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Astrocytoma

Last updated: March 7, 2021

Summary

Astrocytomas are neuroepithelial tumors (gliomas) that arise from the supportive tissue of the brain. These tumors are classified by the WHO into four separate grades depending on the extent of abnormality. Astrocytomas initially present with general symptoms including headaches and/or epileptic seizures, which are rapidly replaced by focal symptoms such as progressive paralysis or aphasia. Low-grade astrocytomas are usually localized, slow-growing, and occur predominantly in younger populations (children and adults aged between 20 and 40). Grade IV astrocytomas, on the other hand, are rapidly growing glioblastomas, which are the most common malignant primary brain tumors in adults aged 60–70. Diagnosis is established based on the patient's clinical history and MRI findings. The treatment for astrocytomas is surgical resection, which may need to be combined with radiotherapy and/or chemotherapy in higher-grade tumors. The prognosis is usually poor for higher-grade tumors regardless of whether they receive treatment, with a life expectancy of several months (maximum of 2 years). However, low-grade astrocytomas can often be completely cured with effective surgical resection.

Differential diagnosis of astrocytomas

Overview of astrocytomas
WHO grade	I		II	III	IV		Variable
Type	Pilocytic astrocytoma ^[1]^[2]^[3]^[4]	Optic glioma ^[5]	Diffuse astrocytoma	Anaplastic astrocytoma ^[6]^[7]	Glioblastoma ^[8]^[9]^[10]		Brainstem glioma ^[11]
Epidemiology	Children and young adults (< 20 years)	Most frequently children (< 10 years)	20–40 years of age	30–50 years of age	60–70 years of age Most common malignant primary nervous system cancer Associated with EGFR mutations (e.g., amplification)		3–10 years of age Comprise 15% of all childhood brain tumors
Location	Most common Cerebellum Posterior cranial fossa (infratentorial) Less common Cerebral hemispheres (supratentorial) Hypothalamus	Optic nerve Chiasm	Cerebral hemisphere		White matter of the cerebral hemisphere Possibly bilateral: butterfly glioma		Brainstem
Symptoms	Vomiting Ataxia Failure to thrive (impaired growth)	Sporadic episodes of vision impairment Bulging of eyeball Impaired eye movements	General clinical features of brain tumors (e.g., epileptic seizures)		General clinical features of brain tumors (e.g., epileptic seizure) Rapid growth → short disease course (several weeks)	Apoplectic glioma Mimics intracranial hemorrhage Symptoms of raised ICP	Vomiting Ataxia Cranial nerve deficits Hydrocephalus
Symptoms	Often associated with neurofibromatosis type I						Vomiting Ataxia Cranial nerve deficits Hydrocephalus
Diagnostics	Characteristics Well-demarcated cystic lesion Bright contrast-enhancing solid nodule in the wall of the cyst MRI T1 hypointense T2 hyperintense Histopathology Microcysts Bipolar cells; hair-like projections Eosinophilic fibers with corkscrew appearance (Rosenthal fibers)	MRI T1 hypointense T2 hyperintense	MRI T1 hypointense or isointense T2 hyperintense CT Hypodense No contrast enhancement	MRI T1 hypointense T2 hyperintense Inhomogenous Perifocal edema No necrosis (in contrast to glioblastoma) CT Positive mass effect Hypodense Variable contrast enhancement	MRI Irregular, enhancing margins with a necrotic core T1 mixed T2 hyperintense Perifocal edema May also have multifocal enhancements Midline shift CT Garland-like contrast enhancement Significant mass effect		MRI T2 hyperintense No contrast enhancement
Treatment	Surgical resection	No treatment in asymptomatic patients with no signs of tumor growth Surgical resection Radiotherapy Unresectable tumors Adjuvant	Complete surgical resection often not possible ; resection until definable margins can be attempted Percutaneous radiotherapy for very diffuse, unresectable tumors	Tumor debulking through surgery Percutaneous radiotherapy/chemotherapy	Surgical resection Palliative percutaneous radiotherapy/chemotherapy (temozolomide) Glucocorticoids		Surgical resection is often difficult
Prognosis	Good: completely curable with complete surgical resection Median survival: > 10 years	Good Many patients have significant long-term visual impairment.	5-year survival rate: ∼ 34% without treatment ∼ 70% with radiation therapy	5-year survival rate: ∼ 23%	Unfavorable Median survival of 15 months		Poor, especially in diffuse pontine gliomas Median survival: ∼ 10 months

Cerebellar pilocytic astrocytoma Diffuse astrocytoma (grade II) Mid-grade glioma Glioblastoma Glioblastoma in the temporal lobe Bilateral glioblastoma (butterfly glioma) Typical locations of brain tumors

Astrocytomas nearly always stain positive for glial fibrillary acidic protein (GFAP).

References

Low grade infiltrative astrocytoma. https://radiopaedia.org/articles/low-grade-infiltrative-astrocytoma. Updated: January 1, 2017. Accessed: February 19, 2017.
Astrocytoma. http://www.mdguidelines.com/astrocytoma. Updated: January 1, 2017. Accessed: February 19, 2017.
Collins VP, Jones DTW, Giannini C. Pilocytic astrocytoma: pathology, molecular mechanisms and markers. Acta Neuropathol. 2015; 129 (6): p.775-788. doi: 10.1007/s00401-015-1410-7 . | Open in Read by QxMD
Pilocytic Astrocytoma. https://radiopaedia.org/articles/pilocytic-astrocytoma. Updated: January 1, 2018. Accessed: November 12, 2018.
Optic Nerve Glioma. http://eyewiki.aao.org/Optic_Nerve_Glioma. Updated: September 27, 2016. Accessed: February 19, 2017.
Smoll NR, Hamilton B. Incidence and relative survival of anaplastic astrocytomas. Neuro Oncol. 2014; 16 (10): p.1400-1407. doi: 10.1093/neuonc/nou053 . | Open in Read by QxMD
Anaplastic Astrocytoma. https://radiopaedia.org/articles/anaplastic-astrocytoma. Updated: April 1, 2018. Accessed: June 28, 2018.
Glioblastoma. https://radiopaedia.org/articles/glioblastoma. Updated: January 1, 2017. Accessed: February 19, 2017.
Nizamutdinov D, Stock EM, Dandashi JA, et al. Prognostication of survival outcomes in patients diagnosed with glioblastoma. World Neurosurg. 2018; 109 : p.e67-e74. doi: 10.1016/j.wneu.2017.09.104 . | Open in Read by QxMD
Westphal M, Maire CL, Lamszus K. EGFR as a Target for Glioblastoma Treatment: An Unfulfilled Promise. CNS Drugs. 2017; 31 (9): p.723-735. doi: 10.1007/s40263-017-0456-6 . | Open in Read by QxMD
Hu J, Western S, Kesari S. Brainstem glioma in adults. Front Oncol. 2016; 6 . doi: 10.3389/fonc.2016.00180 . | Open in Read by QxMD