Treatment of Childhood High-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.
The therapy for both children and adults with supratentorial high-grade astrocytoma includes surgery, radiation therapy, and chemotherapy. Outcome in high-grade gliomas occurring in childhood may be more favorable than that in adults, but it is not clear if this difference is caused by biologic variations in tumor characteristics, therapies used, tumor resectability, or other factors that are presently not understood.[1] The ability to obtain a complete resection is associated with a better prognosis.[2] Radiation therapy is administered to a field that widely encompasses the entire tumor. The radiation therapy dose to the tumor bed is usually at least 54 Gy. Despite such therapy, overall survival rates remain poor. In one trial, children with glioblastoma who were treated on a prospective randomized trial with adjuvant lomustine, vincristine, and prednisone fared better than children treated with radiation therapy alone.[3] Among patients treated with surgery, radiation therapy, and nitrosourea (lomustine)-based chemotherapy, 5-year progression-free survival was 19% ± 3%; survival was 40% in those who had total resections.[4] Similarly, in a trial of multiagent chemoradiotherapy and adjuvant chemotherapy in addition to valproic acid, 5-year event-free survival (EFS) was 13%, but for children with a complete resection of their tumor, the EFS was 48%.[5][Level of evidence: 2A] In adults, the addition of temozolomide during and after radiation therapy resulted in improved 2-year event-free survival as compared with treatment with radiation therapy alone. Adult patients with glioblastoma with a methylated O6-methylguanine-DNA-methyltransferase (MGMT) promoter benefited from temozolomide, whereas those who did not have a methylated MGMT promoter did not.[6,7] The role of temozolomide given concurrently with radiation therapy for children with supratentorial high-grade glioma appears comparable to the outcome seen in children treated with nitrosourea-based therapy [8] and again demonstrated a survival advantage for those children with a methylated MGMT promoter. Younger children may benefit from chemotherapy to delay, modify, or, in selected cases, obviate the need for radiation therapy.[9,10,11] Clinical trials that evaluate chemotherapy with or without radiation therapy are ongoing. Information about ongoing clinical trials is available from the NCI Web site.
Treatment Options Under Clinical Evaluation
The following is an example of a national and/or institutional clinical trial that is currently being conducted or is under analysis. Information about ongoing clinical trials is available from the NCI Web site.
- COG-ACNS0822: The Children's Oncology Group is conducting a randomized phase II/III study of vorinostat and local radiation therapy or temozolomide and local radiation therapy or bevacizumab and radiation therapy followed by maintenance bevacizumab and temozolomide in newly diagnosed high-grade glioma.
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