Astrocytoma medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ammu Susheela, M.D. [2]

Overview

The optimal therapy for astrocytoma depends on the stage at diagnosis. Chemotherapy is recommended for children. Radiation and chemotherapy with stem cell transplant is recommended for adults with high grade astrocytoma.

Medical Therapy

Chemotherapy

• Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). Combination chemotherapy is the use of more than one anticancer drug.
• Systemic chemotherapy is used in the treatment of children with astrocytoma. The way the chemotherapy is given depends on the type of tumor and where the tumor formed in the brain or spinal cord.

High-dose Chemotherapy with Stem Cell Transplant

• High-dose chemotherapy with stem cell transplant is a way of giving high doses of chemotherapy and replacing blood -forming cells destroyed by the cancer treatment. Stem cells (immature blood cells) are removed from the blood or bone marrow of the patient or a donor and are frozen and stored. After the chemotherapy is completed, the stored stem cells are thawed and given back to the patient through an infusion. These reinfused stem cells grow into (and restore) the body's blood cells.
• Treatment depends on the size and type of tumor and the child's general health. The goals of treatment may be to cure the tumor, relieve symptoms, and improve brain function or the child's comfort
• Two related drugs have been shown to shrink or stabilize supependymal giant cell tumors: rapamycin and everolimus. These both belong to the mTOR inhibitor class of immunosuppressants, and are both contraindicated in patients with severe infections.

• Rapamycin showed efficacy in five cases of SEGA in TSC patients, shrinking their tumor volumes by an average of 65%. However, after the drug was stopped, the tumors regrew.
• Everolimus which has a similar structure as rapamycin, but with slightly increased bioavailability and shorter half-life, was studied in 28 patients with SEGA. There was a significant reduction in SEGA size in 75% of the patients, and a mild improvement in their seizures. Everolimus was approved for the treatment of SEGA by the US Food and Drug Administration (FDA) in October, 2010.

• Medicines used to treat primary brain tumors in children include:

• Corticosteroids to reduce brain swelling
• Diuretics (water pills) to reduce brain swelling and pressure
• Anticonvulsants to reduce or prevent seizures
• Pain medicines

• Comfort measures, safety measures, physical therapy, occupational therapy, and other such steps may be required to improve quality of life.
• Despite decades of therapeutic research, curative intervention is still nonexistent for high grade astrocytomas; patient care ultimately focuses on palliative management.

Radiation Therapy

• Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy:
  • External radiation therapy uses a machine outside the body to send radiation toward the cancer.
  • Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer.
• External radiation therapy is used to treat astrocytoma in children. The way the radiation therapy is given depends on the type of tumor and where the tumor formed in the brain or spinal cord.Radiation therapy to the brain can affect growth and development in young children. Certain ways of giving radiation therapy can lessen the damage to healthy brain tissue:
  • Conformal radiation therapy uses a computer to make a 3-dimensional (3-D) picture of the tumor and shapes the radiation beams to fit the tumor. This allows a high dose of radiation to reach the tumor and causes less damage to normal tissue around the tumor.
  • Intensity-modulated radiation therapy (IMRT) uses images created by a computer that show the size and shape of the tumor. Thin beams of radiation of different strengths are aimed at the tumor from many angles.
  • Stereotactic radiation therapy uses a rigid head frame attached to the skull to aim radiation directly to the tumor, causing less damage to normal tissue around the tumor. The total dose of radiation is divided into several smaller doses given over several days. This procedure is also called stereotactic external-beam radiation therapy and stereotaxic radiation therapy.
  • Proton beam radiation therapy is a type of high-energy, external radiation therapy that uses streams of protons (small, positively-charged particles of matter) to kill tumor cells.
• For children younger than 3 years, chemotherapy may be given instead, to delay or reduce the need for radiation therapy.

Treatment Options for Childhood Astrocytomas

Newly Diagnosed Childhood Low-Grade Astrocytomas

• Children with neurofibromatosis type 1 (NF1) may not need treatment unless the tumor grows or signs or symptoms, such as vision problems, appear. When the tumor grows or signs or symptoms appear, treatment may include surgery to remove the tumor, radiation therapy, and/or chemotherapy.
• Children with tuberous sclerosis may develop benign (not cancer) tumors in the brain called subependymal giant cell astrocytomas (SEGAs). Targeted therapy with everolimus or sirolimus may be used instead of surgery, to shrink the tumors.

Recurrent Childhood Low-Grade Astrocytomas.

• Before more cancer treatment is given, imaging tests, biopsy, or surgery are done to find out if there is cancer and how much there is:
• Treatment of recurrent childhood low-grade astrocytoma may include the following:
  • A second surgery to remove the tumor, if surgery was the only treatment given when the tumor was first diagnosed.
  • Radiation therapy to the tumor only, if radiation therapy was not used when the tumor was first diagnosed. Conformal radiation therapy may be given.
  • Chemotherapy, if the tumor recurred where it cannot be removed by surgery or the patient had radiation therapy when the tumor was first diagnosed.
  • Chemotherapy and targeted therapy with bevacizumab.

Newly Diagnosed Childhood High-Grade Astrocytomas

• Treatment of childhood high-grade astrocytoma may include the following:
  • Surgery to remove the tumor, followed by chemotherapy and radiation therapy
  • A clinical trial of chemotherapy with or without radiation therapy
  • A clinical trial of a new treatment

Recurrent Childhood High-Grade Astrocytomas

• Before more cancer treatment is given, imaging tests, biopsy, or surgery are done find out if there is cancer and how much there is.
• Treatment of recurrent childhood high-grade astrocytoma may include the following:
  • Surgery
  • High-dose chemotherapy with stem cell transplant
  • A clinical trial of a new treatment
  • A clinical trial of targeted therapy with dabrafenib