eMedicine Specialties > Pediatrics: General Medicine > Oncology

Astrocytoma: Differential Diagnoses & Workup

Author: Tobey MacDonald, MD, Clinical Director of Neuro-Oncology, Children's Hospital National Medical Center; Associate Professor, Department of Pediatric Hematology-Oncology, George Washington University
Coauthor(s): Roger J Packer, MD, Executive Director, Neuroscience and Behavioral Medicine, Director, Brain Tumor Institute, Children's National Medical Center; Professor of Neurology and Pediatrics, The George Washington University
Contributor Information and Disclosures

Updated: Feb 11, 2009

Differential Diagnoses

Ependymoma
Medulloblastoma
Meningitis, Aseptic
Meningitis, Bacterial

Other Problems to Be Considered

Arteriovenous malformation
Benign intracranial hypertension (pseudotumor cerebri)
Cerebral abscess or parasitic cyst
Choroid plexus papilloma or carcinoma
Craniopharyngioma
CNS lymphoma, leukemic meningitis
Demyelinating disease
Effusion (subdural or epidural)
Hemangioblastoma
Hemorrhage (intracranial or subarachnoid)
Hydrocephaly (any cause)
Midline tumors (germ cell, teratoma)
Metastatic solid tumor (rhabdomyosarcoma, undifferentiated sarcoma, neuroblastoma)
Primary intracranial (skull-based) Ewing sarcoma

Workup

Imaging Studies

The following studies are indicated in patients with suspected astrocytoma:

  • Head CT imaging with and without contrast
    • CT imaging has higher than 95% sensitivity for the detection of brain tumors.
    • On CT scans, most supratentorial low-grade astrocytomas are hypodense with variable contrast enhancement. Calcifications may be present. High-grade tumors show a more heterogeneous density pattern and a more diffuse contrast enhancement.
    • Patients with cerebellar astrocytomas may demonstrate hydrocephalus and contrast enhancement on CT scans. A prominent cystic component is often present.
    • Brainstem astrocytomas typically enhance poorly after contrast and lack calcifications on CT scans. They may appear isodense or hypodense.
  • Head and spine MRI with and without gadolinium
    • MRI is the imaging modality of choice for brainstem astrocytomas.
    • MRI of the head must be performed in all patients with CT scan or clinical findings consistent with astrocytoma. Other tumors, such as medulloblastoma and ependymoma, may have a similar appearance on CT scans. MRI is useful in such instances by better demonstrating the anatomic origin and extent of tumor.
    • MRI is the imaging modality of choice for detecting primary or disseminated spinal cord lesions. Perform an MRI of the spine in all tumors with malignant characteristics.
    • A postoperative MRI is required to measure the extent of surgical resection and the detection of residual disease. Postoperative MRI evaluation must be performed within 72 hours of surgery in order to delineate residual tumor from the postsurgical inflammatory changes that are visualized on MRI at this time.

Procedures

  • CSF cytological examination: This examination is useful in malignant astrocytomas for the detection of microscopic leptomeningeal dissemination.
  • Lumbar puncture: CT imaging or MRI must be performed prior to the lumbar puncture (LP) to rule out the presence of hydrocephaly in those patients suspected of having a brain tumor. Hydrocephaly places the patient at risk for herniation as a consequence of the procedure. In general, the LP is deferred as long as 2 weeks postoperatively in order to avoid identifying tumor cells that may have disseminated as a result of surgery.

