What are the management options for complications of astrocytoma?

Management Options for Complications of Astrocytoma

The management of astrocytoma complications requires a multidisciplinary approach with treatment options including surgery, radiotherapy, chemotherapy, and supportive care, tailored to the specific complications and tumor characteristics. 1, 2

Initial Management

Surgical Intervention

• Transfer to specialized center for evaluation and surgical management is standard 1
• Optimal surgical resection should be performed when possible 1, 2
• Exceptions where biopsy may be preferred over resection:
  • High physiological age
  • Multiple comorbidities
  • Poor performance status
  • Multifocal lesions
  • Tumors in functional or centrally located regions 1

Post-Surgical Complications Management

• Cerebral edema: Dexamethasone should be tapered as quickly as clinically possible to minimize long-term toxicity 2
• Seizures: Anticonvulsant therapy only for patients at risk; discontinue after perioperative period if no seizures occur 2
• Thromboembolism: Prophylactic low-molecular weight heparin and compression stockings recommended 1
  • After 4-5 days post-surgery, therapeutic anticoagulation can be used for thromboembolic complications without undue hemorrhagic risk 1

Management of Recurrence

For tumor recurrence, five therapeutic options can be considered 1:

1. Surgery - decision should be made after multidisciplinary consultation
2. Systemic chemotherapy
3. Local chemotherapy (carmustine implants)
4. Second-line radiotherapy - newer techniques including brachytherapy or stereotactic radiotherapy
5. Palliative care without specific anticancer treatment

Tumor-Type Specific Management

Anaplastic Astrocytoma

• Radiotherapy is standard (level of evidence: A) 1
• Chemotherapy options:
  • Mono-drug chemotherapy with nitrosourea (BCNU)
  • Multidrug chemotherapy with procarbazine, lomustine, and vincristine (PCV)
  • Temozolomide has shown significant efficacy (level of evidence: C) 1, 3
  • Carmustine implants can be used if chemotherapy is indicated 1

Glioblastoma

• Radiotherapy is standard (level of evidence: A) 1
• Chemotherapy: Mono-drug chemotherapy with a nitrosourea is standard (level of evidence: A) 1
• Temozolomide is indicated for:
  • Newly diagnosed glioblastoma concomitantly with radiotherapy and then as maintenance 3
  • Refractory anaplastic astrocytoma after disease progression on nitrosourea and procarbazine 3

Management of Specific Complications

Increased Intracranial Pressure

• Surgical decompression
• Corticosteroids (dexamethasone)
• Osmotic diuretics in acute situations

Neurological Deficits

• Rehabilitation therapy
• Adaptive equipment
• Management of specific deficits (speech therapy, physical therapy)

Chemotherapy-Related Complications

• Myelosuppression: Monitor absolute neutrophil count and platelet count prior to dosing and throughout treatment 3
  • Geriatric patients and women have higher risk 3
• Pneumocystis pneumonia: Prophylaxis required for patients receiving concomitant temozolomide and radiotherapy 3
• Hepatotoxicity: Perform liver function tests at baseline, midway through first cycle, prior to each subsequent cycle, and 2-4 weeks after last dose 3

Radiation-Related Complications

• Radiation necrosis: Occurs in 0-30% of patients following radiosurgery 2
• Cognitive decline: Neurocognitive rehabilitation may be beneficial

Follow-up Care

• Regular MRI surveillance (typically every 3 months initially) 2
• Clinical assessment for neurological symptoms 2
• Ongoing collaboration between neurosurgery, radiation oncology, and medical oncology 2

Important Considerations

• Treatment decisions should be made after multidisciplinary consultation 1, 2
• Patients should be included in clinical trials when possible to evaluate treatment options 1
• Almost all patients with high-grade astrocytomas will develop tumor recurrence or progression despite multimodality treatment 4
• Treatment challenges include molecular/genetic heterogeneity of tumors and limited CNS drug delivery 4