eMedicine Specialties > Neurology > Neuro-oncology

Brainstem Gliomas: Treatment & Medication

Author: Joseph Landolfi, DO, Director of Neuro-oncology, New Jersey Neuroscience Institute Brain Tumor Center; Medical Director, Gamma Knife Program, JFK Medical Center; Associate Professor of Neurology, Seton Hall University School of Graduate Medical Education
Coauthor(s): Anita Venkataramana, MBBS, Clinical Instructor, Department of Neurology, Division of Neuroimmunology/HIV, Johns Hopkins University
Contributor Information and Disclosures

Updated: Jun 30, 2009

Treatment

Medical Care

  • Treatment of brainstem gliomas has been frustrating; at this point, new therapies have yielded little benefit over conventional treatment with radiotherapy alone.
  • Adjuvant chemotherapy is not used in children because efficacy has not been proven. Data have suggested that preradiation chemotherapy may improve survival in pediatric diffuse intrinsic brainstem gliomas.4 Its efficacy in adults is similarly unproven, and at present, postradiotherapy adjuvant chemotherapy cannot be recommended. The effectiveness of chemotherapy at relapse is uncertain, but it may benefit some patients.
  • Chemotherapy options, when considered for use in brainstem gliomas, may include conventional agents such as temozolomide and carboplatin/vincristine. Antiangiogenesis agents have been used with success in supratentorial glioblastomas.  These include thalidomide and bevacizumab. Bevacizumab is a VEGF receptor inhibitor, approved as monotherapy for recurrent glioblastoma multiforme in May 2009.5   Drugs (such as erlotinib) targeted against EGFR, when present, have been modestly effective in supratentorial glioblastoma. If chemotherapy is desired adjuvantly or concurrently with radiotherapy, particularly in the pediatric population, the physician should consider entrance into a clinical trial.
  • Focal radiotherapy is the cornerstone of treatment of brainstem gliomas and can improve or stabilize the patient's condition.6 The conventional dose of radiotherapy ranges from 54-60 Gy, with doses up to 72 Gy given with hyperfractionation. At present, no benefit has been demonstrated with doses greater than 72 Gy; however, this therapy has not demonstrated efficacy in children.
    • Response to radiotherapy, in addition to the dose of radiation, depends on several variables such as tumor location, histologic type, and response to early treatment. Patients who underwent radiation therapy for exophytic tumors have been reported to have better survival rates than those treated for tumors without an exophytic component.
    • Radiotherapy should be administered to any patient with significant and progressive neurologic symptoms. Some adult patients with a tectal or cervicomedullary lesion, or with mild symptoms of long duration, may be candidates for observation alone; radiotherapy can be reserved for patients with clear evidence of tumor progression.

Surgical Care

Surgical resection is performed in conjunction with radiation and/or chemotherapeutic agents.

  • Surgery is most appropriate in tumors of the cervicomedullary junction, dorsal exophytic tumors protruding into the fourth ventricle, cystic tumors, enhancing tumors with clear margins that exert a space-occupying effect, and finally, benign tumors (ie, those with slow clinical progression).
  • Typically, biopsy and/or surgery are not required for diagnosis or treatment of diffuse intrinsic pontine or tectal gliomas and cannot be recommended routinely; diagnosis can be made by MRI alone.

Consultations

  • Neuro-oncologist: The neuro-oncologist should be the primary physician supervising the care of these patients. If a neuro-oncologist is not available, a medical oncologist with expertise in treating brain tumors may be consulted for guidance. Otherwise, the patient should be referred to a reputable institution that specializes in the care of patients with CNS neoplasms.
  • Neurosurgeon: The treating neurosurgeon should have significant experience in resection of CNS neoplasms.
  • Radiation oncologist
  • Neuropathologist
  • Neuroradiologist
  • Neuropsychologist for pretreatment and posttreatment evaluations, when clinically indicated
  • Rehabilitation medicine specialist

Medication

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Corticosteroids

These agents have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.


Dexamethasone (Decadron)

Can be used to reduce tumor- and radiotherapy-associated cerebral edema.

