Last updated July 5, 2022

Radiation Therapy for IDH-Mutant Grade 2 and Grade 3 Diffuse Glioma

Indication and timing for RT

Oligodendroglioma, IDH-mutant and 1p/19q codeleted

For patients with oligodendroglioma, IDH-mutant, 1p/19q codeleted, WHO grade 2, <4 to 6 cm tumor, with gross total resection (defined as <1 cm residual tumor on MRI) and age <40 years, close surveillance alone is recommended. (Strong, Low)
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For patients with oligodendroglioma, IDH-mutant, 1p/19q codeleted, WHO grade 2, with high-risk features, either RT with sequential chemotherapy or RT with concurrent/sequential chemotherapy is conditionally recommended. (Conditional, Low)
Implementation remark: High-risk features include any of the following: subtotal resection, age ≥40 years, tumor size ≥4 to 6 cm, tumor crosses midline, refractory seizures, or presurgical neurological symptoms from tumor.
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For patients with oligodendroglioma, IDH-mutant, 1p/19q codeleted, WHO grade 3, with any extent of surgery, either RT with sequential chemotherapy or RT with concurrent/sequential chemotherapy is recommended. (Strong, Moderate)
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Astrocytoma, IDH-mutant

For patients with astrocytoma, IDH-mutant, WHO grade 2, <4 to 6 cm tumor, with gross total resection (defined as <1 cm residual tumor on MRI) and age <40 years, close surveillance alone is conditionally recommended. (Conditional, Low)
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For patients with astrocytoma, IDH-mutant, WHO grade 2, with high-risk features, either RT with sequential chemotherapy or RT with concurrent/sequential chemotherapy is conditionally recommended. (Conditional, Low)
Implementation remark: High-risk features include any of the following: subtotal resection, age ≥40 years, tumor size ≥4 to 6 cm, tumor crosses midline, refractory seizures, or presurgical neurological symptoms from tumor.
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For patients with astrocytoma, IDH-mutant, WHO grade 3, with any extent of surgery, either RT with sequential chemotherapy or RT with concurrent/sequential chemotherapy is recommended. (Strong, Low)
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Optimal dose of RT and target volume based on risk stratification

For patients with oligodendroglioma, IDH-mutant, 1p/19q codeleted, WHO grade 2 and astrocytoma, IDH-mutant, WHO grade 2, a total prescribed dose of 4500 to 5400 cGy in 180 cGy daily fractions is recommended. (Strong, High)
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For patients with oligodendroglioma, IDH-mutant, 1p/19q codeleted, WHO grade 3, a total prescribed dose of 5940 cGy in 180 cGy daily fractions is recommended. (Strong, Moderate)
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For patients with oligodendroglioma, IDH-mutant, 1p/19q codeleted, WHO grade 3, a total prescribed dose of 5400 to 5760 cGy in 180 cGy daily fractions is conditionally recommended as a treatment option. (Conditional, Expert Opinion)
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For patients with astrocytoma, IDH-mutant, WHO grade 3, a total prescribed dose of 5940 to 6000 cGy in 180 to 200 cGy daily fractions is recommended. (Strong, Moderate)
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For patients with astrocytoma, IDH-mutant, WHO grade 3, a total prescribed dose of 5400 to 5800 cGy in 180 to 200 cGy daily fractions is conditionally recommended as a treatment option. (Conditional, Expert Opinion)
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For patients with oligodendroglioma, IDH-mutant, 1p/19q codeleted, WHO grade 2 and astrocytoma, IDH-mutant, WHO grade 2, the following target volumes defined by MRI are recommended: GTV = residual FLAIR changes, resection cavity, and any residual tumor enhancement on T1 post-contrast; CTV = GTV + 10 to 15 mm expansion; PTV = CTV + 3 to 5 mm expansion. (Strong, Low)
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For patients with oligodendroglioma, IDH-mutant, 1p/19q codeleted, WHO grade 3 and astrocytoma, IDH-mutant, WHO grade 3, the following target volumes defined by MRI are recommended:; GTV = residual FLAIR changes, resection cavity and any residual enhancement on T1 post-contrast; CTV = GTV + 10 to 15 mm expansion; PTV = CTV + 3 to 5 mm expansion; OR, if cone-down/boost is desired:; GTV1 = residual FLAIR changes, resection cavity and any residual enhancement on T1 post-contrast; GTV2 = residual enhancement on T1 post-contrast and resection cavity; CTV1/2 = GTV1/2 + 10 to 15 mm expansion; PTV1/2 = CTV1/2 + 3 to 5 mm expansion. (Strong, Low)
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Optimal RT techniques and field design

