Low-Grade Astrocytoma Treatment & Management

  • Author: George I Jallo, MD; Chief Editor: Tarakad S Ramachandran, MBBS, FRCP(C), FACP   more...
 
Updated: Jan 8, 2010
 

Medical Care

From the history, physical, and radiologic appearance of a tumor on CT scan or MRI, a presumptive diagnosis of a low-grade glioma can be made. The primary care physician should coordinate care with a neurologist, neurosurgeon, and oncologist. The initial treatment steps depend on patient presentation.

  • If the patient presents with seizures, first-line therapy is to start the patient on phenytoin (Dilantin) or carbamazepine (Tegretol).
  • If the patient presents with headache and has significant edema surrounding the tumor, dexamethasone (Decadron) therapy is appropriate in doses ranging from 2-4 mg every 6 hours. With dexamethasone, antiulcer medications (eg, antacid, H2 blocker) usually are prescribed. Corticosteroid therapy also may improve symptoms in patients who have low-grade astrocytomas of the spinal cord.
  • If hydrocephalus is observed on CT scan or MRI and the patient is symptomatic, surgical placement of a ventricular drainage device may be appropriate. Either an external ventricular drain or a ventriculoperitoneal shunt may be inserted. The exact procedure depends on any further plans for surgery.
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Surgical Care

Aside from the initial measures noted in Medical Care, the cornerstone of therapy for most low-grade gliomas is surgery.[2, 3]

  • Of course, tumors in certain locations may be inoperable. However, most clinical series have shown that patients who undergo gross total resection have the longest survival durations. Even subtotal resection is of benefit if the tumor can be removed safely. Histologic diagnosis should be sought in every case (via biopsy or resection) if possible.
  • Surgery is also the primary mode of treatment for low-grade astrocytomas of the spinal cord. Depending on the appearance of the tumor at surgery, a gross total resection, subtotal resection, or only biopsy may be possible. However, resection may lead to symptomatic and objective improvement in these patients. Furthermore, in low-grade astrocytomas, long-term remission (>10 y) and even cure are frequent in both children and adults.
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Consultations

As already mentioned, patients in whom a low-grade glioma is suspected should consult with both a neurologist and a neurosurgeon.

  • The neurologist's role is to document the neurologic examination and to correlate it with the imaging findings. The neurologist also may manage antiepileptic medication if the patient presents with seizures.
  • The neurosurgeon needs to discuss the options for surgery. Particularly important is the need for ventricular drainage if hydrocephalus is present. Further surgery such as a resection or a biopsy also can be considered.
  • In some centers, neuro-oncology specialists are available and may be consulted prior to surgery or after histologic diagnosis is obtained. In lieu of a coordinating neuro-oncologist, medical and radiation oncologists can provide a coordinated plan for adjunctive therapy.
  • In refractory cases of epilepsy, a neurologist specializing in the treatment of epilepsy may be consulted.
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Activity

In general, no restrictions are placed on activity of patients with low-grade glioma. However, patients' activity may relate to their overall neurologic status. The presence of seizures may prevent the patient from driving. Neurologic deficits such as hemiparesis may improve after treatment. Physical therapy is often beneficial.

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Contributor Information and Disclosures
Author

George I Jallo, MD  Professor of Neurosurgery, Pediatrics, and Oncology, Director, Clinical Pediatric Neurosurgery, Department of Neurosurgery, Johns Hopkins University School of Medicine

George I Jallo, MD is a member of the following medical societies: American Association of Neurological Surgeons, American Medical Association, and American Society of Pediatric Neurosurgeons

Disclosure: Codman (Johnson & Johnson) Grant/research funds Consulting; Medtronic Grant/research funds Consulting

Coauthor(s)

Ethan A Benardete, MD, PhD  Staff Physician, Department of Neurosurgery, New York University Medical Center

Ethan A Benardete, MD, PhD is a member of the following medical societies: American Association of Neurological Surgeons and American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Rodrigo O Kuljis, MD  Esther Lichtenstein Professor of Psychiatry and Neurology, Director, Division of Cognitive and Behavioral Neurology, Department of Neurology, University of Miami School of Medicine

Rodrigo O Kuljis, MD is a member of the following medical societies: American Academy of Neurology and Society for Neuroscience

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Jorge C Kattah, MD  Head, Associate Program Director, Professor, Department of Neurology, University of Illinois College of Medicine at Peoria

Jorge C 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

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 None None; Teva Marion None None; Boeringer-Ingelheim Honoraria Speaking and teaching

References

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  2. Lunsford LD, Somaza S, Kondziolka D, Flickinger JC. Survival after stereotactic biopsy and irradiation of cerebral nonanaplastic, nonpilocytic astrocytoma. J Neurosurg. Apr 1995;82(4):523-9. [Medline].

  3. Recht LD, Bernstein M. Low-grade gliomas. Neurol Clin. Nov 1995;13(4):847-59. [Medline].

  4. [Best Evidence] Chang EF, Clark A, Jensen RL, Bernstein M, Guha A, Carrabba G, et al. Multiinstitutional validation of the University of California at San Francisco Low-Grade Glioma Prognostic Scoring System. Clinical article. J Neurosurg. Aug 2009;111(2):203-10. [Medline].

