The first 60 days: Astrocytoma, IDH-mutant (grades 2 to 4)
IDH-mutant astrocytoma is the slow-growing form of adult glioma, defined by a mutation in the IDH1 or IDH2 gene that makes the tumour produce a chemical which rewires its own cells. Surgery first, and then either watchful waiting, the new pill vorasidenib, or radiotherapy with chemotherapy, depending on grade and how much tumour is left. Below, week by week, is what OnCo's record of Astrocytoma, IDH-mutant (grades 2 to 4) says about the first two months: the order is typical, the timing is yours to ask about. Sections appear only where the record has something to say. Orientation, not medical advice.
What happens now
Staging tests establish exactly what and where the cancer is. Everything else follows from the answers.
Maximal safe resection with awake or functional mapping where needed; integrated histological and molecular diagnosis (IDH, 1p/19q, ATRX, CDKN2A/B, methylation class).
Ask which of these were tested and what the results were; see the report reader for what each value means.
These specialties appear in the standard of care for this cancer. In most centres they meet weekly as a tumour board to agree each plan; you can ask when yours was discussed and what was decided.
- PathologistNamed in the standard of care for: Newly diagnosed, all grades, Grade 2, residual or recurrent, low risk.
- RadiologistNamed in the standard of care for: Newly diagnosed, all grades, Grade 2, residual or recurrent, low risk.
- SurgeonNamed in the standard of care for: Newly diagnosed, all grades, Grade 2, residual or recurrent, low risk, Recurrence.
- Medical oncologistNamed in the standard of care for: Grade 2, residual or recurrent, low risk, Grade 2, high risk (age 40 or over, subtotal resection), Grade 3, Grade 4 and 1 more.
- Clinical oncologist (radiotherapy)Named in the standard of care for: Grade 2, residual or recurrent, low risk, Grade 2, high risk (age 40 or over, subtotal resection), Grade 3, Grade 4 and 1 more.
A second opinion from a centre that treats many similar cases is normal, not rude; the standard of care tells you what to compare it against.
Each row is a setting from the standard of care, in the order it usually arises. Not all will apply to you; your stage and biomarkers decide which do. The guideline grade, where recorded, says how strong the evidence is.
- 1.Grade 2, high risk (age 40 or over, subtotal resection)NCCN Guidelines: Central Nervous System Cancers
Radiotherapy followed by PCV (procarbazine, lomustine, vincristine) as in RTOG 9802, or radiotherapy with temozolomide; temozolomide alone was not better than radiotherapy alone in EORTC 22033.
Observation with serial MRI, or vorasidenib for grade 2 tumours not needing immediate radiotherapy or chemotherapy (INDIGO).
Radiotherapy followed by twelve cycles of adjuvant temozolomide (CATNON); concurrent temozolomide is not needed in non-codeleted tumours.
Radiotherapy with concurrent and adjuvant temozolomide, extrapolated from glioblastoma; trials of IDH inhibitors preferred where available.
Re-resection, re-irradiation, lomustine or temozolomide re-challenge, bevacizumab for oedema and symptoms; clinical trials.
Generated from this cancer's standard of care, biomarkers and open problems. Take the group that matches where you are. To tick, add your own and print, open the one-page appointment sheet.
Newly diagnosed
- What is my exact diagnosis, stage, and grade, and which tests established them?Everything else follows from an accurate stage and subtype.
- Which biomarkers have been tested on my tumour (for example IDH1 R132H immunohistochemistry, with sequencing of IDH1 and IDH2 for non-canonical mutations, 1p/19q status, ATRX loss and TP53 mutation, CDKN2A/B homozygous deletion, DNA methylation class and G-CIMP status), and what were the results?These results decide eligibility for targeted therapy, immunotherapy, and trials.
- Which subtype is my cancer, and does that change the recommended treatment?Recognised subtypes for this cancer include Astrocytoma, IDH-mutant, grade 2, Astrocytoma, IDH-mutant, grade 3, Astrocytoma, IDH-mutant, grade 4.
- Is germline (inherited) genetic testing recommended for me or my family?Inherited variants can change treatment and matter for relatives.
Newly diagnosed, all grades
- For my situation (newly diagnosed, all grades), which of the standard options do you recommend and why?Guideline options include: Maximal safe resection with awake or functional mapping where needed; integrated histological and molecular diagnosis (IDH, 1p/19q, ATRX, CDKN2A/B, methylation class).
