Standard treatment of
anaplastic astrocytoma (AA) in good performance patients consists of maximal safe surgical resection followed by focal, fractionated, external beam
radiotherapy (RT) alone or in combination with concurrent and adjuvant
temozolomide (TMZ). Since prospective data regarding the use of
chemoradiotherapy for AA is lacking, the practice is based on the extrapolation of results from a randomized study in
glioblastoma (GB). Whether the data from the GB study can and should be extrapolated is controversial, although a large multicenter, randomized, phase III study is underway to define optimal initial AA treatment. Patients should be tapered off
corticosteroids completely or to the lowest dose necessary to treat
neurologic dysfunction. Anti-epileptic drugs (AED) are not indicated unless there is a history of seizure;
levetiracetam is the preferred AED in
malignant glioma (MG). Unless there is evidence of
intracranial hemorrhage,
venous thromboembolism (VTE) should be treated with
low-molecular-weight heparin (
LMWH)
therapy. At recurrence, patients with good performance status are usually treated with cytotoxic
chemotherapy following, or in lieu of, repeat surgery. TMZ is the preferred chemotherapeutic agent in patients without prior exposure;
lomustine is recommended for
tumors resistant to TMZ. In patients with
neurologic dysfunction secondary to
tumor edema and mass effect who are not amenable to surgery, the use of
bevacizumab is associated with improved neurologic function and better quality of life. Given the limited treatment options at
tumor recurrence, consideration for enrollment on a clinical trial is encouraged.