Early Surgical Resection of Low-grade Glioma Increases Survival

Diffuse low-grade gliomas (LGG) represent a subtype of slow-growing, infiltrative brain tumors that includes grade 2 astrocytomas, oligodendrogliomas, and oligoastrocytomas. However, the optimal treatment strategy for these tumors is controversial and has not been evaluated in controlled studies; early surgical resection may offer some survival benefit but is generally not curative and carries risk of neurologic damage, supporting diagnostic biopsy followed by watchful waiting for malignant tumor progression as a potential alternative therapeutic strategy. To assess whether early resection conferred a survival benefit over the watchful waiting approach, Jakola and colleagues performed a comparative, retrospective population-based analysis of 153 patients with diffuse LGG at 2 Norwegian hospitals. These neurosurgical centers exclusively treated patients within their geographic regions but favored opposing treatment strategies, with one hospital preferring the biopsy and watchful waiting approach and the other preferring early tumor resection. Tumor classification was confirmed by blinded histopathologic review, and overall survival from the start of treatment was evaluated based on regional differences in approach regardless of actual therapy to reduce selection bias. Intriguingly, whereas baseline parameters and the incidence of surgical complications were similar between the 2 groups, the survival of patients treated with early resection was significantly better than that of patients managed with watchful waiting (68% vs 44% expected 7-year survival). This survival benefit was first observed at 3 years and increased over time; median survival was 5.9 years with the biopsy approach but was not reached with the early resection approach. Furthermore, the relative hazard ratio was 1.8 for treatment at the center favoring biopsy and watchful waiting after adjusting for established prognostic factors. These findings support the use of early surgical resection, which both Norwegian hospitals now advocate, as the recommended initial treatment for patients with LGG.

Jakola AS, Myrmel KS, Kloster R, Torp SH, Lindal S, Unsgård G, et al. Comparison of a strategy favoring early surgical resection vs a strategy favoring watchful waiting in low-grade gliomas. JAMA 2012;308:1881–8.