Low grade glioma with different management options

1. Start with the Great name of ALLAH, The most Merciful and the most Beneficial

2. LOW GRADE GLIOMA;
Different Management Option

3. Epidemiology
 Incidence rate 6.5/100,000, mean age
diagnosis 39.4 year
 Better prognosis; 10 year survival 35%
 50 to 75 % chance of dedifferentiate into
high grade with in 6 to 7 year of diagnosis
 Mostly frontal lobe (44%), temporal (28%)
and parietal (14%)
 Cerebellar regions LLG have better
prognosis then Supra-tentorially.

4. Classification
WHO Classification
 Grade I
 Subependymal gaint cell astrocytoma
 Pilocytic astrocytoma
 Grade II
 Diffuse oligodengroglioma (21.1%)
 Diffuse astrocytoma (69.3%)
 Mixed (9.6%)

5. Genetic
profile

6. Factors favours longer survival
 Younger age
 Caucasian race
 Tumor histology
 Extent of resection

7. Risk factors
 High dose radiation
 Increasing age
 Hereditary disorders; Li-fraumeni Syndrome
and neurofibromatosis type 1

8. Clinical presentation
 Seizures (65%- 95%)
 Headache (less common, slow growth,
4.1mm/yr)
 Neurological deficit according to location
(late).

9. Symptoms Management
 Seizures; Levetiracetam from 1g to 4g/day,
as high as 5g
 Post operative seizures prognosis depend
upon extent of resection, preoperative
seizure control, duration of seizures and
seizure type (partial seizures less
controllable)
 Steroids; 16 mg/day to reduce vasogenic
edema; tapered gradually

10. Neuroimaging
T1: isointense/hypointense; T2 homogenous hyperintense
with no contrast enhancement

11. MR spectroscopy:
• Elevated choline
• Reduced N-acetyl-aspartate
• Low creatine concentration
• Increase Choline-creatine ratio
associated with high risk of
transformation into High grade
• Increase choline and decrease
glutathion values represent
IDH1 mutation.

12. Other modalities
 PET scan
(fluorodeoxyglucos
e and
flurothymidine)
highly sensitive for
differentiating LGG
to HGG

13. • Perfusion MRI: increased relative cerebral brain volume
associated with rapid progression of LGG to HGG
• Diffusion tensor imaging: inverse correlation with tumor grade
and axial diffusivity, radial diffusivity and ADC (apparent
diffusion coefficent)
• Functional MRI: for assessment of eloquent brain areas. Helps in
surgical resections
• Magentoencephalography: helps in neuro-navigation and
structural mapping.
• Magnetic source imaging; part of neuro-navigation assisted by
magentoencephalography for somatosensory mapping and
cortical dominance

14. Prognostic factors, outcome and
survival
 High risk of tumor recurrence; preoperative diameter of 4
cm or large, astrocytoma/ oligoastrocytoma histology
type, post-operative residual 1 cm or larger
 UCSF scoring system; 1 point for each factors; eloquent
cortices, kps 80 or less, age >50 year and tumor diameter
> 4cm.
 UCSF score 0-1= 97% 5 year survival rate, 3-4 = 56% 5
year survival rate
 Early radiation improves progression free survival
 Gross total resection had best outcome without recurrence
for 4 year.
 58% of surgical treated patients had 1 time recurrance
within time frame of 36 months

15. Treatment options
 Observation
Indication Benefits Disadvantages
Deep seated One study (small
group)showed no
difference in rate
of malignant
transformation,
overall survival
and quality of life
between observe
and surgical
group
Risk of tumor
progression
Eloquent area Sudden increase
in size with radio
resistances
Associated co
morbidities
Psychological
stress

16. Stereotactic biopsy
Indication Advantages Disadvantages
Worse clinical
status
Effective, day care
procedure
Sampling error
Difficult Anatomical
locations
Low morbidity and
mortality
ICH, SAH and
uncontrolled edema
(<1 %)
Diagnostic
uncertainty
Identification of
radio and chemo
responsive LGG
(IDH mutant type)
Needs additional
imaging and proper
planning
For decision
regarding surgery
or observation in
minimal clinical
symptoms
Costly

17. Main objectives of microsurgical resection
 Maximal resection with less morbidity
 A balance between extent of resection and functional
preservation.
 Relive the mass effect
 Obtaining maximum cyto reduction
 Diagnosis

18. Microsurgical resection
Indication Advantage Disadvantage
Mass effect Reduces cerebral edema Late and severe
neurological deficit
Raise ICP More tissue for
histological diagnosis
Residual tumor
decreases the time
duration for malignant
transformation
Uncontrolled seziures Improve radio and
chemo sensitivity
Doesn’t prevent
malignant transformation
Young age Decrease risk of tumor
progression and
malignant transformation
Post-operative
hemorrahge,
uncontrolled edema,
infection and others
Increases Overall
survival directly
proportional to the extent
of resection

19. Modalities helpful in Tumor resection
 Intraoperative ultrasonography: helpful in detecting
tumor, delineating its margins, differentiating tumor
from peritumoral edema, cyst, necrosis and adjacent
normal brain
 Intraoperative MRI
 Stimulation mapping of cortical area
 Intraoperative fluorescence guided surgery (5-ALA)

20. Radiotherapy
Advantages Disadvantages
50.4 Gy in 28 fractions Increases progression
free survival
Doesn’t increases
overall survival
Side effects:
Dermatitis, alopecia
and lethargy
Low dose radiation
associated with stable
neurocognitive
outcome
High doses associated
with decrease overall
survival

21. Chemotherapy
Advantages Disadvantages
Agents; temozolomide,
PCV (procarbazine,
CCNU/lomustine,
vincristine)
Longer progression free
and overall survival if
used with radiotherapy
Medical complications
Mostly recurrent cancers,
adjuvant radiotherapy
Associated deletion of
1p/19q response better
No affect on PFS and OS
if used post operatively
alone.
Prolong use of TMZ in
recurrent tumor improves
PFS and OS.
TMZ induced
mutagenesis
Decreases the volume
20% preoperatively and
helps in extent of
resection and less
residual (TMZ only)

22. Molecular therapy
Advantage Disadvantage
Agents: bevacizumab
everolimus
Stop progression and
hold the disease
process
Only used for failed
treatments
Objective response No adults patient data
Paediatric group On stopping regime,
the disease started to
progress again

23. JAZAKALLA
H