Protoplasmic astrocytoma: Difference between revisions

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==Overview==
==Overview==
Protoplasmic astrocytoma is a rare variant of [[diffuse astrocytoma|diffuse low grade astrocytoma]] with characteristic histological and imaging features. It has been suggested that protoplasmic astrocytoma represents a variant of [[dysembryoplastic neuroepithelial tumor]]s (DNET), as they share histologic and imaging features. Currently, protoplasmic astrocytoma is classified as a subtype of diffuse low-grade astrocytoma.
Protoplasmic astrocytoma is a rare variant of [[diffuse astrocytoma|diffuse low grade astrocytoma]] with characteristic histological and imaging features. It has been suggested that protoplasmic astrocytoma represents a variant of [[dysembryoplastic neuroepithelial tumor]]s (DNET), as they share histologic and imaging features. Currently, protoplasmic astrocytoma is classified as a subtype of diffuse low-grade astrocytoma.
<br />
== Classification ==
Protoplasmic astrocytoma is a subtype of astrocytoma and is included in the classification of astrocytoma. For more information about the classification of astrocytoma, [[Astrocytoma classification|click here]].
==Pathophysiology==
==Pathophysiology==
===Gross Pathology===
===Gross Pathology===
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===Microscopic Pathology===
===Microscopic Pathology===
*On microscopic histopathological analysis, protoplasmic astrocytoma is characterized by:<ref name=pathoilogypa1>Pathology of protoplasmic astrocytoma. Dr Bruno Di Muzio and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/protoplasmic-astrocytoma. Accessed on January 8, 2016
*On microscopic histopathological analysis, protoplasmic astrocytoma is characterized by:<ref name="pathoilogypa1">Pathology of protoplasmic astrocytoma. Dr Bruno Di Muzio and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/protoplasmic-astrocytoma. Accessed on January 8, 2016
 
::*Scant cytoplasm
::*Scant cytoplasm
::*Rounded prominent nuclear contour
::*Rounded prominent nuclear contour
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:*Mucinous fluid containing microcystic spaces (prominent feature)
:*Mucinous fluid containing microcystic spaces (prominent feature)
:*Abscence of [[mitoses]], microvascular proliferation, and [[necrosis]]
:*Abscence of [[mitoses]], microvascular proliferation, and [[necrosis]]
:*temporal and frontal lobes were the most likely site of origin.<ref name="pmid7785654">{{cite journal| author=Prayson RA, Estes ML| title=Protoplasmic astrocytoma. A clinicopathologic study of 16 tumors. | journal=Am J Clin Pathol | year= 1995 | volume= 103 | issue= 6 | pages= 705-9 | pmid=7785654 | doi=10.1093/ajcp/103.6.705 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7785654  }} </ref>
:*temporal and frontal lobes were the most likely site of origin.<nowiki><ref name="pmid7785654"></nowiki>{{cite journal| author=Prayson RA, Estes ML| title=Protoplasmic astrocytoma. A clinicopathologic study of 16 tumors. | journal=Am J Clin Pathol | year= 1995 | volume= 103 | issue= 6 | pages= 705-9 | pmid=7785654 | doi=10.1093/ajcp/103.6.705 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7785654  }}
</ref>


===Immunohistochemistry===
===Immunohistochemistry===
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==Natural History, Complications and Prognosis==
==Natural History, Complications and Prognosis==
===Natural History===
===Natural History===
*If left untreated, patients with protoplasmic astrocytoma may progress to develop [[seizures]], focal neurological deficits, and [[hydrocephalus]].<ref name=symptomspa1>Clinical presentation of protoplasmic astrocytoma. Dr Bruno Di Muzio and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/protoplasmic-astrocytoma. Accessed on January 8, 2016</ref>
*If left untreated, patients with protoplasmic astrocytoma may progress to develop [[seizures]], focal neurological deficits, and [[hydrocephalus]].<ref name="symptomspa1">Clinical presentation of protoplasmic astrocytoma. Dr Bruno Di Muzio and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/protoplasmic-astrocytoma. Accessed on January 8, 2016</ref>
*Protoplasmic astrocytoma is a slow growing tumor with an indolent course.
*Protoplasmic astrocytoma is a slow growing tumor with an indolent course.


