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Focal brainstem glioma

INTRODUCTION

Gliomas arising in the brainstem (midbrain, pons, and medulla oblongata) account for 10 to 20 percent of all central nervous system (CNS) tumors in children. Brainstem gliomas are heterogeneous, ranging from low-grade tumors that need little treatment to high-grade lesions that are rapidly fatal despite aggressive therapy [1-7]. Prognosis and treatment depend upon histologic features and the location within the brainstem.

Focal brainstem gliomas typically arise in the midbrain and medulla, and are discrete, well-circumscribed tumors without evidence of locally invasive growth or edema (figure 1). Pathologically, these tumors are most often pilocytic or fibrillary astrocytomas, or rarely, gangliogliomas, all of which are considered low-grade tumors (table 1) [8]. (See "Classification of gliomas".)

Approximately 80 percent of pediatric brainstem gliomas arise within the pons, while the remaining 20 percent occur within the medulla, midbrain, and cervicomedullary junction [9-15].

Brainstem gliomas arising the in pons are predominantly diffuse and high-grade; diffuse pontine gliomas are discussed separately. (See "Diffuse pontine glioma".) In contrast, most brainstem gliomas arising outside the pons are focal and low grade. Focal brainstem gliomas are discussed here.

EPIDEMIOLOGY

Brainstem tumors are more common in children than adults, with approximately 300 pediatric and 100 adult cases reported each year in the United States [11,13,16,17]. Brainstem gliomas now account for about 20 percent of all intracranial neoplasms in children under the age of 15 years, compared to 10 percent in the 1970s and 1980s [18-22]. This change appears to reflect the increased detection of focal low-grade brainstem tumors by magnetic resonance imaging (MRI) rather than a true increased incidence.

                     

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Literature review current through: Mar 2014. | This topic last updated: May 20, 2013.
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References
Top
  1. Pool JL. Gliomas in the region of the brain stem. J Neurosurg 1968; 29:164.
  2. Hoffman HJ, Becker L, Craven MA. A clinically and pathologically distinct group of benign brain stem gliomas. Neurosurgery 1980; 7:243.
  3. Albright AL, Guthkelch AN, Packer RJ, et al. Prognostic factors in pediatric brain-stem gliomas. J Neurosurg 1986; 65:751.
  4. Cohen ME, Duffner PK, Heffner RR, et al. Prognostic factors in brainstem gliomas. Neurology 1986; 36:602.
  5. Epstein F, McCleary EL. Intrinsic brain-stem tumors of childhood: surgical indications. J Neurosurg 1986; 64:11.
  6. Stroink AR, Hoffman HJ, Hendrick EB, et al. Transependymal benign dorsally exophytic brain stem gliomas in childhood: diagnosis and treatment recommendations. Neurosurgery 1987; 20:439.
  7. Epstein F, Wisoff J. Intra-axial tumors of the cervicomedullary junction. J Neurosurg 1987; 67:483.
  8. Fisher PG, Breiter SN, Carson BS, et al. A clinicopathologic reappraisal of brain stem tumor classification. Identification of pilocystic astrocytoma and fibrillary astrocytoma as distinct entities. Cancer 2000; 89:1569.
  9. Epstein FJ, Farmer JP. Brain-stem glioma growth patterns. J Neurosurg 1993; 78:408.
  10. Epstein F, Constantini S. Practical decisions in the treatment of pediatric brain stem tumors. Pediatr Neurosurg 1996; 24:24.
  11. Freeman CR, Farmer JP. Pediatric brain stem gliomas: a review. Int J Radiat Oncol Biol Phys 1998; 40:265.
  12. Robertson PL, Allen JC, Abbott IR, et al. Cervicomedullary tumors in children: a distinct subset of brainstem gliomas. Neurology 1994; 44:1798.
  13. Rubin G, Michowitz S, Horev G, et al. Pediatric brain stem gliomas: an update. Childs Nerv Syst 1998; 14:167.
  14. Pollack IF, Hoffman HJ, Humphreys RP, Becker L. The long-term outcome after surgical treatment of dorsally exophytic brain-stem gliomas. J Neurosurg 1993; 78:859.
