Astrocytoma Treatment & Management

  • Author: Benjamin Kennedy; Chief Editor: Jules E Harris, MD   more...
 
Updated: Jan 17, 2012
 

Medical Care

Generally, care of patients with brain tumors is primarily directed by a neurologist or specialist in neurooncology. There is no accepted standard of treatment for low-grade or anaplastic astrocytoma.

A study by Ishkanian et al found that adjuvant radiotherapy for pilocytic astrocytoma significantly prolonged progression-free survival (PFS) at both 5 years and 10 years compared with observation alone. However, the overall survival was equivalent.[17]

Decisions on operative intervention and the use of chemotherapy and radiation therapy are generally best made by a team approach, including input from the involved neurosurgeon, radiation oncologist, and medical oncologist or neurologist.

  • Typically, anaplastic astrocytomas are treated with surgery, radiotherapy, and adjuvant temozolomide. Some practitioners add concomitant temozolomide, though no data from controlled trials exist to support concomitant temozolomide.[18, 19]
  • Anaplastic astrocytomas are usually more responsive to chemotherapy than glioblastomas.[20, 21] For recurrent anaplastic astrocytomas previously treated with nitrosoureas, temozolomide showed a 35% response rate, and compared to therapies with lower response rates, temozolomide provided an increased 6-month survival rate (46% vs 31%).[22, 23] Some smaller survival benefit has been shown with adjuvant BCNU.[24]
  • Treatment of low-grade astrocytomas remains more controversial. The role of maximal surgical resection, timing of radiotherapy, and the role, timing, and appropriate agents of chemotherapy are not clear. The controversy due to a lack of strong data is compounded by the relatively young age of the patients, the relatively indolent natural history of low-grade astrocytomas, and the morbidity associated with these interventions.[25, 26]
  • Patients with an astrocytoma and a history of seizures should receive anticonvulsant therapy with monitoring of the drug concentration in the blood stream. The use of anticonvulsants prophylactically in astrocytoma patients with no prior history of seizures has been reported but remains controversial.
  • The use of corticosteroids, such as dexamethasone, yields rapid improvement in most patients secondary to a reduction of tumor mass effect. Concurrent prophylaxis for gastrointestinal ulcers should be prescribed with corticosteroid administration.
  • Brainstem gliomas: Brainstem tumors account for 10-20%[27] of all CNS tumors in the pediatric population, typically diagnosed between ages 7-9.[28, 29] Though many classification schemes exist, treatment and prognosis for brainstem gliomas typically depends on whether the tumor is diffuse or focal.
  • Diffuse brainstem gliomas make up 58-75%[30] of all brainstem tumors, typically arise in the pons, and are noncircumscribed on MRI. They are often malignant fibrillary astrocytomas (WHO grade III or IV), which infiltrate along white matter tracts into the midbrain and thalamus and have a rapidly progressive and fatal course.
    • Clinical presentation of these tumors often involves ataxia, cerebellar signs, and long tract signs.[31] When clinical and radiographic evidence suggests diffuse brainstem glioma, biopsy is of limited use as tumor histology does not frequently alter treatment.[30, 32, 33, 34, 35, 36, 37, 38]
    • No benefit of surgical resection has been shown, largely due to the eloquence of the region and diffuse and aggressive nature of the tumor.[31, 39] Corticosteroids may provide temporary benefit by reduction of edema. Irradiation has been shown to provide temporary clinical improvement and is sometimes employed, but a large phase III trial showed no benefit.[40] Even with radiation therapy, 1-year survival has been shown to be 35-46%, and 3-year survival 11-17%.[41, 42] Chemotherapy is also sometimes used.[43] No treatment, however, has been shown to cure or prolong survival in these patients, and radiation necrosis and chemotherapy side effects can be significant. Convection-enhanced delivery of chemotherapy offers one potential avenue for improving the prognosis of these patients, and studies are ongoing.
  • Focal brainstem gliomas are usually WHO grade I or II, well-circumscribed on MRI with variable contrast enhancement, are more often found in the medulla and midbrain and have a much better prognosis than diffuse brainstem gliomas. Surgery is often the primary treatment for focal brainstem gliomas as well as dorsal exophytic brainstem gliomas, though the decision to operate, surgical approach, and extent of resection depend on location, patient factors, and the surgeon's judgment. Obstructive hydrocephalus is common, usually treated by a separate procedure, either endoscopic third ventriculostomy or shunt placement.[44]
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Surgical Care

The roles of surgery in the patient with astrocytoma are (1) to remove or debulk the tumor and (2) to provide tissue for histological diagnosis, permitting tailoring of adjuvant therapy and assessment of prognosis.[45] A stereotactic biopsy is a safe and simple method for establishing a tissue diagnosis. The use of stereotactic biopsy can be limited by sampling error and the risk of biopsy-induced intracerebral hemorrhage. Diversion of CSF by external ventricular drain (EVD) or ventriculoperitoneal shunt (VPS) may be required to decrease ICP as part of nonoperative management or prior to definitive surgical therapy if hydrocephalus is present.

Total resection of astrocytoma is often impossible because the tumors often invade into eloquent regions of the brain and exhibit tumor infiltration that is only detectable on a microscopic scale. Therefore, surgical resection only provides for improved survival advantage and histological diagnosis of the tumor rather than offering a cure. However, craniotomy for tumor resection can be performed safely and is generally undertaken with the intent to cause the least possible neurological injury to the patient. Complete resection (>98% based on volumetric MRI) has been shown to improve median survival compared with subtotal resection (13 vs 8.8 mo).[46]

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Consultations

  • A neurologist should be consulted to document a patient's detailed neurological examination. This establishes a baseline and partly assesses the possibility of occult disease. Employing multiple modalities, the neurologist must correlate symptomatology with anatomic and functional imaging. This physician also may manage antiepileptic medication for patients manifesting seizures.
  • A neurosurgeon should be consulted to assess the risks and benefits of surgical resection, stereotactic biopsy, stereotactic radiosurgery, and CSF diversion.
  • A neurooncologist may be consulted to help coordinate a comprehensive therapeutic plan. Once a histological diagnosis is determined, the neurooncologist should be consulted to provide comprehensive adjunctive therapy, including the use of chemotherapy and radiation.
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Activity

  • No broad restrictions on activity are prescribed, other than those dictated by the nature and the extent of neurological symptoms and disability.
  • Seizures, if uncontrolled, may preclude driving.
  • Physical and occupational therapy may be required for recovery of full or partial function.
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Contributor Information and Disclosures
Author

Benjamin Kennedy  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, American Society of Clinical Oncology, Congress of Neurological Surgeons, New York Academy of Sciences, North American Skull Base Society, Pituitary Society, Society for Neuro-Oncology, and Society of Neurological Surgeons

Disclosure: NIH Grant/research funds Other

Specialty Editor Board

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 College of Physician Executives, American College of Physicians, American Federation for Clinical Research, American Federation for Medical Research, American Medical Association, American Medical Informatics Association, American Society of Hematology, Association of Clinical Research Professionals, Eastern Cooperative Oncology Group, European Society for Medical Oncology, Massachusetts Medical Society, and Society for Biological Therapy

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

Rajalaxmi McKenna, MD, FACP  Southwest Medical Consultants, SC, Department of Medicine, Good Samaritan Hospital, Advocate Health Systems

Rajalaxmi McKenna, MD, FACP is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology, and International Society on Thrombosis and Haemostasis

Disclosure: Nothing to disclose.

Chief Editor

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

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

Disclosure: GlobeImmune Salary Consulting

Additional Contributors

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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