Low-grade gliomas in adults

A review

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In recent years, advances in the understanding of low-grade glioma (LGG) biology have driven new paradigms in molecular markers, diagnostic imaging, operative techniques and technologies, and adjuvant therapies. Taken together, these developments are collectively pushing the envelope toward improved quality of life and survival. In this article, the authors evaluate the recent literature to synthesize a comprehensive review of LGGs in the modern neurosurgical era.

Abbreviations used in this paper: CBV = cerebral blood volume; DT = diffusion tensor; EORTC = European Organization for Research and Treatment of Cancer; FET = O-(2-18F-fluoroethyl)-L-tyrosine; FLT = 3′-deoxy-3′-18F-fluorothymidine; fMR imaging = functional MR imaging; GFAP = glial fibrillary acidic protein; KPS = Karonfsky Performance Status; LGG = low-grade glioma; MGMT = O6-methylguanine-methyltransferase; mTOR = mammalian target of rapamycin; PCV = procarbazine/lomustine (CCNU)/vincristine; PDGF = platelet-derived growth factor; rCBV = relative CBV; RTOG = Radiation Therapy Oncology Group; UCSF = University of California at San Francisco.

Article Information

Address correspondence to: Mitchel S. Berger, M.D., Department of Neurological Surgery, University of California at San Francisco, 505 Parnassus Avenue, M779, Box 0112, San Francisco, California 94143. email: bergerm@neurosurg.ucsf.edu.

Please include this information when citing this paper: published online August 19, 2011; DOI: 10.3171/2011.7.JNS101238.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Low-grade glioma histology. Photomicrographs demonstrating basic histological features associated with WHO Grade II astrocytoma (A), oligodendroglioma (B), and oligoastrocytoma (C). H & E, original magnification × 40.

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    Codeletions of 1p and 19q in oligodendrogliomas. Fluorescence in situ hybridization demonstrating deletion of 1p and 19q in anaplastic oligodendroglioma (WHO Grade III). Two red signals (reference probe 1q42) and 1 green signal (arrow) (test probe 1p32) are indicative of deletion of 1p. Two green signals (reference probe 19p13) and 1 red signal (arrow) (test probe 19q13) demonstrate deletion of 19q.

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    Physiological imaging of LGGs. Physiological imaging profiles for WHO Grade II oligodendrogliomas (A), oligoastrocytomas (B), and astrocytomas (C). Apparent diffusion coefficient (ADC) maps demonstrate normal-appearing white matter (green), pink regions characteristic of oligiodendrogliomas, and blue values characteristic of astrocytomas. Similarly, physiological MR imaging modalities can identify histologically specific profiles on the basis of the choline-to-NAA index (CNI), as well as fast spin echo (FSE), FLAIR, and normalized MR perfusion (nPH) signatures. nADC = normalized ADC.

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    Stepwise improvement in overall survival at 10 years with greater extent of resection. Patients with a greater percentage of tumor resection had a significantly longer overall survival (Cox proportional hazards model, p < 0.001; HR 0.972; 95% CI 0.960–0.983). For the purposes of visual display, cases were grouped by extent of tumor resection: 100% (75 patients, 2 events), 90%–99% (26 patients, 3 events), 41%–89% (94 patients, 18 events), and less than 40% (21 patients, 11 events). From Smith JS, et al. J Clin Oncol 2008;26(8):1338–1345. Reprinted with permission. © 2008 American Society of Clinical Oncology. All rights reserved.

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    Seizure-free status and the impact of LGG extent of resection. Negative clinical features are associated with prolonged seizures and simple partial seizures among LGG patients. Engel class outcomes describing the seizure profile for LGG patients following resection: Engel Class I (seizure-free) was associated with gross-total resection and lower rates of Engel classes II (rare seizures), III (meaningful seizure improvement), and IV (no improvement or worsening). Seizure control is far more likely to be achieved after gross-total resection than after subtotal resection/biopsy alone.

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    PTEN methylation and other intracellular signaling pathways in LGGs. A: Immunohistochemical analysis of PKB/Akt phosphorylation, a downstream kinase regulated by PTEN, is a sensitive, indirect method of assessing PTEN activity, as phosphorylation correlates directory with PTEN methylation. B: The PTEN/PI3K/AKT/mTOR pathways are intertwined within a transformed cell, enabling mTOR inhibitors to have broad effect on signaling.

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    Low-grade glioma management flowchart. This treatment algorithm represents the views of the authors, not a validated set of guidelines. AED = antiepileptic drug; DTI = diffusion tensor imaging; ECog = electrocorticography; GTR = gross-total resection; MEG = magnetoencephalography; MRS = MR spectroscopy; STR = subtotal resection. *There is no Level I evidence to support the use of temozolomide for residual tumor.

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