Low-Grade Astrocytoma Treatment & Management: Medical Care, Surgical Care, Consultations
Low-Grade Astrocytoma Treatment & Management: Medical Care, Surgical Care, Consultations
From the history, physical, and radiologic appearance of a tumor on CT scan or MRI, a presumptive diagnosis of a low-grade glioma can be made. The primary care physician should coordinate care with a neurologist, neurosurgeon, and oncologist. The initial treatment steps depend on patient presentation.
If the patient presents with seizures, first-line therapy is to start the patient on phenytoin (Dilantin), carbamazepine (Tegretol), or levetiracetam (Keppra).
If the patient presents with headache and has significant edema surrounding the tumor, dexamethasone (Decadron) therapy is appropriate in doses ranging from 2-4 mg every 6 hours. With dexamethasone, antiulcer medications (eg, antacid, H2 blocker) usually are prescribed. Corticosteroid therapy also may improve symptoms in patients who have low-grade astrocytomas of the spinal cord.
If hydrocephalus is observed on CT scan or MRI and the patient is symptomatic, surgical placement of a ventricular drainage device or an endoscopic third ventriculostomy (ETV) may be appropriate. Either an external ventricular drain or a ventriculoperitoneal shunt may be inserted. The exact procedure depends on any further plans for surgery.
Aside from the initial measures noted in Medical Care, the cornerstone of therapy for most low-grade gliomas is surgery.
Tumors in certain locations may be inoperable. However, most clinical series have shown that patients who undergo gross total resection have the longest survival durations. Even subtotal resection is of benefit if the tumor can be removed safely. Histologic diagnosis should be sought in every case (via biopsy or resection) if possible.
Surgery is also the primary mode of treatment for low-grade astrocytomas of the spinal cord. Depending on the appearance of the tumor at surgery, a gross total resection, subtotal resection, or only biopsy may be possible. However, resection may lead to symptomatic and objective improvement in these patients. Furthermore, in low-grade astrocytomas, long-term remission (>10 y) and even cure are frequent in both children and adults.
Intraoperative 5-ALA fluorescence can be used to help achieve a greater extent of resection. A study published by Sanai et alshowed that intraoperative confocal microscopy can help visualize cellular 5-ALA–induced tumor fluorescence within low-grade gliomas and at the brain-tumor interface. An ongoing study is investigating this further. The Barrow 5-ALA Intraoperative Confocal (BALANCE) Trial will measure the effect of 5-ALA on the amount of glioma tumor removal. The investigators' hypothesis is that 5-ALA fluorescence with the use of the special microscope during surgery will greatly lower the amount of tumor left behind.
The use of intraoperative MRI to guide the resection of gliomas in general has provided surgeons with a new tool to improve the extent of resection. One problem with this technology is its high cost and limited availability. It also extends operating times which could be a downside for patients with high anesthetic risk.
Intraoperative neurophysiological monitoring has been used increasingly in the last few years.(See Intraoperative Neurophysiological Monitoring.) This is a preferred technique to remove lesions close to, or involving, eloquent (functionally important) regions of the brain. The goal of such monitoring is to identify changes in brain and spinal cord function prior to irreversible damage. Intraoperative monitoring also has been effective in localizing anatomical structures, which helps guide the surgeon during dissection.
One of the electrophysiological modalities is intraoperative cortical mapping, which can help to achieve a greater extent of resection. The mapping is often done with small electrodes that stimulate certain areas of the brain and evoke particular responses. This technique is often used in combination with awake craniotomy.
In awake craniotomy, the patient is awake during parts of the procedure. With the patient awake, it is possible to test regions of the brain before they are incised or removed, and patient’s function is tested continuously throughout the operation.
See Brain Cancer Treatment Protocols for summarized information.
Patients in whom a low-grade astrocytoma is suspected should be evaluated primarily by a neurosurgeon. The neurosurgeon will guide the diagnostic evaluation and will ultimately decide upon the best course of treatment which in most cases will include some form of surgical procedure.
