Elsevier

The Lancet Oncology

Volume 15, Issue 9, August 2014, Pages e395-e403
The Lancet Oncology

Review
EANO guideline for the diagnosis and treatment of anaplastic gliomas and glioblastoma

https://doi.org/10.1016/S1470-2045(14)70011-7Get rights and content

Summary

This guideline provides recommendations for diagnostic and therapeutic procedures for patients with malignant gliomas. We differentiate evidence-based standards from reasonable options or non-evidence-based measures that should no longer be considered. The recommendations herein should provide a framework and assurance for the choice of diagnostic procedures and therapeutic measures and aim to reduce complications from unnecessary treatment and cost. The guideline contributes to a critical appreciation of concurrent drugs with a focus on the controlled use of anticonvulsants and steroids. It should serve as a guideline for all professionals involved in the diagnostics and care of glioma patients and also as a source of knowledge for insurance companies and other institutions involved in the cost regulation of cancer care in Europe. Implementation of the recommendations summarised here will need interdisciplinary structures of care for patients with brain tumours and structured processes of diagnostic and therapeutic procedures.

Introduction

This guideline for the diagnosis and treatment of gliomas follows the Third Revision of the WHO Classification of Tumours of the Central Nervous System.1 It covers WHO grade III anaplastic astrocytomas, oligodendrogliomas, and oligoastrocytomas; WHO grade IV glioblastomas (including its variants) and gliomatosis cerebri; and WHO grade III and IV gliomas of brainstem and spinal cord. The guideline covers prevention, early diagnosis and screening, therapy, follow-up, and rehabilitation for patients with malignant gliomas. It does not cover differential diagnoses of gliomas and adverse effects of therapeutic measures in depth. The structure of the guideline was based on the national guideline on gliomas of the German Society of Neurology and the German Cancer Society.

The guideline aims to serve medical professionals of all disciplines involved in the diagnosis and care of patients with glioma, particularly neurologists, neurosurgeons, radiation oncologists, neuropathologists, neuroradiologists, oncologists, paediatric oncologists, epileptologists, psycho-oncologists, rehabilitation specialists, palliative care nursing specialists, and neuro-oncology nursing specialists. Furthermore, the recommendations could serve as a valuable source of information for patients, relatives, other health professionals, and health insurance companies.

Section snippets

General recommendations

Recommendations for the general approach to patients with malignant gliomas, including diagnostic aspects—ie, early diagnosis and prevention, history, clinical examination, neuroimaging, cerebrospinal-fluid analyses, electroencephalography, preoperative management, biopsy and resection, histological classification and grading, molecular diagnostics—and general recommendations for therapy (eg, surgical therapy, radiotherapy, pharmacotherapy, and other therapeutic approaches) are summarised in

Anaplastic astrocytoma—WHO grade III

Anaplastic astrocytomas have inhomogeneous density on CT scans and appear as hyperintense, space-occupying lesions on T2-weighted fluid-attenuated inversion recovery (FLAIR) MRI. They tend to show patchy enhancement after contrast administration and often have peritumoural oedema. However, a substantial proportion (up to 30%) of these tumours can show no enhancement on CT or MRI. Abnormal vessels can be visualised by MRI angiography. Favourable prognostic factors include young age, high

Monitoring and follow-up

Whenever feasible, MRI should be used to monitor the efficacy of pharmacotherapy or as surveillance imaging after completion of treatment.60 Intervals of 3 months are recommended for most patients with malignant gliomas, although longer intervals might be considered for patients with lengthy disease control, notably young patients with 1p/19q-co-deleted oligodendroglial tumours.

Raised intracranial pressure

Raised intracranial pressure due to growth of a glioma is an emergency situation that needs immediate intervention, often with high doses of steroids and occasionally with osmotic agents. Acute surgical decompression is rarely needed. Whether decompressive surgical interventions make sense in the further course of disease, once the diagnosis has already been established and primary therapy given, needs consideration of the options for further treatment after the surgical intervention.

Thromboembolic events

Patients

Conclusions

Guidelines reflect the state of knowledge at a given timepoint. Table 3 summarises the key recommendations of the EANO task force in 2013. The EANO website will inform of future updates on this guideline.

References (72)

  • F Laigle-Donadey et al.

    Brainstem tumors

    Handb Clin Neurol

    (2012)
  • JR Perry et al.

    PRODIGE: a randomized placebo-controlled trial of dalteparin low-molecular-weight heparin thromboprophylaxis in patients with newly diagnosed malignant glioma

    J Thromb Haemost

    (2010)
  • M Weller et al.

