifestations and survival. Acta Neuro-
chir (Wien) 138:280-289, 1996.
22. KimDG, PaekSH, Chi JG, ChunYK, HanDH: Mixed
tumour of schwannoma and meningioma compo-
nents in a patient with NF-2. Acta Neurochir (Wien)
139:1061-1064, 1997.
23. Kim DG, Paek SH, Kim IH, Chi JG, Jung HW, Han
DH, Choi KS, Cho BK: Central neurocytoma: the
role of radiation therapy and long term outcome.
Cancer 79:1995-2002, 1997.
24. Kim DG, Park CK, Paek SH: Bo Sung Sim (1924-
2001): a pioneer of neurosurgery in Korea. J Neuro-
surg 105:494-497, 2006.
25. Kim DG, Sim BS: Statistical analysis of intracranial
tumors in Korea. J Korean Neurosurg Soc 10:533-
541, 1981.
26. KimHJ: [Bo Sung Sim, M.D. (1924-2001)]. J Korean
Neurosurg Soc 32:256-258, 2002 [in Korean].
27. KimSK, Cho BK, Paek SH, Hong SJ, KimHS, Hong
SY, Choe G, Chi JG, NamDH, Wang KC: The detec-
tion of p53 gene mutation using a microdissection
technique in primary intracranial germcell tumors.
Int J Oncol 18:111-116, 2001.
28. Kim SK, Wang KC, Cho BK: Intractable seizures
associated with brain tumor in childhood: lesionec-
tomy and seizure outcome. Childs Nerv Syst
11:634-638, 1995.
29. KimYH, OhSW, LimYJ, ParkCK, Lee SH, KangKW,
Jung HW, Chang KH: Differentiating radiation ne-
crosis from tumor recurrence in high-grade glio-
mas: assessing the efcacy of 18F-FDG PET, 11C-
methionine PET and perfusion MRI. Clin Neurol
Neurosurg 112:758-765, 2010.
30. Kim YH, Park CK, Cho WH, Kim IA, Moon S, Choe
G, Park SH, Kim IH, Kim DG, Jung HW, Lee MM,
Bae SH, Cha SH, Kim CY: Temozolomide during
and after radiation therapy for WHO grade III glio-
mas: preliminary report of a prospective multi-
center study. J Neurooncol 2010 Sep24 [Epubahead
of print].
31. Koh EJ, Phi JH, Park SH, Kim IO, Cheon JE, Wang
KC, Cho BK, Kim SK: Mixed germ cell tumor of the
midbrain: case report. J Neurosurg Pediatr 4:137-
142, 2009.
32. Lee CH, Jung KW, Yoo H, Park S, Lee SH: Epidemi-
ology of primary brain and central nervous system
tumors in Korea. J Korean Neurosurg Soc 48:145-
152, 2010.
33. Louis DN, Ohgaki H, Wiestler OD, Cavenee WK:
WHOClassication of Tumours of the Central Ner-
vous System. Lyon, IARC, 2007.
34. Louis DN, Ohgaki H, Wiestler OD, Cavenee WK,
Burger PC, Jouvet A, Scheithauer BW, Kleihues P:
The 2007 WHOclassicationof tumours of the cen-
tral nervous system. Acta Neuropathol 114:97-109,
2007.
35. Park CK, Lee SH, Han JH, Kim CY, Kim DW, Paek
SH, KimDG, Heo DS, KimIH, Jung HW: Recursive
partitioning analysis of prognostic factors in WHO
grade III glioma patients treated with radiotherapy
or radiotherapy plus chemotherapy. BMC Cancer
9:450, 2009.
36. Phi JH, Park SH, Chae JH, Wang KC, Cho BK, Kim
SK: Papillary glioneuronal tumor present in a pa-
tient with encephalocraniocutaneous lipomatosis:
case report. Neurosurgery 67:E1165-E1169, 2010.
37. Preul MC: History of brain tumor surgery. Neuro-
surg Focus 18; Introduction, 2005.
38. Wang KC, Lee JI, Cho BK, KimIH, KimJY, Shin HY,
AhnHS, HanDH: Treatment outcome andprognos-
tic factors of medulloblastoma. J Korean Med Sci
9:64-73, 1994.
Conict of interest statement: This study was supported by
a grant of the Seoul National University Hospital Research
Fund (04-2010-0470).
received 21 December 2010; accepted 27 April 2011
Citation: World Neurosurg. (2011) 76, 6:555-563.
DOI: 10.1016/j.wneu.2011.04.032
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/$ - see front matter 2011 Elsevier Inc.
All rights reserved.
PEER-REVIEW REPORTS
YOUNG-HOON KIM ET AL. BRAIN TUMOR SURGERY: 10,009 CASES
WORLD NEUROSURGERY 76 [6]: 555-563, DECEMBER 2011 www.WORLDNEUROSURGERY.org 563