Patients who present with seizures must be evaluated by a neurologist, ideally one specializing in epilepsy to ensure the best control of symptoms through judicious use of anti-epileptic medications.
Although most patients with low-grade astrocytomas will initially requiere surgery as their only form of treatment, it is advisable to obtain an oncology consult. Depending on tumor hystology the risk of recurrence will vary and some patients will eventually benefit from combined forms of treatment including chemotherapy and/or radiation therapy.
Other consults should be considered only in individual circumstances (e.g. psychiatry in patients with concomitant psychoaffective disorders).
There are no special dietary restrictions for patients with brain tumors although patients with pre-existing medical conditions which warrant dietary modifications must continue to abide by their previous regimens to avoid potential complications (e.g. episodes of hypo/hyperglicemia in diabetic patients).
In general, no restrictions are placed on activity of patients with low-grade glioma. However, patients' activity may relate to their overall neurologic status. The presence of seizures may prevent the patient from driving. Neurologic deficits such as hemiparesis may improve after treatment. Physical therapy is often beneficial.
Medication
George I Jallo, MD Professor of Neurosurgery, Pediatrics, and Oncology, Director, Clinical Pediatric Neurosurgery, Department of Neurosurgery, Johns Hopkins University School of Medicine
George I Jallo, MD is a member of the following medical societies: American Association of Neurological Surgeons, American Medical Association, American Society of Pediatric Neurosurgeons
Disclosure: Received grant/research funds from Codman (Johnson & Johnson) for consulting; Received grant/research funds from Medtronic for consulting.
Coauthor(s)
Eveline Teresa Hidalgo Staub, MD Neurosurgery Attending, Division of Neurosurgery, General and Pediatric Neurosurgery, Luzerner Kantonsspital
Eveline Teresa Hidalgo Staub, MD is a member of the following medical societies: Swiss Society of Neurosurgery, Swiss Young Neurosurgeons Society
David A Chesler, MD, PhD Clinical and Research Fellow, Division of Pediatric Neurosurgery, Johns Hopkins University School of Medicine
David A Chesler, MD, PhD is a member of the following medical societies: American Association of Neurological Surgeons, American Medical Association, Congress of Neurological Surgeons
Rafael Uribe-Cardenas, MD Resident Physician in Neurosurgery, Department of Neuroscience, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Colombia
Rafael Uribe-Cardenas, MD is a member of the following medical societies: Colombian Association of Neurosurgery
Specialty Editor Board
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Jorge C Kattah, MD Head, Associate Program Director, Professor, Department of Neurology, University of Illinois College of Medicine at Peoria
Jorge C Kattah, MD is a member of the following medical societies: American Academy of Neurology, American Neurological Association, New York Academy of Sciences
Disclosure: Received honoraria from Biogen for consulting; Received honoraria from Bayer Corporation for consulting.
Chief Editor
Tarakad S Ramachandran, MBBS, FRCP, FRCPC Professor Emeritus of Neurology and Psychiatry, Clinical Professor of Medicine, Clinical Professor of Family Medicine, Clinical Professor of Neurosurgery, State University of New York Upstate Medical University; Neuroscience Director, Department of Neurology, Crouse Irving Memorial Hospital
Tarakad S Ramachandran, MBBS, FRCP, FRCPC is a member of the following medical societies: American College of International Physicians, American Heart Association, American Stroke Association, American Academy of Neurology, American Academy of Pain Medicine, American College of Forensic Examiners Institute, National Association of Managed Care Physicians, American College of Physicians, Royal College of Physicians, Royal College of Physicians and Surgeons of Canada, Royal College of Surgeons of England, Royal Society of Medicine
Rodrigo O Kuljis, MD Esther Lichtenstein Professor of Psychiatry and Neurology, Director, Division of Cognitive and Behavioral Neurology, Department of Neurology, University of Miami School of Medicine
Rodrigo O Kuljis, MD is a member of the following medical societies: American Academy of Neurology, Society for Neuroscience
Acknowledgements
Ethan A Benardete, MD, PhD Staff Physician, Department of Neurosurgery, New York University Medical Center
References
A 28-year-old male taxi driver presented to the emergency department after having a seizure. Noncontrast head CT scan was obtained showing the typical appearance of a low-grade astrocytoma. The lesion in the mesial left frontal lobe was hypodense on CT scan.
