Pediatric Astrocytoma Workup

  • Author: Tobey MacDonald, MD; Chief Editor: Max J Coppes, MD, PhD, MBA   more...
 
Updated: Feb 29, 2012
 

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. See the images shown below.This MRI shows a juvenile pilocytic astrocytoma ofThis MRI shows a juvenile pilocytic astrocytoma of the cerebellum. This MRI shows a supratentorial glioblastoma multiThis MRI shows a supratentorial glioblastoma multiforme.
    • 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.
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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.
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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 (see image below), accounting for 85% of cerebellar low-grade gliomas.[3] 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. This section displays the typical biphasic patternThis section displays the typical biphasic pattern of a juvenile pilocytic astrocytoma, consisting of dense, relatively anuclear, fibrillar areas alternating with looser cystic fields.
  • 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 (see top image below). These tumors are clinically aggressive, regionally invasive, and capable of neuraxial dissemination. Grade III refers to anaplastic astrocytoma (see top image below) and grade IV is designated for glioblastoma multiforme (see bottom image below). This section displays the high cellularity, mitosiThis section displays the high cellularity, mitosis, and nuclear atypia characteristic of an anaplastic astrocytoma (grade III). This section displays a typical field of a glioblaThis section displays a typical field of a glioblastoma multiforme (grade IV) with pseudopalisading neovascularity, nuclear atypia, numerous mitoses, and areas of hemorrhage.
  • 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.
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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  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, Neurofibromatosis Clinical Trials Consortium, Pediatric Brain Tumor Consortium, and Society for Neuro-Oncology

Disclosure: Nothing to disclose.

Specialty Editor Board

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.

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  Professor of Pediatrics, Division of Hematology/Oncology, Cincinnati Children's Hospital Medical Center; Clinical Director, Musculoskeletal Tumor Program, Co-Medical Director, Office for Clinical and Translational Research, Cincinnati Children's Hospital Medical Center; Director of Pilot and Collaborative Clinical and Translational Studies Core, Center for Clinical and Translational Science and Training, University of Cincinnati College of Medicine

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.

David Pallares, MD  Clinical Assistant Professor, Department of Pediatrics, Division of Allergy and Immunology, University of Louisville School of Medicine

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  Senior Vice President, Center for Cancer and Blood Disorders, Children's National Medical Center; Professor of Medicine, Oncology, and Pediatrics, Georgetown University School of Medicine; Clinical Professor of Pediatrics, George Washington University School of Medicine and Health Sciences

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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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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