Controversies in the Therapy of Low-Grade Gliomas

In the context of the new WHO classification system, all low-grade gliomas must have an IDH mutation, with or without 1p/19q codeletion. Upon discovery of the tumor, maximal safe surgical resection is the most appropriate first step due to the current inability to differentiate between IDH mutant and IDH wild-type tumors by imaging alone. In the postoperative setting, based on the synthesis and interpretation of the available data, we recommend utilizing conventional radiation therapy and PCV in all high-risk-low-grade gliomas. For patients felt to be in a low risk category, we recommend maintaining a low threshold to initiate treatment. In the setting of tumor recurrence, consideration of all treatment options is reasonable, but treatment with alkylator therapy has the strongest supporting data.