Preoperative MRI of the brain of a 28-year-old male taxi driver who presented to the emergency department after having a seizure. On T1-weighted sequences, the tumor does not enhance and shows decreased signal intensity compared to normal brain. These findings are consistent with low-grade astrocytoma.
For tumors, MRI has the advantage of showing the lesion in multiple planes. This image, a T1-weighted sagittal image of the brain of a 28-year-old male taxi driver who presented to the emergency department after having a seizure, shows the tumor along the mesial aspect of the frontal lobe. Note that mass effect is minimal, typical of a low-grade lesion.
T2-weighted sequences of an MRI of the brain of a 28-year-old male taxi driver who presented to the emergency department after having a seizure show increased signal intensity compared with normal brain. The radiologic appearance is typical of low-grade astrocytoma.
A 9-year-old boy presented with headaches and gradual onset of right hemiparesis. MRI of the brain was obtained. The T2-weighted sequence in this MRI shows a tumor in the left thalamus, which is a typical location for a juvenile pilocytic astrocytoma. Note the relatively well-circumscribed nature of the lesion.
Coronal T1-weighted gadolinium-enhanced MRI of the brain shows the tumor of a 9-year-old boy who presented with headaches and gradual onset of a right hemiparesis. Note the heterogeneous enhancement of the tumor.
Sagittal T1-weighted MRI of the brain shows juvenile pilocytic astrocytoma of a 9-year-old boy who presented with headaches and gradual onset of right hemiparesis. Stereotactic surgery has made resection of these low-grade tumors in this deep location feasible.
A 3-year-old boy presented with speech regression. MRI of the brain revealed a tumor in the left mesial temporal lobe. This T1-weighted gadolinium-enhanced image shows an enhancing tumor involving the hippocampus, uncus, and amygdala. The surgical pathologic studies revealed a low-grade mixed tumor of astrocytes and atypical neurons, a ganglioglioma.
Medical Care
From the history, physical, and radiologic appearance of a tumor on CT scan or MRI, a presumptive diagnosis of a low-grade glioma can be made. The primary care physician should coordinate care with a neurologist, neurosurgeon, and oncologist. The initial treatment steps depend on patient presentation.
If the patient presents with seizures, first-line therapy is to start the patient on phenytoin (Dilantin), carbamazepine (Tegretol), or levetiracetam (Keppra).
If the patient presents with headache and has significant edema surrounding the tumor, dexamethasone (Decadron) therapy is appropriate in doses ranging from 2-4 mg every 6 hours. With dexamethasone, antiulcer medications (eg, antacid, H2 blocker) usually are prescribed. Corticosteroid therapy also may improve symptoms in patients who have low-grade astrocytomas of the spinal cord.
If hydrocephalus is observed on CT scan or MRI and the patient is symptomatic, surgical placement of a ventricular drainage device or an endoscopic third ventriculostomy (ETV) may be appropriate. Either an external ventricular drain or a ventriculoperitoneal shunt may be inserted. The exact procedure depends on any further plans for surgery.
Surgical Care
Aside from the initial measures noted in Medical Care, the cornerstone of therapy for most low-grade gliomas is surgery.
Tumors in certain locations may be inoperable. However, most clinical series have shown that patients who undergo gross total resection have the longest survival durations. Even subtotal resection is of benefit if the tumor can be removed safely. Histologic diagnosis should be sought in every case (via biopsy or resection) if possible.
Surgery is also the primary mode of treatment for low-grade astrocytomas of the spinal cord. Depending on the appearance of the tumor at surgery, a gross total resection, subtotal resection, or only biopsy may be possible. However, resection may lead to symptomatic and objective improvement in these patients. Furthermore, in low-grade astrocytomas, long-term remission (>10 y) and even cure are frequent in both children and adults.