  15. Guillamo JS, Doz F, Delattre JY. Brain stem gliomas. Curr Opin Neurol 2001; 14:711.
  16. Packer RJ. Brain tumors in children. Arch Neurol 1999; 56:421.
  17. Selvapandian S, Rajshekhar V, Chandy MJ. Brainstem glioma: comparative study of clinico-radiological presentation, pathology and outcome in children and adults. Acta Neurochir (Wien) 1999; 141:721.
  18. Smith MA, Freidlin B, Ries LA, Simon R. Trends in reported incidence of primary malignant brain tumors in children in the United States. J Natl Cancer Inst 1998; 90:1269.
  19. Farwell JR, Dohrmann GJ, Flannery JT. Central nervous system tumors in children. Cancer 1977; 40:3123.
  20. Albright AL, Price RA, Guthkelch AN. Brain stem gliomas of children. A clinicopathological study. Cancer 1983; 52:2313.
  21. Stroink AR, Hoffman HJ, Hendrick EB, Humphreys RP. Diagnosis and management of pediatric brain-stem gliomas. J Neurosurg 1986; 65:745.
  22. Tomita T, McLone DG, Naidich TP. Brain stem gliomas in childhood. Rational approach and treatment. J Neurooncol 1984; 2:117.
  23. Ries LA, Smith MA, Gurney JG, et al (Eds). Cancer Incidence and Survival among Children and Adolescents: United States SEER Program 1975-1995, National Cancer Institute, SEER Program. NIH Pub No 99-4649. Bethesda, MD, 1999. p 53.
  24. Duffner PK, Cohen ME, Myers MH, Heise HW. Survival of children with brain tumors: SEER Program, 1973-1980. Neurology 1986; 36:597.
  25. Gurney JG, Severson RK, Davis S, Robison LL. Incidence of cancer in children in the United States. Sex-, race-, and 1-year age-specific rates by histologic type. Cancer 1995; 75:2186.
  26. Kaba SE, Kyritsis AP. Recognition and management of gliomas. Drugs 1997; 53:235.
  27. Goldman JE, Corbin E. Rosenthal fibers contain ubiquitinated alpha B-crystallin. Am J Pathol 1991; 139:933.
  28. Horbinski C, Hamilton RL, Nikiforov Y, Pollack IF. Association of molecular alterations, including BRAF, with biology and outcome in pilocytic astrocytomas. Acta Neuropathol 2010; 119:641.
  29. Schindler G, Capper D, Meyer J, et al. Analysis of BRAF V600E mutation in 1,320 nervous system tumors reveals high mutation frequencies in pleomorphic xanthoastrocytoma, ganglioglioma and extra-cerebellar pilocytic astrocytoma. Acta Neuropathol 2011; 121:397.
  30. Jeuken JW, Wesseling P. MAPK pathway activation through BRAF gene fusion in pilocytic astrocytomas; a novel oncogenic fusion gene with diagnostic, prognostic, and therapeutic potential. J Pathol 2010; 222:324.
  31. MacConaill LE, Campbell CD, Kehoe SM, et al. Profiling critical cancer gene mutations in clinical tumor samples. PLoS One 2009; 4:e7887.
  32. Jacob K, Albrecht S, Sollier C, et al. Duplication of 7q34 is specific to juvenile pilocytic astrocytomas and a hallmark of cerebellar and optic pathway tumours. Br J Cancer 2009; 101:722.
  33. Jones DT, Kocialkowski S, Liu L, et al. Oncogenic RAF1 rearrangement and a novel BRAF mutation as alternatives to KIAA1549:BRAF fusion in activating the MAPK pathway in pilocytic astrocytoma. Oncogene 2009; 28:2119.
  34. Bar EE, Lin A, Tihan T, et al. Frequent gains at chromosome 7q34 involving BRAF in pilocytic astrocytoma. J Neuropathol Exp Neurol 2008; 67:878.
  35. Pfister S, Janzarik WG, Remke M, et al. BRAF gene duplication constitutes a mechanism of MAPK pathway activation in low-grade astrocytomas. J Clin Invest 2008; 118:1739.
  36. Dias-Santagata D, Lam Q, Vernovsky K, et al. BRAF V600E mutations are common in pleomorphic xanthoastrocytoma: diagnostic and therapeutic implications. PLoS One 2011; 6:e17948.
