The Treatment Path for Grade 2 Gliomas — Age Matters

“Someone who is newly diagnosed, is 40 or younger, and has a complete resection of the tumor, that is a group of patients who we feel are probably best managed by monitoring as opposed to starting treatment up front,” Dr. David Peereboom, a medical oncologist from Cleveland Clinic in Cleveland, Ohio, tells SurvivorNet. “…For patients who are older than 40 or have had less than a complete resection, that’s a group who we feel should get treated at the time of diagnosis.”

Treatment for grade 2 gliomas typically involves a combination of options, which may include repeat surgery, chemotherapy, radiation therapy, and targeted therapies like Vorasidenib. Each of these interventions plays a critical role in improving outcomes, and the choice of treatment depends on various factors such as the patient’s age, overall health, and the extent of tumor removal during the initial surgery.

When is Repeat Surgery Needed?

Surgical removal of the tumor is often the first step in managing grade 2 gliomas. The goal of surgery is to remove as much of the tumor as possible without damaging critical areas of the brain that control essential functions like movement, speech, or vision. In cases where a complete resection is not achieved, repeat surgery may be considered.

Repeat surgery is particularly beneficial for patients whose tumors continue to grow or for those experiencing new or worsening symptoms. Advances in surgical techniques, such as the use of intraoperative imaging and awake brain surgery, have significantly improved the precision and safety of these procedures. By removing more of the tumor, repeat surgery can help reduce symptoms, improve quality of life, and delay the need for additional treatments such as radiation or chemotherapy.

Chemotherapy

Chemotherapy is another cornerstone of grade 2 glioma treatment, especially for patients at higher risk of recurrence. Chemotherapy drugs work by targeting and killing rapidly dividing cancer cells, thereby slowing tumor growth and reducing the likelihood of recurrence. One commonly used chemotherapy regimen for grade 2 gliomas involves a combination of the drugs procarbazine, CCNU or lomustine, and vincristine (often referred to as PCV therapy).

Temozolomide, an oral chemotherapy drug, is another option frequently used in glioma treatment. Its relatively mild side effect profile and ease of administration make it a preferred choice for many patients.

“There’s controversy over which aught to be used,” Dr. Peereboom explains. “The PCV has a longer track record since the drugs existed well before temozolomide came to be used, so we have the longest term date … on the other hand PCV has three drugs and that regiment, while effective, has more side effects than temozolomide.”

The decision to use chemotherapy is typically guided by factors such as the tumor’s genetic profile, the patient’s age and overall health, and the extent of tumor resection.

Radiation Therapy

Radiation therapy is a standard treatment for grade 2 gliomas, particularly for patients who have a higher risk of recurrence or who cannot undergo complete surgical removal of their tumor. Radiation therapy uses high-energy beams, such as X-rays or protons, to target and destroy cancer cells. Modern radiation techniques, such as intensity-modulated radiation therapy (IMRT) and proton therapy, allow for precise targeting of the tumor while sparing healthy brain tissue.

Radiation therapy is often administered over several weeks, with patients receiving daily treatments. Although it is an effective way to control tumor growth, it can also have side effects, including fatigue, hair loss, and cognitive changes. Patients undergoing radiation therapy are closely monitored to manage these side effects and ensure the best possible outcomes.

Targeted Therapy

Targeted therapy represents a newer approach to treating grade 2 gliomas. Unlike traditional chemotherapy, which affects both cancerous and healthy cells, targeted therapies are designed to specifically attack the molecular changes driving tumor growth. For example, some grade 2 gliomas have mutations in the IDH1 or IDH2 genes, and targeted drugs are being developed to inhibit these mutations. Vorasidenib is a recently FDA-approved drug that targets IDH mutations in gliomas. IDH mutations are common in low-grade, slow-growing gliomas, and this mutation plays a key role in tumor development. Vorasidenib is an IDH inhibitor. It works by blocking the mutated enzyme, slowing down tumor growth, and extending the time before disease progression.

Additionally, advances in genomic sequencing have allowed researchers to identify other genetic alterations in gliomas that may be susceptible to targeted therapies. While this area of treatment is still evolving, clinical trials are underway to evaluate the effectiveness of these therapies in patients with grade 2 gliomas. Patients interested in targeted therapy should discuss the possibility of participating in a clinical trial with their healthcare team.

The Importance of a Multidisciplinary Approach

Managing grade 2 gliomas often requires the expertise of a multidisciplinary team that includes neurosurgeons, neuro-oncologists, radiation oncologists, and supportive care specialists. This team-based approach ensures that every aspect of a patient’s care is thoroughly evaluated and optimized. For example, neurosurgeons may collaborate with radiation oncologists to determine the ideal timing and type of radiation therapy following surgery, while neuro-oncologists may coordinate chemotherapy and clinical trial participation.

Patients can also benefit from access to supportive care services, such as physical therapy, occupational therapy, and neuropsychological support. These services help address the physical, emotional, and cognitive challenges associated with glioma treatment and improve overall quality of life.

When to Consider a Clinical Trial

Ongoing research and clinical trials play a critical role in advancing the treatment of grade 2 gliomas. These studies are exploring new therapies, including immunotherapies and novel targeted drugs, as well as innovative approaches to combining existing treatments. Patients who participate in clinical trials not only gain access to cutting-edge therapies but also contribute to the scientific understanding of gliomas and help improve care for future patients.

Patients interested in clinical trials should speak with their healthcare team about available options and eligibility criteria.

You can also check out SurvivorNet’s simple Clinical Trial Finder.

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