From: "Robert A. Fink, M.D."
Subject: Recurrence rates for low grade astrocytomas
PubMed medline query
----------
Int J Radiat Oncol Biol Phys 1988 Oct;15(4):837-41
Low-grade astrocytomas: treatment results and prognostic variables.
Medbery CA 3d, Straus KL, Steinberg SM, Cotelingam JD, Fisher WS
Division of Radiation Oncology, Naval Hospital, Bethesda, MD 20814.
Low-grade astrocytomas in adults are uncommon malignant neoplasms of the
central nervous system which are fatal in the great majority of patients
despite a lack of aggressive histologic features. Several series of such
patients have been previously reported, but prognostic factors have not been
fully identified. Between 1960 and 1986, 50 patients with low-grade
astrocytomas have been treated with megavoltage radiation at the Naval
Hospital, Bethesda, MD, following surgical biopsy or excision. Overall
actuarial survival at 10 years for the entire treated group was 32%, similar to
other series. The most significant prognostic factor was patient age, with
decreasing survival for each age decade and a highly significant difference in
survival between patients less than age 40 compared to older patients (p =
.0017). The era of treatment (before or after 1978) was also an important
prognostic indicator (p = .057), largely due to an effect of dose, although
better tumor localization in the CT era may also have played a role. There was
a trend toward increasing survival with increasing dose of radiation, although
not reaching statistical significance at the p = .05 level on multivariate
analysis. Patient sex, extent of surgical resection, use of whole brain
irradiation, and tumor grade did not significantly affect survival. In
comparison, in a separate group of 10 patients who received surgery without
radiation during the same period, all patients who were completely resected
were long-term survivors, whereas none of those with incomplete resections
survived longer than 6 years.
PMID: 3141317, UI: 89033197
J Neurooncol 1996 May-Jun;28(2-3):223-31
Cerebellar astrocytomas in children.
Campbell JW, Pollack IF
Department of Neurological Surgery, Children's Hospital of Pittsburgh, USA.
Cerebellar astrocytomas, as a group, carry a more favorable prognosis than most
other brain tumors, because these neoplasms generally are histologically benign
and amenable to extensive resection. However, it is clear that a number of
factors have an impact on prognosis. In particular, resection extent has been
strongly associated with progression-free survival: patients undergoing gross
total resection appear to have a substantially better prognosis than those
undergoing incomplete resection. Brainstem invasion, which is the factor that
most often precludes a complete resection, has also been associated with a less
favorable prognosis. In addition, histological features indicative of
malignancy are clearly associated with a poor outcome. In contrast to the above
observations, which have been established convincingly in the literature, a
number of issues regarding cerebellar astrocytomas remain unresolved. First,
the correlation between histology and prognosis among patients with low-grade
cerebellar astrocytomas is uncertain: in some series, pilocytic astrocytomas
have been associated with a better prognosis than non-pilocytic tumors, but in
other studies, no such relationship has been observed. Second, the role of
radiotherapy after incomplete resection of a low-grade cerebellar astrocytoma
remains problematic. In view of the lack of convincing data in this regard,
many groups, including our own, defer radiotherapy until there is evidence of
progressive disease that is surgically unresectable. Finally, the frequency of
follow-up in patients with cerebellar astrocytomas remains largely empirical.
Although most recurrences are detected within a few years after initial
surgery, late recurrences are well known, which raises the question of when and
if such patients should be regarded as "cured' of their disease. Long-term
multi-institutional natural history studies are in progress to address the
above issues.
Publication Types:
Review
Review, tutorial
PMID: 8832464, UI: 96429363
Cancer 1988 Nov 15;62(10):2152-65
Grading of astrocytomas. A simple and reproducible method.
Daumas-Duport C, Scheithauer B, O'Fallon J, Kelly P
Department of Pathology, Mayo Clinic, Rochester, Minnesota.
