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Diuse astrocytoma
Dr Mark Thurston and A.Prof Frank Gaillard et al.

Diuse astrocytomas, also referred to as low-grade inltrative

astrocytomas,are designated as WHO II tumours of the brain. The term
diuse inltrating means there is no identiable border between the
tumour and the normal brain tissue even though the borders may appear
well marginated on imaging.

In the 2016 update to the WHO classication of CNS tumours, diuse

astrocytoma is synonymous with the previously described subtype of
brillary astrocytoma.Gemistocytic astrocytomaremains a distinct
subtype, whereas protoplasmic astrocytomasare no longer recognised
as a separate entity 13.

IDH mutation status is critically important, and astrocytomas are now

dened as IDH mutant or IDH wild-type 13.

This article will focus on the general features of diuse astrocytomas

(the most common type). Each subtype mentioned above is discussed in
more detail separately.

On this page:
Article:

Terminology
Epidemiology
Clinical presentation
Pathology
Radiographic features
Treatment and prognosis
Dierential diagnosis
Related articles
References

Images:

Cases and gures

Terminology

The term diuse astrocytoma should not be used for a specic,

non-inltrative tumours of astrocyte-lineage such as pleomorphic
xanthoastrocytoma, subependymal giant cell astrocytomaand pilocytic
astrocytoma, as these have dierent prognoses, treatment and imaging
features.

Diuse astrocytomas are divided into two molecular groups according to

IDH status:

1. IDH mutant
2. IDH wild-type

If IDH status is unavailable they are known as diuse astrocytoma NOS

(not otherwise specied).

Importantly, if IDH is shown to be mutated then 1p19q status must be

determined and shown to be not co-deleted (otherwise even with
astrocytic histology, an IDH mutated, 1p19q co-deleted tumours is now
classied as an oligodendroglioma).

It is also worth noting, that is it likely that the entity diuse astrocytoma
IDH wild-type will eventually vanish, as it is felt that most of these
tumours harbour a variety of other distinctive genetic proles and likely
represent a collection of other tumours with astrocytic histological
dierentiation 13.

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Epidemiology

Diuse low-grade gliomas of the cerebral hemispheres are typically

diagnosed in young adults between 20-45 years old (mean 35 years of
age). There is, in fact, a biphasic distribution, with one peak in childhood
(6-12 years) and the other peak in early adulthood (26-46 years) 1.
Childhood gliomas are mostly diuse brainstem gliomas, which are
discussed separately.

There is a slight male predilection is described (M:F ~1.5) 1.

Clinical presentation

The most common presenting feature (~40% of cases) is a seizure. This

is particularly the case in adults. Headaches are often also present.
Depending on the size of the lesion and its location other features may be
present, such as hydrocephalus and focal neurological dysfunction
including personality change.

Pathology

Diuse low-grade astrocytomas are predominantly composed of a

microcystic tumour matrix within which are embedded brillary
neoplastic astrocytes with mild nuclear atypia and a low cellular
density.Often microcystic spaces containing mucinous uid are present,
a typical nding in brillary astrocytomas, but even more characteristic
and pronounced in protoplasmic astrocytomas.

The occasional occurrence of gemistocytes in a diuse astrocytoma does

not justify the diagnosis of gemistocytic astrocytoma.Gemistocytic
astrocytomas tend to progress more rapidly to anaplastic astrocytoma
and secondary glioblastoma than brillary astrocytomaalthough they
share the WHO grade II.

Mitoses, microvascular proliferation and necrosis are absent (if present

they suggest a high-grade tumour). Like all tumours derived from
astrocytes, brillary astrocytomas stain with glial brillary acidic protein
(gFAP)2-3.
It is well recognised that pathological classication has a high
interobserver variation and thus imperfectly predicts clinical outcomes
11.Recent studies have shown that the genetic status of these tumours
are more reective of their subtypes than the histologic grading (please
refer on isocitrate dehydrogenase (IDH)for a broad discussion on this
topic)11.

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Radiographic features

MRI is the modality of choice for characterising these lesions, and in the
case of smaller tumours, they may be subtle and dicult to see on CT,
especially as they tend not to enhance.

CT

Typically low-grade inltrating astrocytomas appear as isodense or

hypodense regions of positive mass eect, often without any
enhancement (in fact presence of enhancement would suggest higher
grade tumours), although particularly gemistocytic astrocytomas can
demonstrate wispy enhancement.