  37. Pollack IF, Hamilton RL, Sobol RW, et al. IDH1 mutations are common in malignant gliomas arising in adolescents: a report from the Children's Oncology Group. Childs Nerv Syst 2011; 27:87.
  38. Young Poussaint T, Yousuf N, Barnes PD, et al. Cervicomedullary astrocytomas of childhood: clinical and imaging follow-up. Pediatr Radiol 1999; 29:662.
  39. Sun B, Wang CC, Wang J. MRI characteristics of midbrain tumours. Neuroradiology 1999; 41:158.
  40. Pollack IF, Pang D, Albright AL. The long-term outcome in children with late-onset aqueductal stenosis resulting from benign intrinsic tectal tumors. J Neurosurg 1994; 80:681.
  41. Boydston WR, Sanford RA, Muhlbauer MS, et al. Gliomas of the tectum and periaqueductal region of the mesencephalon. Pediatr Neurosurg 1991; 17:234.
  42. Pierre-Kahn A, Hirsch JF, Vinchon M, et al. Surgical management of brain-stem tumors in children: results and statistical analysis of 75 cases. J Neurosurg 1993; 79:845.
  43. Khatib ZA, Heideman RL, Kovnar EH, et al. Predominance of pilocytic histology in dorsally exophytic brain stem tumors. Pediatr Neurosurg 1994; 20:2.
  44. Barkovich AJ, Krischer J, Kun LE, et al. Brain stem gliomas: a classification system based on magnetic resonance imaging. Pediatr Neurosurg 1990; 16:73.
  45. Helton KJ, Weeks JK, Phillips NS, et al. Diffusion tensor imaging of brainstem tumors: axonal degeneration of motor and sensory tracts. J Neurosurg Pediatr 2008; 1:270.
  46. Albright AL, Packer RJ, Zimmerman R, et al. Magnetic resonance scans should replace biopsies for the diagnosis of diffuse brain stem gliomas: a report from the Children's Cancer Group. Neurosurgery 1993; 33:1026.
  47. Warren KE, Frank JA, Black JL, et al. Proton magnetic resonance spectroscopic imaging in children with recurrent primary brain tumors. J Clin Oncol 2000; 18:1020.
  48. Astrakas LG, Zurakowski D, Tzika AA, et al. Noninvasive magnetic resonance spectroscopic imaging biomarkers to predict the clinical grade of pediatric brain tumors. Clin Cancer Res 2004; 10:8220.
  49. Lazareff JA, Bockhorst KH, Curran J, et al. Pediatric low-grade gliomas: prognosis with proton magnetic resonance spectroscopic imaging. Neurosurgery 1998; 43:809.
  50. Roessler K, Ungersboeck K, Aichholzer M, et al. Frameless stereotactic lesion contour-guided surgery using a computer-navigated microscope. Surg Neurol 1998; 49:282.
  51. Hata N, Dohi T, Iseki H, Takakura K. Development of a frameless and armless stereotactic neuronavigation system with ultrasonographic registration. Neurosurgery 1997; 41:608.
  52. Kollias SS, Bernays R, Marugg RA, et al. Target definition and trajectory optimization for interactive MR-guided biopsies of brain tumors in an open configuration MRI system. J Magn Reson Imaging 1998; 8:143.
  53. Moriarty TM, Kikinis R, Jolesz FA, et al. Magnetic resonance imaging therapy. Intraoperative MR imaging. Neurosurg Clin N Am 1996; 7:323.
  54. Tronnier VM, Wirtz CR, Knauth M, et al. Intraoperative diagnostic and interventional magnetic resonance imaging in neurosurgery. Neurosurgery 1997; 40:891.
  55. Teo C, Siu TL. Radical resection of focal brainstem gliomas: is it worth doing? Childs Nerv Syst 2008; 24:1307.
  56. Recinos PF, Sciubba DM, Jallo GI. Brainstem tumors: where are we today? Pediatr Neurosurg 2007; 43:192.
  57. Wisoff JH, Sanford RA, Heier LA, et al. Primary neurosurgery for pediatric low-grade gliomas: a prospective multi-institutional study from the Children's Oncology Group. Neurosurgery 2011; 68:1548.
