Advances in Management of Gliomas

Question 1

What are gliomas?

Answer 1

Primary brain tumours

Question 2

What do Glioma represent?

Answer 2

The commonest tumours that we see in neurology

Question 3

What is an example of secondary tumours that are more common than primary brain tumour?

Answer 3

Brain metastasis

Question 4

What is case example 1

Answer 4

• 46 F presenting with temporal lobe seizures and right insular enhancing tumour
• Jan 04 Biopsy showed Gd II gemistocytic astrocytoma
• Feb 17. Alive and well. PS 0
• Epilepsy is very common presentation of glioma
• Mass lesion in the right insular – relatively de-marketed
• Oedema is spreading through internal capsule
• The characteristic of vasogenic oedema is that it outlines white matter tract
• When there is a breakdown of the BBB – you see gadolinium – it is an enhancer and that it is a bad sign
• Adult tumours enhance
• She’s got a bit of scar tissue – little bit of volume loss but she has no more enhancement
• She died in 2017
• Treatment
- Radiotherapy alone

Question 5

What is case example 2?

Answer 5

• 61F presenting with temporal lobe seizures and right insular thalamic tumour
• Sept 04 Biopsy showed Gd II diffuse astrocytoma
• Jan 18 Alive and well. PS1
• Shes got the insular and the thalamic
• She has a multi-focal process going on
• She was biopsied – to diffuse astrocytoma
• Over the years there has been a dramatic growth – the whole of the insula is infiltrated, and she has got biothalamic involvement
• Treatment
- Surveillance

Question 6

What are the challenges of Low grade tumour?

Answer 6

• All tumours cause mass effect but the growth is so slow that the brain can adapt to an increasing mass up to a certain point
• Slow growth is the absolute key for low grade gliomas
• Variable natural history – tigers and pussy cats
• Long-term survivors (usually young with seizures) not uncommon
• Many LGG infiltrate eloquent regions – surgery is highly risky
• 90% undergo malignant transformation
• No prospective randomised surgical treatment to provide Class 1 evidence
• There is no high quality prospective randomised evidence to support early surgical resection

Question 7

What is the natural history study of LGG?

Answer 7

• Research was carried out over a period of 10 years
• Histologically verified or radiologically suspected Grade II gliomas (astro,oligo, mixed)
• No treatment except AEDs/biopsy
• Six monthly intervals
• Biopsy/resection if clinical/radiological progression

Question 8

What is the progression of LGG?

Answer 8

• Defined either clinically

• Progressive neurological deficit/raised intracranial pressure
• New or significant increase of enhancement with double dose Gd MRI
• NOT volume change alone or increase in seizure frequency

Question 9

What is the imaging protocol?

Answer 9

1. Serial multimodality imaging
   - Conventional T1/T2 sequences
   - Growth rates
   - Diffusion
   - Perfusion
   - Permeability

Question 10

What is the annual growth rate of a non-transforming LGG?

Answer 10

10-15%

Question 11

What is in the higher risk category?

Answer 11

A tumour that is growing visibly over a year

Question 12

What is perfusion imaging?

Answer 12

• Dynamic susceptibility contrast-MRI
• rCBV (relative cerebral blood volume) most validated parameter
• close correlation with microvascular density of tumour tissue marker of neovascularity

Question 13

What is rCBV a measure of?

Answer 13

Angiogenesis

Question 14

When does perfusion go up?

Answer 14

Before enhancement

Question 15

What is the longest ‘lead’ time between elevation of rCBV and appearance of enhancement?

Answer 15

24 months

Question 16

What was the important study in Norway?

Answer 16

• In Norway, there was only 2 neurosurgical centres
• Centre A believed in watchful waiting not operating unless it is low risk surgery
• Centre B would go for early resection\
• The only difference whether you got admitted when presented with brain tumour is where you lived
• Their hypothesis was that patients who had early resection would live younger but will have more deficit because they had more aggressive surgery
• In the centre that had watchful weighting only 30% of patients were getting operated
• 86% of patients are getting operated on

Question 17

What is radiotherapy associated with?

Answer 17

Delayed toxicity

Question 18

What happens in the management of LGG?

Answer 18

1. Early radiotherapy prolongs PFS but not OS
2. Early radiotherapy prolongs OS but not PFS
3. Early radiotherapy prolongs PFS and OS
4. Early radiotherapy has no effect on LGG survival

Question 19

What do long term cognitive deficit affect?

Answer 19

Up to 50% after 12 years

Question 20

What is the risk of second tumours?

Answer 20

1-2% over 10-20 years

Hair loss

Question 21

What is the maximal surgical resection highly dependent on?

Answer 21

Tumour location and surgical expertise

Question 22

Where should radiotherapy and chemotherapy be considered in?

Answer 22

High risk patients or after surveillance in low risk patients for:

• Intractable seizures
• Evidence of increasing rate of growth
• Evidence of the development of higher grade features on MRI such as contrast enhancement

Question 23

What can be used in patients with extensive 1p deleted tumours?

Answer 23

Temozolomide