Treatment of Recurrent Childhood Low-Grade Astrocytomas
Childhood low-grade astrocytomas may recur many years after initial treatment. Recurrent disease is usually at the primary tumor site, though multifocal or widely disseminated disease to other intracranial sites and to the spinal leptomeninges has been documented.[1,2] Most children whose low-grade fibrillary astrocytomas recur will harbor low-grade lesions; however, malignant transformation is possible.
At the time of recurrence, a complete evaluation to determine the extent of the relapse is indicated. Biopsy or surgical resection may be necessary for confirmation of relapse because other entities, such as secondary tumor and treatment-related brain necrosis, may be clinically indistinguishable from tumor recurrence. The need for surgical intervention must be individualized on the basis of the initial tumor type, the length of time between initial treatment and the reappearance of the mass lesion, and the clinical picture.
Incidence and mortality
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An individual plan needs to be tailored on the basis of patient age, tumor location, and prior treatment. If patients have not received radiation therapy, local radiation therapy is the usual treatment, although further chemotherapy in lieu of radiation may be considered.[Level of evidence: 3iiiDi] For those children with low-grade glioma for whom radiation therapy is indicated, conformal radiation therapy approaches appear effective and offer the potential for reducing the acute and long-term toxicities associated with this modality.[6,7] In patients treated with surgery alone whose disease progresses, chemotherapy and/or radiation therapy are options. If recurrence takes place after irradiation, chemotherapy should be considered. Chemotherapy may result in relatively long-term disease control.[8,9] Temozolomide alone or drug combinations, such as carboplatin and vincristine, may be useful at the time of recurrence for children with low-grade gliomas.[8,9,10]
Patients with low-grade astrocytomas who relapse after being treated with surgery alone should be considered for another surgical resection. If this is not feasible, local radiation therapy is the usual treatment. If there is recurrence in an unresectable site after irradiation, chemotherapy should be considered.
Entry into studies of novel therapeutic approaches should be considered for patients with recurrent brain tumors.[13,14] Information about ongoing clinical trials is available from the NCI Web site.
Treatment Options Under Clinical Evaluation
Early-phase therapeutic trials may be available for selected patients. These trials may be available via Children's Oncology Group phase I institutions, the Pediatric Brain Tumor Consortium, or other entities. Information about ongoing clinical trials is available from the NCI Web site.
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with recurrent childhood cerebellar astrocytoma and recurrent childhood cerebral astrocytoma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.