Brain Stem Gliomas medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Sujit Routray, M.D. [2]
Overview
Medical therapy
The treatment is significantly influenced by tumor type, morphology and location. Radiation and chemotherapy are a key part of the treatment regime. For treatment purposes, patients are grouped as having newly diagnosed or recurrent disease.[1][2]
The overview of the treatment regime is as follows:
A) Newly diagnosed brainstem gliomas
Diffuse brainstem gliomas
Focal brainstem gliomas
- Surgical resection (with or without radiation therapy and chemotherapy)
- Observation (with or without cerebrospinal fluid diversion)
- Radiation therapy, chemotherapy, and alternative approaches for inoperable focal or low-grade tumors
B) Recurrent brainstem gliomas
Diffuse brainstem gliomas
Focal brainstem gliomas
Newly diagnosed brainstem gliomas
Diffuse brainstem gliomas
The standard treatment options for newly diagnosed diffuse brainstem gliomas include the following:
1) Radiation therapy.
Conventional treatment for children with diffuse brainstem glioma is radiation therapy. The conventional dose of radiation ranges between 54 Gy and 60 Gy given locally to the primary tumor site in single daily fractions. Such treatment will result in transient benefit for most patients, but more than 90% of patients will die within 18 months of diagnosis. Radiation-induced changes may occur a few months after the completion of radiation therapy and may mimic tumor progression. When considering the efficacy of additional treatment, care needs to be taken to separate radiation-induced change from progressive disease.
The efficacy of hyperfractionated and hypofractionated radiation therapy and radiosensitizers have not demonstrated improved outcomes using these radiation techniques.
- Hyperfractionated (twice daily) radiation therapy techniques have been used to deliver a higher dose, and studies using doses as high as 78 Gy have been completed. Evidence demonstrates that these increased radiation therapy doses do not improve the duration or rate of survival for patients with DIPGs, whether given alone or in combination with chemotherapy.
- Hypofractionated radiation therapy results in survival rates comparable to conventional fractionated radiation therapy techniques, possibly with less treatment burden.
- Studies evaluating the efficacy of various radiosensitizers as a means for enhancing the therapeutic effect of radiation therapy have been undertaken but to date have failed to show any significant improvement in outcome.
2) Chemotherapy only (infants < 3 years old)
Similar to the treatment of other brain tumors, radiation therapy is often omitted for infants with diffuse brainstem gliomas, and chemotherapy-only approaches are utilized.
Focal brainstem gliomas
The standard treatment options for newly diagnosed focal brainstem gliomas include the following:
1) Surgical resection (with or without radiation therapy and chemotherapy)
In general, maximal surgical resection is attempted. Patients with residual tumor may be candidates for additional therapy, including 3-dimensional conformal radiation therapy approaches, with or without adjuvant chemotherapy.
2) Observation (with or without cerebrospinal fluid diversion)
Patients with small tectal lesions and hydrocephalus but no other neurological deficits may be treated with cerebrospinal fluid diversion alone and have follow-up with sequential neuroradiographic studies unless there is evidence of progressive disease.
A period of observation may be indicated before instituting any treatment for patients with neurofibromatosis type 1. Brain stem gliomas in these children may be indolent and may require no specific treatment for years.[24]
3) Radiation therapy, chemotherapy, and alternative approaches for inoperable focal or low-grade tumors
In selected circumstances, adjuvant therapy in the form of radiation therapy or chemotherapy can be considered in a child with a newly diagnosed focal or low-grade brain stem glioma. Decisions regarding the need for such therapy depend on the age of the child, the extent of resection obtainable, and associated neurologic deficits.
Alternative approaches for the treatment of inoperable brain stem gliomas include the following:
- Stereotactic iodine I-125 brachytherapy approaches, with or without adjuvant chemotherapy.
- The use of BRAF inhibitors for tumors harboring a V600E mutation.[28]
Recurrent brainstem gliomas
Diffuse brainstem gliomas
The standard treatment option for recurrent diffuse brainstem gliomas include the following:
1) Palliative care
Given the dismal prognosis for patients with diffuse brainstem gliomas, progression of the pontine lesion is anticipated generally within 1 year of completing radiation therapy. In most cases, biopsy at the time of clinical or radiologic progression is not recommended. To date, no salvage regimen has been shown to extend survival. Patients should be considered for entry into trials of novel therapeutic approaches because there are no standard agents that have demonstrated a clinically significant activity.
Palliative care is provided for these patients whether or not disease-directed therapy is administered.
Focal brainstem gliomas
The treatment considerations at the time of recurrence are dependent on prior treatment. The standard treatment option for recurrent focal brainstem gliomas include the following:
1) Repeat surgical resection
The need for surgical intervention must be individualized on the basis of the initial tumor type, the location within the brain stem, the length of time between initial treatment, the appearance of the mass lesion, and the clinical picture.
2) Radiation therapy
The radiation therapy include 3-dimensional conformal radiation therapy.
3) Chemotherapy
Carboplatin and vincristine may be effective in children with recurrent low-grade exophytic gliomas.
References
- ↑ Treatment of brainstem gliomas. National Cancer Institute. http://www.cancer.gov/types/brain/hp/child-glioma-treatment-pdq#section/_45
- ↑ Rx of Brainstem gliomas. Dr Yuranga Weerakkody and Dr Frank Gaillard et al. Radiopaedia 2015. http://radiopaedia.org/articles/brainstem-glioma