Radiotherapy vs. observation (after biopsy or surgical resection)
There is randomised evidence that the addition of adjuvant radiotherapy to the tumour/tumour bed following biopsy or surgical resection improves survival over surgery ± chemotherapy in high grade gliomas.r
Chemotherapy plus radiotherapy vs radiotherapy alone
The evidence supporting the addition of chemotherapy to adjuvant radiotherapy for 1p19q co-deleted tumours comes from the phase III randomised controlled trials: EORTC 26951 (2006r and 2013r), RTOG 9402 (2006r and 2013r) and for 1p/19q non-co-deleted anaplastic tumours, the EORTC study 26053-22054/RTOG 8034 (CATNON) (2017r).
EORTC 26951 and RTOG 9402 involved a total of 659 patients comparing post-operative procarbazine, lomustine and vincristine (PCV) chemotherapy and radiotherapy with radiotherapy alone in patients with grade III glioma.r In patients with 1p/19q co-deleted and IDH-1 mutant tumours there is evidence to support the use of post-operative PCV chemotherapy either pre- or following radiotherapy.rrr Patients with 1p/19q non-codeleted tumours had worse outcomes than patients with 1p/19q co-deletion tumours and did not derive a survival benefit from PCV.rr
The CATNON trial provides evidence to support the use of temozolomide following radiation in patients with 1p/19q non-co-deleted anaplastic glioma.r The CATNON trial randomly assigned 748 to one of four treatment groups: radiotherapy alone (59.4 Gy in 33 fractions of 1.8 Gy), radiotherapy with adjuvant temozolomide (TMZ), or radiotherapy with concurrent TMZ (with or without adjuvant TMZ).
For further information on the evidence supporting these chemotherapy regimens see link to Anaplastic glioma PCV (procarbazine lomustine vinCRISTine) and Anaplastic glioma temozolomide following radiation protocols.
Anaplastic astrocytoma, IDH wild type
IDH wild type anaplastic astrocytomas are rare, and most have genetic features characteristic of IDH wild type glioblastoma. Management of these tumours is often extrapolated from glioblastoma.
Summary of treatment regimens
|| RT and PCV (sequential)
||RT and adjuvant TMZ
||IDH wild type (rare)
More aggressive behaviour
Often managed along the lines of glioblastoma.