- Author: Benjamin Kennedy, MD; Chief Editor: Jules E Harris, MD, FACP, FRCPC more...
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
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.
Inpatient & Outpatient Medications
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.
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.
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.
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 :
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.
Greenberg MS. Astrocytoma. Handbook of Neurosurgery. 4th ed. Lakeland, Fla: Greenberg Graphics Inc; 1997. Vol 1: 244-256.
Sathornsumetee S, Rich JN, Reardon DA. Diagnosis and treatment of high-grade astrocytoma. Neurol Clin. 2007 Nov. 25(4):1111-39, x. [Medline].
Furnari FB, Fenton T, Bachoo RM, Mukasa A, Stommel JM, Stegh A, et al. Malignant astrocytic glioma: genetics, biology, and paths to treatment. Genes Dev. 2007 Nov 1. 21(21):2683-710. [Medline].
Walker MD. Adjuvant therapy for brain tumor. Int Adv Surg Oncol. 1980. 3:351-69. [Medline].
Recinos PF, Sciubba DM, Jallo GI. Brainstem tumors: where are we today?. Pediatr Neurosurg. 2007. 43(3):192-201. [Medline].
Kleihues P, Burger PC, Scheithauer BW. The new WHO classification of brain tumours. Brain Pathol. 1993 Jul. 3(3):255-68. [Medline].
Kesari S. Understanding glioblastoma tumor biology: the potential to improve current diagnosis and treatments. Semin Oncol. 2011 Dec. 38 Suppl 4:S2-10. [Medline].
Davis RL, Kleihues P, Burger PC. Anaplastic Astrocytoma. Kleihues P, Cavenee WK, eds. Pathology and Genetics: Tumours of the Nervous System. Lyon, France: International Agency for Cancer Research; 1997. 14-15.
Kleihues P, Davis RL, Ohgaki H. Low-grade diffuse astrocytoma. Kleihues P, Cavenee WK, eds. Pathology and Genetics: Tumours of the Nervous System. Lyon, France: International Agency for Cancer Research; 1997. 10-14.
Cavenee WK, Bigner DD, Newcomb EW. Diffuse astrocytomas. Kleihues P, Cavenee WK, eds. Pathology and Genetics: Tumours of the Nervous System. Lyon, France: International Agency for Cancer Research; 1997. 2-9.
Cavin LW, Dalrymple GV, McGuire EL, Maners AW, Broadwater JR. CNS tumor induction by radiotherapy: a report of four new cases and estimate of dose required. Int J Radiat Oncol Biol Phys. 1990 Feb. 18(2):399-406. [Medline].
Wen PY, Kesari S. Malignant gliomas in adults. N Engl J Med. 2008 Jul 31. 359(5):492-507. [Medline].
Ostrom QT, Gittleman H, Stetson L, Virk SM, Barnholtz-Sloan JS. Epidemiology of gliomas. Cancer Treat Res. 2015. 163:1-14. [Medline].
Hardell L, Carlberg M. Mobile phone and cordless phone use and the risk for glioma - Analysis of pooled case-control studies in Sweden, 1997-2003 and 2007-2009. Pathophysiology. 2015 Mar. 22 (1):1-13. [Medline].
Lahkola A, Auvinen A, Raitanen J, Schoemaker MJ, Christensen HC, Feychting M, et al. Mobile phone use and risk of glioma in 5 North European countries. Int J Cancer. 2007 Apr 15. 120(8):1769-75. [Medline].
Inskip PD, Tarone RE, Hatch EE, Wilcosky TC, Shapiro WR, Selker RG, et al. Cellular-telephone use and brain tumors. N Engl J Med. 2001 Jan 11. 344(2):79-86. [Medline].
Brüstle O, Ohgaki H, Schmitt HP, Walter GF, Ostertag H, Kleihues P. Primitive neuroectodermal tumors after prophylactic central nervous system irradiation in children. Association with an activated K-ras gene. Cancer. 1992 May 1. 69(9):2385-92. [Medline].
Chawengchao B, Petmitr S, Ponglikitmongkol M, Chanyavanich V, Sangruji T, Theerapuncharoen V, et al. Detection of a novel point mutation in the p53 gene in grade II astrocytomas by PCR-SSCP analysis with additional Klenow treatment. Anticancer Res. 2001 Jul-Aug. 21(4A):2739-43. [Medline].
Chaichana KL, McGirt MJ, Niranjan A, Olivi A, Burger PC, Quinones-Hinojosa A. Prognostic significance of contrast-enhancing low-grade gliomas in adults and a review of the literature. Neurol Res. 2009 Nov. 31(9):931-9. [Medline].
