Immediate Induction and Consolidation Therapy May Improve Outcomes for Patients with Anaplastic Astrocytoma: a Case Series

Abstract

Despite advances in chemotherapy and radiation, prognosis for all patients with high grade gliomas remains poor. In anaplastic astrocytomas (WHO III) GTR is associated with a 5 year progression free survival (PFS) of 44% compared to 22% when surgical resection is sub-total. While initial studies demonstrated post-radiation chemotherapy improved outcomes, successive chemotherapeutic trials were unable to significantly improve outcomes. Recent trials in adults with recurrent glioblastoma multiforme have shown that the combination of Bevacixumab and Irinotecan have improved 6 month PFS was 46% and overall survival (OS) at 6 months of 77%. Although these adult studies were encouraging, results were not replicated in children with similar pathology. This case series presents two pediatric patients with anaplastic astrocytoma treated with an induction therapy of Temozolamide (90mg/m2 x 42 days) plus standard radiation therapy (5400 cGy) very shortly after surgical resection, followed by a consolidation treatment regimen of 8-cycles of chemotherapy with Bevacizumab (10mg/m2) and Irinotecan (125mg/m2), given on days 1 and 15 of 21 day cycles. These patients did extraordinarily well on this therapeutic regimen, surpassing expectations, with one patient having 18 months of PFS and one patient achieving CR1 at the time of this publication for 20 months. The treatment regimen was well tolerated without unanticipated toxicities or episodes of severe neutropenia induced by this therapy. We are encouraged by the improvements in PFS and OS in these two patients as well as the acceptability of toxicity in this case series and thus recommend prompt induction and consolidation chemotherapy following resection of these neoplasms.