Low grade glioma pathology vs radiological diagnosis No conflicts - PowerPoint PPT Presentation

ESMO Preceptorship Programme Brain tumour – Athens – 28-29 Sept 2018 Amin Ali The Christie, Manchester Low grade glioma – pathology vs radiological diagnosis

 No conflicts of interest ESMO PRECEPTORSHIP PROGRAMME

 37 year old lady primigravida at 25 weeks  Found unconscious (Nov 2017) with evidence of GTC seizure  Intubated and stabilised in ITU, unfortunately complicated to have intrauterine death and seizures ESMO PRECEPTORSHIP PROGRAMME

 MRI brain (Nov 2011): LGG crossing corpus collosum  Right frontal craniotomy and limited debulking (30%) ESMO PRECEPTORSHIP PROGRAMME

 Pathology review: IDH1 WT (IHC) , 1p19q intact, diffuse astrocytoma, WHO grade 2  Neuro-rehabilitation for 2 months ESMO PRECEPTORSHIP PROGRAMME

 MRI brain (Jan 2018): Overall similar size but some new contrast enhancement inferiorly. Significant mass effect Pre-op Post-op (limited debulking) ESMO PRECEPTORSHIP PROGRAMME

 MDT opinion: elective safe debulking resection of right frontal component  Patient agreed and had subtotal resection (March 2018)  Histology: Subtotal resection of grade II diffuse astrocytoma , IDH1 mutant (molecular) , ATRXm, Ki- 67 <4%  Patient recovered from surgery well with performance status 0 ESMO PRECEPTORSHIP PROGRAMME

 Given imaging appearances and extent of disease, managed as grade III  Planned concurrent chemoradiation 59.4Gy/33fr followed by adjuvant Temozolomide up to 12 cycle ESMO PRECEPTORSHIP PROGRAMME

Latest – 29 August 2018  Completed concurrent chemoradiation 10/7/18  Back to full time work after 1 month post radiotherapy  Developed partial seizure at work  Admitted A&E – MRI showed response to radiotherapy although she does have considerable extensive bilateral residual frontal tumour  Increased anti-epileptic  Came for cycle 1 adjuvant Temozolamide – reduced dose due to thrombocytopenia grade 3 ESMO PRECEPTORSHIP PROGRAMME

PRE-CRT 1 MONTH POST CRT ESMO PRECEPTORSHIP PROGRAMME

Discussion points  How much should you try to resect - does debulking have a benefit over biopsy?  Not all IDH mutations are picked up with IHC - role of molecular testing  Pathology grade 2 vs Radiology grade 3 – management?  Young patient – discrepancy of disease extent vs clinical symptoms ESMO PRECEPTORSHIP PROGRAMME

Acknowledgement  Dr Catherine McBain  ESMO ESMO PRECEPTORSHIP PROGRAMME

ESMO Preceptorship Programme Thank you