Glioma

Template:Short description {{SAFESUBST:#invoke:Unsubst||date=__DATE__ |$B= Template:Ambox }} Template:Use dmy dates Template:Infobox medical condition (new)

A glioma is a type of primary tumor that starts in the glial cells of the brain or spinal cord. They are malignant but some are extremely slow to develop.<ref name="CRUK23">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref name="CRUK">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Gliomas comprise about 30% of all brain and central nervous system tumors and 80% of all malignant brain tumors.<ref name=Goodenberger2012>Template:Cite journal</ref> They are a few common types that include astrocytoma (cancer of astrocytes), glioblastoma (an aggressive form of astrocytoma), oligodendroglioma (cancer of oligodendrocytes), and ependymoma (cancer of ependymal cells).

Signs and symptoms

Symptoms of gliomas depend on the part of the central nervous system (CNS) that is affected. A brain glioma can cause headaches, vomiting, memory loss, seizures, vision problems, speech difficulties, and cranial nerve disorders as a result of increased intracranial pressure.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Cognitive impairments such as vision loss arise in glioma patients when a tumor arises in or around their optic nerve.<ref>Template:Cite journal</ref> Spinal cord gliomas can cause pain, weakness, or numbness in the extremities. Gliomas do not usually metastasize by the bloodstream, but they can spread via the cerebrospinal fluid and cause "drop metastases" to the spinal cord. Complex visual hallucinations have been described as a symptom of low-grade glioma.<ref>Template:Cite journal</ref>

Children with sub-acute CNS disorders that produces cranial nerve abnormalities (especially of cranial nerve VII and the lower bulbar nerves), long-tract signs, unsteady gait secondary to spasticity, and some behavioral changes are likely to have a pontine glioma, a tumor of the brainstem.<ref>PRETEST pediatrics p. 224</ref>

Causes

Hereditary disorders

The exact causes of gliomas are not known. Hereditary disorders such as neurofibromatoses (type 1 and type 2) and tuberous sclerosis complex are known to predispose to their development.<ref>Template:Cite book</ref> Different oncogenes can cooperate in the development of gliomas.<ref>Template:Cite journal</ref>

Radiation

The best-known risk factor is exposure to ionizing radiation, and CT scan radiation is an important cause.<ref name="nrsCT1">Smoll NR, Brady Z, Scurrah KJ, Lee C, Berrington de González A, Mathews JD. Computed tomography scan radiation and brain cancer incidence. Neuro-Oncology. 2023 Jan 14;https://doi.org/10.1093/neuonc/noad012</ref><ref name="nrsIR1">Smoll NR, Brady Z, Scurrah K, Mathews JD. Exposure to ionizing radiation and brain cancer incidence: The Life Span Study cohort. Cancer Epidemiology. 2016 Jun;42:60–5.</ref> The dose-response for the relationship between low-dose ionizing radiation and glioma risk is a risk increase of 55% per 100 milligray of radiation.<ref name="nrsCT1" /> A link between gliomas and electromagnetic radiation from cell phones has not been conclusively proven.<ref>Template:Cite journal</ref> It was considered possible,<ref>Template:Cite journal</ref><ref>Template:Cite press release</ref> though several large studies have found no conclusive evidence, as summarized by the National Institute of Health's National Cancer Institute review of the topic<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> and its numerous citations,<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> and the FCC.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> However, further research is still being pursued to obtain more robust evidence and verify that there is no relationship (the NIH's National Institute of Environmental Health Sciences most recent press release discussed an ongoing study<ref>Template:Cite press release</ref> showing mildly positive results,<ref>Template:Cite bioRxiv</ref> although it appears there may have been issues with the control group dying prematurely<ref>Template:Cite news</ref>).

