低度恶性胶质瘤治疗指南

 

1. In patients with low grade glioma and controlled epilepsy as the single symptom, surgery may be deferred until clinical or radiological progression. (Level of Evidence 4- Recommendation grade C)

当可控的癫痫作为唯一症状的低度恶性胶质瘤患者，在没有出现临床上或者影像上的进展的时候，手术可以推迟。 上海东方医院神经外科魏社鹏

In one retrospective study by van Veelen et al, it was shown that in patients with controlled seizures as the single symptom, the prognosis is not influenced by the timing of the surgery. It could be, therefore, safe to defer surgery until clinical or radiological progression in patients with controlled epilepsy only.

Veelen等一项回顾性研究发现，以癫痫发作为单一症状的胶质瘤病人，其预后并没有被手术的时机所影响，故建议在病人的临床症状和影像学结果没有出现进展之前，尽可能的推迟手术也是很安全的。

In 1994 Berger et al analyzed the effect of extent of resection on recurrence in patients with low grade gliomas. They found that for tumours greater than 10 cm3 a greater percent of resection and a smaller volume of residual disease convey a significant advantage in terms of recurrence, compared to those that had a less aggressive resection or biopsy. For tumours smaller than 10 cm3 no recurrence was detected over 3 to 4 years, regardless of percent of resection.

1994年，Berger等发现那些体积大于10立方厘米的肿瘤，术中切除越多，则复发越迟，而那些体积小于10立方厘米的肿瘤，切除程度和复发则没有联系。

 

2. In patients with increased intracranial pressure, neurological deficits, uncontrollable seizures, or in those who have clinical or radiological progression, maximal resection, when safe, should be attempted. (Level of Evidence 3- Recommendation grade B)

对于有颅内压增高症状的病人，以及有神经功能缺损，未控制的癫痫，或者临床或者影像上出现进展的病人，在安全的前提下，尽可能做根治性的切除。

 

3. Postsurgical radiation therapy may be deferred until clinical or radiological progression. When Radiation therapy is indicated, the dose should be between 45 and 54 Gy. (Level of Evidence 1- Recommendation grade A)

术后放疗可以被推迟，直到出现临床或者影像上的进展。当施行放疗时，剂量应当在45-54Gy之间。

A clinical trial (EORTC 22845) performed in 2002 compared immediate RT given after surgery versus RT after tumour recurrence. Although the progression-free survival time was 5.3 years for immediate RT versus 3.4 years for RT deferred and the seizures were better controlled in the first group, using the “wait and see” approach and delaying the RT had no adverse impact on median survival.

2002年的一项临床试验，将术后立即放疗和那些出现进展后再行放疗的病人进行了比较发现，尽管术后立即放疗的病人有5.3年的稳定期，延迟放疗的群体有3.4年的稳定期，而且癫痫的控制在前者海较为容易。但是，和术后立即放疗相比，观察随访以及延迟放疗对中位生存期并没有不利的影响。

 

Based on these data it seems appropriate to defer the post-surgical RT until progression of disease. When RT is indicated, the dose should be 45Gy to 54 Gy.

由此，延迟放疗至出现进展可行，剂量控制在45-54Gy之间较为妥当。

 

4. Radiotherapy alone may be offered in patients with progressive tumours. (Level of Evidence 1- ecommendation grade A) 进展性的低度恶性胶质瘤患者可以单给放疗。

 

5. Chemotherapy should not be added to radiation therapy, since the combination shows no benefit in comparison to RT alone and increases the toxicity. (Level of Evidence 1- Recommendation grade A). 化疗不建议跟放疗联合，因为此种协同和单纯放疗相比，并没有任何好处，反而增加了治疗的毒性。

 

6. Chemotherapy such as temozolomide may be offered in patients with progressive tumours that harbour combined 1p/19q loss of heterozygosity. (Level of Evidence 4- Recommendation grade C)

 化疗药物例如替莫唑胺可以给予那些处在进展期中的且含有1p/19q的肿瘤患者

The largest study to date was performed by Kaloshi et al. They retrospectively reviewed their experience of 149 patients with progressive low grade gliomas who received temozolomide as their initial treatment after surgery. Fifty-three percent of the patients had objective response, the median PFS was 28 months, and the 3-year survival was 69.8%. The treatment was well tolerated. Interestingly, combined 1p/19q loss of heterozygosity (LOH) was significantly associated with a higher rate (p=0.02) and longer objective response to chemotherapy (p=0.0017), and longer PFS (p=0.00041) and overall survival (p=0.04). This study was limited by its retrospective design, but adds evidence that low grade gliomas respond to temozolomide, and that 1p/19q LOH is associated with chemosensitivity and improved outcome. Kaloshi等组织的一项回顾性的研究发现，149例进展性的低度恶性胶质瘤患者在术后接受了替莫唑胺为首次治疗，有53%的病人有了客观的反应，无症状期为28个月，3年的生存期为69.8%，并且治疗耐受性良好。那些有1p和19q缺失的的患者反应尤其良好。

 

7. For high risk patients (criteria defined in discussion) inclusion in a clinical trial is recommended. In the absence of a clinical trial adjuvant chemotherapy and radiation therapy may be considered on an individual basis.

有高危险因素的正在进行临床试验的病人，可以给化疗。对于那些未进行临床试验的患者，放疗联合化疗的给予要按照个体化原则来进行。

 

Based on the analysis of the two EORTC trials10,11 patients with low grade gliomas are divided into two prognostic groups. The high risk patients are defined as those who meet at least three of the following criteria: age ≥40 years, largest preoperative tumor diameter ≥6 cm, tumor crossing midline, tumor of astrocytoma histology, or preoperative neurologic deficits (Neurologic Function Score >1), while the low risk patients are those with two or less of these criteria. The RTOG 98-02 trial defines high risk as age ≥40 years or subtotal resection/biopsy and low risk as age <40 years and gross total resection.

低度恶性胶质瘤患者中，高危险因素群体必须满足如下的条件：年龄大于40岁，肿瘤直径大于6cm，肿瘤通过中线，组织分类为星形细胞瘤或者术前有神经系统缺损症状。

所谓低危险因素群体：即含有上述的两个一下的特征者。

 

一般的，年龄大约40岁或者未能全切的患者为高危险群体

年龄小于40岁，肉眼全切的患者为低危险群体。