Management of glioma

Management

• managment is via a multidisciplinary team (MDT), comprising specialists, clinical nurse specialists and allied health professionals
  • multiple factors influence the best form of treatment
    • general fitness level of the patient,
    • the neurological status and mode of presentation,
    • size and location of the tumour and
    • the radiological appearance, especially whether the tumour is likely to be a high or low grade glioma

High Grade Gliomas:

• neurosurgery is indicated in all patients with a radiological suspicion of a high grade glioma
  
  
• post operative radiotherapy has been shown conclusively to confer prognostic advantage in patients with high grade gliomas
  • most patients undergo a six-week course of treatment, although shorter courses may be used in patients who are less fit
    
    
• chemotherapy
  • concomitant chemotherapy with temozolomide alongside radiotherapy is indicated in patients with grade 4 tumours and good medical and neurological status
  • post-radiotherapy chemotherapy with temozolomide or PCV (procarbazine, lomustine and vincristine) may also be used, particularly in patients with radiological evidence of disease progression
    
    
• carmustine implants and temozolomide are NICE approved for the treatment of newly diagnosed high-grade glioma

Low grade gliomas:

• previously, many patients with radiological features of low grade gliomas were managed conservatively with watchful waiting and MRI surveillance
  
  
• an improved understanding of the natural history of low grade, particularly grade 2, gliomas has acknowledged almost inevitable progression to high grade gliomas - therefore the evidence in favour of prognostic benefit and potential cure with total resection, have significantly changed the management of patients with low grade gliomas
  • surgical resection should be considered as part of initial management (within 6 months of radiological diagnosis) to:
    • obtain a histological and molecular diagnosis, and
    • remove as much of the tumour as safely possible after discussion of the possible extent of resection at multidisciplinary meeting and with the person with the brain tumour, and their relatives and carers
      • if surgical resection is not appropriate, consider a biopsy to obtain a histological and molecular diagnosis
      • consider active monitoring without a histological diagnosis for lesions with radiological features typical of very low-grade tumours, for example optic pathway glioma (2)
        
        
• techniques such as awake surgery with motor and language mapping are useful to increase the safety and extent of surgery in low grade gliomas in and near eloquent brain
  
  
• it is unclear whether subtotal resection confers any prognostic advantage
  
  
• evidence that PCV chemotherapy (procarbazine, CCNU [lomustine] and vincristine) after radiotherapy improves overall survival and progression-free survival compared with radiotherapy alone (2)

Reference:

• Walker M, Alexander E, Hunt W et al. Evaluation of BCNU and/or radiotherapy in the treatment of anaplastic gliomas. J Neurosurg 1978; 49 (3): 333-43.
• NICE (July 2018). Brain tumours (primary) and brain metastases in adults