Disclosures: Martin van den Bent, MD, PhD Grant/Research/Clinical Trial Support: AbbVie [Glioblastoma (ABT-414)]; Roche [Glioblastoma (Bevacizumab)]. Speakers' Bureau: MSD [Glioma (Temozolomide)]. Patrick Y Wen, MD Grant/Research/Clinical Trial Support: Agios; Angiochem; AstraZeneca; Exelixis; GlaxoSmith Kline; Karyopharm; Novartis; Sanofi-Aventis; Regeneron Pharmaceuticals, Inc.; Vascular Biogenics [Neurooncology]; Genentech/Roche [Neurooncology (Avastin)]. Speaker's Bureau: Merck [Neuroonocology]. Consultant/Advisory Boards: AbbVie; Cavion; Celldex; Cubist; Midatech; Momenta; Novartis; Novocure; SigmaTau; Vascular Biogenics [Neurooncology]; Genentech/Roche [Neurooncology (Avastin)]. Jay S Loeffler, MD Nothing to disclose. April F Eichler, MD, MPH Equity Ownership/Stock Options: Johnson & Johnson [Dementia (galantamine), Epilepsy (topiramate)].
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence.
INTRODUCTION — Oligodendroglial tumors constitute between 5 and 20 percent of all glial tumors. Oligodendroglial tumors typically arise in the fourth to sixth decades, with low-grade tumors occurring at an earlier age than anaplastic tumors. Despite the prolonged clinical course seen with oligodendroglial tumors, the outcome is almost always fatal.
Historically, the management of patients with anaplastic oligodendroglial tumors was based upon results from studies in patients with malignant gliomas, carried out prior to the recognition of the molecular and prognostic differences between oligodendroglial and other glial tumors. Compared with astrocytic tumors, oligodendroglial tumors are more likely to harbor certain favorable molecular markers, such as co-deletion of the short arm of chromosome 1 (1p) and the long arm of chromosome 19 (19q) and mutations in isocitrate dehydrogenase (IDH). Such mutations are relevant to treatment planning and prognosis.
The treatment of anaplastic oligodendroglial tumors will be reviewed here. The clinical manifestations, pathology, and molecular prognostic factors of oligodendroglial tumors and the management of low-grade oligodendrogliomas are discussed separately. (See "Clinical features, pathology, and prognostic factors for oligodendroglial tumors" and "Management of low-grade glioma".)
SURGERY — Surgery provides tissue to establish the diagnosis and is used to relieve symptoms due to mass effect in patients with suspected anaplastic oligodendroglial tumors. As with other high-grade gliomas, maximal resection is the preferred approach, but partial resection or biopsy may be required, depending upon the location and extent of the tumor. (See "Clinical manifestations and initial surgical approach to patients with high-grade gliomas", section on 'Extent of resection'.)
There are no randomized trials that have established the benefit of maximal surgical resection compared with a more limited resection, and such studies are unlikely to be conducted. Evidence supporting this approach specifically in oligodendroglial tumors comes from secondary analyses of two large trials, which demonstrated a positive association between a more extensive resection and prolonged survival [1,2]. However, in retrospective studies, small, superficial tumors with a relatively favorable prognosis are more likely to have been extensively resected, while large, deep-seated, or midline tumors with a poorer prognosis will not have been completely resected .
Limited data suggest that the presence of a mutation in isocitrate dehydrogenase 1 (IDH1) or IDH2 may be an additional factor relevant to the association between extent of resection and overall survival. In a retrospective series of high-grade astrocytic tumors, a positive association between gross total resection (of both enhancing and nonenhancing components) and overall survival was observed for IDH1-mutant tumors but not wild-type tumors . It is not yet clear whether this effect is also relevant for oligodendroglial tumors, or whether the association is confounded by factors relating to resectability.
