Supratentorial grade II astrocytoma: biological features and clinical course

doi:10.1016/S1474-4422(03)00434-4

The Lancet Neurology

Volume 2, Issue 7, July 2003, Pages 395-403

https://doi.org/10.1016/S1474-4422(03)00434-4 Get rights and content

Summary

Because of its unpredictable clinical course, treatment strategies for low-grade (grade II) astrocytoma vary from “wait and see” to gross tumour resection followed by immediate radiotherapy. Clinical studies on grade II astrocytoma show that 5-year-survival ranges from 27% to 85% of patients with very few consistent prognostic variables besides the patient's age and the presence of neurological deficit. There is no universally recognised choice of therapy for patients with astrocytoma grade II, partly because of the shortcomings of histological classification systems. Routine microscopy tends to underestimate malignancy grading of astrocytomas and in most cases cannot distinguish between indolent and progressive subtypes. Recent studies suggest that proliferation and genetic markers can be used to identify subgroups of astrocytoma grade II with a rapid progressive clinical course. Therefore these markers should be included in ongoing and future clinical studies of patients with astrocytoma grade II.

Section snippets

Presenting symptoms and imaging of grade II astrocytoma

Epileptic seizure is the most common presenting symptom of grade II astrocytoma and occurs in about 80% of the patients;8, 9, 10 this is probably due to the superficial localisation and low growth rate of the tumour in many cases.¹¹ Focal neurological deficit (30%) and mental changes (10–30%) are less common. Symptoms caused by raised intracranial pressure, such as headache, vomiting, and papilloedema (10%), are rare.8, 9, 10

Before CT, focal neurological deficit and raised intracranial pressure

Clinical course and prognostic features

The course of grade II astrocytoma is still largely unpredictable for several reasons. First, proliferation and progression are highly variable.²⁵ Second, studies are difficult to interpret, as they are mostly retrospective in nature and include other subgroups of low-grade gliomas. Furthermore, the use of different treatment strategies may be an important confounder in most studies.

Recent studies have used CT and MRI to predict the clinical course, and have tried to describe prognostic

Treatment strategies

Age is an important factor in the design of treatment strategies for grade II astrocytoma. In older patients, the tumours are commonly more malignant than in younger patients. Most studies use 40 years (some use 35 years) of age as a cut-off point. There is agreement that patients older than 35–40 years should have aggressive treatment—ie, maximum tumour resection followed by radiation therapy.2, 52 Aggressive treatment is also recommended for younger patients with increased intracranial

Histological grading systems

At present, astrocytomas are either classified according to the St Anne-Mayo grading system⁶⁰ or according to the WHO protocol.⁶¹ In both systems tumours are graded—in the most anaplastic areas—according to their nuclear atypia, mitotic activity, endothelial proliferation, and necrosis (panel).

The St Anne-Mayo system divides astrocytomas into four grades. However, in practice, this is a three-grade system because grade 1 astrocytomas are very rarely found. The most prominent feature of St

Biological features of grade II astrocytoma

Phenotype and genotypic differences underlie the variable clinical course seen in patients with grade II astrocytoma. The development of astrocytoma is associated with genetic instability and an imbalance between proliferation and apoptosis of astrocytes. Recent studies have suggested that markers for proliferation activity75, 76 and certain cytogenetic changes77, 78 may predict the malignant transformation from grade II to grade III or IV astrocytoma.

Conclusions

Because of the unpredictable clinical course of grade II astrocytoma, treatment strategies range from gross tumour resection followed by immediate radiotherapy to a “wait and see” approach. At present the best prognostic variable is the patient's age; other indicators of poor prognosis include neurological deficit and a low performance score at time of presentation.

For young patients (under 35 or 40 years of age) with indolent grade II astrocytoma, the efficacy of surgical intervention and

Search strategy and selection criteria

Data for this review were identified by searches of Pubmed and Cancerlit (1980–2002) and from references of relevant articles. The search terms were “astrocytoma grade II”, “astrocytoma grade 2”, “low-grade astrocytoma”, “treatment”, and “prognosis”. Exclusion criteria were “spinal cord” and “child” and “juvenile”. Only papers published in English or German were reviewed. Only CT/MRI studies of 40 or more adult patients were included.