===Complications===
===Complications===
*Common complication of protoplasmic astrocytoma include:<ref name=symptomspa1>Clinical presentation of protoplasmic astrocytoma. Dr Bruno Di Muzio and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/protoplasmic-astrocytoma. Accessed on January 8, 2016</ref>
*Common complication of protoplasmic astrocytoma include:<ref name="symptomspa1">Clinical presentation of protoplasmic astrocytoma. Dr Bruno Di Muzio and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/protoplasmic-astrocytoma. Accessed on January 8, 2016</ref>
:*[[Hydrocephalus]]
:*[[Hydrocephalus]]


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===Symptoms===
===Symptoms===
*Symptoms of protoplasmic astrocytoma include:<ref name=symptomspa1>Clinical presentation of protoplasmic astrocytoma. Dr Bruno Di Muzio and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/protoplasmic-astrocytoma. Accessed on January 8, 2016</ref>
*Symptoms of protoplasmic astrocytoma include:<ref name="symptomspa1">Clinical presentation of protoplasmic astrocytoma. Dr Bruno Di Muzio and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/protoplasmic-astrocytoma. Accessed on January 8, 2016</ref>
:*[[Headaches]]
:*[[Headaches]]
:*[[Seizures]]  
:*[[Seizures]]  
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==CT==
==CT==
*Head CT scan is helpful in the diagnosis of protoplasmic astrocytoma. On CT scan, protoplasmic astrocytoma is characterized by:<ref name=radiologicalfeaturspa1>Radiological features of protoplasmic astrocytoma. Dr Bruno Di Muzio and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/protoplasmic-astrocytoma. Accessed on January 8, 2016</ref>
*Head CT scan is helpful in the diagnosis of protoplasmic astrocytoma. On CT scan, protoplasmic astrocytoma is characterized by:<ref name="radiologicalfeaturspa1">Radiological features of protoplasmic astrocytoma. Dr Bruno Di Muzio and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/protoplasmic-astrocytoma. Accessed on January 8, 2016</ref>
:*Hypodense mass  
:*Hypodense mass  
:*Positive mass effect
:*Positive mass effect
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==MRI==
==MRI==
*The possibility that a primary cerebral neoplasm represents a protoplasmic astrocytoma should be considered in a patient with a large frontal or temporal tumor that has a very high signal on T2 with a large proportion of the tumor showing substantial T2 FLAIR suppression.<ref name="pmid20644924">{{cite journal| author=Tay KL, Tsui A, Phal PM, Drummond KJ, Tress BM| title=MR imaging characteristics of protoplasmic astrocytomas. | journal=Neuroradiology | year= 2011 | volume= 53 | issue= 6 | pages= 405-11 | pmid=20644924 | doi=10.1007/s00234-010-0741-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20644924  }} </ref>
*The possibility that a primary cerebral neoplasm represents a protoplasmic astrocytoma should be considered in a patient with a large frontal or temporal tumor that has a very high signal on T2 with a large proportion of the tumor showing substantial T2 FLAIR suppression.<ref name="pmid20644924">{{cite journal| author=Tay KL, Tsui A, Phal PM, Drummond KJ, Tress BM| title=MR imaging characteristics of protoplasmic astrocytomas. | journal=Neuroradiology | year= 2011 | volume= 53 | issue= 6 | pages= 405-11 | pmid=20644924 | doi=10.1007/s00234-010-0741-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20644924  }} </ref>
*Brain MRI is helpful in the diagnosis of protoplasmic astrocytoma. On MRI, protoplasmic astrocytoma is characterized by:<ref name=radiologicalfeaturspa1>Radiological features of protoplasmic astrocytoma. Dr Bruno Di Muzio and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/protoplasmic-astrocytoma. Accessed on January 8, 2016</ref><ref name=radiographicfeaturesga1>Radiographic features of low grade infiltrative astrocytoma. Dr Ahmed Abd Rabou and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/low-grade-infiltrative-astrocytoma. Accessed on January 8, 2016</ref>
*Brain MRI is helpful in the diagnosis of protoplasmic astrocytoma. On MRI, protoplasmic astrocytoma is characterized by:<ref name="radiologicalfeaturspa1">Radiological features of protoplasmic astrocytoma. Dr Bruno Di Muzio and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/protoplasmic-astrocytoma. Accessed on January 8, 2016</ref><ref name="radiographicfeaturesga1">Radiographic features of low grade infiltrative astrocytoma. Dr Ahmed Abd Rabou and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/low-grade-infiltrative-astrocytoma. Accessed on January 8, 2016</ref>


