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2017 EANO指南：成人星形胶质细胞和少突胶质细胞瘤的诊断和治疗

已有 2223 次阅读 2017-5-15 07:38 |个人分类:临床指南和病例解析|系统分类:观点评述

Key recommendations

Karnofsky performance score, neurological function, age, and individual risks and benefits should be considered for clinical decision making. I A
Screening and prevention have no major role for patients with gliomas. IV ..
Patients with germ line variants or suspected hereditary cancer syndromes should receive genetic counselling and subsequently might be referred for molecular genetic testing. IV ..
First choice diagnostic imaging approach is MRI with and without contrast enhancement. IV ..
Pseudoprogression should be considered in patients with an increase in tumour volume on neuroimaging in the first months after local therapeutic interventions, including radiotherapy and experimental local treatments. II B
Clinical decision making without obtaining a definitive WHO diagnosis at least by biopsy should occur only in exceptional situations. IV ..
Glioma classification should follow the new WHO classification of tumours of the central nervous system 2016. IV ..
Immunohistochemistry for mutant IDH1-R132H protein and nuclear expression of ATRX should be performed routinely in the diagnostic assessment of gliomas. IV ..
IDH mutation status should be assessed by immunohistochemistry for IDH1-R132H. If negative, immunohistochemistry should be followed by sequencing of IDH1 codon 132 and IDH2 codon 172 in all WHO grade II and III astrocytic and oligodendroglial gliomas and in all glioblastomas of patients younger than 55 years to allow for integrated diagnoses according to the WHO classification and to guide treatment decisions. IV ..
1p/19q codeletion status should be determined in all IDH-mutant gliomas with retained nuclear expression of ATRX. II B MGMT promoter methylation status should be determined in elderly patients with glioblastoma and in IDH-wild-type WHO grade II and III gliomas to guide decision for the use of temozolomide instead of or in addition to radiotherapy. I B
Residual tumour volume after surgery is a prognostic factor, therefore efforts to obtain complete resections are justified across all glioma entities. IV ..
Prevention of new permanent neurological deficits has higher priority than extent of resection in the current surgical approach to gliomas. IV ..

IDH-mutant gliomas (WHO grade II or II)
Standard of care for WHO grade II astrocytomas (1p/19q-non-codeleted) that require further treatment includes resection, as feasible, or biopsy followed by involved field radiotherapy and maintenance procarbazine, lomustine, and vincristine chemotherapy (RTOG 9802 trial).I B
Standard of care for 1p/19q-non-codeleted anaplastic astrocytoma includes resection, as feasible, or biopsy followed by involved field radiotherapy and maintenance temozolomide. II B
Patients with 1p/19q-codeleted WHO grade II oligodendroglial tumours requiring further treatment should be treated with radiotherapy plus procarbazine, lomustine, and vincristine chemotherapy. III B
Patients with 1p/19q-codeleted anaplastic oligodendroglial tumours should be treated with radiotherapy plus procarbazine,lomustine, and vincristine chemotherapy (EORTC 26951 and RTOG 9402 trials). II B
Temozolomide chemotherapy is standard treatment at progression after surgery and radiotherapy for most patients with WHO grade II and III gliomas. II B

Glioblastoma, IDH-wild-type (WHO grade IV)
Standard of care for glioblastoma, IDH-wild-type (age <70 years, Karnofsky performance score ≥70) includes resection as feasible or biopsy followed by involved-field radiotherapy and 6 cycles of concomitant and maintenance temozolomide chemotherapy (EORTC 26981 NCIC CE.3 trial). I A
Temozolomide is particularly active in patients with MGMT promoter methylation whereas its activity in patients with MGMT promoter-unmethylated tumours is marginal. II B
Elderly patients not considered candidates for concomitant or maintenance temozolomide plus radiotherapy should be treated based on MGMT promoter methylation status (Nordic,19 NOA-08,20 and NCIC CE.6 EORTC 606221 trials) with radiotherapy (eg, 15 × 2·66 Gy) or temozolomide (5 out of 28 days). II B
Standards of care are not well defined at recurrence. Nitrosourea regimens, temozolomide rechallenge and, with consideration of the country-specific label, bevacizumab are pharmacological options, but an effect on overall survival remains unproven. When available, recruitment into appropriate clinical trials should be considered. II B
IDH=isocitrate dehydrogenase. MGMT=O⁶-methylguanine DNA methyltransferase. RTOG=Radiation Therapy Oncology Group. EORTC=European Organisation for Research