This study determines the effectiveness and reproducibility of a previously
published method of grading gliomas. The method under study is for use on
"ordinary astrocytoma" cell types, i.e., fibrillary, protoplasmic,
gemistocytic, anaplastic astrocytomas and glioblastomas, and is based upon the
recognition of the presence or absence of four morphologic criteria: nuclear
atypia, mitoses, endothelial proliferation, and necrosis. The method results in
a summary score which is translated into a grade as follows: 0 criteria = grade
1, 1 criterion = grade 2, 2 criteria = grade 3, 3 or 4 criteria = grade 4. The
histologic material and clinical data were derived from a previously reported
series of patients with astrocytomas, radiotherapeutically treated at Mayo
Clinic between the years 1960 and 1969. From this series, initially graded 1 to
4, according to the Kernohan system, 287 "ordinary astrocytomas" were entered
into the study; 51 pilocytic astrocytomas and microcystic cerebellar-type
astrocytomas also were included for comparison. Among ordinary astrocytomas,
the grading method under study distinguished 0.7% of grade 1, 17% of grade 2,
18% of grade 3, and 65.3% of grade 4. A 15-year period of follow-up was
available on all surviving patients. Statistical analysis showed that in
ordinary astrocytomas, each of the four histologic criteria, as well as the
resultant grade, were strongly correlated to survival (P less than 0.0001).
Median survival was 4 years in grade 2, 1.6 years in grade 3, and 0.7 years in
grade 4 tumors. Of the two patients with grade 1 ordinary astrocytomas, 1 had
11 years of survival, and the other was alive at 15 years. Furthermore, based
upon the Cox Model, grade was found to be the major prognostic factor,
superceding the effects of age, sex, and location. Among ordinary astrocytomas,
the grading system under consideration clearly distinguished four distinct
grades of malignancy, whereas, the Kernohan grading system accurately
distinguished only two major groups of patients. Survival curve of patients
with our grade 2 tumors coincided with the grade 1 and 2 Kernohan survival
curves. Similarly, our grade 4 survival curve coincided with the Kernohan grade
3 and 4 survival curves. As a result, our proposed grading method generated an
individualized curve corresponding to grade 3 tumors. Double-blind grading
between two independent observers was concordant in 94% of ordinary
astrocytomas; reproducibility was 81% in low-grade (grades 1 and 2) and 96% in
high-grade (grades 3 and 4) astrocytomas of ordinary type.
PMID: 3179928, UI: 89028094
Neurosurgery 1989 May;24(5):686-92
Prognostic factors in well-differentiated cerebral astrocytomas in the adult.
Soffietti R, Chio A, Giordana MT, Vasario E, Schiffer D
Second Department of Neurology, University of Torino, Italy.
Eighty-five "well-differentiated" astrocytomas in adults (age, greater than or
equal to 18 years), operated on between 1950 and 1982, were retrospectively
reviewed. The pilocytic variant was not included. Twenty-four clinical and 8
histological factors were analyzed to investigate their importance in
predicting length of survival. Multivariate analysis showed that the following
variables were correlated with survival time (P less than 0.01): extent of
surgical removal, altered consciousness during preoperative examination, focal
deficit as presenting symptom, performance status (Karnofsky rating) after
surgery, and vessel size in the surgical specimen. Total removal of the tumor
was related to a higher 5-year survival rate (51%) than subtotal removal
(23.5%), and none of the patients with partial removal survived more than 5
years. Postoperative radiotherapy (40-55 Gy) improved only the 1- and 3-year
survival rates. Based on the significant factors provided by multivariate
analysis, a score was developed to detect subgroups with different prognoses.
Median survival time ranged from 383 days for patients with a score greater
than or equal to 2.5 to 1,533 days for those with a score less than 0.5; no
patient with a score greater than or equal to 1.5 survived more than 10 years.
The percentage of recurring astrocytomas that showed anaplastic areas in the
second biopsy specimen was 79%. Total surgical removal is the most important
factor in the management of well-differentiated astrocytomas, whereas the
efficacy of postoperative radiotherapy still needs to be confirmed by
prospective and randomized studies. The rationale for treating incompletely
resected astrocytomas with radiation therapy could lie in the high incidence of
malignant transformation.
Comments:
Comment in: Neurosurgery 1990 Feb;26(2):359-60
PMID: 2716976, UI: 89238900
J Neurosurg 1989 Oct;71(4):487-93
Supratentorial anaplastic gliomas in adults. The prognostic importance of
extent of resection and prior low-grade glioma.
Winger MJ, Macdonald DR, Cairncross JG
Department of Oncology, University of Western Ontario, London, Canada.