Calcication is not common (10-20% of cases)1 and may be related to

oligodendroglial components (i.e oligoastrocytoma).

Cystic or uid attenuation components are also encountered, particularly

in gemistocytic and protoplasmic varieties.

MRI

Reported signal characteristics include:

T1
isointense to hypointense compared to white matter
usually conned to the white matters and causes expansion of
the adjacent cortex
T2/FLAIR
mass-like hyperintense signals
always follow the white matter distribution and cause
expansion of the surrounding cortex
cortex can also, be involved in late cases in comparison to the
oligodendroglioma, which is a cortical-based tumour from the
 start
the "microcystic changes" along the lines of spread of the
inltrative astrocytoma is a unique behaviour for the
inltrative astrocytoma,however, it is only appreciated in a
few number of cases
high T2 signal is NOT related to cellularity or cellular atypia,
but rather oedema,demyelination and other degenerative
change 10
DWI/ADC
typically has facilitated diusion, with lower ADC values
suggesting higher grade
T1 C+ (Gd)
no enhancement is often the rule but small ill-dened areas of
enhancement are not rare; however,when enhancement is
seen it should be considered as a warning sign for
progression to a higher grade
MR spectroscopy
typically will show elevated choline peak, low NAA peak,
elevated choline:creatine ratio
elevated myo-inositol and mI/Cr ratio.
there is lack of the lactate peak seen at 1:33
the lactate peak represents the necrosis seen in aggressive
mostly WHO grade IV tumours
MR perfusion:no elevation of rCBV

Nuclear medicine

PET
has FDG uptake similar to the normal white matter
FDG,18-F-Choline and 11C-choline PET useful for biopsy
(most hypermetabolic area)

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Treatment and prognosis

Treatment depends on clinical presentation, the size of the tumour and

location. Historically these tumours were managed as follows:

biopsy to conrm the diagnosis and observe

surgical resection if feasible
usually radiotherapy at the time of recurrence or progression
There is an increasing body of evidence that suggests that
chemotherapy+/- radiotherapy, usually reserved for tumours that
progressed to higher grades, may be of benet in lower grade tumours
also.

Dierential diagnosis

Possible imaging dierential considerations include:

infarction:major vascular territory

cerebritis, encephalitis:herpes simplex encephalitis, ADEM
anaplastic astrocytoma
cortical based tumours: oligodendroglioma, angiocentric glioma

References
Related articles

Astrocytic tumour

astrocytic tumours
WHO classication of CNS tumours
WHO grading of CNS tumours
VASARI MRI feature set
diuse astrocytoma grading[+]
grade I:[+]
grade II:
chordoid glioma of the third ventricle
low-grade diuse astrocytoma
brillary astrocytoma(no longer recognised)
protoplasmic astrocytoma(no longer recognised)
gemistocytic astrocytoma
oligoastrocytoma
pilomyxoid astrocytoma
pleomorphic xanthoastrocytoma
grade III[+]
grade IV:[+]
glioblastoma vs cerebral metastasis
radiation-induced gliomas
gliomatosis cerebri(growth pattern)
specic locations[+]
treatment response[+]
prognostic genetic markers[+]

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URL of Article https://radiopaedia.org/articles/diuse-astrocyt

Article information
rID: 14598
System: Central Nervous System
Section: Pathology
Synonyms or Alternate Spellings:

Diuse astrocytoma
Low grade astrocytoma
Low grade inltrating astrocytoma
Low grade diuse astrocytoma
 Low grade inltrative astrocytomas
Diuse low grade astrocytoma
Diuse astroctyoma IDH wild-type
Diuse astroctyoma IDH mutant
Diuse astroctyoma NOS

Cases and gures

WHO 2016 diuse glioma classicationWHO 2016 diuse glioma

classication
Drag here to reorder.
Case 1: diuse brillary astrocytomaCase 1: diuse brillary
astrocytoma
Drag here to reorder.

Case 2: gemistocytic astrocytomaCase 2: gemistocytic astrocytoma

Drag here to reorder.

Case 3Case 3
Drag here to reorder.
Case 4: basal ganglionic diuse inltrationCase 4: basal ganglionic
diuse inltration
Drag here to reorder.

Case 6: low grade gliomaCase 6: low grade glioma

Drag here to reorder.

Case 7Case 7
Drag here to reorder.
Case 8Case 8
Drag here to reorder.
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