For patients with IDH-mutant WHO grade 2 and grade 3 diffuse glioma, IMRT/VMAT is recommended to reduce acute and late toxicity, especially for tumors located near critical OARs. (Strong, Low)
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For patients with IDH-mutant WHO grade 2 and grade 3 diffuse glioma, 3-D CRT is recommended as a treatment option, when IMRT/VMAT is unavailable. (Strong, Moderate)
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For patients with IDH-mutant WHO grade 2 and grade 3 diffuse glioma, proton therapy is conditionally recommended as an option to reduce acute and late toxicity, especially for tumors located near critical OARs. (Conditional, Low)
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For patients with IDH-mutant WHO grade 2 and grade 3 diffuse glioma, optimization of radiation field design is recommended to ensure target coverage and OAR avoidance. (Strong, Moderate)
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For patients with IDH-mutant WHO grade 2 and grade 3 diffuse glioma receiving RT, daily image guidance is recommended. (Strong, Expert Opinion)
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Adverse effects of RT

For patients with IDH-mutant WHO grade 2 and grade 3 diffuse glioma, assessment, surveillance, and management by an interprofessional and/or multidisciplinary care team is recommended for toxicity management. (Strong, Expert Opinion)
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Multidisciplinary care team management for common toxicities

Table 7. Multidisciplinary care team management for common toxicities

Toxicity Management Considerations – Baseline and Ongoing (As Needed)
Neurocognitive function Neuropsychological testing (where available)
Neuroendocrine function Pituitary function testing for patients with hypothalamic/pituitary axis within the radiation treatment field or with clinical symptoms
Neurological deficit Rehabilitation medicine (including physical therapy and occupational therapy)
Vision Acuity and visual field testing for patients with optic pathway within the radiation treatment field or with clinical symptoms
Hearing Auditory and vestibular testing for patients with cochlea within the radiation treatment field or with clinical symptoms
Permanent alopecia Wig and hair loss consultation (where available)
Cerebrovascular complications Vascular medicine consultation (with neurologist and/or neurosurgeon)
Financial/psychosocial Social services (eg, social worker, adolescent and young adult-life specialist, and financial counsellor)
Quality of Life Survivorship and supportive care (eg, palliative care provider, onco-psychologist, and mental health counselor)

Recommendation Grading

Overview

Title

Radiation Therapy for IDH-Mutant Grade 2 and Grade 3 Diffuse Glioma

Authoring Organization

Publication Month/Year

May 31, 2022

Document Type

Guideline

Country of Publication

US

Document Objectives

This guideline provides evidence-based recommendations for adults with isocitrate dehydrogenase (IDH)-mutant grade 2 and grade 3 diffuse glioma, as classified in the 2021 World Health Organization (WHO) Classification of Tumours. It includes indications for radiation therapy (RT), advanced RT techniques, and clinical management of adverse effects.

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Hospital, Outpatient, Radiology services

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Treatment, Management

Diseases/Conditions (MeSH)

D018787 - Radiation Oncology, D005910 - Glioma

Keywords

radiation therapy, Brain Metastases, glioma, Gliomas

Source Citation

Lia M. Halasz, Albert Attia, Lisa Bradfield, Daniel J. Brat, John P. Kirkpatrick, Nadia N. Laack, Nafisha Lalani, Emily S. Lebow, Arthur K. Liu, Heather M. Niemeier, Joshua D. Palmer, Katherine B. Peters, Jason Sheehan, Reena P. Thomas, Sujay A. Vora, Daniel R. Wahl, Stephanie E. Weiss, D. Nana Yeboa, Jim Zhong, Helen A. Shih, Radiation Therapy for IDH-Mutant Grade 2 and Grade 3 Diffuse Glioma: An ASTRO Clinical Practice Guideline, Practical Radiation Oncology, 2022, ISSN 1879-8500, https://doi.org/10.1016/j.prro.2022.05.004

Supplemental Methodology Resources

Data Supplement, Data Supplement, Evidence Tables

Methodology

Number of Source Documents
67
Literature Search Start Date
January 1, 2005
Literature Search End Date
July 1, 2020