Chaichana KL, McGirt MJ, Laterra J, Olivi A, Quiñones-Hinojosa A. Recurrence and malignant degeneration after resection of adult hemispheric low-grade gliomas. J Neurosurg. 2010 Jan. 112(1):10-7. [Medline].
Helseth A, Mørk SJ. Neoplasms of the central nervous system in Norway. III. Epidemiological characteristics of intracranial gliomas according to histology. APMIS. 1989 Jun. 97(6):547-55. [Medline].
Ishkanian A, Laperriere NJ, Xu W, et al. Upfront observation versus radiation for adult pilocytic astrocytoma. Cancer. 2011 Sep 1. 117(17):4070-9. [Medline].
Kizilbash SH, Giannini C, Voss JS, Decker PA, Jenkins RB, Hardie J, et al. The impact of concurrent temozolomide with adjuvant radiation and IDH mutation status among patients with anaplastic astrocytoma. J Neurooncol. 2014 Oct. 120 (1):85-93. [Medline].
van den Bent MJ. Anaplastic oligodendroglioma and oligoastrocytoma. Neurol Clin. 2007 Nov. 25(4):1089-109, ix-x. [Medline].
Butowski NA, Sneed PK, Chang SM. Diagnosis and treatment of recurrent high-grade astrocytoma. J Clin Oncol. 2006 Mar 10. 24(8):1273-80. [Medline].
Yung WK, Prados MD, Yaya-Tur R, Rosenfeld SS, Brada M, Friedman HS, et al. Multicenter phase II trial of temozolomide in patients with anaplastic astrocytoma or anaplastic oligoastrocytoma at first relapse. Temodal Brain Tumor Group. J Clin Oncol. 1999 Sep. 17(9):2762-71. [Medline].
Wong ET, Hess KR, Gleason MJ, Jaeckle KA, Kyritsis AP, Prados MD, et al. Outcomes and prognostic factors in recurrent glioma patients enrolled onto phase II clinical trials. J Clin Oncol. 1999 Aug. 17(8):2572-8. [Medline].
Brown PD. Low-grade gliomas: the debate continues. Curr Oncol Rep. 2006 Jan. 8(1):71-7. [Medline].
Cloughesy T. The impact of recent data on the optimization of standards of care in newly diagnosed glioblastoma. Semin Oncol. 2011 Dec. 38 Suppl 4:S11-20. [Medline].
Littman P, Jarrett P, Bilaniuk LT, Rorke LB, Zimmerman RA, Bruce DA, et al. Pediatric brain stem gliomas. Cancer. 1980 Jun 1. 45(11):2787-92. [Medline].
Berger MS, Edwards MS, LaMasters D, Davis RL, Wilson CB. Pediatric brain stem tumors: radiographic, pathological, and clinical correlations. Neurosurgery. 1983 Mar. 12(3):298-302. [Medline].
Epstein F, Wisoff JH. Intrinsic brainstem tumors in childhood: surgical indications. J Neurooncol. 1988 Dec. 6(4):309-17. [Medline].
Steck J, Friedman WA. Stereotactic biopsy of brainstem mass lesions. Surg Neurol. 1995 Jun. 43(6):563-7; discussion 567-8. [Medline].
Rajshekhar V, Chandy MJ. Computerized tomography-guided stereotactic surgery for brainstem masses: a risk-benefit analysis in 71 patients. J Neurosurg. 1995 Jun. 82(6):976-81. [Medline].
Albright AL, Price RA, Guthkelch AN. Brain stem gliomas of children. A clinicopathological study. Cancer. 1983 Dec 15. 52(12):2313-9. [Medline].
Amundson EW, McGirt MJ, Olivi A. A contralateral, transfrontal, extraventricular approach to stereotactic brainstem biopsy procedures. Technical note. J Neurosurg. 2005 Mar. 102(3):565-70. [Medline].
Kaplan AM, Albright AL, Zimmerman RA, Rorke LB, Li H, Boyett JM, et al. Brainstem gliomas in children. A Children's Cancer Group review of 119 cases. Pediatr Neurosurg. 1996. 24(4):185-92. [Medline].
Tomita T, McLone DG, Naidich TP. Brain stem gliomas in childhood. Rational approach and treatment. J Neurooncol. 1984. 2(2):117-22. [Medline].
Albright AL. Tumors of the pons. Neurosurg Clin N Am. 1993 Jul. 4(3):529-36. [Medline].