Selection of therapy — Following surgery, further treatment with radiation therapy (RT) and/or chemotherapy is required in patients with anaplastic oligodendroglial tumors due to the high likelihood of tumor recurrence. Both RT and chemotherapy are active treatment modalities, but there is ongoing uncertainty regarding the optimal approach in various patient subgroups. The presence or absence of a 1p19q co-deletion and MGMT status are factors that may help to determine the optimal approach:
●For patients with 1p19q co-deleted tumors, we recommend adjuvant treatment that includes both radiation therapy (RT) and chemotherapy. This approach is supported by two large randomized trials in patients with anaplastic oligodendroglial tumors, in which the addition of PCV (procarbazine, lomustine, vincristine) to RT was associated with improved progression-free and overall survival compared with RT alone in those with 1p19q co-deleted tumors. The timing of PCV in relation to RT remains uncertain, as does the optimal chemotherapy regimen. Although PCV was the regimen used in both randomized trials, temozolomide is easier to administer and has better patient tolerance. (See 'RT plus chemotherapy' below and 'PCV versus temozolomide' below.)
●Patients with non-co-deleted tumors should receive postoperative RT, but the benefit of additional chemotherapy is less certain than in patients with 1p19q co-deleted tumors. We suggest RT alone in most patients with non-co-deleted tumors. Combined treatment with RT and chemotherapy is a reasonable consideration in selected patients, such as those with MGMT methylated tumors. (See 'Radiation therapy' below and 'RT plus chemotherapy' below.)
●There are two ongoing multicenter randomized trials in patients with anaplastic gliomas designed to address many of these uncertainties. (See 'Ongoing radomized trials' below.)
Radiation therapy — Randomized trials that included high-grade gliomas of all types have demonstrated that adjuvant RT with doses of 60 to 65 Gy in 30 to 35 fractions provides a significant survival benefit. The effectiveness of RT has not been assessed in randomized trials specifically looking at patients with oligodendroglial tumors. (See "Adjuvant radiation therapy for high-grade gliomas".)
Although retrospective studies have given conflicting results about whether postoperative RT prolongs survival in low-grade oligodendroglial tumors [5-10], postoperative RT has been considered an integral component of the treatment of patients with anaplastic oligodendroglial tumors.
RT plus chemotherapy — Two cooperative group randomized phase III trials with prolonged follow-up provide strong, complementary evidence that a combination of both RT and chemotherapy following surgery is associated with an improvement in survival on long-term follow-up in the subset of patients with 1p19q co-deletion [11,12].
Both trials provide evidence that other molecular subgroups may benefit from adding chemotherapy to radiotherapy, but firm conclusions are not possible due limitations inherent in post hoc analyses [11,13,14]. Proposed candidate markers are the presence of an IDH mutation and MGMT methylation.
EORTC 26951 — In the EORTC 26951 trial, 368 patients were randomly assigned to immediate RT only or RT followed by six cycles of PCV . The total dose of RT on each treatment arm was 60 Gy. The results of this trial were originally published in 2006 with a median follow-up of five years . The results of the trial were updated in 2013 with a median follow-up of almost 12 years .
Patients were eligible to receive additional treatment after progression following their initial management. Among patients who initially were treated with RT plus PCV, 53 percent received subsequent chemotherapy, primarily with temozolomide. Among those who were given RT alone, 88 percent received subsequent chemotherapy, generally with PCV and/or temozolomide.
Results from EORTC 26951 include the following:
●At a median follow-up of 60 months , progression-free survival (PFS) was already significantly prolonged with adjuvant PCV compared to RT alone (23 versus 13 months), but the difference in overall survival at that time was not statistically significant (40 versus 31 months without adjuvant chemotherapy).
●With more prolonged follow-up, the survival curves with the two initial treatment regimens diverged , and the benefit from initial combined chemotherapy (PCV) and RT was seen primarily in patients whose tumors contained the 1p/19q co-deletion. Samples from 316 of 368 patients (86 percent) were available for analysis for 1p/19q co-deletion.
•Among the 80 patients whose tumor contained the 1p/19q co-deletion, PFS was significantly increased when patients were treated with RT plus PCV compared with RT alone (median 157 versus 50 months, HR 0.42, 95% CI 0.24-0.74), and there was a trend toward increase in overall survival (median not reached versus 112 months, HR 0.56, 95% CI 0.31-1.03).
