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The management of low grade glioma is one of the most controversial areas in clinical neuro-oncology. There are numerous reviews and editorials outlining the difficulties in management of these lesions.1–3 Indeed, the pivotal questions about their management remain unanswered. However, the concept of management of low grade gliomas is not unitary but much more a composite of different challenges depending on the clinical presentation, signs, neuroradiology, perspectives of neurologists, the opinion of the neurosurgeon, and perhaps most importantly, the aspirations of the patient. It is true therefore that in many patients there will be a dilemma about what is considered optimal management since there is no good evidence base to underpin any single management undertaken. Conversely, however, there are many groups of patients with various low grade gliomas in whom management decisions are made more easily and pragmatically. In this review, the current approaches to different low grade gliomas presenting with different symptom complexes in different regions of the brain will be reviewed and the rationale for decision making discussed.
THE SPECTRUM OF LOW GRADE GLIOMA
Under the recent World Health Organization classification of primary intracranial tumours, low grade gliomas would encompass grade I and grade II neuro-epithelial tumours. The more common grade I tumours are pilocytic astrocytoma, dysembryoblastic neuro-epithelial tumours (DNET), pleomorphic xantho-astrocytoma (PXA), neurocytoma, and ganglioglioma. The more common grade II tumours include astrocytoma, oligodendroglioma, and mixed oligoastrocytoma. This spectrum of discreet neuropathological entities is important since the grade I tumours generally can be cured by surgical excision and their symptoms very often alleviated.4 Conversely, with the grade II tumours, these are generally incurable but have median survival times of > 5 years.1–3 Tumours with oligodendodrial components generally do better than astrocytomas, with prognosis being partially related to gene deletions on chromosome 1p and 19q.5,6 Some grade …