I have reviewed the notes provided and agree that they are consistent with an aggressive high-grade tumor. Given the patient's age, history, and pathology data, I would recommend the following given the diagnosis of anaplastic astrocytoma and information noted above.
1. Do you confirm the treatment in place?
There was no clear recommendation in the notes I reviewed. My suggestions are:
- Would consider treatment with standard of care drug temozolomide first before moving to more experimental options below:
Yung WK, Prados MD, et al. Multicenter phase II trial of temozolomide in patients with
anaplastic astrocytoma or anaplastic oligoastrocytoma at first relapse. Temodal Brain Tumor Group. J Clin Oncol. 1999 Sep;17(9):2762-71. Erratum in: J Clin Oncol 1999
Stupp R, Mason WP, van den Bent MJ, et al. Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N Engl J Med. 2005 Mar 10;352(10):987-96.
- Would recommend a Brain Tumor Center locally that has clinical trial options to try investigational agents such as below or can be used off-label by local oncologist if possible.
- AVASTIN (bevacizumab) + chemotherapy are the best option currently. A large phase - II trial finished recently and the data is positive and available soon. But other earlier trials have already shown benefit as referenced below.
Vredenburgh JJ, Desjardins A, et al, Phase II trial of bevacizumab and irinotecan in recurrent malignant glioma. Clin Cancer Res. 2007 Feb 15;13(4):1253-9.
- Can also consider Tarceva + rapamycin
Doherty L, Gigas DC, Kesari S, Drappatz J, Kim R, Zimmerman J, Ostrowsky L, Wen PY.
Pilot study of the combination of EGFR and mTOR inhibitors in recurrent malignant gliomas.
Neurology. 2006 Jul 11;67(1):156-8.
- Can also consider Gleevec+ hydrea
Desjardins A, Quinn JA, Vredenburgh JJ, Sathornsumetee S, Friedman AH, Herndon JE, McLendon RE, Provenzale JM, Rich JN, Sampson JH, Gururangan S, Dowell JM, Salvado A, Friedman HS, Reardon DA. Phase II study of imatinib mesylate and hydroxyurea for recurrent grade III malignant gliomas. J Neurooncol. 2007 May;83(1):53-60. Epub 2007 Jan 24.
Kesari S, Ramakrishna N, Sauvageot C, Stiles CD, Wen PY. Targeted molecular therapy of malignant gliomas. Curr Oncol Rep. 2006 Jan;8(1):58-70.
2. Is it possible to consider surgical intervention?
unlikely to be help for this particular patient based on location and likely hood that the
surgeon will not achieve a gross total resection, if patient has symptoms of mass effect or concern that either the imaging represents necrosis or progression to glioblastoma then reasonable to consider reresection if safe.
3. Which are the Centers of Excellence in Italy?
There are several physicians/centers that I am aware of that have good reputations:
- Alba A. Brandes, Department of Medical Oncology, Azienda Unità Sanitaria Locale Bellaria-Maggiore, Bologna, Italy.
- Riccardo Soffietti;Division of Neuro-oncology, Departments of Neuroscience and Oncology, University and San Giovanni Battista Hospital, Torino, Italy
- Department of Neuro-oncology, Istituto Nazionale Neurologico C. Besta, Milan, Via Celoria 11, Milan, Italy.
There maybe others closer to you location.
For patients with recurrent disease, the prognosis is guarded and best to seek treatments at academic centers where clinical trials are performed to give patient better options.
All of these recommendations have to be taken in context of functional status and balancing quality of life.