Intraoperative 5-ALA fluorescence can be used to help achieve a greater extent of resection. A study published by Sanai et alshowed that intraoperative confocal microscopy can help visualize cellular 5-ALA–induced tumor fluorescence within low-grade gliomas and at the brain-tumor interface. An ongoing study is investigating this further. The Barrow 5-ALA Intraoperative Confocal (BALANCE) Trial will measure the effect of 5-ALA on the amount of glioma tumor removal. The investigators' hypothesis is that 5-ALA fluorescence with the use of the special microscope during surgery will greatly lower the amount of tumor left behind.
The use of intraoperative MRI to guide the resection of gliomas in general has provided surgeons with a new tool to improve the extent of resection. One problem with this technology is its high cost and limited availability. It also extends operating times which could be a downside for patients with high anesthetic risk.
Intraoperative neurophysiological monitoring has been used increasingly in the last few years.(See Intraoperative Neurophysiological Monitoring.) This is a preferred technique to remove lesions close to, or involving, eloquent (functionally important) regions of the brain. The goal of such monitoring is to identify changes in brain and spinal cord function prior to irreversible damage. Intraoperative monitoring also has been effective in localizing anatomical structures, which helps guide the surgeon during dissection.
One of the electrophysiological modalities is intraoperative cortical mapping, which can help to achieve a greater extent of resection. The mapping is often done with small electrodes that stimulate certain areas of the brain and evoke particular responses. This technique is often used in combination with awake craniotomy.
In awake craniotomy, the patient is awake during parts of the procedure. With the patient awake, it is possible to test regions of the brain before they are incised or removed, and patient’s function is tested continuously throughout the operation.
See Brain Cancer Treatment Protocols for summarized information.
Consultations
Patients in whom a low-grade astrocytoma is suspected should be evaluated primarily by a neurosurgeon. The neurosurgeon will guide the diagnostic evaluation and will ultimately decide upon the best course of treatment which in most cases will include some form of surgical procedure.
Patients who present with seizures must be evaluated by a neurologist, ideally one specializing in epilepsy to ensure the best control of symptoms through judicious use of anti-epileptic medications.
Although most patients with low-grade astrocytomas will initially requiere surgery as their only form of treatment, it is advisable to obtain an oncology consult. Depending on tumor hystology the risk of recurrence will vary and some patients will eventually benefit from combined forms of treatment including chemotherapy and/or radiation therapy.
Other consults should be considered only in individual circumstances (e.g. psychiatry in patients with concomitant psychoaffective disorders).
Diet
There are no special dietary restrictions for patients with brain tumors although patients with pre-existing medical conditions which warrant dietary modifications must continue to abide by their previous regimens to avoid potential complications (e.g. episodes of hypo/hyperglicemia in diabetic patients).
Activity
In general, no restrictions are placed on activity of patients with low-grade glioma. However, patients' activity may relate to their overall neurologic status. The presence of seizures may prevent the patient from driving. Neurologic deficits such as hemiparesis may improve after treatment. Physical therapy is often beneficial.
Medication
George I Jallo, MD Professor of Neurosurgery, Pediatrics, and Oncology, Director, Clinical Pediatric Neurosurgery, Department of Neurosurgery, Johns Hopkins University School of Medicine
George I Jallo, MD is a member of the following medical societies: American Association of Neurological Surgeons, American Medical Association, American Society of Pediatric Neurosurgeons
Disclosure: Received grant/research funds from Codman (Johnson & Johnson) for consulting; Received grant/research funds from Medtronic for consulting.