Infection with cytomegalovirus

Some studies have reported that glioblastomas are infected with cytomegalovirus, with suggestions that this may speed the development of tumors.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> However, this is a controversial opinion, with recent in-depth studies failing to find an association between viral infection and glioma growth.<ref>Template:Cite journal</ref> There is also evidence that previous studies may have been impacted by false-positive antibody staining artifacts.<ref>Template:Cite journal</ref>

Farming

Studies have shown that farmers have higher rates of gliomas compared to the general population. In a 2021 meta-analysis, 40 of 52 studies since 1998 reported positive associations between farming and brain cancer with effect estimates ranging from 1.03 to 6.53, of which 80% are gliomas. Livestock farming was associated with a greater risk compared with crop farming. Farmers with documented exposure to pesticides had greater than a 20% elevated risk of brain cancer.<ref>Template:Cite journal</ref>Template:Unreliable source? The TRACTOR project study, including 1,017 brain tumors among 1,036,069 farm managers, published in 2022, showed an increased risk of glioma in pig farming (HR = 2.28), crop farming (HR = 1.28) and fruit arboriculture (HR = 1.72)<ref>Template:Cite journal</ref>Template:Medical citation needed

Other causes

Data show that architects, surveyors, retail workers, butchers, and engineers have higher rates of gliomas.<ref name=":0">Template:Cite journal</ref>

Inherited polymorphisms of the DNA repair genes

Germ-line (inherited) polymorphisms of the DNA repair genes ERCC1, ERCC2 (XPD) and XRCC1 increase the risk of glioma.<ref name="pmid24500421">Template:Cite journal</ref> This indicates that altered or deficient repair of DNA damage contributes to the formation of gliomas. DNA damages are a likely major primary cause of progression to cancer in general.<ref name="Bernstein">Template:Citation</ref> Excess DNA damages can give rise to mutations through translesion synthesis. Furthermore, incomplete DNA repair can give rise to epigenetic alterations or epimutations.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> Such mutations and epimutations may provide a cell with a proliferative advantage which can then, by a process of natural selection, lead to progression to cancer.<ref name="Bernstein"/>

Epigenetic repression of DNA repair genes is often found in progression to sporadic glioblastoma. For instance, methylation of the DNA repair gene MGMT promoter was observed in 51% to 66% of glioblastoma specimens.<ref name="pmid22672670">Template:Cite journal</ref><ref name=Spiegel>Template:Cite journal</ref> In addition, in some glioblastomas, the MGMT protein is deficient due to another type of epigenetic alteration. MGMT protein expression may also be reduced due to increased levels of a microRNA that inhibits the ability of the MGMT messenger RNA to produce the MGMT protein.<ref name=Spiegel /> Zhang et al.<ref name="pmid22570426">Template:Cite journal</ref> found, in the glioblastomas without methylated MGMT promoters, that the level of microRNA miR-181d is inversely correlated with protein expression of MGMT and that the direct target of miR-181d is the MGMT mRNA 3'UTR (the three prime untranslated region of MGMT messenger RNA).<ref>Template:Cite journal</ref>

Epigenetic reductions in expression of another DNA repair protein, ERCC1, were found in an assortment of 32 gliomas.<ref name="pmid19626585">Template:Cite journal</ref> For 17 of the 32 (53%) of the gliomas tested, ERCC1 protein expression was reduced or absent. In the case of 12 gliomas (37.5%) this reduction was due to methylation of the ERCC1 promoter. For the other 5 gliomas with reduced ERCC1 protein expression, the reduction could have been due to epigenetic alterations in microRNAs that affect ERCC1 expression.<ref>Template:Cite journal</ref>

When expression of DNA repair genes is reduced, DNA damages accumulate in cells at a higher than normal level, and such excess damages cause increased frequencies of mutation.<ref name=Narayanan>Template:Cite journal</ref><ref name=Hegan>Template:Cite journal</ref><ref name=Tutt>Template:Cite journal</ref> Mutations in gliomas frequently occur in either isocitrate dehydrogenase (IDH) 1 or 2 genes.<ref name=":1">Template:Cite journal</ref> One of these mutations (mostly in IDH1) occurs in about 80% of low grade gliomas and secondary high-grade gliomas.<ref name=Cohen>Template:Cite journal</ref> Wang et al.<ref name="pmid22824796">Template:Cite journal</ref> pointed out that IDH1 and IDH2 mutant cells produce an excess metabolic intermediate, 2-hydroxyglutarate, which binds to catalytic sites in key enzymes that are important in altering histone and DNA promoter methylation. Thus, mutations in IDH1 and IDH2 generate a "DNA CpG island methylator phenotype or CIMP"<ref name="pmid10411935">Template:Cite journal</ref><ref name="pmid24834258">Template:Cite journal</ref> that causes promoter hypermethylation and concomitant silencing of tumor suppressor genes such as DNA repair genes MGMT and ERCC1. On the other hand, Cohen et al.<ref name=Cohen /> and Molenaar et al.<ref name=":1" /> pointed out that mutations in IDH1 or IDH2 can cause increased oxidative stress. Increased oxidative damage to DNA could be mutagenic. This is supported by an increased number of DNA double-strand breaks in IDH1-mutated glioma cells.<ref>Template:Cite journal</ref> Thus, IDH1 or IDH2 mutations act as driver mutations in glioma carcinogenesis, though it is not clear by which role they are primarily acting. A study, involving 51 patients with brain gliomas who had two or more biopsies over time, showed that mutation in the IDH1 gene occurred prior to the occurrence of a p53 mutation or a 1p/19q loss of heterozygosity, indicating that an IDH1 mutation is an early driver mutation.<ref name="pmid19246647">Template:Cite journal</ref>

