Highlights from the Annual Neurosurgical Conference: New Standards in Diffuse Lower-Grade Glioma Authors: Mitchel S. Berger, MD; Macarena de la Fuente, MD; Michael Lim, MD

https://www.medscape.org/viewarticle/1002598?sso=true&uac=148436CN&src=mkmcmr_reeng_recap_mscpedu_activity thank you for your recent participation in the activity: Highlights from the Annual Neurosurgical Conference: New Standards in Diffuse Lower-Grade Glioma Below are some key learning points to help reinforce the impact of this activity. ☑ Evolving Surgical Approaches: Maximal safe resection aims to remove all FLAIR abnormality (gross total) or extend beyond visible margins (supratotal). Advanced surgical tools including brain mapping and intraoperative imaging help define tumor margins, enabling more complete resections while preserving function in eloquent brain areas. ☑ Molecular Classification and Risk Stratification: The field has evolved from histology-based to molecular-based classification, with IDH mutations (detected in 50-80% of low-grade gliomas) and methylation profiling guiding treatment decisions. This molecular understanding has redefined risk stratification beyond the traditional age and resection extent factors. ☑ Post-Surgical Management Options: Historically, low-risk patients (under 40 with complete resection) were observed, while high-risk patients received radiation with PCV. The FDA approval of vorasidenib now offers a new option for patients with IDH-mutated grade 2 gliomas after any degree of surgery. ☑ INDIGO Trial and IDH Inhibition: The phase 3 INDIGO trial showed vorasidenib significantly improved progression-free survival versus placebo (27.7 vs 11 months) in IDH-mutated grade 2 gliomas. Early phase trials of other IDH inhibitors also demonstrated improved outcomes for non-enhancing tumors, establishing metabolic targeting as an effective approach. ☑ Future Directions in Systemic Therapy: Current investigations include combinatorial approaches with vorasidenib plus other agents such as peptide vaccines and checkpoint inhibitors like pembrolizumab. Off-label use of ivosidenib for grade 3 and enhancing tumors shows promise while awaiting further clinical validation.