  58. Di Maio S, Gul SM, Cochrane DD, et al. Clinical, radiologic and pathologic features and outcome following surgery for cervicomedullary gliomas in children. Childs Nerv Syst 2009; 25:1401.
  59. Pirotte BJ, Lubansu A, Massager N, et al. Results of positron emission tomography guidance and reassessment of the utility of and indications for stereotactic biopsy in children with infiltrative brainstem tumors. J Neurosurg 2007; 107:392.
  60. Pérez-Gómez JL, Rodríguez-Alvarez CA, Marhx-Bracho A, Rueda-Franco F. Stereotactic biopsy for brainstem tumors in pediatric patients. Childs Nerv Syst 2010; 26:29.
  61. Rachinger W, Grau S, Holtmannspötter M, et al. Serial stereotactic biopsy of brainstem lesions in adults improves diagnostic accuracy compared with MRI only. J Neurol Neurosurg Psychiatry 2009; 80:1134.
  62. Bowers DC, Krause TP, Aronson LJ, et al. Second surgery for recurrent pilocytic astrocytoma in children. Pediatr Neurosurg 2001; 34:229.
  63. Krieger MD, Gonzalez-Gomez I, Levy ML, McComb JG. Recurrence patterns and anaplastic change in a long-term study of pilocytic astrocytomas. Pediatr Neurosurg 1997; 27:1.
  64. Shibamoto Y, Takahashi M, Dokoh S, et al. Radiation therapy for brain stem tumor with special reference to CT feature and prognosis correlations. Int J Radiat Oncol Biol Phys 1989; 17:71.
  65. Schild SE, Stafford SL, Brown PD, et al. The results of radiotherapy for brainstem tumors. J Neurooncol 1998; 40:171.
  66. Schulz-Ertner D, Debus J, Lohr F, et al. Fractionated stereotactic conformal radiation therapy of brain stem gliomas: outcome and prognostic factors. Radiother Oncol 2000; 57:215.
  67. Shrieve DC, Wara WM, Edwards MS, et al. Hyperfractionated radiation therapy for gliomas of the brainstem in children and in adults. Int J Radiat Oncol Biol Phys 1992; 24:599.
  68. Freeman CR. Hyperfractionated radiotherapy for diffuse intrinsic brain stem tumors in children. Pediatr Neurosurg 1996; 24:103.
  69. Freeman CR, Bourgouin PM, Sanford RA, et al. Long term survivors of childhood brain stem gliomas treated with hyperfractionated radiotherapy. Clinical characteristics and treatment related toxicities. The Pediatric Oncology Group. Cancer 1996; 77:555.
  70. Packer RJ, Boyett JM, Zimmerman RA, et al. Outcome of children with brain stem gliomas after treatment with 7800 cGy of hyperfractionated radiotherapy. A Childrens Cancer Group Phase I/II Trial. Cancer 1994; 74:1827.
  71. Freeman CR, Krischer JP, Sanford RA, et al. Final results of a study of escalating doses of hyperfractionated radiotherapy in brain stem tumors in children: a Pediatric Oncology Group study. Int J Radiat Oncol Biol Phys 1993; 27:197.
  72. Kihlström L, Lindquist C, Lindquist M, Karlsson B. Stereotactic radiosurgery for tectal low-grade gliomas. Acta Neurochir Suppl 1994; 62:55.
  73. Fuchs I, Kreil W, Sutter B, et al. Gamma Knife radiosurgery of brainstem gliomas. Acta Neurochir Suppl 2002; 84:85.
  74. Hadjipanayis CG, Kondziolka D, Gardner P, et al. Stereotactic radiosurgery for pilocytic astrocytomas when multimodal therapy is necessary. J Neurosurg 2002; 97:56.
  75. Yen CP, Sheehan J, Steiner M, et al. Gamma knife surgery for focal brainstem gliomas. J Neurosurg 2007; 106:8.
  76. Fuss M, Hug EB, Schaefer RA, et al. Proton radiation therapy (PRT) for pediatric optic pathway gliomas: comparison with 3D planned conventional photons and a standard photon technique. Int J Radiat Oncol Biol Phys 1999; 45:1117.
