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Treatment of Childhood Low-Grade Astrocytomas

    To determine and implement optimum management, treatment is often guided by a multidisciplinary team of cancer specialists who have experience treating childhood brain tumors.

    In infants and young children, low-grade astrocytomas presenting in the hypothalamus may result in the diencephalic syndrome, which is manifested by failure to thrive in an emaciated, seemingly euphoric child. Such children may have little in the way of other neurologic findings, but can have macrocephaly, intermittent lethargy, and visual impairment.[1] Because the location of these tumors makes a surgical approach difficult, biopsies are not always done. This is especially true in patients with neurofibromatosis type 1 (NF1).[2] When associated with NF1, tumors may be of multifocal origin.

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    For children with low-grade optic pathway astrocytomas, treatment options should be considered not only to improve survival but also to stabilize visual function.[3,4] Children with isolated optic nerve tumors have a better prognosis than those with lesions that involve the chiasm or that extend along the visual pathway.[1,2,5,6]; [7][Level of evidence: 3iiC] Children with NF1 also have a better prognosis, especially when the tumor is found in asymptomatic patients at the time of screening.[5,8] Observation is an option for patients with NF1 or nonprogressive masses.[1,5,9,10] Spontaneous regressions of optic pathway gliomas have been reported in children with and without NF1.[11,12,13]

    Surgery

    Surgical resection is the primary treatment for childhood low-grade astrocytoma [1,2,5,14] and surgical feasibility is determined by tumor location. For example, complete or near complete removal can be obtained in 90% to 95% of patients with pilocytic tumors that occur in the cerebellum. Similarly, circumscribed, grade I hemispheric tumors are often amenable to complete surgical resection.[14,15,16] For children with isolated optic nerve lesions and progressive symptoms, complete surgical resection or local radiation therapy may result in prolonged progression-free survival (PFS).[17]

    Factors related to outcome for children with low-grade gliomas treated with surgery followed by observation were identified in a Children's Oncology Group study that included 518 evaluable patients.[14] Overall outcome for the entire group was 78% PFS at 8 years and 96% overall survival (OS) at 8 years. The following factors were related to prognosis:[14]

    • Histology: Approximately three-fourths of patients had pilocytic astrocytoma, and PFS and OS for these patients was superior to that of children with nonpilocytic tumors.
    • Extent of resection: Patients with gross total resection had 8-year PFS exceeding 90% and OS of 99%. By comparison, approximately one-half of patients with any degree of residual tumor (as assessed by operative report and by postoperative imaging) showed disease progression by 8 years, although OS exceeded 90%.
    • Age: Younger children (age <5 years) showed higher rates of tumor progression but there was no significant age effect for OS in multivariate analysis.
    • Tumor location: Cerebellar and cerebral tumors showed higher PFS at 8 years compared with patients with midline and chiasmatic tumors (84% ± 1.9% versus 51% ± 5.9%).
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