    Epilepsy meets cancer: when, why, and what to do about it?

    Lancet Oncol

    (2012)
  • DN Louis et al.

    WHO classification of tumours of the central nervous system

    (2007)
  • B Wiestler et al.

    ATRX loss refines the classification of anaplastic gliomas and identifies a subgroup of IDH mutant astrocytic tumors with better prognosis

    Acta Neuropathol

    (2013)
  • MD Walker et al.

    Evaluation of BCNU and/or radiotherapy in the treatment of anaplastic gliomas: a cooperative clinical trial

    J Neurosurg

    (1978)
  • MD Walker et al.

    Randomized comparisons of radiotherapy and nitrosoureas for the treatment of malignant glioma after surgery

    N Engl J Med

    (1980)
  • LA Stewart

    Chemotherapy in adult high-grade glioma: a systematic review and meta-analysis of individual patient data from 12 randomised trials

    Lancet

    (2002)
  • Randomized trial of procarbazine, lomustine, and vincristine in the adjuvant treatment of high-grade astrocytoma: a Medical Research Council trial

    J Clin Oncol

    (2001)
  • W Wick et al.

    NOA-04 randomized phase III trial of sequential radiochemotherapy of anaplastic glioma with procarbazine, lomustine, and vincristine or temozolomide

    J Clin Oncol

    (2009)
  • W Wick et al.

    Prognostic or predictive value of MGMT promoter methylation in gliomas depends on IDH1 mutation

    Neurology

    (2013)
  • WKA Yung et al.

    Multicenter phase II trial of temozolomide in patients with anaplastic astrocytoma or anaplastic oligoastrocytoma at first relapse

    J Clin Oncol

    (1999)
  • M Brada et al.

    Temozolomide versus procarbazine, lomustine, and vincristine in recurrent high-grade glioma

    J Clin Oncol

    (2010)
  • A Desjardins et al.

    Bevacizumab plus irinotecan in recurrent WHO grade 3 malignant gliomas

    Clin Cancer Res

    (2008)
  • MC Chamberlain et al.

    Salvage chemotherapy with bevacizumab for recurrent alkylator-refractory anaplastic astrocytoma

    J Neurooncol

    (2009)
  • K Seystahl et al.

    Bevacizumab alone or in combination with irinotecan in recurrent WHO grade II and grade III gliomas

    Eur Neurol

    (2013)
  • H Arita et al.

    Upregulating mutations in the TERT promoter commonly occur in adult malignant gliomas and are strongly associated with total 1p19q loss

    Acta Neuropathol

    (2013)
  • G Cairncross et al.

    Phase III trial of chemoradiotherapy for anaplastic oligodendroglioma: long-term results of RTOG 9402

    J Clin Oncol

    (2013)
  • G Cairncross et al.

    Phase III trial of chemotherapy plus radiotherapy compared with radiotherapy alone for pure and mixed anaplastic oligodendroglioma: Intergroup Radiation Therapy Oncology Group Trial 9402

    J Clin Oncol

    (2006)
  • MJ van den Bent et al.

    Adjuvant procarbazine, lomustine, and vincristine improves progression-free survival but not overall survival in newly diagnosed anaplastic oligodendrogliomas and oligoastrocytomas: a randomized European Organisation for Research and Treatment of Cancer phase III trial

    J Clin Oncol

    (2006)
  • MJ van den Bent et al.

    Adjuvant procarbazine, lomustine, and vincristine chemotherapy in newly diagnosed anaplastic oligodendroglioma: long-term follow-up of EORTC brain tumor group study 26951

    J Clin Oncol

    (2013)
  • MC Chamberlain et al.

    Bevacizumab for recurrent alkylator-refractory anaplastic oligodendroglioma

    Cancer

    (2009)
  • S Taillibert et al.

    Bevacizumab and irinotecan for recurrent oligodendroglial tumors

    Neurology

    (2009)
  • JS Barnholtz-Sloan et al.

    Patterns of care and outcomes among elderly individuals with primary malignant astrocytoma

    J Neurosurg

    (2008)
  • C Hartmann et al.

    Patients with IDH1 wild type anaplastic astrocytomas exhibit worse prognosis than IDH1-mutated glioblastomas, and IDH1 mutation status accounts for the unfavorable prognostic effect of higher age: implications for classification of gliomas

    Acta Neuropathol

    (2010)
  • V Vuorinen et al.

    Debulking or biopsy of malignant glioma in elderly people—a randomised study

    Acta Neurochir (Wien)

    (2003)
  • Cited by (0)

    View full text