What is the recommended management approach for patients with Longitudinal Infiltrative Low-Grade Glioma (LILGG) in radiology?

From the Guidelines

The recommended management approach for patients with Longitudinal Infiltrative Low-Grade Glioma (LILGG) involves a multidisciplinary strategy combining surveillance imaging, surgical intervention when appropriate, and adjuvant therapies based on tumor characteristics and progression.

Key Considerations

• Initial management typically includes high-quality MRI surveillance at regular intervals (every 3-6 months initially, extending to 6-12 months if stable) to monitor for growth or malignant transformation 1.
• Surgical resection should be considered for accessible tumors causing symptoms, demonstrating growth, or showing features concerning for higher-grade transformation.
• Complete resection is preferred when feasible without causing neurological deficits, as it improves overall survival.
• For unresectable or partially resected tumors, watchful waiting with regular imaging is appropriate until progression occurs.
• Adjuvant therapy including radiation and/or chemotherapy (commonly temozolomide at 75-100 mg/m² daily for 21 days in a 28-day cycle) may be indicated for progressive disease, particularly in older patients or those with high-risk molecular features such as IDH-wildtype status 1.

Treatment Approach

This approach balances tumor control with preservation of neurological function and quality of life, recognizing that LILGGs often have an indolent course but carry potential for malignant transformation over time.

• Fractionated focal radiotherapy (60 Gy, 2 Gy · 30, or equivalent doses/fractionations) is the standard treatment after resection or biopsy 1.
• Concomitant and adjuvant temozolomide chemotherapy has been demonstrated to significantly improve median and 2-year survival in a large randomized trial in glioblastoma 1.

Patient Evaluation

Patients should be evaluated by a specialized multidisciplinary team, with special consideration given to performance status and neurological function 1.

From the Research

Management Approach for Longitudinal Infiltrative Low-Grade Glioma (LILGG)

The management of LILGG involves a multidisciplinary approach, including surgery, radiotherapy, and chemotherapy.

• Maximal safe resection is recommended as the initial treatment, as it improves both progression-free and overall survival 2, 3.
• Radiotherapy may be deferred in patients with low-risk LILGG, but combined chemoradiotherapy has not been prospectively evaluated in this population 2.
• Chemotherapy alone may be considered as a treatment option, particularly for patients with high-risk LILGG, although it has only been prospectively studied once 2.
• Temozolomide chemotherapy has shown clinical benefits and radiological response in patients with progressive LILGG 4.

Treatment Considerations

When determining the best course of treatment for LILGG, several factors must be considered, including:

• The patient's age and overall health
• The tumor's location and size
• The patient's performance status and quality of life
• The potential risks and benefits of each treatment option
• The integration of molecular biomarkers with histology to improve classification and prognosis 2, 3.

Ongoing Research and Future Directions

Ongoing clinical trials are investigating targeted therapies with lower morbidity rates and improved quality of life for patients with LILGG 5.

• The role of temozolomide in the management of LILGG is being further evaluated 3, 4.
• The characterization of prognostic relevance of molecular markers and advanced imaging techniques requires intensification of research and validation efforts 3, 6.