A retrospective analysis is presented of factors affecting the length of
survival of 285 consecutive adults with newly diagnosed biopsy-proven
supratentorial anaplastic glioma (188 cases of glioblastoma multiforme, 76 of
anaplastic astrocytoma, 11 of anaplastic mixed glioma, and 10 of anaplastic
oligodendroglioma) treated at a regional cancer center from July, 1982, through
December, 1987. The approach to initial therapy included maximum feasible
resection and radiotherapy. The median survival time for all patients was 35
weeks. Multivariate analysis demonstrated that age, duration of symptoms,
preirradiation performance status, tumor histology, accessibility to resection,
extent of resection, radiotherapy, and prior low-grade glioma were significant
independent variables influencing survival. The prognostic importance of age,
duration of symptoms, performance status, and tumor histology are already
recognized, but three "new" findings are reported. First, patients with
anaplastic oligodendroglioma had the longest median survival time (278 weeks).
Second, corrected for accessibility and all other variables, patients with
gross total resection lived longer than those with partial resection, and
patients with any degree of resection lived longer than those who underwent
only a biopsy procedure. Third, patients with anaplastic glioma in whom there
was a prior history of low-grade glioma lived significantly longer after the
diagnosis of anaplastic glioma than did patients in whom the anaplastic glioma
apparently arose de novo.
PMID: 2552044, UI: 90011290
Neurosurgery 1992 Oct;31(4):636-42; discussion 642
Treatment and survival of low-grade astrocytoma in adults--1977-1988.
McCormack BM, Miller DC, Budzilovich GN, Voorhees GJ, Ransohoff J
Department of Neurosurgery, New York University Medical Center, New York.
A retrospective review of the records of the Division of Neuropathology at the
New York University Medical Center between 1977 and 1988 revealed 53 cases of
adult supratentorial astrocytomas. Fifty were fibrillary, and three were
gemistocytic. Two additional patients had pilocytic tumors and were not
included in the study. The majority of patients had either a subtotal (64%) or
gross total resection (19%). Biopsy (17%) was performed for deep-seated lesions
and for those lesions confined to eloquent cortex. Forty-eight patients (91%)
received postoperative radiation therapy. The median survival was 7 1/4 years
with a 5-year survival of 64%. Multivariate regression analysis demonstrated
that the most important prognosticators for improved survival were young age,
absence of contrast enhancement of the original tumor on computed tomography
(CT) and the performance status of the patient. Patients with hemispheric
tumors died from dedifferentiation into an anaplastic astrocytoma or a
glioblastoma multiforme, with a median time to recurrence of 4.5 years from the
original surgery. Survival from the time of recurrence was 12 months.
Subsequent operations confirmed progression towards malignancy in six of seven
(86%) recurrent tumors. CT contrast enhancement of the original tumor was
associated with a 6.8-fold increase in risk for later recurrence. Patients with
thalamic tumors (six patients) had a poor prognosis with a median survival of
less than 2 years. A review of their CT scans suggest that four died of
progressive low-grade disease; however, confirmatory autopsy data were
available for only one patient. This study supports others that have shown
improved survival for adult patients with astrocytomas treated in the CT era.
PMID: 1407448, UI: 93025515
Neurosurg Rev 1996;19(4):217-20
Management of pilocytic astrocytoma.
Kayama T, Tominaga T, Yoshimoto T
Department of Neurosurgery, Tohoku University School of Medicine, Sendai,
Japan.
Pilocytic astrocytoma, when totally resected, has a favorable outcome compared
to other astrocytomas. However, when residual tumor remains, the prognosis is
less satisfactory. Our study addressed the issues of prognosis in cases of
residual tumor and the effect of post-surgical radiation therapy on tumor
recurrence. We analyzed 41 cases of pilocytic astrocytoma which were diagnosed
by histologic examination. Twenty-six patients were 15 years old or younger,
and 15 patients were 16 years old or older. An analysis of the relationship
between age and tumor location revealed a cerebellar predominance in both age
groups; however, there were more brain stem and basal ganglia tumors among
adults. Overall prognosis was favorable, with a 2-year survival rate of 97.6%,
94.6% at 5 years, and 94.6% at 10 years. Children had a better prognosis than
adults due to more favorable tumor location. Gross total resection resulted in
the best prognosis, i.e., no recurrence during a 10-year follow-up period.
Radiation treatment after surgery suppressed residual tumor. We concluded that
the best treatment for pilocytic astrocytoma is: 1) total resection, if
possible, followed by 2) irradiation of any residual tumor to suppress
recurrence.
PMID: 9007882, UI: 97160382
Return to index of Dr. Fink's posts