Coauthor(s)
Eveline Teresa Hidalgo Staub, MD Neurosurgery Attending, Division of Neurosurgery, General and Pediatric Neurosurgery, Luzerner Kantonsspital
Eveline Teresa Hidalgo Staub, MD is a member of the following medical societies: Swiss Society of Neurosurgery, Swiss Young Neurosurgeons Society
David A Chesler, MD, PhD Clinical and Research Fellow, Division of Pediatric Neurosurgery, Johns Hopkins University School of Medicine
David A Chesler, MD, PhD is a member of the following medical societies: American Association of Neurological Surgeons, American Medical Association, Congress of Neurological Surgeons
Rafael Uribe-Cardenas, MD Resident Physician in Neurosurgery, Department of Neuroscience, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Colombia
Rafael Uribe-Cardenas, MD is a member of the following medical societies: Colombian Association of Neurosurgery
Specialty Editor Board
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Jorge C Kattah, MD Head, Associate Program Director, Professor, Department of Neurology, University of Illinois College of Medicine at Peoria
Jorge C Kattah, MD is a member of the following medical societies: American Academy of Neurology, American Neurological Association, New York Academy of Sciences
Disclosure: Received honoraria from Biogen for consulting; Received honoraria from Bayer Corporation for consulting.
Chief Editor
Tarakad S Ramachandran, MBBS, FRCP, FRCPC Professor Emeritus of Neurology and Psychiatry, Clinical Professor of Medicine, Clinical Professor of Family Medicine, Clinical Professor of Neurosurgery, State University of New York Upstate Medical University; Neuroscience Director, Department of Neurology, Crouse Irving Memorial Hospital
Tarakad S Ramachandran, MBBS, FRCP, FRCPC is a member of the following medical societies: American College of International Physicians, American Heart Association, American Stroke Association, American Academy of Neurology, American Academy of Pain Medicine, American College of Forensic Examiners Institute, National Association of Managed Care Physicians, American College of Physicians, Royal College of Physicians, Royal College of Physicians and Surgeons of Canada, Royal College of Surgeons of England, Royal Society of Medicine
Rodrigo O Kuljis, MD Esther Lichtenstein Professor of Psychiatry and Neurology, Director, Division of Cognitive and Behavioral Neurology, Department of Neurology, University of Miami School of Medicine
Rodrigo O Kuljis, MD is a member of the following medical societies: American Academy of Neurology, Society for Neuroscience
Acknowledgements
Ethan A Benardete, MD, PhD Staff Physician, Department of Neurosurgery, New York University Medical Center
References
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A 28-year-old male taxi driver presented to the emergency department after having a seizure. Noncontrast head CT scan was obtained showing the typical appearance of a low-grade astrocytoma. The lesion in the mesial left frontal lobe was hypodense on CT scan.
Preoperative MRI of the brain of a 28-year-old male taxi driver who presented to the emergency department after having a seizure. On T1-weighted sequences, the tumor does not enhance and shows decreased signal intensity compared to normal brain. These findings are consistent with low-grade astrocytoma.
For tumors, MRI has the advantage of showing the lesion in multiple planes. This image, a T1-weighted sagittal image of the brain of a 28-year-old male taxi driver who presented to the emergency department after having a seizure, shows the tumor along the mesial aspect of the frontal lobe. Note that mass effect is minimal, typical of a low-grade lesion.
T2-weighted sequences of an MRI of the brain of a 28-year-old male taxi driver who presented to the emergency department after having a seizure show increased signal intensity compared with normal brain. The radiologic appearance is typical of low-grade astrocytoma.
A 9-year-old boy presented with headaches and gradual onset of right hemiparesis. MRI of the brain was obtained. The T2-weighted sequence in this MRI shows a tumor in the left thalamus, which is a typical location for a juvenile pilocytic astrocytoma. Note the relatively well-circumscribed nature of the lesion.
Coronal T1-weighted gadolinium-enhanced MRI of the brain shows the tumor of a 9-year-old boy who presented with headaches and gradual onset of a right hemiparesis. Note the heterogeneous enhancement of the tumor.
Sagittal T1-weighted MRI of the brain shows juvenile pilocytic astrocytoma of a 9-year-old boy who presented with headaches and gradual onset of right hemiparesis. Stereotactic surgery has made resection of these low-grade tumors in this deep location feasible.
A 3-year-old boy presented with speech regression. MRI of the brain revealed a tumor in the left mesial temporal lobe. This T1-weighted gadolinium-enhanced image shows an enhancing tumor involving the hippocampus, uncus, and amygdala. The surgical pathologic studies revealed a low-grade mixed tumor of astrocytes and atypical neurons, a ganglioglioma.
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