Anaplastic astrocytoma management
Treatment consists of maximal safe resection, radiotherapy, and chemotherapy. Trials of patients with newly diagnosed grade III glioma have shown survival benefit from adding chemotherapy to radiotherapy compared with initial treatment using radiotherapy alone. Both temozolomide and the combination of procarbazine, lomustine, and vincristine provide survival benefit. In contrast, trials that compare single modality treatment of chemotherapy alone with radiotherapy alone did not observe survival differences. Currently, for patients with grade III gliomas who require postsurgical treatment, the preferred treatment consists of a combination of radiotherapy and chemotherapy 1).
After treatment, all patients have to undergo brain magnetic resonance imaging procedure quarterly or half-yearly for 5 years and then on an annual basis. In patients with recurrent tumor, wherever possible re-resection or re-irradiation or chemotherapy can be considered along with supportive and palliative care. High-grade malignant glioma should be managed in a multidisciplinary center
Treatment of noncodeleted AA based on preliminary results from the CATNON clinical trial consists of maximal safe resection followed by radiotherapy with post-radiotherapy temozolomide (TMZ) chemotherapy. The role of concurrent TMZ and whether IDH1 subgroups benefit from TMZ is currently being evaluated in the recently completed randomized, prospective Phase III clinical trial, CATNON 2).
In 2017 the Interim results from the CATNON trial was that adjuvant temozolomide chemotherapy was associated with a significant survival benefit in patients with newly diagnosed non-co-deleted anaplastic glioma. Further analysis of the role of concurrent temozolomide treatment and molecular factors is needed 3).
VFLAIR/VCE-T1WI is an important classifier that could divide the high grade astrocytoma (HGA) into 2 subtypes with distinct invasive features. Patients with proliferation-dominant HGA can benefit from extensive resection of the FLAIR abnormality region, which provides the theoretical basis for a personalized resection strategy 4).
The criteria used to assess extent of resection (EOR) have an impact on findings of association between EOR and survival. Current assessment of EOR mainly relies on pre and postoperative contrast-enhanced T1 weighted images (CE-T1WI).
This method is subject to several inherent limitations, including failure to evaluate nonenhancing components of glioma.
To solve this problem, fluid attenuated inversion recovery (FLAIR) imaging is added in the RANO criteria 5).