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The role of surgery in the management of patients with diffuse low grade glioma

A systematic review and evidence-based clinical practice guideline

  • Topic Review & Clinical Guidelines
  • Published:
Journal of Neuro-Oncology Aims and scope Submit manuscript

Abstract

Question

Should patients with imaging suggestive of low grade glioma (LGG) undergo observation versus treatment involving a surgical procedure?

Target population

These recommendations apply to adults with imaging suggestive of a WHO grade 2 glioma (oligodendroglioma, astrocytoma, or oligo-astrocytoma).

Recommendations

Surgical resection is recommended over observation to improve overall survival for patients with diffuse low-grade glioma (Level III) although observation has no negative impact on cognitive performance and quality of life (Level II).

Question

What is the impact of extent of resection on progression free survival (PFS) or overall survival (OS) in LGG patients?

Target population

These recommendations apply to adults with imaging suggestive of a WHO grade 2 glioma (oligodendroglioma, astrocytoma, or oligo-astrocytoma).

Recommendations

Impact of extent of resection on PFS

Level II

It is recommended that GTR or STR be accomplished instead of biopsy alone when safe and feasible so as to decrease the frequency of tumor progression recognizing that the rate of progression after GTR is fairly high.

Impact of extent of resection on OS

Level III

Greater extent of resection can improve OS in LGG patients.

Question

What tools are available to increase extent of resection in LGG patients?

Target population

These recommendations apply to adults with imaging suggestive of a WHO grade 2 glioma (oligodendroglioma, astrocytoma, or oligo-astrocytoma).

Recommendations

Intraoperative MRI during surgery

Level III

The use of intraoperative MRI should be considered as a method of increasing the extent of resection of LGGs.

Question

What is the impact of surgical resection on seizure control and accuracy of pathology in low grade glioma patients?

Target population

These recommendations apply to adults with imaging suggestive of a WHO grade 2 glioma (oligodendroglioma, astrocytoma, or oligo-astrocytoma).

Recommendations

Surgical resection and seizure control

Level III

After taking into account the patient’s clinical status and tumor location, gross total resection is recommended for patients with diffuse LGG as a way to achieve more favorable seizure control.

Accuracy of diagnosis

Level III

Taking into account the patient’s clinical status and tumor location, surgical resection should be carried out to maximize the chance of accurate diagnosis.

Question

What tools can improve the safety of surgery for LGGs in eloquent locations?

Target population

These recommendations apply to adults with imaging suggestive of a WHO grade 2 glioma (oligodendroglioma, astrocytoma, or oligo-astrocytoma).

Recommendations

Preoperative imaging

Level III

It is recommended that preoperative functional MRI and diffusion tensor imaging be utilized in the appropriate clinical setting to improve functional outcome after surgery for LGG.

Intraoperative Mapping of Tumors in Eloquent Areas

Level III

Intraoperative mapping is recommended for patients with diffuse LGGs in eloquent locations compared to patients with non-eloquently located diffuse LGGs as a way of preserving function.

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Acknowledgments

We acknowledge the significant contributions of Laura Mitchell, Senior Manager of Guidelines for the Congress of Neurological Surgeons; the Joint Guidelines Committee (JGC) of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons for their review, comments and suggestions; Jeffrey Wagner and Sung Won Han for assistance with data collection and compilation and Anne Woznica and Mary Bodach for their assistance with the literature searches. We also acknowledge the following individual JGC members for their contributions throughout the review process: Kevin Cockroft, MD, Sepideh Amin-Hanjani, MD, Kimon Bekelis, MD, Isabelle Germano, MD, Daniel Hoh, MD, Steven Hwang, MD, Cheerag Dipakkumar Upadhyaya, MD, Christopher Winfree, MD, and Brad Zacharia, MD.

Disclosures

Dr. Kalkanis is a consultant for Arbor and Varian. Dr. Olson is a consultant for the American Cancer Society; has received research funding from the National Cancer Institute, Genentech, and Millenium; and has received investigational drug provision from Merck.

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Authors and Affiliations

  1. Department of Neurosurgery, University of California, 505 Parnassus Avenue, Room M779, San Francisco, CA, 94143-0112, USA

    Manish K. Aghi

  2. Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA

    Brian V. Nahed

  3. Department of Neurosurgery, University Hospitals, Cleveland, OH, USA

    Andrew E. Sloan

  4. Department of Neurosurgery, Kansas University Medical Center, Kansas City, KS, USA

    Timothy C. Ryken

  5. Department of Neurosurgery, Henry Ford Health System, Detroit, MI, USA

    Steven N. Kalkanis

  6. Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA

    Jeffrey J. Olson

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  1. Manish K. Aghi
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Correspondence to Manish K. Aghi.

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Aghi, M.K., Nahed, B.V., Sloan, A.E. et al. The role of surgery in the management of patients with diffuse low grade glioma. J Neurooncol 125, 503–530 (2015). https://doi.org/10.1007/s11060-015-1867-1

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