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{| style="border: 0px; font-size: 90%; margin: 3px; width:1000px"
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==Other Imaging Findings==
==Other Imaging Findings==
===Magnetic Resonance Spectroscopy===
===Magnetic Resonance Spectroscopy===
*[[Nuclear magnetic resonance spectroscopy|MR spectroscopy]] may be helpful in the diagnosis of protoplasmic astrocytoma, which demonstrates elevated [[choline]]/[[creatine]] ratio.<ref name=radiologicalfeaturspa1>Radiological features of protoplasmic astrocytoma. Dr Bruno Di Muzio and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/protoplasmic-astrocytoma. Accessed on January 8, 2016</ref>
*[[Nuclear magnetic resonance spectroscopy|MR spectroscopy]] may be helpful in the diagnosis of protoplasmic astrocytoma, which demonstrates elevated [[choline]]/[[creatine]] ratio.<ref name="radiologicalfeaturspa1">Radiological features of protoplasmic astrocytoma. Dr Bruno Di Muzio and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/protoplasmic-astrocytoma. Accessed on January 8, 2016</ref>


===Magnetic Resonance Perfusion===
===Magnetic Resonance Perfusion===
*[[Perfusion weighted imaging|MR perfusion]] may be helpful in the diagnosis of protoplasmic astrocytoma, which demonstrates no elevation of relative cerebral blood volume (rCBV).<ref name=radiologicalfeaturspa1>Radiological features of protoplasmic astrocytoma. Dr Bruno Di Muzio and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/protoplasmic-astrocytoma. Accessed on January 8, 2016</ref>
*[[Perfusion weighted imaging|MR perfusion]] may be helpful in the diagnosis of protoplasmic astrocytoma, which demonstrates no elevation of relative cerebral blood volume (rCBV).<ref name="radiologicalfeaturspa1">Radiological features of protoplasmic astrocytoma. Dr Bruno Di Muzio and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/protoplasmic-astrocytoma. Accessed on January 8, 2016</ref>


==Electroencephalogram==
==Electroencephalogram==
*[[Electroencephalogram|Electroencephalogram (EEG)]] is performed in cases of protoplasmic astrocytoma to record the continuous electrical activity of the brain and locate the seizure activity.<ref name=radfa1>Radiographic features of fibrillary astrocytoma. Dr Henry Knipe and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/fibrillary-astrocytoma. Accessed on January 4, 2016</ref>
*[[Electroencephalogram|Electroencephalogram (EEG)]] is performed in cases of protoplasmic astrocytoma to record the continuous electrical activity of the brain and locate the seizure activity.<ref name="radfa1">Radiographic features of fibrillary astrocytoma. Dr Henry Knipe and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/fibrillary-astrocytoma. Accessed on January 4, 2016</ref>


==Biopsy==
==Biopsy==
*[[Biopsy]] of the protoplasmic astrocytoma tumor, taken through a needle during a simple surgical procedure, helps to confirm the diagnosis.<ref name=treatmentandprognosispa1>Treatment and prognosis of protoplasmic astrocytoma. Dr Bruno Di Muzio and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/protoplasmic-astrocytoma. Accessed on January 8, 2016</ref>
*[[Biopsy]] of the protoplasmic astrocytoma tumor, taken through a needle during a simple surgical procedure, helps to confirm the diagnosis.<ref name="treatmentandprognosispa1">Treatment and prognosis of protoplasmic astrocytoma. Dr Bruno Di Muzio and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/protoplasmic-astrocytoma. Accessed on January 8, 2016</ref>


==Treatment==
==Treatment==
*The treatment of protoplasmic astrocytoma depends on the clinical presentation, tumor size, and location.<ref name=treatmentandprognosispa1>Treatment and prognosis of protoplasmic astrocytoma. Dr Bruno Di Muzio and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/protoplasmic-astrocytoma. Accessed on January 8, 2016</ref>
*The treatment of protoplasmic astrocytoma depends on the clinical presentation, tumor size, and location.<ref name="treatmentandprognosispa1">Treatment and prognosis of protoplasmic astrocytoma. Dr Bruno Di Muzio and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/protoplasmic-astrocytoma. Accessed on January 8, 2016</ref>
:*'''Surgery''': The predominant therapy for protoplasmic astrocytoma is [[surgery|surgical resection]].<ref name=treatmentandprognosispa1>Treatment and prognosis of protoplasmic astrocytoma. Dr Bruno Di Muzio and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/protoplasmic-astrocytoma. Accessed on January 8, 2016</ref>  
 
