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Pediatric Astrocytoma Follow-up

  • Author: Tobey J MacDonald, MD; Chief Editor: Max J Coppes, MD, PhD, MBA  more...
 
Updated: Nov 25, 2014
 

Further Outpatient Care

See the list below:

  • Chemotherapy: Chemotherapy for low-grade astrocytomas is currently administered in an outpatient setting for approximately 1 year.
  • Radiotherapy: Begin daily outpatient local radiotherapy after recovery from surgery for a high-grade astrocytoma or early recurrent and/or progressive low-grade astrocytoma. This is generally administered over 6 weeks (usual dose is 160-180 Gy/d).
  • Physical and neurologic examination
    • For resected low-grade astrocytomas, outpatient examinations every 1-3 months are sufficient.
    • For patients requiring radiotherapy, perform weekly monitoring of clinical response and potential treatment-related adverse effects during radiotherapy and then every 1-3 months thereafter for at least 1 year.
    • Protocols using investigational chemotherapy in place of, or following, radiotherapy dictate how frequently these examinations are conducted.
    • After 12-18 months from completion of therapy, these examinations are generally reduced to every 6 months for the next 2 years and annually thereafter, provided no interim complications occur.
    • Routinely perform baseline neuropsychology and developmental testing at the completion of therapy and annually thereafter.
  • Imaging studies
    • 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.
    • MRI with contrast of the head should be performed every 3 months for the first 12-18 months after surgery and 4-6 weeks following the completion of radiotherapy. Subsequent imaging may be performed in conjunction with the physical and neurologic examination schedule, unless clinically indicated sooner. If a child is treated on an investigational clinical trial regimen, the protocol dictates the frequency of the imaging studies required.
    • Perform MRI of the spine annually in those patients with high-grade tumors unless evidence of leptomeningeal spread is noted at diagnosis, in which case the frequency of such examination is increased in accordance with the response to treatment.
  • Laboratory studies
    • Weekly CBC counts and annual neuroendocrine studies (eg, thyroid function tests, growth hormone, luteinizing hormone [LH]/follicle-stimulating hormone [FSH], estradiol) are all that is required during radiotherapy unless otherwise dictated by investigational regimens or if clinically indicated.
    • The CBC count is used to monitor hematopoietic toxicity and determine whether intervention should be carried out to maintain hemoglobin levels at or above 10 g/dL in order to maximize radiation efficacy.
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Inpatient & Outpatient Medications

See the list below:

  • Dexamethasone and antiseizure medications may be necessary to reduce the respective inflammatory response (edema) and seizure activity associated with the tumor and/or therapy.
  • Investigational protocols may dictate other medications, including chemotherapy.
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Transfer

See the list below:

  • Transfer patient to a pediatric center that can provide appropriate MRI imaging studies; pediatric neurosurgery; and pediatric hematology, oncology, or neuro-oncology. Pediatric radiation oncology and neurology may also be necessary for treatment and follow-up.
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Complications

See the list below:

  • Obstructive hydrocephaly
  • Neurologic impairment
  • Radiation-induced effects
    • Neurocognitive decline
    • Endocrinologic dysfunction
    • Mineralizing microangiopathy with ischemia or infarct
    • Secondary CNS malignancies
    • Transient headaches, fatigue, nausea, vomiting, and anorexia
  • Chemotherapy-induced effects
    • Myelosuppression, infection, nausea, vomiting, anorexia, renal damage, hepatic damage, hearing damage, neurotoxicity, and secondary malignancies may occur.
    • Investigational chemotherapy for either high-grade or low-grade tumors may cause complications such as fever, neutropenia, or suspected infection; therefore, hospitalization may be necessary.
    • Infertility and impairment of growth may also be long-term sequelae of therapy.
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Prognosis

See the list below:

