Low grade glioma Low grade glioma • Radiotherapy in low grade gliomas benefit with local control advantage • Patients with high risk factors need immediate radiation after surgery • RT dose of 50-54 Gy in 2 Gy/Fr • Fractionated radiosurgery in optic nerve glioma and small volume disease • RT causes cognitive function impairment, so low risk group may receive observation • Young pts, with seizures, near total excision and oligo component may be observed [email protected]
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Low grade gliomaLow grade glioma
• Radiotherapy in low grade gliomas benefit with local control advantage
• Patients with high risk factors need immediate radiation after surgery
• RT dose of 50-54 Gy in 2 Gy/Fr
• Fractionated radiosurgery in optic nerve glioma and small volume disease
• RT causes cognitive function impairment, so low risk group may receive observation
• Young pts, with seizures, near total excision and oligo component may be observed
• Patient on follow up after surgery need stringent follow up
• Patients with irregular follow up should also be treated with early RT
A group of brain tumours: A group of brain tumours: •Astrocytoma Gr IIAstrocytoma Gr II•Oligodendroglioma Gr IIOligodendroglioma Gr II•Mixed oligoastrocytoma Gr IIMixed oligoastrocytoma Gr II
• Slow and insidious course; majority with seizuresSlow and insidious course; majority with seizures• Prognostication very difficult; some remain indolent and some recur Prognostication very difficult; some remain indolent and some recur
within short timewithin short time
• Surgery is the treatment of choiceSurgery is the treatment of choice• Surgery rarely ever totalSurgery rarely ever total
• Eventually majority (60-80%) transform into high-gradeEventually majority (60-80%) transform into high-grade
• Majority of the LGG pts eventually receive RT when Majority of the LGG pts eventually receive RT when progressed to high gradeprogressed to high grade
• There is no debate on There is no debate on NO RT versus RTNO RT versus RT
• But, on RT But, on RT earlyearly after surgery or RT after surgery or RT at progression (late)at progression (late)
Radiotherapy doseRadiotherapy doseRTOG Ph-III randomized studyRTOG Ph-III randomized study
Necrosis more with higher RT doseNecrosis more with higher RT dose
Timing of RT – upfront or at progressionTiming of RT – upfront or at progressionEORTC 22845/ MRC BR 04 – 311 patients: Early resultsEORTC 22845/ MRC BR 04 – 311 patients: Early results
RT protocol:1.CT Scan & MRI scan based planning2.CT scan based planning3.GTV= Gross disease4.CTV= GTV+1-2 cm (covering the Flair)5.PTV= CTV+0.5 cm 6.Dose : 54Gy/30#/6Wk
7.No Boost8.No High dose per fraction9.NO Conc TMZ
Right temporal lobe • No significant correlation between dose and drop in IQ
Normal brain • No correlation.
Factors influencing QOL scores
Apart from disease status, treatment modality and follow up,
Other factors also influence interpretation of QOL such as:
- Socio-cultutal status
- Economical status
- Educational status
QOL data should be interpreted with socio-cultural and geographical background
Jalali, Dutta et al, J NeuroOncol 2010
Prospective assessment: Barthel Index Low grade/benign brain tumours
Progression & transformationProgression & transformationLGG may progress without transformation:
Increase in tumour size without transformation to High grade - No contrast enhancing - Low perfusion - MR spectro: No Choline peak - Need to treat as low grade glioma
LGG may progress with transformation:
Increase tumour size & transformation to high grade - Contrast enhancing (Patchy) - Higher perfusion - MR spectro: Choline peak - Need to treat as High grade glioma
RT+TMZ: NecrosisRT+TMZ: Necrosis
Chambairlain et al JNO 2006Chambairlain et al JNO 2006
TMZ (75mg/m2) add 9Gy RT equivalent dosage of effectTMZ (75mg/m2) add 9Gy RT equivalent dosage of effect