Histologic Findings

  • Childhood astrocytomas represent different histopathologic entities, such as pure astrocytoma (commonly pilocytic and fibrillary type in children), oligodendroglioma, and mixed tumors of both cell types. Astrocytomas are composed of glial fibrillary acidic protein (GFAP)–positive bipolar or stellate cells. Oligodendrogliomas are characterized by monotonous collections of spheroidal cells. The classification of gliomas is based primarily on their degree of anaplasia, rather than on histologic type.
  • Tumors that are modestly cellular and contain few or none of the histologic criteria of malignancy are designated low-grade or grade I and II lesions, according to the WHO. Unifying features are their slowly evolving nonaggressive clinical behavior and relatively benign histological appearance.
  • Grade I is primarily designated for the typical pilocytic astrocytoma, accounting for 85% of cerebellar low-grade gliomas. It is composed of astrocytes interwoven with a fine fibrillary background and often has a characteristic microcystic component and Rosenthal fibers. The newly described pilomyxoid variant of low-grade astrocytoma has unusual histologic features, including abundance of myxoid background, the absence of Rosenthal fibers, and the presence of an angiocentric pattern. Whether or not this is a variant of pilocytic astrocytoma or a distinct entity remains unclear. Grade II is reserved for diffuse astrocytomas composed of moderately cellular astrocytes, oligodendrocytes, or both.
  • High-grade tumors are characterized by the presence of several histologic features of malignancy that include hypercellularity, cytologic and nuclear atypia, mitoses, necrosis, and endothelial proliferation. These tumors are clinically aggressive, regionally invasive, and capable of neuraxial dissemination. Grade III refers to anaplastic astrocytoma and grade IV is designated for glioblastoma multiforme.
  • The most common lesions of the brain stem are diffuse intrinsic pontine gliomas (80%). They are not amenable to biopsy except in about 25% of cases, in which an exophytic portion is present. Autopsy reveals that most of these cases are found to be high-grade tumors. Tumors arising in other areas of the brain stem are more likely to be low-grade and may be focal (<2 cm), cystic, or dorsal exophytic from the floor of the fourth ventricle, or they may arise from the cervicomedullary junction.

More on Astrocytoma

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

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Keywords

astrocytoma, glioma, brain tumors, pilocytic astrocytoma, diffuse astrocytoma, anaplastic astrocytoma, glioblastoma multiforme, Li-Fraumeni syndrome, neurofibromatosis, NF1, leukemia, intracranial pressure, ICP, seizures, hypothalamic tumor, growth hormone deficiency, diabetes insipidus, precocious puberty, spinal astrocytomas, monoparesis, quadriparesis, tuberous sclerosis, Li-Fraumeni syndrome

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Contributor Information and Disclosures

Author

Tobey MacDonald, MD, Clinical Director of Neuro-Oncology, Children's Hospital National Medical Center; Associate Professor, Department of Pediatric Hematology-Oncology, George Washington University
Tobey MacDonald, MD is a member of the following medical societies: American Association for Cancer Research, Children's Oncology Group, Pediatric Brain Tumor Consortium, and Society for Neuro-Oncology
Disclosure: Nothing to disclose.

Coauthor(s)

Roger J Packer, MD, Executive Director, Neuroscience and Behavioral Medicine, Director, Brain Tumor Institute, Children's National Medical Center; Professor of Neurology and Pediatrics, The George Washington University
Roger J Packer, MD is a member of the following medical societies: American Academy of Neurology, American Neurological Association, American Pediatric Society, Child Neurology Society, Children's Oncology Group, Neurofibromatosis Clinical Trials Consortium, Pediatric Brain Tumor Consortium, and Society for Neuro-Oncology
Disclosure: Nothing to disclose.

Medical Editor

Samuel Gross, MD, Professor Emeritus, Department of Pediatrics, University of Florida; Clinical Professor, Department of Pediatrics, University of North Carolina; Adjunct Professor, Department of Pediatrics, Duke University
Samuel Gross, MD is a member of the following medical societies: American Association for Cancer Research, American Society for Blood and Marrow Transplantation, American Society of Clinical Oncology, American Society of Hematology, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Timothy P Cripe, MD, PhD, Professor of Pediatric Hematology/Oncology, University of Cincinnati; Director, Translational Research Trials Office, Department of Pediatrics, Cincinnati Children's Hospital Medical Center
Timothy P Cripe, MD, PhD is a member of the following medical societies: American Association for the Advancement of Science, American Pediatric Society, American Society of Hematology, American Society of Pediatric Hematology/Oncology, and Society for Pediatric Research
Disclosure: Nothing to disclose.

CME Editor

David Pallares, MD, Clinical Assistant Professor, Department of Pediatrics, Division of Allergy and Immunology, University of Louisville
David Pallares, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology
Disclosure: Nothing to disclose.

Chief Editor

Max J Coppes, MD, PhD, MBA, Executive Director, Center for Cancer and Blood Disorders, Children's National Medical Center; Professor of Medicine, Oncology, and Pediatrics, Georgetown University
Max J Coppes, MD, PhD, MBA is a member of the following medical societies: American Association for Cancer Research, American Society of Pediatric Hematology/Oncology, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
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