•In the 236 patients whose tumor did not have the 1p/19q co-deletion, the prognosis was substantially worse and the impact of adding chemotherapy to RT was limited (PFS median 15 versus 9 months, HR 0.73, 95% CI 0.56-0.97, and overall survival median 25 versus 21 months, HR 0.83, 95% CI 0.62-1.10).
In a subset analysis that included data from 115 patients whose tumors were available for methylation profiling, MGMT methylation and a CpG island hypermethylated phenotype (CIMP) were also predictive of a benefit from PCV . For patients with MGMT methylated tumors, median overall survival was significantly longer in the RT plus PCV arm compared with RT alone (8.65 versus 1.98 years). A similar benefit from PCV was observed in patients with CIMP tumors (9.51 versus 3.27 years).
In the subset of 178 patients with known IDH1 mutation status, the presence of an IDH1 mutation was associated with significantly improved median overall survival (8.4 versus 1.4 years) . Firm conclusions could not be drawn regarding IDH1 mutation status (independent of 1p19q status) as a predictive marker of benefit from PCV in this dataset due to the small number of patients in each subgroup.
RTOG 9402 — In the RTOG 9402 trial, 291 patients with anaplastic oligodendrogliomas or anaplastic oligoastrocytomas were eligible for analysis after random assignment to either four cycles of intensified PCV followed by RT or immediate RT without chemotherapy. The cumulative dose of RT on both treatment arms was 60 Gy. The results of RTOG 9402 were originally published in 2006  and were subsequently updated in 2013 .
●In the initial report of results from this trial , PFS was significantly increased with PCV followed by RT compared with RT alone (2.6 versus 1.7 years), but the difference in overall survival was not significant (4.9 versus 4.7 years).
●With 11.3 years follow-up , however, results were dependent upon the 1p19q status of the tumor and were consistent with those seen in the EORTC 26951 trial.
•For patients whose tumors contained the 1p/19q co-deletion, overall survival was significantly prolonged in patients treated with intensified PCV followed by RT compared with those given only RT initially (median 14.7 versus 7.3 years, HR 0.59, 95% CI 0.37-0.95).
•For patients whose tumors did not contain the 1p/19q co-deletion, prognosis was again substantially worse, and the impact of therapy not statistically significant (median survival 2.6 versus 2.7 years, HR 0.85, 95% CI 0.58-1.23).
A subsequent subset analysis examined the IDH mutation status in 210 of 291 tumors, of which 156 (74 percent) were IDH mutated . For patients with an IDH-mutant tumor, overall survival was significantly prolonged by the addition of PCV to RT for those with concomitant 1p19q co-deletion (14.7 versus 6.8 years, HR 0.49, 95% CI 0.28-0.85), as expected from earlier analyses; in addition, however, patients with IDH-mutant, non-co-deleted tumors also appeared to benefit from PCV plus RT versus RT alone (median survival 5.5 versus 3.3 years, HR 0.56, 95% CI 0.32-0.99). Patients with IDH wild-type tumors had a poor prognosis and did not appear to benefit from the addition of PCV (median survival 1.3 versus 1.8 years, p=0.67).
Order of therapy — The optimal order of RT and chemotherapy when given as a combined approach for anaplastic oligodendrogliomas is uncertain. In the EORTC 26951 study, PCV was administered after completion of RT; in the RTOG 9402 study, four cycles of intensified PCV were administered immediately before RT.
Consensus-based guidelines from the National Comprehensive Cancer Network (NCCN) recommend that PCV be administered after RT (as per EORTC 26951), since the intensive PCV regimen given prior to RT was not tolerated as well.
PCV versus temozolomide — Oligodendroglial tumors are markedly more sensitive to chemotherapy than astrocytic tumors, but the optimal chemotherapy regimen (PCV or temozolomide) remains uncertain.
This chemosensitivity was initially demonstrated with a PCV regimen (procarbazine, lomustine, and vincristine) in patients who had recurred or progressed after RT [16-21]. These observations led to the evaluation of PCV as part of a combined modality approach for the initial management of these patients in the trials reviewed above, as well as to its use in the treatment of recurrent disease. Subsequent studies showed that temozolomide is also highly active [22,23].
