Glioma and glioblastoma

IDH-wildtype (no IDH mutation). The most common and fastest-growing glioma, usually after the age of 50. Always grade 4.

Usually in younger adults (30s and 40s). Grade 2, 3 or 4. Grows more slowly than glioblastoma and does better with treatment.

IDH-mutant with 1p/19q codeletion. Grade 2 or 3. Responds well to radiotherapy and chemotherapy; many patients live for many years.

• Low-grade gliomas of children (pilocytic astrocytoma): often cured with surgery alone.
• Diffuse midline glioma (H3 K27-altered): in the brainstem or deep brain, mostly in children and young adults.
• Ependymoma: in the brain or spinal cord; surgery and radiotherapy.

The main scan. Shows the size and position of the tumour, the swelling around it, and helps plan surgery. A CT is often the first scan in emergency.

Tissue is needed to confirm the diagnosis. When safe, the surgeon removes as much as possible in the same operation; if the tumour is deep, a needle biopsy is done.

• IDH mutation and 1p/19q: decide the type.
• MGMT methylation: when present, temozolomide works better.
• Others such as ATRX, TERT, EGFR, CDKN2A and H3 K27M help with grading.

Neurological examination, and sometimes eye, memory or speech assessment, to record how you are before treatment.

Before starting chemotherapy, immunotherapy or targeted therapy, these tests check that you are fit for treatment, and give a starting point to compare with later.

Before immunotherapy, also:

Sometimes needed, depending on your treatment:

• Pregnancy test for women who could be pregnant.
• Calcium and magnesium: for example before cisplatin or bone-strengthening injections.
• Dental check-up before bone-strengthening injections (zoledronic acid or denosumab), as they can rarely affect the jaw bone.
• Hearing test before cisplatin, in some patients.
• Clotting tests (PT/INR) before a biopsy or chemoport.

Your doctor will choose the tests that apply to you. Some of them are repeated during treatment.

• The molecular report can take 2 to 3 weeks. It decides the type and grade, and therefore the treatment.
• Radiotherapy usually starts 3 to 6 weeks after surgery, once the wound has healed, so waiting for the reports does not delay treatment.

Slow growing. Some are watched with MRI after surgery; others need treatment soon.

Faster growing. Radiotherapy and chemotherapy are given after surgery.

The fastest growing, including glioblastoma. Treatment starts within a few weeks of surgery.

1. Surgery: safe maximum removal.
2. Radiotherapy with temozolomide tablets daily for 6 weeks.
3. Temozolomide alone for 6 cycles (5 days every 4 weeks).
4. Older or frail patients: a shorter 3-week course of radiotherapy, with temozolomide (especially if MGMT is methylated).
5. Tumour treating fields (a device worn on the scalp) is an option in some centres.

Side effects: radiotherapy · temozolomide · steroids

1. Surgery: safe maximum removal.
2. Grade 2 with little tumour left: vorasidenib tablets, or regular MRI, may delay radiotherapy for years.
3. Grade 2 high risk, or grade 3: radiotherapy followed by temozolomide for 12 cycles.
4. Grade 4: treated like glioblastoma.

Side effects: radiotherapy · temozolomide · vorasidenib

1. Surgery: safe maximum removal.
2. Grade 2 with little tumour left: vorasidenib or regular MRI.
3. Grade 2 high risk, or grade 3: radiotherapy followed by PCV chemotherapy (procarbazine, lomustine, vincristine) or temozolomide.

Side effects: radiotherapy · PCV · vorasidenib

1. A second operation when possible.
2. Lomustine chemotherapy, or temozolomide again.
3. Bevacizumab to reduce swelling and steroid need.
4. Radiotherapy again in selected patients.
5. A clinical trial, where available.

• Dexamethasone (steroid) reduces swelling around the tumour and quickly eases headache and weakness. It can raise blood sugar, increase appetite, disturb sleep and mood, and is reduced slowly; never stop it suddenly.
• Seizure tablets (levetiracetam and others) are taken regularly; some cause sleepiness or mood change. Do not stop them on your own.
• If you have had a seizure, do not drive until your doctor says it is safe.

• Tiredness, which builds up during and after treatment.
• Hair loss in the treated area, which may be permanent.
• Headache or worsening of symptoms from swelling (steroids help).
• Over years, some people notice memory or concentration problems.

• Nausea: take an anti-sickness tablet an hour before, on an empty stomach at bedtime.
• Constipation and tiredness.
• Low platelets and white cells: blood tests every week during radiotherapy, then before each cycle.
• An antibiotic (co-trimoxazole) is often given during radiotherapy to prevent a lung infection.

• Low blood counts, nausea and tiredness.
• Vincristine: tingling or numbness of fingers and toes.
• Procarbazine: avoid foods rich in tyramine (aged cheese, cured meats, alcohol), as they can raise blood pressure.

• Usually well tolerated.
• Can affect the liver: liver blood tests are checked regularly, especially in the first months.

A seizure lasting more than 5 minutes or repeated seizures, sudden severe headache with vomiting, new weakness, confusion or drowsiness, or fever of 38°C or more during chemotherapy need urgent care.

When to seek help urgently