Grade 2, residual or recurrent, low risk
- For my situation (grade 2, residual or recurrent, low risk), which of the standard options do you recommend and why?Guideline options include: Observation with serial MRI, or vorasidenib for grade 2 tumours not needing immediate radiotherapy or chemotherapy (INDIGO).
- Am I a candidate for Vorasidenib, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of INDIGO apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Grade 2, high risk (age 40 or over, subtotal resection)
- For my situation (grade 2, high risk (age 40 or over, subtotal resection)), which of the standard options do you recommend and why?Guideline options include: Radiotherapy followed by PCV (procarbazine, lomustine, vincristine) as in RTOG 9802, or radiotherapy with temozolomide; temozolomide alone was not better than radiotherapy alone in EORTC 22033.
- Am I a candidate for Procarbazine, Lomustine (CCNU), Vincristine or related drugs, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of EORTC 22033-26033 apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Grade 3
- For my situation (grade 3), which of the standard options do you recommend and why?Guideline options include: Radiotherapy followed by twelve cycles of adjuvant temozolomide (CATNON); concurrent temozolomide is not needed in non-codeleted tumours.
- Am I a candidate for Temozolomide, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of CATNON (EORTC 26053-22054) apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Grade 4
- For my situation (grade 4), which of the standard options do you recommend and why?Guideline options include: Radiotherapy with concurrent and adjuvant temozolomide, extrapolated from glioblastoma; trials of IDH inhibitors preferred where available.
- Am I a candidate for Temozolomide, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of EORTC 26981 / NCIC CE.3 (Stupp trial) apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Recurrence
- For my situation (recurrence), which of the standard options do you recommend and why?Guideline options include: Re-resection, re-irradiation, lomustine or temozolomide re-challenge, bevacizumab for oedema and symptoms; clinical trials.
- Am I a candidate for Lomustine (CCNU), Temozolomide, Bevacizumab (glioblastoma use), and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Any stage
- Are there clinical trials I could join, for example of Vorasidenib, Safusidenib, Olutasidenib, DNA methylation profiling?Trials are how the next standard of care is set; asking early keeps options open.
- Would a second opinion at a high-volume centre change anything, and can you help arrange it?Rare or high-stakes decisions benefit from a centre that treats many similar patients.
- What supportive care (symptom control, nutrition, exercise, mental health, financial help) is available from the start?Supportive care improves quality of life and helps patients complete treatment.
- I read that “Whether vorasidenib should replace radiotherapy and chemotherapy or only defer them, and what to do at progression on it”. How does that affect my plan?Open problems are where trials and second opinions matter most.
- I read that “No IDH inhibitor has yet shown benefit in grade 3 or 4 IDH-mutant astrocytoma”. How does that affect my plan?Open problems are where trials and second opinions matter most.
Trials open now for this cancer in OnCo, largest phase first. Joining a trial is a decision like any other: ask what the comparison arm is, whether a placebo is used, and what happens if you leave. The cancer page searches ClinicalTrials.gov live for more.
Much of what helps in the first weeks is free if you know to ask: testing, helplines, rides and lodging, second opinions, trial travel.
- Astrocytoma, IDH-mutant (grades 2 to 4): the full pageIDH-mutant astrocytoma is the slow-growing form of adult glioma, defined by a mutation in the IDH1 or IDH2 gene that makes the tumour produce a chemical which rewires its own cells. Surgery first, and then either watchful waiting, the new pill vorasidenib, or radiotherapy with chemotherapy, depending on grade and how much tumour is left.
- One-page appointment sheetYour questions, the words you may hear, what to bring, and space for the answers. Print it.
- Treatment sequencingWhich treatment tends to follow which, line by line.
- NavigatorStandard of care for your stage, what you have tried, and trials near you.
- MGMT promoter methylation: A chemical switch that turns off a DNA-repair gene.
- Extent of resection (RANO resect classes): How much of a brain tumour the surgeon removes, measured on an MRI scan soon after the operation.
- Blood-brain barrier (BBB): The tight seal around brain blood vessels that keeps most drugs out, one of the two main reasons brain cancer is so hard to treat.
- Re-irradiation: Giving radiotherapy again to a region that has already been treated, once thought impossible because normal tissues remember the first dose.
Every term links to the glossary.