  77. McAllister B, Archambeau JO, Nguyen MC, et al. Proton therapy for pediatric cranial tumors: preliminary report on treatment and disease-related morbidities. Int J Radiat Oncol Biol Phys 1997; 39:455.
  78. Khoo VS, Oldham M, Adams EJ, et al. Comparison of intensity-modulated tomotherapy with stereotactically guided conformal radiotherapy for brain tumors. Int J Radiat Oncol Biol Phys 1999; 45:415.
  79. Cardinale RM, Benedict SH, Wu Q, et al. A comparison of three stereotactic radiotherapy techniques; ARCS vs. noncoplanar fixed fields vs. intensity modulation. Int J Radiat Oncol Biol Phys 1998; 42:431.
  80. Huang E, Teh BS, Strother DR, et al. Intensity-modulated radiation therapy for pediatric medulloblastoma: early report on the reduction of ototoxicity. Int J Radiat Oncol Biol Phys 2002; 52:599.
  81. Ma L, Xia P, Verhey LJ, Boyer AL. A dosimetric comparison of fan-beam intensity modulated radiotherapy with Gamma Knife stereotactic radiosurgery for treating intermediate intracranial lesions. Int J Radiat Oncol Biol Phys 1999; 45:1325.
  82. Kato T, Sawamura Y, Tada M, et al. Cisplatin/vincristine chemotherapy for hypothalamic/visual pathway astrocytomas in young children. J Neurooncol 1998; 37:263.
  83. Packer RJ, Lange B, Ater J, et al. Carboplatin and vincristine for recurrent and newly diagnosed low-grade gliomas of childhood. J Clin Oncol 1993; 11:850.
  84. Packer RJ, Ater J, Allen J, et al. Carboplatin and vincristine chemotherapy for children with newly diagnosed progressive low-grade gliomas. J Neurosurg 1997; 86:747.
  85. Bouffet E, Amat D, Devaux Y, Desuzinges C. Chemotherapy for spinal cord astrocytoma. Med Pediatr Oncol 1997; 29:560.
  86. Ronghe M, Hargrave D, Bartels U, et al. Vincristine and carboplatin chemotherapy for unresectable and/or recurrent low-grade astrocytoma of the brainstem. Pediatr Blood Cancer 2010; 55:471.
  87. Prados MD, Edwards MS, Rabbitt J, et al. Treatment of pediatric low-grade gliomas with a nitrosourea-based multiagent chemotherapy regimen. J Neurooncol 1997; 32:235.
  88. Gururangan S, Cavazos CM, Ashley D, et al. Phase II study of carboplatin in children with progressive low-grade gliomas. J Clin Oncol 2002; 20:2951.
  89. Bouffet E, Jakacki R, Goldman S, et al. Phase II study of weekly vinblastine in recurrent or refractory pediatric low-grade glioma. J Clin Oncol 2012; 30:1358.
  90. Nicholson HS, Kretschmar CS, Krailo M, et al. Phase 2 study of temozolomide in children and adolescents with recurrent central nervous system tumors: a report from the Children's Oncology Group. Cancer 2007; 110:1542.
  91. Khaw SL, Coleman LT, Downie PA, et al. Temozolomide in pediatric low-grade glioma. Pediatr Blood Cancer 2007; 49:808.
  92. Hood TW, Shapiro B, Taren JA. Treatment of cystic astrocytomas with intracavitary phosphorus 32. Acta Neurochir Suppl (Wien) 1987; 39:34.
  93. Disabato JA, Handler MH, Strain JD, et al. Successful use of intracavitary bleomycin for low-grade astrocytoma tumor cyst. Pediatr Neurosurg 1999; 31:246.
  94. Steinbok P, Hukin J. Intracystic treatments for craniopharyngioma. Neurosurg Focus 2010; 28:E13.
  95. Li KW, Roonprapunt C, Lawson HC, et al. Endoscopic third ventriculostomy for hydrocephalus associated with tectal gliomas. Neurosurg Focus 2005; 18:E2.
