Neurosurgical Consultants: Nervous System Tumors - Malignant: Anaplastic Astrocytoma

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Martin L. Lazar, MD, FACS, FAANS
James E. Bland, MD, FAANS

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ANAPLASTIC ASTROCYTOMA

Anaplastic Astrocytomas are among the most common Primary Malignant Brain Tumors. These tumors represent approximately one third of all Astrocytomas and about one quarter of all Gliomas. They occur at any age but typically are found in older patients. Their peak incidence is in the fifth and sixth decades of life.

Malignant Astrocytomas generally have a poor prognosis, with an average survival of two (2) years. Both types of malignant Glial tumors (Anaplastic Astrocytomas and Glioblastomas) spread through the extracellular space and along the compact white matter tracts that connect each part of the Brain with every other part of the Brain.

SYMPTOMS

Seizures and focal neurological deficits are common presenting symptoms. In addition, any of the symptoms described previously, may be present at the time of diagnosis.

DIAGNOSIS

MRI Scan is the single most useful Neuroimaging study. It provides detailed information about the size, location and gross architectural features of these tumors as well as identifying the extent of Cerebral Edema (swelling) and effect upon the surrounding Brain tissue.

Figure 1: MRI Scan (Transaxial View) of a 34 year old Asian Female with a two (2) week history of severe headache with confusion. This scan demonstrates a large, partially cystic Right Frontal Lobe tumor with considerable edema, midline shift and Ventricular compression.

Figure 2: MRI Scan (Gadolinium enhanced Sagittal Series - Same Patient as in Figure1)
Large Cyst within the tumor (Right-angled Arrows)
"Gadolinium" uptake indicative of the of the considerable blood supply to this highly malignant brain tumor (dense white areas identified by Horizontal Arrows).

Figure 3: MRI Scan (Coronal View+ Gadolinium-Same Patient as in Figures 1 & 2)
The large partially cystic, "enhancing" tumor has caused considerable "midline" shift. (The Horizontal Arrows indicate the "Shifted" Midline structure.)
Edema surrounds the tumor (Vertical Arrows indicating the dark grey area.)
COMPARE Figures 1-3 to Figures 4-5 of the same patient which were taken at 5 years post-operative radical Right Frontal Lobectomy for a Grade 3 Glioma followed by Radiation and Chemotherapy. This lady subsequently has had 2 successful pregnancies and is neurologically intact.

TREATMENT

Surgery

Surgery to reduce the bulk of the tumor, followed by Radiation Therapy, has become the standard against which other treatments are compared. One must consider that these tumors cannot usually be cured with surgery alone, although the Neurosurgeons of Neurosurgical Consultants are encouraged by their increasing experience with long term survival using a combination of aggressive approaches. The goals of treatment, if "cure" is not possible, should be to prolong survival, together with a higher quality of life.

Because of the infiltrative nature of Astrocytoma, it is unlikely that surgery will ever be the single definitive treatment for these neoplasms. However, increasingly safe and aggressive tumor resection is possible with the advent of technological advances such as intra-operative MRI and Ultrasonic imaging systems, as well as, actual tumor-brain interface "visualization", using Fluorescence-guided resection techniques..

Figure 4 A (Left): MRI Scan (Transaxial View-Gadolinium enhanced in the same patient as Figures 1, 2, 3 & 5) demonstrates a radical Right Frontal Lobectomy. (Quadrangular Arrow)

Figure 4 B (Right): MRI Scan (Same Patient-Coronal View-Gadolinium enhanced) after radical Right Frontal Lobectomy (Quadrangular Arrow.)

Figure 5: "Metabolic" MRI Scan (Transaxial View-Same Patient)
There is no evidence of residual or recurrent tumor at a point 5 years post-operative radical Right Frontal Lobectomy/Chemotherapy & Radiation Therapy.
COMPARE Figures 4 & 5 to Figures 1-3 from the same patient who had an Anaplastic Astrocytoma (Grade 3 Glioma).

NEW TREATMENT CONCEPTS

FLUORESCENCE- Guided Neurosurgery

FLUORESCENCE is one of the most advanced concepts for the surgical management of an infiltrative Brain tumor and the ONLY METHOD that permits the Neurosurgeon to visually identify the tumor that infiltrates Brain tissue. This technique (developed primarily in Europe) involves the ingestion of a medication (5-aminolevulinic acid or "ALA" dissolved in water) that is taken up in certain molecules of the tumor which when subjected to a special violet-blue light beamed through the Neurosurgical Operating Microscope actually ("lights up") glows.

Figure 6: Simulated Fluorescence
ALA has been taken up in certain molecules of the tumor which when subjected to a special violet-blue light beamed through the Neurosurgical Operating Microscope actually( "lights up") glows.

Tumor Cell Culture Helps Chemotherapy Decisions

The Neurosurgeons of Neurosurgical Consultants firmly believe that aggressive resection of the tumor, is the first definitive step in the treatment of these tumors. Other steps include Chemotherapy and Radiation Therapy. Some additional technologies have also helped to improve their outcomes. For example, it is now possible to grow cultures of the tumor and subject these in the laboratory to sensitivity testing against various chemotherapy agents prior to initiating Chemotherapy in a clinical setting.

New Chemotherapies

Traditional management has been to use "standard" forms of chemotherapy. Currently there are some unconventional chemotherapeutic alternatives that offer considerable hope for improved quality and length of survival. New therapies such as Temodar (temozolamide), Avastin (bevacizumab which is an anti-angiogenesis medication) and CPT-11 are currently being used by one of our Neuro-oncologists. Preliminary results have been encouraging. The reader may wish to view the "Virtual Trials" website for additional information.

Direct Chemotherapy

In some tumor cases we choose to place a special chamber called an "Ommaya Reservoir" under the scalp, with an attached catheter residing in the "bed" of the tumor, after resection has been completed. This permits the Neuro-oncologist to instill chemotherapeutic medications directly into the tumor bed. This is a far more effective methodology than placing "chemotherapy wafers in the tumor bed.

Radiation Therapy

Radiation therapy continues to have an important place in the treatment of many of these tumors. Refinements have been made that make this treatment less toxic than in previous years.

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This page last edited on 2/19