Rapid Recurrence and Anaplastic Transformation of a Pilocytic Astrocytoma in an Elderly Patient: Case Report and Review of the Literature

Rare vermian pilocytic astrocytoma with recurrent spontaneous hemorrhage in the elderly: A case report and review of literature

Background

Pilocytic astrocytoma (PA) is a benign glial tumor predominately seen in pediatrics and early adolescence with associated overall good outcomes. Very few cases of elderly PA have been reported in the literature, and they are known to display unique anatomic, histologic, and genetic peculiarities distinct from pediatric disease. We report a rare case of vermian PA in an octogenarian with recurrent spontaneous intratumoral hemorrhage as a presenting symptom. Furthermore, a review of the literature on the peculiarities of PA in the elderly will be discussed.

Case Description

An 81-year-old woman presented with features suggestive of repeated posterior fossa hemorrhages characterized by headaches, diplopia, and alteration in sensorium occurring about 5 months apart. Brain neuroimaging showed a cerebellar vermian tumor with features suggestive of repeated intratumoral bleeding. She had an initial ventriculoperitoneal shunting for acute hydrocephalus and subsequently had a suboccipital craniotomy and subtotal tumor excision due to morbid adherence to the brainstem. The histologic diagnosis was PA with Ki-67 <1% and negative for isocitrate dehydrogenase-1. There was a slow but progressive clinical improvement, and she has remained symptom-free for 4 years on follow-up.

Conclusion

PA in the elderly is a rare disease with distinct histologic and genetic peculiarities. This case review showed one of the oldest cases of cerebellar vermian PA presenting with recurrent spontaneous intratumoral hemorrhage, an extremely rare occurrence in benign glioma. Although complete surgical excision is recommended, partial resection is advocated for morbidly adherent tumors. Overall prognosis is worse in elderly PA.

Effect of Perioperative Dexmedetomidine Anesthesia on Prognosis of Elderly Patients with Gastrointestinal Tumor Surgery

It was to investigate the influence of perioperative dexmedetomidine (DEX) anesthesia on the prognosis of elderly patients with gastrointestinal tumor (GIT) surgery. 90 patients who underwent laparoscopic radical gastrectomy for GIT were included. They were randomly divided into the experimental group (45 cases) with DEX+general anesthesia, and the control group (45 cases) with epidural anesthesia+general anesthesia. The indicators after surgery were compared between the two groups. The mean arterial pressure (MAP) was 74.8 ± 3.5 mmHg and the heart rate (HR) was 52.7 ± 8.2 beats/min⁻¹ in the experimental group, significantly lower than those of the control group (P < 0.05). The Visual Analog Scale (VAS) scores of both groups decreased greatly associated to those before surgery (P < 0.05). The levels of cortisol (COR) and immune adhesion inhibitor (FEIR) in the experimental group were significantly dissimilar from those in the control group (P < 0.05). The tumor necrosis factor-alpha (TNF-α) was 96.4 ± 21.8 ng/L in the experimental group, observably lower than that in the control group (P < 0.05). The postoperative diamine oxidase (DAO) and D-lactate (D-lac) were 62.4 ± 9.3 μmol/mL and 33.8 ± 7.2 ng/L, respectively, in the experimental group, much lower than those in the control group (P < 0.05). There were also significant differences in the initial recovery of bowel sounds, defecation, and total length of hospital stay (LOHS) between the groups (P < 0.05). DEX anesthesia had ideal sedative and analgesic effects, improving the prognosis of patients during surgery, and shortening the LOHS. Thus, it deserved a clinical application value.

Concise review of radiosurgery for contemporary management of pilocytic astrocytomas in children and adults

Pilocytic astrocytoma (PA) may be seen in both adults and children as a distinct histologic and biologic subset of low-grade glioma. Surgery is the principal treatment for the management of PAs; however, selected patients may benefit from irradiation particularly in the setting of inoperability, incomplete resection, or recurrent disease. While conventionally fractionated radiation therapy has been traditionally utilized for radiotherapeutic management, stereotactic irradiation strategies have been introduced more recently to improve the toxicity profile of radiation delivery without compromising tumor control. PAs may be suitable for radiosurgical management due to their typical appearance as well circumscribed lesions. Focused and precise targeting of these well-defined lesions under stereotactic immobilization and image guidance may offer great potential for achieving an improved therapeutic ratio by virtue of radiosurgical techniques. Given the high conformality along with steep dose gradients around the target volume allowing for reduced normal tissue exposure, radiosurgery may be considered a viable modality of radiotherapeutic management. Another advantage of radiosurgery may be the completion of therapy in a usually shorter overall treatment time, which may be particularly well suited for children with requirement of anesthesia during irradiation. Several studies have addressed the utility of radiosurgery particularly as an adjuvant or salvage treatment modality for PA. Nevertheless, despite the growing body of evidence supporting the use of radiosurgery, there is need for a high level of evidence to dictate treatment decisions and establish its optimal role in the management of PA. Herein, we provide a concise review of radiosurgery for PA in light of the literature.