Adult

24 mg IV bolus followed by maintenance dose of 4 mg PO tid/qid; for intracranial neoplasms, higher doses may be required in patients with severe cerebral edema or herniation syndrome secondary to tumor

Pediatric

Not established

Coadministration with warfarin or heparin increases risk of bleeding

Documented hypersensitivity; systemic fungal infections; documented hypersensitivity

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Increases risks of multiple complications, including severe infections; monitor adrenal insufficiency when tapering drug; abrupt discontinuation may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections are possible complications

More on Brainstem Gliomas

Overview: Brainstem Gliomas
Differential Diagnoses & Workup: Brainstem Gliomas
Treatment & Medication: Brainstem Gliomas
Follow-up: Brainstem Gliomas
Multimedia: Brainstem Gliomas
References
Further Reading
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References

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  2. Ueoka DI, Nogueira J, Campos JC, Maranhão Filho P, Ferman S, Lima MA. Brainstem gliomas--retrospective analysis of 86 patients. J Neurol Sci. Jun 15 2009;281(1-2):20-3. [Medline].

  3. Grau SJ, Rachinger W, Holtmannspoetter M, Herms J, Tonn JC, Kreth FW. Serial Stereotactic Biopsy of Brainstem Lesions in Adults Improves Diagnostic Accuracy Compared to MRI Only. J Neurol Neurosurg Psychiatry. Jun 10 2009;[Medline].

  4. Frappaz D, Schell M, Thiesse P et al. Preradiation chemotherapy may improve survival in pediatric diffuse intrinsic pontine gliomas: Final results of BSG 98 prospective trial. Neuro Oncol. Aug/2008;10(4):599-607. [Medline].

  5. Raza S, Donach M. Bevacizumab in adult malignant brainstem gliomas. J Neurooncol. Jun 9 2009;[Medline].

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Keywords

brainstem tumors, pontine lesions, tectal lesions, hydrocephalus, cervicomedullary lesions, neurofibromatosis, intrinsic pontine gliomas, tectal gliomas, cervicomedullary gliomas, intracranial tumors

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Contributor Information and Disclosures

Author

Joseph Landolfi, DO, Director of Neuro-oncology, New Jersey Neuroscience Institute Brain Tumor Center; Medical Director, Gamma Knife Program, JFK Medical Center; Associate Professor of Neurology, Seton Hall University School of Graduate Medical Education
Joseph Landolfi, DO is a member of the following medical societies: Alpha Omega Alpha
Disclosure: Schering-Plough Honoraria Speaking and teaching; Genetech Honoraria Speaking and teaching

Coauthor(s)

Anita Venkataramana, MBBS, Clinical Instructor, Department of Neurology, Division of Neuroimmunology/HIV, Johns Hopkins University
Disclosure: Nothing to disclose.

Medical Editor

Edward L Hogan, MD, Professor, Department of Neurology, Medical College of Georgia; Emeritus Professor and Chair, Department of Neurology, Medical University of South Carolina
Edward L Hogan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Neurological Association, American Society for Biochemistry and Molecular Biology, Phi Beta Kappa, Sigma Xi, Society for Neuroscience, and Southern Clinical Neurological Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Jorge Kattah, MD, Head, Program Director, Professor, Department of Neurology, University of Illinois College of Medicine at Peoria
Jorge Kattah, MD is a member of the following medical societies: American Academy of Neurology, American Neurological Association, and New York Academy of Sciences
Disclosure: Biogen Honoraria Consulting; Bayer Corporation Honoraria Consulting

CME Editor

Matthew J Baker, MD, Consulting Staff, Collier Neurologic Specialists, Naples Community Hospital
Matthew J Baker, MD is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Chief Editor

Tarakad S Ramachandran, MBBS, FRCP(C), FACP, Professor of Neurology, Clinical Professor of Medicine, Clinical Professor of Family Medicine, Clinical Professor of Neurosurgery, State University of New York Upstate Medical University; Chair, Department of Neurology, Crouse Irving Memorial Hospital
Tarakad S Ramachandran, MBBS, FRCP(C), FACP is a member of the following medical societies: American Academy of Neurology, American Academy of Pain Medicine, American College of Forensic Examiners, American College of International Physicians, American College of Managed Care Medicine, American College of Physicians, American Heart Association, American Stroke Association, Royal College of Physicians, Royal College of Physicians and Surgeons of Canada, Royal College of Surgeons of England, and Royal Society of Medicine
Disclosure: Abbott Labs  Honoraria Consulting; Teva Marion Honoraria Consulting; Boeringer-Ingelheim Honoraria Speaking and teaching

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