Thread by @AshleySumrallMD

In light of today's plenary @ASCO #asco23 👀
Grade 2 gliomas👉🏻 a tutorial. #btsm
Considered a low-grade glioma, but also considered to be a terminal illness. How? These tumors are incurable and affect adults, teens, & children. #asco23 1/

They are insidious and will sometimes stay quiet for years. They may be oligodendrogliomas (aka lazy tumors) or the more aggressive astrocytomas. I often tell my pts that grade 2 tumors have 2 goals in life: grow BIGGER and/ or change to a more aggressive form. 2/

On the imaging, they often do not enhance, and can sometimes be missed. The key is to look at T2 and flair images. These pts must be monitored closely because the tumors can become motivated to change at any time. 3/

@WHO reclassified primary brain tumors in 2021 👉🏻 ncbi.nlm.nih.gov/pmc/articles/P… for the first time, Neuro-Oncology was able to incorporate a solid biomarker into tumor classification. #IDH 4/

When you examine these tumors under the microscope, they may have little to no cell division. This is very misleading, though, b/c these are actually tumors that will cause terminal illness. It can be very hard to reconcile this clinically! #btsm 5/

Let's consider oligodendroglioma first. @NIHBrainTumor has a nice ed page on this tumor tight. Essentially, this is the laziest of the low-grade gliomas. When you find one of these tumors that is 1p19q codeleted & IDH-mut, I affectionately refer to this as a "couch potato" 6/

Tx recs very for this tumor based on location, associated clinical pres, & extent of resection. RT +/- chemo has been used for yrs. Survival varies & is measured in years. cancer.gov/rare-brain-spi… 7/

Next up are the astrocytomas. I affectionately call these the "teenagers." They want to grow up, grow out of their area, & appear "older" like high grade gliomas. The image of a teen sneaking out is what I often use! They are mischievous, and not to be trusted! 8/

We watch these astrocytomas closely, often imaging pts every 2 to 4 months for years, just waiting... tx strategies have varied over the yrs from OBS to RT to chemoRT. Still, OS is poor. 5 year OS range: 58 to 72% and 5 year PFS: 37-55%. OS ranges vary considerably! 9/

Astrocytomas love to progress to grade 3 or grade 4 gliomas, sadly. Most will make this transition eventually. When this happens, prognosis drops dramatically. This is why we never call grade 2 gliomas "benign." Never! 10/

The tx of pts w grade 2 gliomas has been one of the most controversial areas in our field for yrs. Why? Brain surgery comes first, then brain RT has been the cornerstone of tx. This leads to fatigue, cognitive effects, mood d/o, & dec QOL. We've tried for yrs to do better... 11/