Pathophysiology

High-grade gliomas are highly vascular tumors and have a tendency to infiltrate diffusely.<ref name="Malignant glioma: genetics and biol"/> They have extensive areas of necrosis and hypoxia. Often, tumor growth causes a breakdown of the blood–brain barrier in the vicinity of the tumor. As a rule, high-grade gliomas almost always grow back even after complete surgical excision, so are commonly called recurrent cancer of the brain.Template:Medical citation needed<ref>Template:Cite journal</ref>

Conversely, low-grade gliomas grow slowly, often over many years, and can be followed without treatment unless they grow and cause symptoms.Template:Medical citation needed

Several acquired (not inherited) genetic mutations have been found in gliomas. Tumor suppressor protein 53 (p53) is mutated early in the disease.<ref>Template:Cite journal</ref> p53 is the "guardian of the genome", which, during DNA and cell duplication, makes sure the DNA is copied correctly and destroys the cell (apoptosis) if the DNA is mutated and cannot be fixed. When p53 itself is mutated, other mutations can survive. Phosphatase and tensin homolog (PTEN), another tumor suppressor gene, is itself lost or mutated. Epidermal growth factor receptor, a growth factor that normally stimulates cells to divide, is amplified and stimulates cells to divide too much. Together, these mutations lead to cells dividing uncontrollably, a hallmark of cancer. In 2009, mutations in IDH1 and IDH2 were found to be part of the mechanism and associated with a less favorable prognosis.<ref>Template:Cite journal</ref>

Diagnosis

Classification

By type of cell

Gliomas are named according to the specific type of cell with which they share histological features, but not necessarily from which they originate. The main types of glioma are:<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

• Ependymomas: ependymal cells
• Astrocytomas: astrocytes (glioblastoma multiforme is a malignant astrocytoma and the most common primary brain tumor among adults).
• Oligodendrogliomas: oligodendrocytes
• Brainstem glioma: develop in the brain stem
• Optic nerve glioma: develop in or around the optic nerve
• Chordoid glioma, a rare low-grade tumor of the third ventricle<ref name="Zarghouni">Template:Cite journal</ref>
• Mixed gliomas, such as oligoastrocytomas, contain cells from different types of glia

By grade

Gliomas are further categorised according to their grade, which is determined by pathologic evaluation of the tumor. The neuropathological evaluation and diagnostics of brain tumor specimens is performed according to WHO Classification of Tumours of the Central Nervous System.<ref>Template:Cite journal</ref><ref>Template:Cite bookTemplate:Page needed</ref>

File:MRI glioma 28 yr old male.JPG

Low-grade brain glioma in a 28-year-old male. (Taken on 10 July 2007)

• Biologically benign gliomas [WHO grade I] are comparatively low risk and can be removed surgically depending on their location<ref name="Malignant glioma: genetics and biol">Template:Cite journal</ref>
• Low-grade gliomas [WHO grade II] are well-differentiated (not anaplastic); these tend to exhibit benign tendencies and portend a better prognosis for the patient. However, they have a uniform rate of recurrence and increase in grade over time so should be classified as malignant.
• High-grade [WHO grades III–IV] gliomas are undifferentiated or anaplastic; these are malignant and carry a worse prognosis. Despite being classified as a high-grade glioma, infant-type hemispheric gliomas have relatively good clinical outcomes, yet they endure significant deficits, making them good candidates for therapy de-escalation and trials of molecular targeted therapy.<ref>Neuro-Oncology, Volume 25, Issue Supplement_1, June 2023, Pages i38–i39, https://doi.org/10.1093/neuonc/noad073.152</ref>

Of numerous grading systems in use, the most common is the World Health Organization (WHO) grading system for astrocytoma, under which tumors are graded from I (least advanced disease—best prognosis) to IV (most advanced disease—worst prognosis).