:*'''Radiotherapy''': [[Radiotherapy]] may be used in protoplasmic astrocytoma post-operatively or at the time of recurrence or progression.<ref name=biopsyga1>Treatment and prognosis of low grade infiltrative astrocytoma. Dr Ahmed Abd Rabou and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/low-grade-infiltrative-astrocytoma. Accessed on January 8, 2016</ref>
:*'''Surgery''': The predominant therapy for protoplasmic astrocytoma is [[surgery|surgical resection]].<ref name="treatmentandprognosispa1">Treatment and prognosis of protoplasmic astrocytoma. Dr Bruno Di Muzio and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/protoplasmic-astrocytoma. Accessed on January 8, 2016</ref>
:*'''Chemotherapy''': [[Chemotherapy]] may have a role in recurrent and de-differentiated tumors.<ref name=biopsyga1>Treatment and prognosis of low grade infiltrative astrocytoma. Dr Ahmed Abd Rabou and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/low-grade-infiltrative-astrocytoma. Accessed on January 8, 2016</ref>
:*'''Radiotherapy''': [[Radiotherapy]] may be used in protoplasmic astrocytoma post-operatively or at the time of recurrence or progression.<ref name="biopsyga1">Treatment and prognosis of low grade infiltrative astrocytoma. Dr Ahmed Abd Rabou and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/low-grade-infiltrative-astrocytoma. Accessed on January 8, 2016</ref>
:*'''Chemotherapy''': [[Chemotherapy]] may have a role in recurrent and de-differentiated tumors.<ref name="biopsyga1">Treatment and prognosis of low grade infiltrative astrocytoma. Dr Ahmed Abd Rabou and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/low-grade-infiltrative-astrocytoma. Accessed on January 8, 2016</ref>




Revision as of 15:59, 17 July 2019

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

Synonyms and keywords: Protoplasmic astrocytomas; Diffuse astrocytoma; Low grade astrocytoma

Overview

Protoplasmic astrocytoma is a rare variant of diffuse low grade astrocytoma with characteristic histological and imaging features. It has been suggested that protoplasmic astrocytoma represents a variant of dysembryoplastic neuroepithelial tumors (DNET), as they share histologic and imaging features. Currently, protoplasmic astrocytoma is classified as a subtype of diffuse low-grade astrocytoma.


Classification

Protoplasmic astrocytoma is a subtype of astrocytoma and is included in the classification of astrocytoma. For more information about the classification of astrocytoma, click here.

Pathophysiology

Gross Pathology

Microscopic Pathology

  • On microscopic histopathological analysis, protoplasmic astrocytoma is characterized by:[1]

Immunohistochemistry

  • Protoplasmic astrocytoma is demonstrated by positivity to tumor marker such as GFAP.

Differentiating Protoplasmic Astrocytoma from other Diseases

  • Protoplasmic astrocytoma must be differentiated from:

Epidemiology and Demographics

Age

  • Protoplasmic astrocytoma is a rare disease that tends to affect young adults.
  • The mean age at diagnosis is 32 years.

Gender

  • Males are more commonly affected with protoplasmic astrocytoma than females. The male to female ratio is approximately 1.67 to 1.[2]

Natural History, Complications and Prognosis

Natural History

  • If left untreated, patients with protoplasmic astrocytoma may progress to develop seizures, focal neurological deficits, and hydrocephalus.[3]
  • Protoplasmic astrocytoma is a slow growing tumor with an indolent course.

Complications

  • Common complication of protoplasmic astrocytoma include:[3]

History and Symptoms

History

  • When evaluating a patient for protoplasmic astrocytoma, you should take a detailed history of the presenting symptom (onset, duration, and progression), other associated symptoms, and a thorough family and past medical history review.

Symptoms

  • Symptoms of protoplasmic astrocytoma include:[3]

CT

  • Head CT scan is helpful in the diagnosis of protoplasmic astrocytoma. On CT scan, protoplasmic astrocytoma is characterized by:[4]
  • Hypodense mass
  • Positive mass effect
  • No enhancement
  • Cystic or fluid attenuation, due to the aforementioned prominent mucinous microcystic component

MRI

  • The possibility that a primary cerebral neoplasm represents a protoplasmic astrocytoma should be considered in a patient with a large frontal or temporal tumor that has a very high signal on T2 with a large proportion of the tumor showing substantial T2 FLAIR suppression.[5]
  • Brain MRI is helpful in the diagnosis of protoplasmic astrocytoma. On MRI, protoplasmic astrocytoma is characterized by:[4][6]
MRI component Findings

