Astrocytomas

Stud. Francesca Ochea, Carol Davila University of Medicine and Pharmacy

Coord. assoc. prof. dr. Ligia Tataranu, Bagdasar-Arseni Emergency Hospital
 Gliomas

Gliomas comprise a group of primary central nervous system (CNS)

neoplasms with characteristics of neuroglial cells (eg, astrocytes,
oligodendrocytes) that express varying degrees of aggressiveness.

The slower growing lesions are commonly referred to as low-grade

gliomas (LGGs), while the more rapidly progressive tumors are
referred to as high-grade gliomas (HGGs).

LGGs are less common, comprising approximately one-fifth of

CNS glial tumors.
WHO grading system

Grade Brain tissue infiltration

I Small zone of infiltration

Eg. Pilocytic astocitoma

II Diffuse infiltration, low malignity

Eg. Diffuse astroytoma

III Diffuse infiltration, high malignity

Eg. Anaplastic astrocytoma

IV Diffuse infiltration, extreme malignity

Eg. Glioblastoma
 Low Grade Gliomas

LGGs can be divided into several distinct entities based upon

their histopathologic appearance.

These differences correlate with important differences in

biologic behavior and thus have important implications for
patient management.

LGGs can develop anywhere in the CNS, although studies

usually are directed to a particular location (eg, cerebral
hemispheres, optic pathways, brainstem).
 Low Grade Gliomas

Bailey and Cushing originally proposed that gliomas were

derived from transformation of normal glial cells during their
development.
Astrocytomas were tumors with the appearance of astrocytes,
while oligodendrogliomas had the appearance of
oligodendrocytes.

Kernohan estimated the prognosis of glial tumors based upon

the extent of observed anaplastic features (ie, mitoses,
endothelial proliferation, cellular atypia, necrosis).
Such a classification proved to be of prognostic value,
especially for astrocytomas.
 Low Grade Gliomas

Although the term LGG is widely used, it is not explicitly

defined in either system.

LGG describes a spectrum of primary brain tumors composed of

cells that histologically resemble one or more differentiated
types of macroglial cells (diffuse and fibrillary astrocytes,
oligodendrocytes, ependymal cells) without evidence of
anaplasia.

In the Kernohan scheme, LGGs encompass grade I and II

tumors.
Low Grade Gliomas
 Low Grade Gliomas

LGGs have been referred to as "benign" gliomas, but this is a

misnomer.

Although these tumors have a more favorable natural history

than HGGs, LGGs are only occasionally associated with
prolonged (>10 years) survival and frequently develop
characteristics similar to more aggressive brain tumors.
 Low Grade Gliomas
A tentative diagnosis of LGG often can be made based upon the
clinical presentation and imaging findings.

An LGG is highly likely when a patient presents with a transient

neurologic disturbance consistent with seizure and imaging
studies (MRI and/or CT) reveal a nonenhancing hemispheric
lesion that produces little mass effect .

By MRI, these tumors are best seen on T2-weighted MRI

sequences.

They are frequently nonenhancing on T1-gadolinium sequences.

Calcifications are sometimes present, most commonly in

oligodendrogliomas.
 Low Grade Gliomas

There is an abnormal poorly enhancing well defined intra-axial lesion in the

subcortical white matter of left high parietal lobe.
The lesion is seen as hypointense on T1.
 Low Grade Gliomas

The lesion is seen as hyperintense on T2 and FLAIR.

 Diffuse astrocytomas

Diffuse astrocytomas generally occur in adults with a peak age

incidence in their late 30s, approximately 20 years younger than
in those with HGGs.

Most commonly arise in the cerebral hemispheres.

Widely infiltrate surrounding neural tissues.

 Diffuse astrocytomas
Can be subdivided based upon their histopathologic appearance into the
following variants:

●Fibrillary — Fibrillary tumors typically arise from deeper white

matter. They are firm and rubbery due to the neuroglial fibrils that they
produce. Microscopically, fine neuroglial fibrils form a matrix between
the cells.

●Gemistocytic — Gemistocytic astrocytomas are composed of

gemistocytes, which are cells that appear exceptionally large and are
densely packed. In many cases, distention of their cell bodies results in
a globoid appearance . Although it has been suggested that these tumors
are better classified as anaplastic astrocytomas, the reported survival
figures and prognostic determinants generally mirror those for diffuse
fibrillary astrocytomas .

●Protoplasmic — Astrocytoma cells can resemble protoplasmic

astrocytes. Protoplasmic tumors are the least common variant of diffuse
astrocytomas and tend to arise in the cerebral cortex. They may have a
better prognosis than other diffuse astrocytomas.
 Low grade gliomas

Although the natural history of low-grade gliomas vary greatly,

most patients eventually deteriorate.