There are no randomized trials in patients treated with chemotherapy alone that directly compare PCV and temozolomide. In the NOA4 trial in patients with anaplastic glioma, the efficacy of the two regimens was similar, but long-term follow up is not yet available and the study was not powered for comparison between PCV and temozolomide . Temozolomide is generally preferred over the PCV regimen, based upon its ease of administration and better patient tolerance, although PCV remains an option.
The administration of temozolomide with RT, including discussion of side effects and monitoring, is reviewed elsewhere. (See "Initial postoperative therapy for glioblastoma and anaplastic astrocytoma", section on 'Temozolomide'.)
Chemotherapy with deferred RT — The sensitivity of oligodendroglial tumors to chemotherapy and concerns about the potential for delayed neurotoxicity from RT have led to the use of chemotherapy rather than RT as the initial treatment in some patients with 1p19q co-deleted anaplastic oligodendroglial tumors [25,26]. This approach has not been compared directly with RT plus chemotherapy but is one of the three treatment arms in an ongoing large randomized trial in patients with 1p1q co-deleted anaplastic gliomas. (See 'Ongoing radomized trials' below.)
Chemotherapy versus RT was evaluated in the initial stage of a phase III trial (NOA-4) that included patients with anaplastic astrocytomas, anaplastic oligoastrocytomas, and oligodendrogliomas . There was no significant difference in time to treatment failure either in patients with oligodendroglial tumors or those with malignant astrocytomas at the time of the first report, but long-term follow up is needed to determine the impact on overall survival. (See "Initial postoperative therapy for glioblastoma and anaplastic astrocytoma", section on 'Adjuvant RT or chemotherapy alone'.)
Ongoing radomized trials — There are two ongoing randomized trials designed to address many of the uncertainties described above:
●In a phase III Alliance for Clinical Trials in Oncology/EORTC intergroup trial (“CODEL”), patients with 1p19q co-deleted anaplastic gliomas are randomly assigned to one of three treatment arms: RT followed by PCV; RT with concurrent and adjuvant temozolomide; and temozolomide alone (NCT00887146).
●In a phase III EORTC/North American intergroup trial (“CATNON”), patients with non-co-deleted anaplastic gliomas are randomly assigned to one of four treatment arms: RT; RT with concurrent temozolomide; RT followed by temozolomide; and RT with concurrent and adjuvant temozolomide (NCT00626990).
RECURRENT DISEASE — Both PCV and temozolomide have activity in patients who have failed an initial chemotherapy regimen, although response rates are lower and the duration of disease control is generally shorter compared to treatment at first diagnosis or at first recurrence after RT.
Repeat surgery and re-irradiation are also utilized in selected patients. (See "Management of recurrent high-grade gliomas", section on 'Localized therapy' and "Management of recurrent high-grade gliomas", section on 'Reirradiation'.)
The activity of temozolomide after failure with PCV was illustrated by a retrospective series of 48 patients with anaplastic oligodendrogliomas and oligoastrocytomas . In this series, 21 patients (44 percent) had an objective response, including eight with a complete remission. The median PFS was 7 months and the median overall survival was 10 months. Treatment was well tolerated, and the primary toxicity was thrombocytopenia. In other series on similar patients, an objective response rate of 25 percent was noted.
PCV regimen — Experience with PCV after progression on temozolomide is more limited. Nonetheless, there is evidence that PCV is active in some patients who have progressed after previous treatment with temozolomide. In a retrospective study of 24 patients, second-line PCV induced an objective response in 17 percent of cases, 50 percent were progression-free at six months, and 21 percent were progression-free at 12 months .
Bevacizumab — Bevacizumab has some activity in patients with recurrent glioblastoma. (See "Management of recurrent high-grade gliomas", section on 'Bevacizumab'.)