Epstein F. Intrinsic brain stem tumors of childhood. Surgical indications. Prog Exp Tumor Res. 1987. 30:160-9. [Medline].
Mandell LR, Kadota R, Freeman C, Douglass EC, Fontanesi J, Cohen ME, et al. There is no role for hyperfractionated radiotherapy in the management of children with newly diagnosed diffuse intrinsic brainstem tumors: results of a Pediatric Oncology Group phase III trial comparing conventional vs. hyperfractionated radiotherapy. Int J Radiat Oncol Biol Phys. 1999 Mar 15. 43(5):959-64. [Medline].
Packer RJ, Boyett JM, Zimmerman RA, Albright AL, Kaplan AM, Rorke LB, et al. Outcome of children with brain stem gliomas after treatment with 7800 cGy of hyperfractionated radiotherapy. A Childrens Cancer Group Phase I/II Trial. Cancer. 1994 Sep 15. 74(6):1827-34. [Medline].
Fischbein NJ, Prados MD, Wara W, Russo C, Edwards MS, Barkovich AJ. Radiologic classification of brain stem tumors: correlation of magnetic resonance imaging appearance with clinical outcome. Pediatr Neurosurg. 1996. 24(1):9-23. [Medline].
Allen JC, Siffert J. Contemporary chemotherapy issues for children with brainstem gliomas. Pediatr Neurosurg. 1996. 24(2):98-102. [Medline].
Intensity-Modulated RT 'Excellent' for Pediatric Low-Grade Glioma. Medscape Medical News. Available at http://www.medscape.com/viewarticle/803892. Accessed: May 19, 2013.
Paulino AC, Mazloom A, Terashima K, Su J, Adesina AM, Okcu MF, et al. Intensity-modulated radiotherapy (IMRT) in pediatric low-grade glioma. Cancer. 2013 Apr 30. [Medline].
Laws ER Jr, Taylor WF, Clifton MB, Okazaki H. Neurosurgical management of low-grade astrocytoma of the cerebral hemispheres. J Neurosurg. 1984 Oct. 61(4):665-73. [Medline].
Lacroix M, Abi-Said D, Fourney DR, Gokaslan ZL, Shi W, DeMonte F, et al. A multivariate analysis of 416 patients with glioblastoma multiforme: prognosis, extent of resection, and survival. J Neurosurg. 2001 Aug. 95(2):190-8. [Medline].
Duffau H. A new philosophy in surgery for diffuse low-grade glioma (DLGG): oncological and functional outcomes. Neurochirurgie. 2013 Feb. 59(1):2-8. [Medline].
Joo M, Park SH, Chang SH, Kim H, Choi CY, Lee CH, et al. Cytogenetic and molecular genetic study on glioblastoma arising in granular cell astrocytoma: a case report. Hum Pathol. 2011 Dec 26. [Medline].
Drucker KL, Gianinni C, Decker PA, Diamandis EP, Scarisbrick IA. Prognostic significance of multiple kallikreins in high-grade astrocytoma. BMC Cancer. 2015 Aug 1. 15:565. [Medline].
Albright AL. Diffuse brainstem tumors: when is a biopsy necessary?. Pediatr Neurosurg. 1996. 24(5):252-5. [Medline].
Karremann M, Rausche U, Roth D, Kühn A, Pietsch T, Gielen GH, et al. Cerebellar location may predict an unfavourable prognosis in paediatric high-grade glioma. Br J Cancer. 2013 Jul 18. [Medline].
Kleihues P, Kiessling M, Janzer RC. Morphological markers in neuro-oncology. Curr Top Pathol. 1987. 77:307-38. [Medline].
Levy LF, Auchterlonie WC. Primary cerebral neoplasia in Rhodesia. Int Surg. 1975 May. 60(5):286-92. [Medline].
National Institutes of Health news release. Adding chemotherapy following radiation treatment improves survival for adults with low-grade gliomas, a slow-growing type of brain tumor. National Institutes of Health. Available at http://www.nih.gov/news/health/feb2014/nci-03.htm. Accessed: March 3, 2014.
Tatter BS, Wilson CB, Harsh GR. Neuroepithelial tumors of the adult brain. Youman's Neurological Surgery. 4th ed. Philadelphia, Pa: WB Saunders Company; 1996. 2612-2684.
Zhou YH, Hess KR, Liu L, Linskey ME, Yung WK. Modeling prognosis for patients with malignant astrocytic gliomas: quantifying the expression of multiple genetic markers and clinical variables. Neuro Oncol. 2005 Oct. 7(4):485-94. [Medline]. [Full Text].