  • Low-grade astrocytoma
    • The 10-year survival rate for completely resected low-grade cerebellar astrocytomas is near 100%, with little or no morbidity. It is 60-95% for all low-grade tumors, including those incompletely resected and treated with radiotherapy.
    • Supratentorial tumors may result in residual motor deficits or seizure disorder. Radiotherapy may lead to neurocognitive impairment, neuroendocrine dysfunction, or ischemia and infarct.
  • High-grade astrocytoma: Those who survive (< 30%) are often left with some degree of motor, neurocognitive, or endocrinologic dysfunction.
  • Astrocytoma of the brain stem
    • Patients with dorsal exophytic and cervicomedullary tumors treated by complete surgical resection have survival rates of more than 90%.
    • Survival may be 50-100% for those with small focal tumors of the midbrain or tectal region treated with surgery and/or radiotherapy. In sharp contrast, patients with diffuse pontine lesions rarely survive.
    • Surgery to these areas can result in paralysis of multiple cranial nerves, mutism, and a compromised respiratory effort.
  • Astrocytoma of the visual pathway
    • The 10-year survival rate for patients with intracranial tumors (chiasm or deeper) is 40-85%, in contrast to the 90-100% for those with intraorbital tumors.
    • Fewer than half of all patients have improvement in their visual deficits noted at diagnosis.
    • As many as 50% of prepubertal children develop endocrinologic dysfunction from radiotherapy.
  • Astrocytoma of the spinal cord: The overall survival rate for patients with low-grade astrocytomas with various degrees of resection and postoperative radiotherapy is 67% at 20 years, whereas those with high-grade tumors rarely survive.
  • Khelifa-Gallois et al conducted a study of functional outcomes in adolescents and adults who were treated for a low-grade cerebellar astrocytoma in childhood.[9] The study cohort consisted of 18 adolescents and 46 adults. Data regarding academic achievement, professional status, and neurologic, cognitive and behavioral disturbances were collected through the use of self-completed and parental questionnaires for adolescents and of phone interviews for adults. For the adolescents, a control group filled in the same questionnaires. Mean time of lapse from surgery was 7.8 years for adolescents and 12.9 years for adults. Five adults (11%) had major sequelae related to postoperative complications, postoperative mutism, and/or brain stem involvement. For all the other participants reported cognitive difficulties and difficulties related to mild neurologic sequelae (ie, fine motor skills, balance) although academic achievement was similar to that of control participants. The investigators concludedthatlong-term functional outcomes of patients with low-grade cerebellar astrocytoma are generally favorable in the absence of postoperative complications and brain stem involvement.[9]
  • Chen et al reported that in patients with astrocytoma, the expression of human transcriptional coactivator 4 (PC4) is upregulated, as determined on the basis of Western blot and immunohistochemical staining.[10] They found that elevated expression of PC4 was strongly correlated with the progression of astrocytoma and was associated with poor overall survival. An in vitro study demonstrated that siRNA-mediated PC4 downregulation significantly inhibited the proliferation and invasiveness of human glioma cells. The investigators concluded that PC4 might play a role in human astrocytoma progression and that it is useful in the prognosis of patients with astrocytoma.[10]
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Patient Education

See the list below:

  • Refer patients and their family members for psychosocial counseling.
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Contributor Information and Disclosures
Author

Tobey J MacDonald, MD Professor, Department of Pediatrics, Emory University School of Medicine; Director, Pediatric Brain Tumor Program, Aflac Chair for Neuro-Oncology, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta

Tobey J MacDonald, MD is a member of the following medical societies: American Association for Cancer Research, Society for Neuro-Oncology, International Society of Paediatric Oncology

Disclosure: Nothing to disclose.

Coauthor(s)

Roger J Packer, MD Senior Vice President, Neuroscience and Behavioral Medicine, Director, Brain Tumor Institute, Children’s National Medical CenterProfessor 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, Society for Neuro-Oncology, Pediatric Brain Tumor Consortium, Neurofibromatosis Clinical Trials Consortium

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Timothy P Cripe, MD, PhD, FAAP Chief, Division of Hematology/Oncology/BMT, Gordon Teter Endowed Chair in Pediatric Cancer, Nationwide Children's Hospital; Professor of Pediatrics, Ohio State University College of Medicine

Timothy P Cripe, MD, PhD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Association for the Advancement of Science, American Association for Cancer Research, American Pediatric Society, American Society of Gene and Cell Therapy, American Society of Pediatric Hematology/Oncology, Connective Tissue Oncology Society, Society for Pediatric Research, Children's Oncology Group

Disclosure: Nothing to disclose.

Chief Editor

Max J Coppes, MD, PhD, MBA Executive Vice President, Chief Medical and Academic Officer, Renown Heath

Max J Coppes, MD, PhD, MBA is a member of the following medical societies: American College of Healthcare Executives, American Society of Pediatric Hematology/Oncology, Society for Pediatric Research

Disclosure: Nothing to disclose.

Acknowledgements

Samuel Gross, MD Professor Emeritus, Department of Pediatrics, University of Florida College of Medicine; Clinical Professor, Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine; Adjunct Professor, Department of Pediatrics, Duke University School of Medicine

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.

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This MRI shows a juvenile pilocytic astrocytoma of the cerebellum.
This MRI shows a supratentorial glioblastoma multiforme.
This section displays the typical biphasic pattern of a juvenile pilocytic astrocytoma, consisting of dense, relatively anuclear, fibrillar areas alternating with looser cystic fields.
This section displays the high cellularity, mitosis, and nuclear atypia characteristic of an anaplastic astrocytoma (grade III).
This section displays a typical field of a glioblastoma multiforme (grade IV) with pseudopalisading neovascularity, nuclear atypia, numerous mitoses, and areas of hemorrhage.
 
 
 
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