低级别胶质瘤

Gliomapatientsgroup:twofournineonefiveeightseven seven eight胶质瘤病友群：249158778Inpatientswithlowgradegliomaandcontrolledepilepsyasthesinglesymptom,surgerymaybedeferreduntilclinicalorradiologicalprogression.(LevelofEvidence4-RecommendationgradeC)当可控的癫痫作为唯一症状的低度恶性胶质瘤患者InoneretrospectivestudybyvanVeelenetal,itwasshownthatinpatientswithcontrolledseizuresasthesinglesymptom,theprognosisisnotinfluencedbythetimingofthesurgery.Itcouldbe,therefore,safetodefersurgeryuntilclinicalorradiologicalprogressioninpatientswithcontrolledepilepsyonly.Veelen术也是很安全的。In1994Bergeretalanalyzedtheeffectofextentofresectiononrecurrenceinpatientswithlowgradegliomas.Theyfoundthatfortumoursgreaterthan10cm3agreaterpercentofresectionandasmallervolumeofresidualdiseaseconveyasignificantadvantageintermsofrecurrence,comparedtothosethathadalessaggressiveresectionorbiopsy.Fortumourssmallerthan10cm3norecurrencewasdetectedover3to4years,regardlessofpercentofresection.19941010立方厘米的肿瘤，切除程度和复发则没有联系。Inpatientswithincreasedintracranialpressure,neurologicaldeficits,uncontrollableseizures,orinthosewhohaveclinicalorradiologicalprogression,maximalresection,whensafe,shouldbeattempted.(LevelofEvidence3-RecommendationgradeB)出现进展的病人，在安全的前提下，尽可能做根治性的切除。Postsurgicalradiationtherapymaybedeferreduntilclinicalorradiologicalprogression.WhenRadiationtherapyisindicated,thedoseshouldbebetween45and54Gy.(LevelofEvidence1-RecommendationgradeA)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。Aclinicaltrial(EORTC22845)performedin2002comparedimmediateRTgivenaftersurgeryversusRTaftertumourrecurrence.Althoughtheprogression-freesurvivaltimewas5.3yearsforimmediateRTversus3.4yearsforRTdeferredandtheseizureswerebettercontrolledinthefirstgroup,usingthe“waitandsee”approachanddelayingtheRThadnoadverseanimpactonmedisurvival.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5.33.4年的稳定期，而且生存期并没有不利的影响。Basedonthesedataitseemsappropriatetodeferthepost-surgicalRTuntilprogressionofdisease.WhenRTisindicated,thedoseshouldbe45Gyto54Gy.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。Radiotherapyalonemaybeofferedinpatientswithprogressivetumours.(LevelofEvidence1-ecommendationgradeA)进展性的低度恶性胶质瘤患者可以单给放疗。Chemotherapyshouldnotbeaddedtoradiationtherapy,sincethecombinationshowsnobenefitincomparisontoRTaloneandincreasesthetoxicity.(LevelofEvidence1-RecommendationgradeA).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。Chemotherapysuchastemozolomidemaybeofferedinpatientswithprogressivetumoursthatharbourcombined1p/19qlossofheterozygosity.(LevelofEvidence4-RecommendationgradeC)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ThelargeststudytodatewasperformedbyKaloshietal.Theyretrospectivelyreviewedtheirexperienceof149patientswithprogressivelowgradegliomaswhoreceivedtemozolomideastheirinitialtreatmentaftersurgery.Fifty-threepercentofthepatientshadobjectiveresponse,themedianPFSwas28months,andthe3-yearsurvivalwas69.8%.Thetreatmentwaswelltolerated.Interestingly,combined1p/19qlossofheterozygosity(LOH)wassignificantlyassociatedwithahigherrate(p=0.02)andlongerobjectiveresponsetochemotherapy(p=0.0017),andlongerPFS(p=0.00041)andoverallsurvival(p=0.04).Thisstudywaslimitedbyitsretrospectivedesign,butaddsevidencethatlowgradegliomasrespondtotemozolomide,andthat1p/19qLOHisassociatedwithchemosensitivityandimprovedoutcome.Kaloshi等组织的一项回顾性的研究发53%的病人28个月，3年的生存期为69.8%1p19q缺失的的患者反应尤其良好。Forhighriskpatients(criteriadefinedindiscussion)inclusioninaclinicaltrialisrecommended.Intheabsenceofaclinicaltrialadjuvantchemotherapyandradiationtherapymaybeconsideredonanindividualbasis.放疗联合化疗的给予要按照个体化原则来进行。BasedontheanalysisofthetwoEORTCtrials10,11patientswithlowgradegliomasaredividedintotwoprognosticgroups.Thehighriskpatientsaredefinedasthosewhomeetatleastthreeofthefollowingcriteria:age≥40years,largestpreoperativetumordiameter≥6cm,tumorcrossingmidline,tumorofastrocytomahistology,orpreoperativeneurologicdeficits(NeurologicFunctionScore>1),whilethelowriskpatientsarethosewithtwoorlessofth