Published in:
01-12-2015 | Topic Review & Clinical Guidelines
The role of initial chemotherapy for the treatment of adults with diffuse low grade glioma
A systematic review and evidence-based clinical practice guideline
Published in: Journal of Neuro-Oncology | Issue 3/2015
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Target population
Adult patients (older than 18 years of age) with newly diagnosed World Health Organization (WHO) Grade II gliomas (Oligodendroglioma, astrocytoma, mixed oligoastrocytoma).
Question
Is there a role for chemotherapy as adjuvant therapy of choice in treatment of patients with newly diagnosed low-grade gliomas?
Recommendations
Level III
Chemotherapy is recommended as a treatment option to postpone the use of radiotherapy, to slow tumor growth and to improve progression free survival (PFS), overall survival (OS) and clinical symptoms in adult patients with newly diagnosed LGG.
Question
Who are the patients with newly diagnosed LGG that would benefit the most from chemotherapy?
Recommendation
Level III
Chemotherapy is recommended as an optional component alone or in combination with radiation as the initial adjuvant therapy for all patients who cannot undergo gross total resection (GTR) of a newly diagnosed LGG. Patient with residual tumor >1 cm on post-operative MRI, presenting diameter of >4 cm or older than 40 years of age should be considered for adjuvant therapy as well.
Question
Are there tumor markers that can predict which patients can benefit the most from initial treatment with chemotherapy?
Recommendation
Level III
The addition of chemotherapy to standard RT is recommended in LGG patients that carry IDH mutation. In addition, temozolomide (TMZ) is recommended as a treatment option to slow tumor growth in patients who harbor the 1p/19q co-deletion.
Question
How soon should the chemotherapy be started once the diagnosis of LGG is confirmed?
Recommendation
There is insufficient evidence to make a definitive recommendation on the timing of starting chemotherapy after surgical/pathological diagnosis of LGG has been made. However, using the 12 weeks mark as the latest timeframe to start adjuvant chemotherapy is suggested. It is recommended that patients be enrolled in properly designed clinical trials to assess the timing of chemotherapy initiation once diagnosis is confirmed for this target population.
Question
What chemotherapeutic agents should be used for treatment of newly diagnosed LGG?
Recommendation
There is insufficient evidence to make a recommendation of one particular regimen. Enrollment of subjects in properly designed trials comparing the efficacy of these or other agents is recommended so as to determine which of these regimens is superior.
Question
What is the optimal duration and dosing of chemotherapy as initial treatment for LGG?
Recommendation
Insufficient evidence exists regarding the duration of any specific cytotoxic drug regimen for treatment of newly diagnosed LGG. Enrollment of subjects in properly designed clinical investigations assessing the optimal duration of this therapy is recommended.
Question
Should chemotherapy be given alone or in conjunction with RT as initial therapy for LGG?
Recommendation
Insufficient evidence exists to make recommendations in this regard. Hence, enrollment of patients in properly designed clinical trials assessing the difference between chemotherapy alone, RT alone or a combination of them is recommended.
Question
Should chemotherapy be given in addition to other type of adjuvant therapy to patients with newly diagnosed LGG?
Recommendation
Level II: It is recommended that chemotherapy be added to the RT in patients with unfavorable LGG to improve their progression free survival.