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1、management of low grade gliomas,robert r johnson, m.d. department of radiation oncology july 15, 2010,table of contents,background pathological classification molecular features presentation treatment technique,background,slow-growing tumors 10% of primary brain tumors in adults 20-25% of gliomas 20
2、00 cases/year in u.s. divided into: pilocytic astrocytoma diffusely infiltrating glioma,background,pilocytic astrocytoma more common in children (jpa) cerebellum do occur in young adults low grade even after recurrence cured by surgery 90% long-term survival after complete resection 70-80% after inc
3、omplete resection,background,diffusely infiltrating glioma 3rd-4th decade of life 20 years earlier than high-grade gliomas slow growing but eventually fatal 80% transform to high-grade,histological subtypes,astrocytoma 50% fibrillary protoplasmic gemistocytic behaves more like anaplastic astrocytoma
4、 oligodendroglioma 28% oligoastrocytoma 22%,prognosis,42,688 patients diagnosed between 1995-2006 astrocytoma 5-year survival 47% oligoastrocytoma 5-year survival 57% oligodendroglioma 5-year survival 79%,http:/cbtrus.org/2010-NPCR-SEER/Table23.pdf,pathological classification,who grading I: slow-gro
5、wing, non-malignant pilocytic astrocytoma II: relatively slow-growing, can recur as higher-grade tumor astrocytoma, oligodendroglioma, oligoastrocytoma,pathological classification,st anne-mayo classification based on 4 criteria: nuclear atypia mitoses endothelial proliferation necrosis grade I: 0/4
6、pilocytic astrocytoma grade II: 1/4 astrocytoma, oligodendroglioma, oligoastrocytoma,molecular features,ploidy better prognosis with diploid relative to aneuploid proliferation better prognosis with ki-67 index 60 randomized to 54 gy/30 fractions vs observation and radiation at progression,van den b
7、ent et al. lancet 2005;366:985-990.,eortc 22485,eortc 22485,eortc 22485,65% patients in observation group treated with radiation at recurrence median survival after recurrence 3.4 years vs 1.0 years favoring observation group 70% histologically confirmed recurrences high-grade no quality of life stu
8、dy,eortc 22485,conclusions no difference in overall survival for early vs delayed radiotherapy longer time to recurrence with early rt unknown if rt or recurrence is worse for quality of life seizures at 1 year 25% with rt, 41% with observation P = 0.03,eortc 22484,379 patients with resected or biop
9、sied low-grade glioma inclusion criteria supratentorial low-grade glioma incompletely resected pilocytic astrocytoma 16-65 years karnofsky 60 randomized to 45 gy/25 fractions vs 59.4 gy/33 fractions,karim et al. ijrobp 1996; 36:549-556.,eortc 22484,5 year os 58% vs 59%,5 year pfs 47% vs 50%,eortc 22
10、484,interesting subgroup analyses extent of resection size of tumor,eortc 22484,outcome analyzed by extent of resection significant improvements in os and pfs with more extensive surgery no dose response,eortc 22484,eortc 22484,eortc 22484,acute toxicity more common in high-dose arm 15% vs 8% required 1 week break no difference in late toxicity no radionecrosis in either arm,