  5. Alvord EC, Lofton S. Gliomas of the optic nerve or chiasm. Outcome by patients' age, tumor site, and treatment. J Neurosurg. Jan 1988;68(1):85-98. [Medline].

  6. Clark GB, Henry JM, McKeever PE. Cerebral pilocytic astrocytoma. Cancer. Sep 1 1985;56(5):1128-33. [Medline].

  7. Constantini S, Houten J, Miller DC, et al. Intramedullary spinal cord tumors in children under the age of 3 years. J Neurosurg. Dec 1996;85(6):1036-43. [Medline].

  8. Franzini A, Leocata F, Cajola L, Servello D, Allegranza A, Broggi G. Low-grade glial tumors in basal ganglia and thalamus: natural history and biological reappraisal. Neurosurgery. Nov 1994;35(5):817-20; discussion 820-1. [Medline].

  9. Hakyemez B, Erdogan C, Ercan I, et al. High-grade and low-grade gliomas: differentiation by using perfusion MR imaging. Clin Radiol. Apr 2005;60(4):493-502. [Medline].

  10. Komotar RJ, Mocco J, Carson BS, et al. Pilomyxoid astrocytoma: a review. MedGenMed. 2004;6(4):42. [Medline].

  11. Laws ER, Taylor WF, Clifton MB, Okazaki H. Neurosurgical management of low-grade astrocytoma of the cerebral hemispheres. J Neurosurg. Oct 1984;61(4):665-73. [Medline].

  12. Lote K, Egeland T, Hager B, et al. Survival, prognostic factors, and therapeutic efficacy in low-grade glioma: a retrospective study in 379 patients. J Clin Oncol. Sep 1997;15(9):3129-40. [Medline].

  13. Macdonald DR. Low-grade gliomas, mixed gliomas, and oligodendrogliomas. Semin Oncol. Apr 1994;21(2):236-48. [Medline].

  14. McCormack BM, Miller DC, Budzilovich GN, et al. Treatment and survival of low-grade astrocytoma in adults--1977-1988. Neurosurgery. Oct 1992;31(4):636-42; discussion 642. [Medline].

  15. McCormick PC, Stein BM. Spinal cord tumors in adults. Neurological Surgery. 1996;4:3102-122.

  16. Morantz R A. Low-grade astrocytomas. In: Kaye AH, Laws ER Jr, eds. Brain Tumors: An Encyclopedic Approach. New York: Churchill Livingstone; 1995:433-48.

  17. Salcman M. Radical surgery for low-grade glioma. Clin Neurosurg. 1990;36:353-66. [Medline].

  18. Vandenberg SR, Sampaio Lopes MB. Classification. In: Berger MS, Wilson CB, eds. The Gliomas. Philadelphia: WB Saunders; 1999:172-91.

 
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A 28-year-old male taxi driver presented to the emergency department after having a seizure. Noncontrast head CT scan was obtained showing the typical appearance of a low-grade astrocytoma. The lesion in the mesial left frontal lobe was hypodense on CT scan.
Preoperative MRI of the brain of a 28-year-old male taxi driver who presented to the emergency department after having a seizure. On T1-weighted sequences, the tumor does not enhance and shows decreased signal intensity compared to normal brain. These findings are consistent with low-grade astrocytoma.
For tumors, MRI has the advantage of showing the lesion in multiple planes. This image, a T1-weighted sagittal image of the brain of a 28-year-old male taxi driver who presented to the emergency department after having a seizure, shows the tumor along the mesial aspect of the frontal lobe. Note that mass effect is minimal, typical of a low-grade lesion.
T2-weighted sequences of an MRI of the brain of a 28-year-old male taxi driver who presented to the emergency department after having a seizure show increased signal intensity compared with normal brain. The radiologic appearance is typical of low-grade astrocytoma.
A 9-year-old boy presented with headaches and gradual onset of right hemiparesis. MRI of the brain was obtained. The T2-weighted sequence in this MRI shows a tumor in the left thalamus, which is a typical location for a juvenile pilocytic astrocytoma. Note the relatively well-circumscribed nature of the lesion.
Coronal T1-weighted gadolinium-enhanced MRI of the brain shows the tumor of a 9-year-old boy who presented with headaches and gradual onset of a right hemiparesis. Note the heterogeneous enhancement of the tumor.
Sagittal T1-weighted MRI of the brain shows juvenile pilocytic astrocytoma of a 9-year-old boy who presented with headaches and gradual onset of right hemiparesis. Stereotactic surgery has made resection of these low-grade tumors in this deep location feasible.
A 3-year-old boy presented with speech regression. MRI of the brain revealed a tumor in the left mesial temporal lobe. This T1-weighted gadolinium-enhanced image shows an enhancing tumor involving the hippocampus, uncus, and amygdala. The surgical pathologic studies revealed a low-grade mixed tumor of astrocytes and atypical neurons, a ganglioglioma.
 
 
 
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