Solid data are lacking, all results are from uncontrolled studies and are consistent with short duration effects consistent with a normalization of vasculature and anti-edema effect, despite high response rates. A retrospective analysis of 22 patients with recurrent, alkylator-refractory anaplastic oligodendroglioma  (all with co-deletion of 1p/19q and previously treated with surgery, RT, adjuvant chemotherapy, and one chemotherapy regimen for recurrent disease) noted a partial response observed in 15 cases (68 percent). Despite that, the median time to progression and median survival in this cohort were only 6.8 and 8.5 months, respectively. Another series of 25 patients with recurrent oligodendroglial tumors recurrent after RT and at least one chemotherapy regimen observed an objective response rate of 72 percent with the combination of bevacizumab plus irinotecan, with a median progression-free survival of only 140 days . No clear correlation was found between the genotype and outcome.
Other agents — The management of patients who have progressed on either temozolomide or PCV is experimental. Other agents that have shown some activity as second-line chemotherapy in patients with anaplastic oligodendroglial tumors include paclitaxel, irinotecan, carboplatin, and the combination of etoposide plus cisplatin. Response rates with these agents have generally been low (less than 15 percent), and almost all patients' progress in less than 12 months. (See "Experimental treatment approaches for high-grade gliomas".)
SURVEILLANCE AFTER TREATMENT — There are no formal clinical trials that define the optimal frequency for follow-up after treatment.
Guidelines from the National Comprehensive Cancer Network (NCCN) recommend the following schedule for follow-up imaging :
●For patients with malignant gliomas including both anaplastic oligodendrogliomas and anaplastic oligoastrocytomas, a repeat MRI should be obtained two to six weeks after completion of radiation therapy, then every two to four months for two to three years, and less frequently thereafter.
Assessment of response and progression — Patient management decisions require an assessment of both initial response to treatment as well as subsequent evidence of progressive disease. Traditionally, this approach has used the Macdonald criteria which rely upon measurement of areas of contrast enhancement .
New criteria have been proposed by the Response Assessment in Neuro-Oncology (RANO) working group to address problems in assessing patients with pseudoprogression or in assessing progressive disease in patients with nonenhancing lesions [34,35]. (See "Assessment of disease status and surveillance after treatment in patients with brain tumors".)
SUMMARY AND RECOMMENDATIONS
●Oligodendroglial tumors (ie, oligodendroglioma and oligoastrocytoma) have important differences from other glial tumors, with significant ramifications for patient management. Many of these tumors contain a characteristic co-deletion of the short arm of chromosome 1 (1p) and the long arm of chromosome 19 (19q), which has been correlated with both a striking sensitivity to chemotherapy and a more prolonged natural history, independent of specific treatment. (See 'Introduction' above.)
●Tissue should be tested whenever possible to determine whether co-deletion of 1p19q is present. Testing for MGMT and IDH mutations should also be considered. (See "Clinical features, pathology, and prognostic factors for oligodendroglial tumors", section on 'Genetic abnormalities'.)
●For patients with a newly-diagnosed anaplastic oligodendroglioma or oligoastrocytoma, we suggest maximal surgical resection consistent with preservation of neurologic function (Grade 2C). Although gross total resection is preferred whenever possible, subtotal resection or stereotactic biopsy may be required depending upon the location and extent of the tumor. (See 'Surgery' above.)
●For patients whose tumor contains the characteristic 1p/19q co-deletion, we recommend adjuvant treatment that includes both radiation therapy (RT) and chemotherapy (Grade 1A). Whether chemotherapy should be given before or after RT remains uncertain. Although PCV (procarbazine, lomustine, vincristine) has been demonstrated to be effective in two phase III trials, temozolomide is easier to administer and has better patient tolerance. (See 'RT plus chemotherapy' above.)
●For patients whose tumor does not contain the 1p/19q co-deletion, we suggest postoperative RT, with chemotherapy withheld until there is evidence of disease progression (Grade 2C). Combined treatment with RT and chemotherapy is a reasonable consideration in selected patients, such as those with MGMT methylated tumors. (See 'Radiation therapy' above and 'RT plus chemotherapy' above.)
●Patients with oligodendroglial tumors should be followed after treatment with imaging. For those with anaplastic lesions, a repeat MRI should be obtained two to six weeks after completion of radiation therapy, then every two to four months for two to three years, and less frequently thereafter. For those with low-grade tumors, repeat MRI should be obtained every three to six months for five years, and then at least annually thereafter. (See 'Surveillance after treatment' above.)
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