  96. Vandertop WP, Hoffman HJ, Drake JM, et al. Focal midbrain tumors in children. Neurosurgery 1992; 31:186.
  97. May PL, Blaser SI, Hoffman HJ, et al. Benign intrinsic tectal "tumors" in children. J Neurosurg 1991; 74:867.
  98. Robertson PL, Muraszko KM, Brunberg JA, et al. Pediatric midbrain tumors: a benign subgroup of brainstem gliomas. Pediatr Neurosurg 1995; 22:65.
  99. Squires LA, Allen JC, Abbott R, Epstein FJ. Focal tectal tumors: management and prognosis. Neurology 1994; 44:953.
  100. Wellons JC 3rd, Tubbs RS, Banks JT, et al. Long-term control of hydrocephalus via endoscopic third ventriculostomy in children with tectal plate gliomas. Neurosurgery 2002; 51:63.
  101. Lapras C, Bognar L, Turjman F, et al. Tectal plate gliomas. Part I: Microsurgery of the tectal plate gliomas. Acta Neurochir (Wien) 1994; 126:76.
  102. Bowers DC, Georgiades C, Aronson LJ, et al. Tectal gliomas: natural history of an indolent lesion in pediatric patients. Pediatr Neurosurg 2000; 32:24.
  103. Dağlioğlu E, Cataltepe O, Akalan N. Tectal gliomas in children: the implications for natural history and management strategy. Pediatr Neurosurg 2003; 38:223.
  104. Yeh DD, Warnick RE, Ernst RJ. Management strategy for adult patients with dorsal midbrain gliomas. Neurosurgery 2002; 50:735.
  105. Ternier J, Wray A, Puget S, et al. Tectal plate lesions in children. J Neurosurg 2006; 104:369.
  106. Stark AM, Fritsch MJ, Claviez A, et al. Management of tectal glioma in childhood. Pediatr Neurol 2005; 33:33.
  107. Lagares A, Gómez PA, Lobato RD, et al. Ganglioglioma of the brainstem: report of three cases and review of the literature. Surg Neurol 2001; 56:315.
  108. Weiner HL, Freed D, Woo HH, et al. Intra-axial tumors of the cervicomedullary junction: surgical results and long-term outcome. Pediatr Neurosurg 1997; 27:12.
  109. Giovanini MA, Mickle JP. Long-term access to cystic brain stem lesions using the Ommaya reservoir: technical case report. Neurosurgery 1996; 39:404.
  110. Pendl G, Vorkapic P, Koniyama M. Microsurgery of midbrain lesions. Neurosurgery 1990; 26:641.
  111. Fisher PG, Tihan T, Goldthwaite PT, et al. Outcome analysis of childhood low-grade astrocytomas. Pediatr Blood Cancer 2008; 51:245.
  112. Abbott R, Shiminski-Maher T, Wisoff JH, Epstein FJ. Intrinsic tumors of the medulla: surgical complications. Pediatr Neurosurg 1991; 17:239.
  113. Wang C, Zhang J, Liu A, et al. Surgical treatment of primary midbrain gliomas. Surg Neurol 2000; 53:41.
  114. Mulhern RK, Heideman RL, Khatib ZA, et al. Quality of survival among children treated for brain stem glioma. Pediatr Neurosurg 1994; 20:226.
  115. Ris MD, Beebe DW, Armstrong FD, et al. Cognitive and adaptive outcome in extracerebellar low-grade brain tumors in children: a report from the Children's Oncology Group. J Clin Oncol 2008; 26:4765.
  116. Landier W, Bhatia S, Eshelman DA, et al. Development of risk-based guidelines for pediatric cancer survivors: the Children's Oncology Group Long-Term Follow-Up Guidelines from the Children's Oncology Group Late Effects Committee and Nursing Discipline. J Clin Oncol 2004; 22:4979.
  117. Guillamo JS, Monjour A, Taillandier L, et al. Brainstem gliomas in adults: prognostic factors and classification. Brain 2001; 124:2528.
  118. Landolfi JC, Thaler HT, DeAngelis LM. Adult brainstem gliomas. Neurology 1998; 51:1136.
  119. Salmaggi A, Fariselli L, Milanesi I, et al. Natural history and management of brainstem gliomas in adults. A retrospective Italian study. J Neurol 2008; 255:171.