By location

Gliomas can be classified according to whether they are above or below a membrane in the brain called the tentorium.<ref>Template:Cite journal</ref> The tentorium separates the cerebrum (above) from the cerebellum (below).

• The supratentorial is above the tentorium, in the cerebrum, and mostly found in adults (70%).<ref name="Persaud-Sharma 16">Template:Cite journal</ref>
• The infratentorial is below the tentorium, in the cerebellum, and mostly found in children (70%).<ref name="Persaud-Sharma 16"/>
• The pontine tumors are located in the pons of the brainstem. The brainstem has three parts (pons, midbrain, and medulla); the pons controls critical functions such as breathing, making surgery on these extremely dangerous.<ref>Template:Cite journal</ref>

Integrated diagnosis

File:Diagnosis of diffuse glioma.png

Diagnosis of diffuse glioma. MVP = microvascular proliferation. The presence and absence of the diagnostically most relevant molecular alterations for each tumor type are highlighted with red and green boxes.<ref name=Weller2020>Template:Cite journal
"This article is licensed under a Creative Commons Attribution 4.0 International License"</ref>

The modern approach to the diagnosis of diffuse gliomas takes mainly the histopathology and molecular profile into account.<ref name=Weller2020/> Tissue specimens obtained through biopsy sampling in patients with diffuse gliomas are routinely assessed by immunohistochemistry for the presence of R132H-mutant IDH1 and loss of nuclear ATRX.<ref name=Weller2020/> In patients aged >55 years with a histologically typical glioblastoma, without a pre-existing lower grade glioma, with a non-midline tumor location and with retained nuclear ATRX expression, immunohistochemical negativity for IDH1 R132H suffices for the classification as IDH-wild-type glioblastoma.<ref name=Weller2020/> In all other instances of diffuse gliomas, a lack of IDH1 R132H immunopositivity should be followed by IDH1 and IDH2 DNA sequencing to detect or exclude the presence of non-canonical mutations.<ref name=Weller2020/> IDH-wild-type diffuse astrocytic gliomas without microvascular proliferation or necrosis should be tested for EGFR amplification, TERT promoter mutation and a +7/–10 cytogenetic signature as molecular characteristics of IDH-wild-type glioblastomas.<ref name=Weller2020/> In addition, the presence of histone H3.3 G34R/V mutations should be assessed by immunohistochemistry or DNA sequencing to identify H3.3 G34-mutant diffuse hemispheric gliomas, in particular in young patients with IDH-wild-type gliomas (such as those <50 years of age with nuclear ATRX loss in tumour cells).<ref name=Weller2020/> Diffuse gliomas of the thalamus, brainstem or spinal cord should be evaluated for histone H3 K27M mutations and loss of nuclear K27-trimethylated histone H3 (H3K27me3) to identify H3 K27M-mutant diffuse midline gliomas.<ref name=Weller2020/>

Treatment

File:Management of IDH wild type glioblastoma.png

Management of IDH wild type glioblastoma, WHO grade 4. KPS, Karnofsky performance status.<ref name=Weller2020/>

File:Management of IDH-mutant glioma.png

Management of IDH-mutant glioma. KPS, Karnofsky performance status; PCV, procarbazine, lomustine and vincristine.<ref name=Weller2020/>

