Gliomas in adults: Guidance on investigations, diagnosis, treatment and surveillance

Abstract

Primary brain tumours are rare but carry a significant morbidity and mortality burden. Malignant gliomas are the most common subtype and their incidence is increasing within our ageing population. The diagnosis and treatment of gliomas involves substantial interplay between multiple specialties, including general medical physicians, radiologists, pathologists, surgeons, oncologists and allied health professionals. At any point along this pathway, patients can present to acute medicine with complications of their cancer or anti-cancer therapy. Increasing the awareness of malignant gliomas among general physicians is paramount to delivering prompt radiological and histopathological diagnoses, facilitating access to earlier and individualised treatment options and allows for effective recognition and management of anticipated complications. This article discusses evidence-based real-world practice for malignant gliomas, encompassing patient presentation, diagnostic pathways, treatments and their complications, and prognosis to guide management outside of specialist centres.

Keywords: Complications; Diagnosis; Glioma; Management; Presentation.

Fig. 1

Schematic showing the diagnostic pathway used for diagnosis of diffuse gliomas in adults. Orange panels show molecular tests commonly used for diagnosis and prognosis: solid lines indicate diagnostic use; dotted lines indicate tests used in prognostication/grading; dashed lines indicate tests used for treatment response prediction. Blue panels indicate diagnostic entities as defined in the 2021 WHO Classification of Central Nervous System Tumours. CDKN2A/B deletion in Astrocytoma, IDH-mutant confers CNS WHO grade 4.

Fig. 2

Glioblastoma (A–D). A not enhancing (A, postcontrast FSE T1-weighted image), infiltrating lesion (B, T2-weighted image), with restricted diffusion (C, ADC map) and high perfusion on DSC-MR imaging map (D, rCBV map) is seen in the frontal lobes, which involves the corpus callosum. Lymphoma (E–H). A contrast-enhancing (E, postcontrast FSE T1-weighted image) heterogeneous lesion, surrounded by oedema (F, T2-weighted image), with restricted diffusion (G, high b value DWI image) is seen in the splenium of the corpus callosum. In contrast to GBM, the lesion does not demonstrate high perfusion on DSC-MR imaging sequence (H, rCBV map). Reprinted from Magnetic Resonance Imaging Clinics of North America, Vol 24, Issue 1, Margareth Kimura,L. Celso Hygino da Cruz, Multiparametric MR Imaging in the Assessment of Brain Tumors, pg 87–122, Copyright 2016, with permission from Elsevier.

Fig. 3

Image of a thermoplastic shell for immobilisation during radiotherapy. Image courtesy of The Brain Tumour Charity. All rights reserved.

Fig. 4

Image of a radiotherapy treatment machine: a linear accelerator. Image courtesy of The Brain Tumour Charity. All rights reserved.