For many patients there will be a period of relative radiographic

and clinical stability that averages five to seven years for
astrocytic tumors and often longer for oligodendroglial tumors.

However, tumor growth eventually accelerates, and the clinical

course then is indistinguishable from that of an high-grade
glioma (ie, anaplastic astrocytoma, anaplastic
oligodendroglioma, anaplastic oligoastrocytoma, glioblastoma).
 Low grade gliomas
Immediate surgery is generally required for patients presenting
with a large mass or extensive neurologic symptoms, both to
establish the diagnosis and debulk the tumor.

Gross total resection is often not possible without a significant

risk of serious neurological sequelae because of the diffuse
infiltrative nature of these tumors, however, and a combined
modality approach using adjuvant radiation
therapy and/or chemotherapy may be indicated.

The optimal timing of additional therapy is uncertain, however,

and the decision to proceed with immediate versus delayed
postoperative therapy must be individualized.
 Low grade gliomas

●For young patients (≤40 years) who undergo complete resection of a

tumor with favorable molecular features, is recommended initial
observation after surgery. It is expected that these patients will
eventually recur and require additional therapy at the time of
progression.

●For older patients with residual disease and one or more unfavorable
molecular features, is suggested immediate postoperative therapy.

●For patients who do not fall into either of these categories, the more
risk factors present, the more likely the patients are to be treated with
immediate postoperative therapy.
 High grade gliomas

High-grade gliomas are malignant, often rapidly progressive

brain tumors that are divided into:
• anaplastic gliomas (anaplastic astrocytoma, anaplastic
oligodendroglioma, and anaplastic oligoastrocytoma)
• glioblastoma (GBM)
based upon their histopathologic features.
 High grade gliomas

Patients with high-grade glioma typically present with subacute

and progressive neurologic signs and symptoms that vary
according to the location of the tumor within the brain.

Magnetic resonance imaging (MRI) of the brain provides

confirmatory evidence of a mass lesion, but a tissue diagnosis is
ultimately required to distinguish high-grade gliomas from other
primary and metastatic brain tumors.
 High grade gliomas
Contrast-enhanced MRI is superior to computed tomography
(CT) for the characterization of brain tumors. On MRI, high-
grade gliomas are typically hypointense on T1-weighted images,
and enhance heterogeneously following contrast infusion.

Enhancing tumor can be distinguished from the surrounding

hypointense signal of edema on T1-weighted sequences.

Regardless of the histologic grade, high-grade gliomas generally

show increased T2 and FLAIR signal intensity. However, some
anaplastic gliomas do not manifest contrast enhancement.
High grade gliomas
High grade gliomas
High grade gliomas

Typical appearances of a butterfly glioma,

with little possible differential.
Pathologically proven.
 High grade gliomas

A tissue diagnosis in patients with a presumed high-grade

glioma is essential.

This can be accomplished either at the time of surgical resection

or in a separate biopsy procedure.

Biopsy alone is used in situations where the lesion is not

amenable to resection, a meaningful amount of tumor tissue
cannot be removed, or the patient's overall clinical condition will
not permit surgery.

In the remaining cases, maximal safe resection is the preferred

initial approach to both diagnosis and management
 High grade gliomas

The initial treatment for high-grade gliomas is resection.

Maximal resection with preservation of neurologic function is an
important goal in the initial management of patients with high-
grade gliomas, and the extent of surgery must be balanced with
preservation of neurologic function.

The available evidence suggests that aggressive resection is

associated with improved functional status and possibly with
prolonged survival.
 High grade gliomas

The most important prognostic factors affecting outcome in patients

with high-grade glioma are age, tumor grade (anaplastic glioma versus
GBM), Karnofsky performance status (KPS) and several molecular
genetic alterations.

The extent of initial surgical resection also appears to influence

prognosis.
 High grade gliomas

High-grade gliomas are rapidly progressive tumors that are best

managed with a combined modality approach, incorporating maximal
surgical resection, adjuvant postoperative radiation therapy, and
adjuvant chemotherapy.
 Take home messages

1. Low grade gliomas are slower growing lesions than high grade
gliomas.

2. Low grade gliomas are not benign tumors. LGG’s will eventually
reccur and develop characteristics similar to HGG’s.

3. Immediate surgery with gross total resection is recommended for

both types, while adjuvant therapy must be individualised based
on patient’s comorbidities and HP findings.

4. The best treatment is total resection without neurological damage.

Thank you!