Treatment for brain gliomas depends on the location, the cell type, and the grade of malignancy. Current treatment options include surgical removal, radiation (radiation therapy), and chemotherapy. In some cases, tumour treating fields (alternating electric field therapy), a recently developed technology, may be used.<ref>Template:Cite journal</ref> Often, treatment is a combined approach, using surgery, radiation therapy, and chemotherapy. For many, treatment consists of just surgery, or even "watchful waiting" (waiting to see when an intervention is justified due to tumour progression). Doctors carefully balance the specifics of the patient's tumour and the downsides of intervention, since there can be significant side effects from medical intervention, despite recent attempts to predict outcomes have been proposed.<ref>Template:Cite journal</ref>

Awake surgery can be performed to monitor for example language and other cognitive functions, as well as motor functions and vision.<ref>Template:Cite journal</ref> Awake surgery is known to improve extent of resection while perserving functions<ref>Template:Cite journal</ref> and exetent of resection is directly associated with survival in low-grade gliomas.<ref>Template:Cite journal</ref>

Radiation and chemotherapy remain the mainstays of treatment beyond surgery. Radiation therapy is delivered in the form of external beam radiation or the stereotactic approach using radiosurgery. Temozolomide is a common chemotherapy drug which can be administered easily in an outpatient setting and is able to cross the blood–brain barrier effectively.

There are a wide variety of novel treatments currently being tested in clinical trials, ranging from IDH inhibitors like Ivosidenib, to the recently approved Dendritic cell-based cancer vaccine approach.<ref name="Hart2013" /> Treatment using immunotherapy is another promising research path that may help treat glioma in the near future.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> Experimental therapies like oncolytic viruses have shown potential therapeutic benefits in clinical trials (but have not been approved for use in non-experimental settings).<ref>Template:Cite journal</ref>

Refractory disease

For recurrent high-grade glioblastoma, recent studies have taken advantage of angiogenic blockers such as bevacizumab in combination with conventional chemotherapy, with encouraging results.<ref name="pmid17947716">Template:Cite journal</ref>

Relative effectiveness

A 2017 meta-analysis compared surgical resection versus biopsy as the initial surgical management option for a person with a low-grade glioma.<ref name=Jiang2017>Template:Cite journal</ref> Results show the evidence is insufficient to make a reliable decision.<ref name=Jiang2017 /> The relative effectiveness of surgical resection compared to biopsy for people with malignant glioma (high-grade) is unknown.<ref>Template:Cite journal</ref>

For high-grade gliomas, a 2003 meta-analysis compared radiotherapy with radiotherapy and chemotherapy. It showed a small but clear improvement from using chemotherapy with radiotherapy.<ref>Template:Cite journal</ref> A 2019 meta-analysis suggested that for people with less aggressive gliomas, radiotherapy may increase the risk of long term neurocognitive side effects.<ref name=":2">Template:Cite journal</ref> Whilst, evidence is uncertain on whether there are long term neurocognitive side effects associated with chemoradiotherapy.<ref name=":2" />

Temozolomide is effective for treating Glioblastoma Multiforme (GBM) compared to radiotherapy alone.<ref name=Hart2013>Template:Cite journal</ref> A 2013 meta-analysis showed that Temozolomide prolongs survival and delays progression, but is associated with an increase in side effects such as blood complications, fatigue, and infection.<ref name="Hart2013" /> For people with recurrent GBM, when comparing temozolomide with chemotherapy, there may be an improvement in the time-to-progression and the person's quality of life, but no improvement in overall survival, with temozolomide treatment.<ref name=Hart2013 /> Evidence suggests that for people with recurrent high-grade gliomas who have not had chemotherapy before, there are similar survival and time-to-progression outcomes between treatment with temozolomide or the chemotherapy multidrug known as PCV (procarvazine, lomustine and vincristine).<ref>Template:Cite journal</ref>

A mutational analysis of 23 initial low-grade gliomas and recurrent tumors from the same patients has challenged the benefits and usage of Temozolomide. The study showed that when lower-grade brain tumors of patients are removed and patients are further treated with Temozolomide, 6 out of 10 times the recurrent tumors were more aggressive and acquired alternative and more mutations.<ref>Template:Cite journal</ref> As one of the last authors, Costello, stated "They had a 20- to 50-fold increase in the number of mutations. A patient who received surgery alone who might have had 50 mutations in the initial tumor and 60 in the recurrence. But patients who received TMZ might have 2,000 mutations in the recurrence."<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Further, new mutations were verified to carry known signatures of Temozolomide induced mutations. The research suggests that Temozolomide for the treatment of certain brain tumors should be thoroughly thought. Unjudicious usage of Temozolomide might lower the prognosis of the patients further, or increase their burden. Further understanding of the mechanisms of Temozolomide induced mutations and novel combination approaches could be promising.Template:Medical citation needed

