PowerPoint Presentation

Management Of GliomasMade By: Dr. Isha JaiswalGuided By Prof. Kamal SahniDate:13 January 2016

Topics to be coveredGeneral managementManagement of low grade gliomas: overviewPilocytic astrocytomanon pilocytic/diffuse infiltrating gliomasManagement of high grade gliomas: overviewAnaplastic gliomasGlioblastoma multiformae

Medical management

For Cerebral oedema: Glucocorticoids used :Dexamethasone preferred because of minimal mineral-corticoid effects.Lower doses :shown to be as effective as higher doses-2 to 4 mg bd preferredshould be discontinued or tapered to the lowest dose necessary, as soon as possible. taper is necessary to prevent rebound in cerebral edema and also to allow the pituitaryadrenal axis to recover.

For seizures

Patients with seizures require anticonvulsants. Levetiracetam preferred: nonhepatic isozymes inducing carbamazepine, phenobarbital, and phenytoin (induce hepatic cytochrome P450 isozymes) reduce the efficacy of corticosteroids & chemotherapy.

Prophylactic anticonvulsant use remains controversialAmerican Academy of Neurology recommended against it because of lack of efficacy and potential side effects like cognitive impairment, myelosuppression, liver dysfunction, and dermatologic reactions.FOR PATIENT WHO HAVE UNDERGONE ANY TREATMENTANY FORM OF SURGERY,BIPSY OR RR: prophylactic anticonvulsant given for shortest period of time*Glantz MJ, Cole BF, Forsyth PA, et al. Practice parameter: anticonvulsant prophylaxis in patients with newly diagnosed brain tumors. Report of the Quality Standards Subcommittee of the American Academy of Neurology.Neurology2000;54:18861893.

Definitive treatment of gliomas: optionsSurgery: Resection For CureSurgical DebulkingBiopsy CSF Diversion Procedures

Radiotherapy

Chemotherapy

LOW GRADE GLIOMAS

Goals:

Prolong progression-free survival & overall survival Improve, maintain, slow the decline in neurological function Minimize treatment-related effectsTreatment Options:

ObservationSurgeryRadiationChemotherapy

Observation:Includes MRI monitoring at regular intervals (e.g., every 6 months) to detect radiologic progression before new signs and symptoms occur.PROS:Low grade Gliomas: considered relatively favourable natural history compared o high gradelack of proven benefit for surgery or radiation therapy in improving overall survivalNo treatment associated morbidities CONS:Natural history is significantly worse than that of an age- and sex matched control population

Based on this observation is under treatmentMaximal Safe Surgical Resection followed by PORT improve survival , and may cure pts.

Survival curves for pts with various subtypes of low-grade glioma compared age and sex matched control population. ,Adapted from Shaw EG: The low-grade glioma debate. Evidence defending the position of early radiation therapy. Clin Neurosurg 42:488-494, 1995.

SurgeryPros:benefits of surgery on seizures / raised ICT are fairly dramaticEarly Surgery delays reappearance of symptoms and tumor growthImaging can be misleading in upto 40% cases ,surgery provides histological confirmationSurvival advantage to gross resection in retrospective literature

Cons:Possibility of complications in a minimally symptomatic person

With advancement in technology ,morbidity of surgery has decreased hence surgery is the mainstay of treatment

Observation with MRI monitoring :can be reserved for very few patients with 1cm tumor and minimal symptoms

Extent of resection :No prospective randomized trials to assess the impact of maximal tumor resection so maximal safe resection preferred

Look refernce for 1 cm tumor11

Adjuvant Radiation (RT)TimingDoseTreatment volume

Adjuvant radiotherapyPROSImproves outcome in unresectable & partially resectable tumorsincreased Progression Free SurvivalRT does not decrease seizureCONSNo improvement in overall survivalIncreased morbidity especially in young pt :neurocognitive decline , dementia , behavioural changes, vasculopathy, development of 2nd malignancy.

RT does not improve symptoms: seizure may increase seizure due to increased edema compressing elooes not decreasquent areas13

total 362 eligible pts accrued between 1998 and 2002. Median follow-up time 4 years. For 111 favourable pts observed on Arm 1, OS at 2- and 5-yrs is 99% and 94%. PFS at 2- and 5-yrs is 82% and 50%

Risk Factors predictive of a poorer PFS 1. Pre-operative tumor diameter of >/=4 cm 2. Astrocytoma histology 3. Residual tumor of >/=1 cm2 on Postop MR

Patients with:All 3 unfavorable factors- PFS at 5years -13%None of the three factors- PFS at 5years -70%

RT vs observationA Phase II Study Of Observation In Favourable Low-grade Glioma And A Phase III Study Of Radiation With Or Without PCV Chemotherapy In Unfavorable Low-grade Glioma

total of 362 eligible/analyzable pts were accrued between 1998 and 2002. Median follow-up time is 4 years. For the 111 favorable pts observed on Arm 1, OS at 2- and 5-yrs is 99% and 94%. PFS at 2- and 5-yrs is 82% and 50%14

Indications for observation So, on the basis of above data

Observation after surgery can be a reasonable strategy for the most favorable subset i.e.

age 40 years Preoperative tumor diameter