How Do You Treat Gliomas at Recurrence?

When gliomas recur, the approach to treatment requires nuanced decision-making informed by the tumor’s characteristics, the patient’s prior treatments, and the available resources. As glioma management continues to evolve with advances in molecular therapies, surgery, and multidisciplinary collaboration, healthcare providers face critical choices to optimize patient outcomes.

At SNO 2024, SurvivorNet gathered a group of distinguished experts for a panel including Dr. Katie Peters, a neuro-oncologist at Duke Health, Dr. Alexandra Miller, a neuro-oncologist at NYU Langone Health, Dr. Erin Dunbar, a neuro-oncologist at Piedmont Healthcare, and Dr. Ganesh Rao, Chair of Neurosurgery at Baylor College of Medicine. They shared their expertise on navigating the complexities of recurrent glioma care.

Recurrences and Their Variability

Glioma recurrence is not a uniform event, and the type of recurrence dictates the treatment path.

As Dr. Miller explains, “There are recurrences, and there are recurrences.” For example, a low-grade tumor that returns as a non-enhancing, resectable lesion presents a lower-risk scenario. In such cases, patients may benefit significantly from IDH inhibitors like vorasidenib, which can provide effective control while delaying more aggressive treatments.

In contrast, recurrences that involve more complex or high risk disease often necessitate more conventional treatments such as radiation and chemotherapy.

Tailoring the treatment plan to the specifics of the recurrence is necessary. This ensures that each patient receives the most appropriate care for their clinical disease status.

Surgery for Recurrent Gliomas

Surgery remains a valuable tool in managing recurrent gliomas, especially when imaging indicated the need for updated molecular or histological information. Dr. Dunbar emphasizes the importance of re-evaluating the tumor through additional tissue sampling.

“Is there patchy enhancement? Are there worrisome signs on imaging? One of the answers might be to get more tissue—biopsy or resect at a center with advanced intraoperative tools,” she explains. 

Advanced surgical techniques, such as intraoperative mapping and awake craniotomy, allow for maximal safe resection, even in more delicate areas of the brain. Access to advanced surgical capabilities may be limited for patients in low-volume centers. In these cases, connecting with high-volume centers through tumor boards or direct referrals can ensure patients benefit from such surgical capabilities. 

Integrating Molecular Therapies

With the development of IDH inhibitors, such as vorasidenib, another treatment option for recurrent gliomas has become available. As Dr. Peters points out, the use of IDH-directed therapies in recurrence is still being refined, particularly in patients who have previously received such treatments.

Ongoing studies are helping define the role of these therapies in recurrent settings, but early data suggests that patients with recurrent low-grade IDH-mutant gliomas can derive meaningful benefits from these targeted drugs.

The Role of Multidisciplinary Collaboration

For providers managing glioma recurrences in low-volume centers, multidisciplinary collaboration is extremely valuable. Dr. Dunbar highlights the importance of leveraging virtual tumor boards and consultation networks, such as those offered by the Society of Neuro-Oncology and NIH. These platforms allow community providers to connect with experts, ensuring that complex cases are reviewed comprehensively. “We’ve never had more ability to be connected to make great decisions,” she notes, emphasizing the importance of “phoning a friend” when faced with challenging cases.

By low-volume centers collaborating with larger academic centers and participating in tumor boards, providers can ensure their patients receive cutting-edge and optimal care while maintaining a local connection for ongoing management.

Managing glioma recurrence is a complex process that requires a personalized approach for every patient. By carefully assessing the type and extent of the recurrence, incorporating advanced surgical and molecular options, and fostering strong collaboration through multidisciplinary networks, healthcare providers can deliver the most optimal care for their patients.

Staying current with evolving treatment strategies, including the role of targeted therapies like IDH inhibitors, ensures that patients receive the most appropriate interventions at each stage of their journey. Through education and teamwork, providers can navigate the challenges of recurrent gliomas to help improve outcomes for their patients.