Grade 2 Glioma

Grade 2 gliomas tend to occur in younger adults. The management of these tumours is surgical resection where possible. If not possible then until mid 2010, unless symptomatic, a watch and wait policy was often employed, as this delayed the late toxicity of radiotherapy, and RT compared to active monitoring did not improve OS, just PFS, in high risk tumours (partial resection/biopsy/>40years old with CR). However in mid 2010, a seminal paper published the long term results of RT v RT and PCV. This found that combination treatment improved 10 year OS. However we do not know if monitoring and then using combination treatment is just as good or not, but earlier treatment will definitely result in long term side effects, especially concerning is the risk of long term neurotoxicity. So now in high risk patients we have a discussion with the patient about the potential pro and cons.

In addition around the same time the results of the BR 13 trial were published which looked at those with high risk disease and gave RT or TMZ- the outcomes of the initial analysis were the same between the two arms for PFS (long term data maturation still required), but this trial has been overcome by the outcomes from the combination treatment trial.

Some people with grade 2 glioma progress to more aggressive tumours.

Molecular subtyping is introducing tumours that are more likely to be more aggressive, for example IDH wild type non-co-deleted grade 2 glioma: the management of these is currently uncertain.

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Radiation plus Procarbazine, CCNU, and Vincristine in Low-Grade Glioma
Buckner et al
NEJM 2016

Seminal paper that changed management of grade 2 glioma in 2016- adding PCV to those treated with RT

Temozolomide chemotherapy versus radiotherapy in high-risk low-grade glioma (EORTC 22033-26033): a randomised, open-label, phase 3 intergroup study
Baumert et al
Lancet Oncology 2016

Results (intial) of the superseded BR13 trial, showing similar PFS for RT v TMZ in high risk LGG