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TREATMENT AND MANAGEMENT OF ASTROCYTOMA

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 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.
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 6month 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.
No benefit of surgical resection has been shown, largely due to the eloquence of
the region and diffuse and aggressive nature of the tumor. 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.Even with radiation therapy, 1-year survival has
been shown to be 35-46%, and 3-year survival 11-17%. Chemotherapy is also
sometimes used. 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.