Categorization of tumor: Since treatment varies with tumor type, the first step in management of a brainstem glioma is to categorize it as a focal, exophytic, diffuse, or cervicomedullary tumor.
Focal, exophytic, and cervicomedullary tumors: These tumors can be managed initially with surgery. They all share the feature that treatment tolerance is a function of the clinical state of the patient. Therapy is best tolerated by a patient with minimal or no symptoms or signs of neurological dysfunction. Therefore, treatment is best initiated at the time of the tumor’s discovery.
Diffuse intrinsic pontine glioma: Patients with diffuse intrinsic pontine gliomas should be evaluated by the oncology team for radiation therapy, with or without adjuvant chemotherapy.
Diffuse intrinsic pontine glioma: Patients with diffuse intrinsic pontine gliomas may receive chemotherapy before, concomitant with, or after radiation therapy. To date, however, chemotherapy has no proven efficacy.
Schedule dictated by expectations of tumor behavior: Beyond the standard postoperative visits, follow-up is dictated by the tumor pathology (benign versus malignant), extent of resection, and postoperative neurological status.
Benign tumors: Benign tumors require close imaging follow-up initially after surgical resection. Eventually, if MRI scans show that the tumor is stable, imaging can be obtained annually in the absence of new symptoms.
Malignant tumors: Malignant tumors should be followed more closely in a multidisciplinary fashion with early involvement by neuro-oncology. These patients will be seen frequently by oncologists as adjuvant therapy is administered.