New Research Directions

Newcastle disease has been noted to be helpful in some cases of glioma.<ref>Template:Cite journal</ref> Phase III trials with Newcastle Disease Virus Vaccine (MTH-68/H) are expected soon. Strains of Newcastle disease virus have also been used to create viral vector vaccine candidates against Ebola and Covid-19.<ref>Template:Cite journal</ref> Torticollis in fowl shows the level of avian severity.

Prognosis

Template:Update Prognosis of gliomas is given in relation to what grade (as scored by the World Health Organization system) of tumour the patient presents with. Typically, any tumour presenting as above WHO grade I (i.e. a malignant tumour as opposed to a benign tumour) will have a prognosis resulting in eventual death, varying from years (WHO grade II/III) to months (WHO grade IV).<ref name="Malignant glioma: genetics and biol"/><ref>Template:Cite journal</ref> Prognosis can also be given based on cellular subtype, which may also impact prognosis.

Low grade

For low-grade tumors, the prognosis is somewhat more optimistic. Patients diagnosed with a low-grade glioma are 17 times as likely to die as matched patients in the general population.<ref name="lgg">Template:Cite journal</ref> The age-standardized 10-year relative survival rate was 47% according to research in 2014.<ref name="lgg"/> One study reported that low-grade oligodendroglioma patients have a median survival of 11.6 years;<ref>Template:Cite journal</ref> another reported a median survival of 16.7 years.<ref>Template:Cite journal</ref> Unfortunately, approximately 70% of low-grade (WHO grade-II) will progress to high-grade tumours within 5–10 years<ref name="Malignant glioma: genetics and biol"/> Grade II gliomas, despite often being labeled as benign, are considered a uniformly fatal illness.<ref>Template:Cite journal</ref>

High grade

This group comprises anaplastic astrocytomas and glioblastoma multiforme. Whereas the median overall survival of anaplastic (WHO grade III) gliomas is approximately 3 years, glioblastoma multiforme has a poor median overall survival of c. 15 months.<ref>Template:Cite journal</ref>

Postoperative conventional daily radiotherapy improves survival for adults with good functional well‐being and high grade glioma compared to no postoperative radiotherapy. Hypofractionated radiation therapy has similar efficacy for survival as compared to conventional radiotherapy, particularly for individuals aged 60 and older with glioblastoma.<ref>Template:Cite journal</ref>

Diffuse midline glioma

Diffuse midline glioma (DMG), also known as diffuse intrinsic pontine glioma (DIPG), primarily affects children, usually between the ages of 5 and 7.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> The median survival time with DIPG is under 12 months.<ref>Template:Cite journal</ref> Surgery to attempt tumour removal is usually not possible or advisable for pontine gliomas. By their very nature, these tumours invade diffusely throughout the brain stem, growing between normal nerve cells. Aggressive surgery would cause severe damage to neural structures vital for arm and leg movement, eye movement, swallowing, breathing, and even consciousness.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref>Template:MEDRS Trials of drug candidates have been unsuccessful.<ref>Template:Cite journal</ref> The disease is primarily treated with radiation therapy alone.Template:Medical citation needed

IDH1 and IDH2-mutated glioma

Patients with glioma carrying mutations in either IDH1 or IDH2 have a relatively favorable survival, compared with patients with glioma with wild-type IDH1/2 genes. In WHO grade III glioma, IDH1/2-mutated glioma have a median prognosis of ~3.5 years, whereas IDH1/2 wild-type glioma perform poor with a median overall survival of c. 1.5 years.<ref name=":1" /><ref>Template:Cite journal</ref>

External links

• Glioma Template:Webarchive at the Human Protein Atlas Template:Webarchive
• American Brain Tumor Association: Malignant Gliomas
• Brain and Spinal Tumors: Hope Through Research (National Institute of Neurological Disorders and Stroke)
• WHO Classification of Glioma
• Glioma Images MedPix Database