Guidelines Summary

Treatment guidelines for diffuse astrocytic and oligodendroglial tumors in adults have been published by the American Society of Clinical Oncology (ASCO) and Society of Neuro-Oncology (SNO).^[49]The guidelines contain the following recommendations for treatment of astrocytomas:

For IDH-mutant, 1p19q non-codeleted, central nervous system (CNS) World Health Organization (WHO) grade 2 astrocytoma (low-grade diffuse glioma), offer radiation therapy (RT) with adjuvant chemotherapy (temozolomide [TMZ] or procarbazine, CCNU, and vincristine [PCV]).
In IDH-mutant, 1p19q non-codeleted, CNS WHO grade 2 astrocytoma, given its natural history, initial therapy may be deferred until radiographic or symptomatic progression in some patients with positive prognostic factors (eg, complete resection, younger age) or concerns about short- and long-term toxicity.
For IDH-mutant, 1p19q non-codeleted CNS WHO grade 3 astrocytoma, offer RT with adjuvant TMZ.
IDH-mutant CNS WHO grade 4 astrocytoma may be treated like IDH-mutant, non-codeleted, CNS WHO grade 3 astrocytoma (formerly anaplastic astrocytoma); or like IDH-wildtype, CNS WHO grade 4 glioblastoma (formerly IDH-wildtype glioblastoma), with concurrent TMZ and RT.
IDH-wildtype, CNS WHO grade 2 or 3 astrocytoma may be treated according to recommendations for IDH-wildtype, CNS WHO grade 4 glioblastoma.

See the image below.

IDH-mutant astrocytoma treatment guidelines.

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Medication

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Media Gallery

Low-grade diffuse astrocytoma and low cellularity with minimal nuclear atypia.
Diffuse astrocytoma with microcyst formation.
Gemistocytic astrocytoma tumor cells have eosinophilic cytoplasm with nuclei displaced to the periphery.
Characteristic pilocytic astrocytoma, long bipolar tumor cells, and Rosenthal fibers.
Anaplastic astrocytoma with high cellularity with marked nuclear atypia.
Gross specimen of a low-grade astrocytoma.
Axial CT scan, precontrast and postcontrast, shows a low-grade astrocytoma of the left frontal lobe. The tumor is nonenhancing.
Coronal postcontrast T1-weighted MRI shows a low-grade astrocytoma in the right inferior frontal lobe just above the sylvian fissure. No enhancement is present post–gadolinium administration.
Axial T2-weighted MRI shows a low-grade astrocytoma of the inferior frontal lobe with mild mass effect and no surrounding edema.
IDH-mutant astrocytoma treatment guidelines.
Higher-grade IDH-mutant astrocytoma, with nuclear atypia and mitoses. Courtesy of Wikipedia (https://en.wikipedia.org/wiki/Anaplastic_astrocytoma).
2021 WHO classification of gliomas.

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Author

Jeffrey N Bruce, MD Edgar M Housepian Professor of Neurological Surgery Research, Vice-Chairman and Professor of Neurological Surgery, Director of Columbia Brain Tumor Center, Director of Bartoli Brain Tumor Laboratory, Department of Neurosurgery, Columbia University Vagelos College of Physicians and Surgeons

Jeffrey N Bruce, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, American Society of Clinical Oncology, Congress of Neurological Surgeons, New York Academy of Sciences, North American Skull Base Society, Pituitary Society, Society for Neuro-Oncology, Society of Neurological Surgeons

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Theracle, Inc. <br/>Received grant/research funds from NIH for other.

Coauthor(s)

Michael G Argenziano, BA MD Candidate, Columbia University Vagelos College of Physicians and Surgeons

Disclosure: Nothing to disclose.

Colin P Sperring, BS MD Candidate, Columbia University Vagelos College of Physicians and Surgeonsw

Disclosure: Nothing to disclose.

Nina Teresa Yoh, MD Resident Physician, Department of Neurological Surgery, Columbia University Irving Medical Center, New York-Presbyterian Hospital

Nina Teresa Yoh, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, Congress of Neurological Surgeons, Gold Humanism Honor Society, Neurocritical Care Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Herbert H Engelhard, III, MD, PhD, FACS, FAANS Affiliated Professor of Bioengineering, University of Illinois at Chicago

Herbert H Engelhard, III, MD, PhD, FACS, FAANS is a member of the following medical societies: American Association for Cancer Research, American Association of Neurological Surgeons, American College of Surgeons, American Medical Association, Congress of Neurological Surgeons, Illinois State Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

Robert C Shepard, MD, FACP Associate Professor of Medicine in Hematology and Oncology at University of North Carolina at Chapel Hill; Vice President of Scientific Affairs, Therapeutic Expertise, Oncology, at PRA International

Robert C Shepard, MD, FACP is a member of the following medical societies: American Association for Cancer Research, American Association for Physician Leadership, European Society for Medical Oncology, Association of Clinical Research Professionals, American Federation for Clinical Research, Eastern Cooperative Oncology Group, Society for Immunotherapy of Cancer, American Medical Informatics Association, American College of Physicians, American Federation for Medical Research, American Medical Association, American Society of Hematology, Massachusetts Medical Society

Disclosure: Nothing to disclose.

Benjamin C Kennedy, MD Assistant Professor of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania; Director of Epilepsy and Functional Neurosurgery, The Children’s Hospital of Philadelphia

Disclosure: Nothing to disclose.

Acknowledgements

We wish to acknowledge previous contributions to this chapter from Patrick Senatus, MD, PhD and Allen Waziri, MD.