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Previous work in anaplastic astrocytoma (AA) demonstrated that the survival benefit from gross total resection (GTR) is modified by age and tumor location. Here, we determined the influence of age and tumor location on survival benefit from GTR in diffuse astrocytoma (DA).
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ReviewSupratentorial grade II astrocytoma: biological features and clinical course

Summary

Section snippets

Presenting symptoms and imaging of grade II astrocytoma

Clinical course and prognostic features

Treatment strategies

Histological grading systems

Biological features of grade II astrocytoma

Conclusions

Search strategy and selection criteria

Neurol Clin

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Bull Cancer Radiother

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Lancet

Lancet Oncol

Cancer Genet Cytogenet

Semin Cancer Biol

Mutat Res

Incidence of primary central nervous system cancers in South and East Netherlands in 1989-1994

Neuroepidemiology

Radiation therapy in the management of low-grade supratentorial astrocytomas

J Neurosurg

Hereditary tumor syndromes of the nervous system: overview and rare syndromes

Brain Pathol

A report on radiation-induced gliomas

Cancer

Cellular-telephone use and brain tumors

N Engl J Med

Descriptive epidemiology of cerebral gliomas in France

Cancer

Survival, prognostic factors, and therapeutic efficacy in low-grade glioma: a retrospective study in 379 patients

J Clin Oncol

Supratentorial World Health Organization grade 2 astrocytomas and oligoastrocytomas: a new pattern of prognostic factors

Cancer

Supratentorial low-grade glioma in adults: an analysis of prognostic factors and timing of radiation

J Clin Oncol

The prognosis of primary intracerebral tumours presenting with epilepsy: the outcome of medical and surgical management

J Neurol Neurosurg Psychiatry

Neurosurgical management of low-grade astrocytoma of the cerebral hemispheres

J Neurosurg

Survival of patients with well-differentiated astrocytomas diagnosed in the era of computed tomography

Neurosurgery

Supratentorial low-grade astrocytomas in adults

Neurosurgery

Efficacy of neuroradiological imaging, neurological examination, and symptom status in follow-up assessment of patients with high-grade gliomas

J Neurosurg

Imaging-based stereotaxic serial biopsies in untreated intracranial glial neoplasms

J Neurosurg

Prognostic significance of contrast enhancement in low-grade astrocytomas of the adult cerebrum

Radiology

Unreliability of contemporary neurodiagnostic imaging in evaluating suspected adult supratentorial (low-grade) astrocytoma

J Neurosurg

Age and the risk of anaplasia in magnetic resonance-nonenhancing supratentorial cerebral tumors

Cancer

How often are nonenhancing supratentorial gliomas malignant? A population study

Neurology

Prognostic value positron emission tomography with [18F]fluoro-2-deoxy-D-glucose in the low-grade glioma

Neurosurgery

Clinical value of PET with 18F-fluorodeoxyglucose and L-methyl-11C-methionine for diagnosis of recurrent brain tumor and radiation injury

Acta Radiol

Serial evaluation of patients with brain tumors using volume MRI and 3D 1H MRSI

NMR Biomed

Low-grade gliomas

Low-grade cerebral astrocytomas. Survival and quality of life after radiation therapy

Cancer

Treatment and survival of low-grade astrocytoma in adults—1977-1988

Neurosurgery

Supratentorial low-grade astrocytoma. Correlation of computed tomography findings with effect of radiation therapy and prognostic variables

Cancer

Long-term prognosis of low grade astrocytoma

Zentralbl Neurochir

The effect of extent of resection on recurrence in patients with low grade cerebral hemisphere gliomas

Cancer

Low grade supratentorial astrocytomas. Management and prognostic factors

Cancer

Review
Supratentorial grade II astrocytoma: biological features and clinical course