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Astrocytoma Follow-up

  • Author: Benjamin Kennedy, MD; Chief Editor: Jules E Harris, MD, FACP, FRCPC  more...
 
Updated: Sep 24, 2015
 

Further Outpatient Care

Outpatient management includes the following:

  • Patients should consult a neurologist to observe the progression of neurological signs and symptoms and to manage steroid and anticonvulsant regimens
  • Outpatient neurosurgery observation is necessary for tumor monitoring and management of hydrocephalus if a shunt has been placed
  • Postoperative and postirradiation chemotherapy trials using nitrosourea and other agents are likely to benefit patients with malignant astrocytomas, but the benefit for patients with well-differentiated astrocytomas is questionable
  • Frequency of postoperative MRIs is determined by both the neurosurgeon and other physicians involved in the ongoing care of the patient, including the neurooncologist and radiation oncologist
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Further Inpatient Care

Management of low-grade astrocytomas is controversial. The tumors may be radiographically stable and clinically quiescent for long periods after the initial presentation.

Therapeutic options include observation, radiation, and resection with and without radiation. Unless an astrocytoma is resected completely, radiation therapy should be considered. In higher-grade lesions, even if gross total resection is confirmed radiographically, postoperative radiation therapy is indicated because microscopic disease remains. If no resection is undertaken and radiation is contemplated, a stereotactic biopsy is recommended to establish the histological grade of the tumor definitively.

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Inpatient & Outpatient Medications

 

 

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Transfer

See the list below:

  • If surgery is anticipated, patients should be transferred to institutions with an appropriately equipped and adequately staffed neurosurgical intensive care unit for postoperative monitoring.
  • Patients may require extensive or focused postoperative rehabilitation that may necessitate transfer to specialized institutions dedicated to physical and occupational therapy.
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Complications

Although neurological injury (potentially devastating) and death are possible sequelae of operative intervention, neurosurgery for astrocytomas is generally intended to decrease tumor bulk while avoiding permanent neurological injury. Transient deficits due to local swelling or injury may occur, but they often improve after a course of physical therapy and rehabilitation.

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Prognosis

Prognosis for survival after operative intervention and radiation therapy can be favorable for low-grade astrocytomas. For low-grade lesions, the mean survival time after surgical intervention has been reported as 6-8 years. For those patients who undergo surgical resection, the prognosis depends on whether the neoplasm progresses to a higher-grade lesion.

In the case of anaplastic astrocytoma, symptomatic improvement or stabilization is the rule after surgical resection and irradiation. High-quality survival is observed in 60-80% of these patients. Factors such as youth, functional status, extent of resection, and adequate irradiation affect the duration of postoperative survival.

Irradiation of incompletely resected tumors can increase 5-year postoperative survival rates from 0-25% for low-grade astrocytomas and from 2-16% for anaplastic astrocytomas. Furthermore, the median survival rate of patients with anaplastic astrocytoma who undergo both resection and irradiation has been reported to be twice that of patients receiving only operative therapy (5 y vs 2.2 y).

Attempts have been made to determine prognosis and response to various treatment modalities based on the individual pattern of genetic changes in a particular tumor. For example, patients with oligodendrogliomas that exhibit chromosomal changes at band 1p19q are known to have better responses to the procarbazine, lomustine (CCNU), vincristine (PCV) regimen of chemotherapy.

Efforts are under way to identify similar unique susceptibilities associated with other commonly altered genes and proteins in astrocytomas. Other groups are working on developing models that will allow for a more accurate assessment of prognosis based on a combination of molecular profiling of the tumors and clinical characteristics of the patient.[52]

In high-grade astrocytoma, elevations in glioblastoma kallikrein 6 (KLK6), kallikrein 7 (KLK7), and kallikrein 9 (KLK9) proteins may have prognostic utility as markers of patient survival. Kallikrein levels and associated outcomes were as follows[53] :

  • Elevated KLK6- or KLK7-IR – Poor patient prognosis
  • Increased percent of tumor immunoreactive for KLK6 or KLK9  – Decreased survival
  • KLK6 immunoreactivity score <10, KLK6 <3% tumor core stained, or KLK7 immunoreactivity score <9 – Significantly improved survival.
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Contributor Information and Disclosures
Author

Benjamin Kennedy, MD Columbia University College of Physicians and Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Jeffrey N Bruce, MD Edgar M Housepian Professor of Neurological Surgery Research, Vice-Chairman and Professor of Neurological Surgery, Director of Brain Tumor Tissue Bank, Director of Bartoli Brain Tumor Laboratory, Department of Neurosurgery, Columbia University College of Physicians and Surgeons

Jeffrey N Bruce, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for the Advancement of Science, American Association of Neurological Surgeons, New York Academy of Sciences, North American Skull Base Society, Society of Neurological Surgeons, Society for Neuro-Oncology, American Society of Clinical Oncology, Congress of Neurological Surgeons, Pituitary Society

Disclosure: Received grant/research funds from NIH for other.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Jules E Harris, MD, FACP, FRCPC Clinical Professor of Medicine, Section of Hematology/Oncology, University of Arizona College of Medicine, Arizona Cancer Center

Jules E Harris, MD, FACP, FRCPC is a member of the following medical societies: American Association for the Advancement of Science, American Society of Hematology, Central Society for Clinical and Translational Research, American Society of Clinical Oncology

Disclosure: Nothing to disclose.

Additional Contributors

Robert C Shepard, MD, FACP Associate Professor of Medicine in Hematology and Oncology at University of North Carolina at Chapel Hill; Vice President of Scientific Affairs, Therapeutic Expertise, Oncology, at PRA International

Robert C Shepard, MD, FACP is a member of the following medical societies: American Association for Cancer Research, American Association for Physician Leadership, European Society for Medical Oncology, Association of Clinical Research Professionals, American Federation for Clinical Research, Eastern Cooperative Oncology Group, Society for Immunotherapy of Cancer, American Medical Informatics Association, American College of Physicians, American Federation for Medical Research, American Medical Association, American Society of Hematology, Massachusetts Medical Society

Disclosure: Nothing to disclose.

Acknowledgements

We wish to acknowledge previous contributions to this chapter from Patrick Senatus, MD, PhD and Allen Waziri, MD.

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Low-grade fibrillary astrocytoma and low cellularity with minimal nuclear atypia.
Fibrillary astrocytoma with microcyst formation.
Gemistocytic astrocytoma tumor cells have eosinophilic cytoplasm with nuclei displaced to the periphery.
Characteristic pilocytic astrocytoma, long bipolar tumor cells, and Rosenthal fibers.
Anaplastic astrocytoma with high cellularity with marked nuclear atypia.
Gross specimen of a low-grade astrocytoma.
Axial CT scan, precontrast and postcontrast, shows a low-grade astrocytoma of the left frontal lobe. The tumor is nonenhancing.
Coronal postcontrast T1-weighted MRI shows a low-grade astrocytoma in the right inferior frontal lobe just above the sylvian fissure. No enhancement is present post–gadolinium administration.
Axial T2-weighted MRI shows a low-grade astrocytoma of the inferior frontal lobe with mild mass effect and no surrounding edema.
 
 
 
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