T1

  • Hypointense compared to white matter

T2

  • Hyperintense compared to white matter

Fluid-attenuated inversion recovery (FLAIR)

  • Large areas of T2 hyperintensity suppress on FLAIR
  • These are not macrocystic, but rather represent the areas with abundant microcystic change

T1 with contrast

  • Little or no enhancement

Diffusion weighted imaging (DWI)

  • No restricted diffusion

Other Imaging Findings

Magnetic Resonance Spectroscopy

Magnetic Resonance Perfusion

  • MR perfusion may be helpful in the diagnosis of protoplasmic astrocytoma, which demonstrates no elevation of relative cerebral blood volume (rCBV).[4]

Electroencephalogram

  • Electroencephalogram (EEG) is performed in cases of protoplasmic astrocytoma to record the continuous electrical activity of the brain and locate the seizure activity.[7]

Biopsy

  • Biopsy of the protoplasmic astrocytoma tumor, taken through a needle during a simple surgical procedure, helps to confirm the diagnosis.[8]

Treatment

  • The treatment of protoplasmic astrocytoma depends on the clinical presentation, tumor size, and location.[8]
  • Surgery: The predominant therapy for protoplasmic astrocytoma is surgical resection.[8]
  • Radiotherapy: Radiotherapy may be used in protoplasmic astrocytoma post-operatively or at the time of recurrence or progression.[9]
  • Chemotherapy: Chemotherapy may have a role in recurrent and de-differentiated tumors.[9]


 
 
 
 
 
 
 
 
 
 
 
 
Treatment of protoplasmic astrocytoma
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Surgery
 
 
 
Radiotherapy
 
 
 
Chemotherapy
 
 
 
 
 
 
 
 
 
 
 
 
 

References

  1. ↑ Pathology of protoplasmic astrocytoma. Dr Bruno Di Muzio and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/protoplasmic-astrocytoma. Accessed on January 8, 2016
    • Scant cytoplasm
    • Rounded prominent nuclear contour
    • Flaccid processes
    • Low cellular density
    • Mild nuclear atypia (enlarged, irregular contour, hyperchromasia, and coarsened nuclear chromatin pattern)
    • Mucinous fluid containing microcystic spaces (prominent feature)
    • Abscence of mitoses, microvascular proliferation, and necrosis
    • temporal and frontal lobes were the most likely site of origin.<ref name="pmid7785654">Prayson RA, Estes ML (1995). "Protoplasmic astrocytoma. A clinicopathologic study of 16 tumors". Am J Clin Pathol. 103 (6): 705–9. doi:10.1093/ajcp/103.6.705. PMID 7785654.
  2. ↑ Prayson RA, Estes ML (1995). "Protoplasmic astrocytoma. A clinicopathologic study of 16 tumors". Am J Clin Pathol. 103 (6): 705–9. doi:10.1093/ajcp/103.6.705. PMID 7785654.
  3. ↑ 3.0 3.1 3.2 Clinical presentation of protoplasmic astrocytoma. Dr Bruno Di Muzio and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/protoplasmic-astrocytoma. Accessed on January 8, 2016
  4. ↑ 4.0 4.1 4.2 4.3 Radiological features of protoplasmic astrocytoma. Dr Bruno Di Muzio and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/protoplasmic-astrocytoma. Accessed on January 8, 2016
  5. ↑ Tay KL, Tsui A, Phal PM, Drummond KJ, Tress BM (2011). "MR imaging characteristics of protoplasmic astrocytomas". Neuroradiology. 53 (6): 405–11. doi:10.1007/s00234-010-0741-2. PMID 20644924.
  6. ↑ Radiographic features of low grade infiltrative astrocytoma. Dr Ahmed Abd Rabou and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/low-grade-infiltrative-astrocytoma. Accessed on January 8, 2016
  7. ↑ Radiographic features of fibrillary astrocytoma. Dr Henry Knipe and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/fibrillary-astrocytoma. Accessed on January 4, 2016
  8. ↑ 8.0 8.1 8.2 Treatment and prognosis of protoplasmic astrocytoma. Dr Bruno Di Muzio and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/protoplasmic-astrocytoma. Accessed on January 8, 2016
  9. ↑ 9.0 9.1 Treatment and prognosis of low grade infiltrative astrocytoma. Dr Ahmed Abd Rabou and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/low-grade-infiltrative-astrocytoma. Accessed on January 8, 2016

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