Low-grade astrocytomas: the prognostic value of fibrillary, gemistocytic, and protoplasmic tumor histology

Clinical article

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Low-grade astrocytomas are slow-growing, infiltrative gliomas that over time may progress into more malignant tumors. Various factors have been shown to affect the time to progression and overall survival including age, performance status, tumor size, and the extent of resection. However, more recently it has been suggested that histological subtypes (fibrillary, protoplasmic, and gemistocytic) may impact patient outcome. In this study the authors have performed a large comparative population-based analysis to examine the characteristics and survival of patients with the various subtypes of WHO Grade II astrocytomas.


Patients diagnosed with fibrillary, protoplasmic, and gemistocytic astrocytomas were identified through the Surveillance, Epidemiology, and End Results (SEER) database. The chi-square test and Student t-test were used to evaluate differences in patient and treatment characteristics between astrocytoma subtypes. Kaplan-Meier analysis was used to assess overall survival, and the log-rank test was used to evaluate the differences between survival curves. Univariate and multivariate analyses were also performed to determine the effect of various patient, tumor, and treatment variables on overall survival.


A total of 500 cases were included in the analysis, consisting of 326 fibrillary (65.2%), 29 protoplasmic (5.8%), and 145 gemistocytic (29%) variants. Gemistocytic astrocytomas presented at a significantly older age than the fibrillary variant (46.8 vs 37.7 years, p < 0.0001), with protoplasmic and fibrillary subtypes having a similar age. Although protoplasmic and fibrillary variants underwent radiotherapy at similar rates, gemistocytic tumors more frequently received radiotherapy (p = 0.0001). Univariate analysis revealed older age, larger tumor size, and the use of radiotherapy to be poor prognostic factors, with resection being associated with improved survival. The gemistocytic subtype (hazard ratio [HR] 1.62 [95% CI 1.27–2.07], p = 0.0001) also resulted in significantly worse survival than fibrillary tumors. Bivariate analyses demonstrated that older age, the use of radiotherapy, and resection significantly influenced median survival. Tumor subtype also affected median survival; patients who harbored gemistocytic tumors experienced less than half the median survival of fibrillary and protoplasmic tumors (38 vs 82 months, p = 0.0003). Multivariate analysis revealed increasing age (HR 1.05 [95% CI 1.04–1.05], p < 0.0001), larger tumor size (HR 1.02 [95% CI 1.01–1.03], p = 0.0002), and the use of resection (HR 0.70 [95% CI 0.52–0.94], p = 0.018) to be independent predictors of survival. Examination of tumor subtype revealed that the gemistocytic variant (HR 1.30 [95% CI 0.98–1.74], p = 0.074) was associated with worse patient survival than fibrillary tumors, although this only approached significance. The protoplasmic subtype did not affect overall survival (p = 0.33).


Gemistocytic tumor histology was associated with worse survival than fibrillary and protoplasmic astrocytomas. As protoplasmic astrocytomas have a survival similar to fibrillary tumors, there may be limited utility to the identification of this rare variant. However, increased attention should be paid to the presence of gemistocytes in low-grade gliomas as this is associated with shorter time to progression, increased malignant transformation, and reduced overall survival.

Abbreviations used in this paper:GFAP = glial fibrillary acidic protein; HR = hazard ratio; LGA = low-grade astrocytoma; SEER = Surveillance, Epidemiology, and End Results.

Article Information

Address correspondence to: Cory Adamson, M.D., Ph.D., M.P.H., M.H.Sc., Division of Neurosurgery, DUMC 2624, Durham, North Carolina 27710. email: cory.adamson@duke.edu.

Please include this information when citing this paper: published online May 10, 2013; DOI: 10.3171/2013.4.JNS122329.

© AANS, except where prohibited by US copyright law.



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    Kaplan-Meier survival curves of patients with WHO Grade II astrocytomas showing patients older than 40 years to have worse survival than younger patients.

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    Kaplan-Meier survival curves of patients with WHO Grade II astrocytomas showing significantly worse survival for elderly patients (> 65 years).

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    Kaplan-Meier survival curves of patients with WHO Grade II astrocytomas showing patients who received radiotherapy to have worse survival.

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    Kaplan-Meier survival curves of patients with WHO Grade II astrocytomas showing patients who underwent resection to have better survival than those who only received biopsies.

  • View in gallery

    Kaplan-Meier survival curves of patients with WHO Grade II astrocytomas showing gemistocytic tumors to have significantly worse survival than fibrillary and protoplasmic astrocytomas.



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