CNS Low Grade Gliomas

Question 1

What grade is diffuse astrocytoma?

Answer 1

Grade 2

Question 2

Can grade 1 astrocytoma undergo malignant transformation?

Answer 2

No

Question 3

Is grade 1 astrocytoma commoner in adults or children?

Answer 3

Children (rare in adults)

Question 4

Name 3 locations grade 1 astrocytomas commonly occur?

Answer 4

Optic nerve
Hypothalamus
Cerebellum

Question 5

How much enhancement do low grade astrocytomas show on MRI with gadolinium?

Answer 5

Little or none

Question 6

What grade is anaplastic astrocytoma?

Answer 6

Grade 3

Question 7

How do you know an MRI is a FLAIR sequence?

Answer 7

Signal from CSF supressed

Question 8

Enhancement on a scan means (in general terms, 1 word)

Answer 8

Leakage

Question 9

Restricted diffusion on scan does it mean there is high or low cellularity?

Answer 9

High

Question 10

Two types of glioma that NEVER show IDH mutations?

Answer 10

(1) Grade 1

2) primary GBM (ie has not arisen from a low grade glioma

Question 11

Which chromosomal hallmark is associated with oligodendroglial pathology?

Answer 11

1p19q loss

Question 12

What does 1p19q loss mean for chemo sensitivity and prognosis?

Answer 12

chemo sensitive

Good

Question 13

Most common IDH1 mutation which codon?

Answer 13

132 (accounts for 80% of IDH mutations)

Question 14

What molecular marker is a marker of astrocytic behaviour?

Answer 14

ATRX Loss

Question 15

A low grade glioma has IDH wild type, what does this mean?

Answer 15

Bad prognosis,

Behaves like grade 4

Question 16

Two molecular markers in a low grade glioma which mark it out as good prognosis?

Answer 16

IDH Mutation
And
1p19q loss

Question 17

Can 1p19q loss and ATRX loss co exist?

Answer 17

No mutually exclusive

Question 18

Name the 5 poor prognostic factors for low grade gliomas

Answer 18

Age more >= 40 
Histology Astrocytic 
Big tumour >=6cm 
Crosses midline or shifting 
Pre op neurological deficit 

2 high risk

Question 19

Evidence for resecting low grade gliomas?

Answer 19

There are no RCTs but case series indicate that gross total resection is likely to be beneficial

Question 20

Adjuvant DXT for low grade glioma- what is the benefit of immediate v wait until progression?

Answer 20

PFS is shorter but NO OS advantage

Question 21

In high risk low grade glioma what was the OS for the RTOG9802 study of post op dxt v dxt plus 6 cycles PCV?

Answer 21

OS 13.3 yrs v 7.8 years favouring adding PCV

Question 22

A patient has had a low grade glioma resection name 2 factors that would make you give adjuvant chemo and DXT?

Answer 22

Either
Age less than or = 40
Or
Subtotal resection

Question 23

A patient has had a LGG resected age 56. What further treatment would you offer them?

Answer 23

DXT 54 Gy
Followed by
PCV 6 cycles

Question 24

What is PCV chemo?

Answer 24

Procarbazine
CCNU (lomustine)
Vincristine

Question 25

What is the other name for lomustine?

Answer 25

CCNU

Question 26

Management of grade 4 glioma

Answer 26

Debulk if possible
DXT with concomitant Temozolamide 75mg/m2 daily
Adjuvant TMZ 150mg/m2

Question 27

What is the difference in mgt between grade 3 and grade 4 glioma

Answer 27

Grade 4 everyone gets chemo TMZ plus DXT

Grade 3 DXT then if 1p19q deleted get PCV up to 6 cycles adj