Should I get a second opinion?

Yes, particularly for low-grade glioma, where the decisions about when and how to treat are often judgment calls. Treatment has changed significantly in the past few years, and a specialist evaluation with full molecular profiling is the best way to ensure the plan reflects the current standard of care.

Low-Grade Glioma

Specialized surgical and medical care for Grade 2 brain tumors, including modern molecular therapies.

Overview

What Is a Low-Grade Glioma?

Low-grade glioma is a slower-growing type of brain tumor that develops from the supportive cells of the brain. It’s classified as WHO Grade 2, which means it grows more slowly than high-grade gliomas, but it isn’t benign and usually requires treatment. Most patients are diagnosed in their 20s, 30s, or 40s.

Common symptoms include a first-time seizure, gradual changes in memory, concentration, or speech, persistent headaches, mood or personality changes, and weakness or numbness on one side of the body. Many patients are first diagnosed after a seizure or after imaging done for another reason.

Treatment usually starts with surgery to remove as much of the tumor as safely possible, sometimes followed by a targeted oral medication, radiation, or chemotherapy depending on the tumor’s specific features. Dr. Sherman has experience treating low-grade gliomas at Rutgers Cancer Institute in New Brunswick, NJ.

Call our office at 732-235-6333 or send us a message.

The information on this page is general educational information and is not medical advice. It does not create a doctor-patient relationship or reflect a treatment recommendation for any individual. Treatment decisions require an individual evaluation by a qualified physician.

Low-grade glioma symptoms often develop gradually, sometimes over years, and they can be subtle enough to be dismissed as stress, fatigue, or unrelated conditions. Many patients are diagnosed after a single significant event that finally prompts imaging.

Here’s what makes symptoms worth investigating.

A first seizure in adulthood. This is the most common presenting symptom of a low-grade glioma. A first seizure in an adult always warrants brain imaging, even if everything seems fine afterward. Many patients with low-grade gliomas are diagnosed because a first seizure led to an MRI.

Subtle cognitive or memory changes. Gradual changes in short-term memory, concentration, word-finding, or mental sharpness that have been building over months, and that friends or family have started to notice, are worth evaluating. These are easy to attribute to stress or sleep, but a pattern that keeps building is a pattern worth looking at.

Persistent headaches with any new pattern. New headaches that are gradually worsening, or headaches that come with nausea, vomiting, or vision changes, warrant brain imaging.

Personality, mood, or behavior changes. Subtle shifts in patience, judgment, or emotional regulation that seem out of character can be early signs of a frontal lobe tumor. These are often more obvious to family members than to the patient.

New weakness or sensory changes on one side of the body. Focal neurologic symptoms, those affecting one specific side or one specific function, warrant prompt evaluation.

New vision or speech changes. Any new difficulty with vision, blurring, loss of peripheral vision, or any new trouble with speech or language, should be reported to a doctor.

When to treat it as an emergency. Sudden severe symptoms, loss of consciousness, sudden inability to speak, or a seizure that doesn’t stop should be treated as an emergency. Go to the nearest emergency room rather than waiting for an appointment.

For most low-grade glioma symptoms, the pace is measured in days to a couple of weeks rather than hours. Low-grade gliomas are slower-growing, and while the diagnosis is serious, it’s not typically the kind of situation that requires a rush to an emergency room unless there are acute symptoms.

Imaging

MRI of the brain with and without contrast is the standard imaging study for any suspected brain tumor. Low-grade gliomas typically appear as diffuse, non-enhancing or minimally enhancing masses on MRI, often with relatively indistinct borders because of their infiltrative growth pattern. The absence of strong contrast enhancement is one of the features that helps distinguish low-grade from high-grade gliomas on imaging, though it is not definitive. Additional MRI sequences, including MR spectroscopy and perfusion imaging, are sometimes used to gather more information before a biopsy or surgery.

Tissue Diagnosis and Molecular Profiling

Definitive diagnosis of a low-grade glioma requires tissue, obtained either through a stereotactic biopsy or, more commonly, during surgical removal of the tumor. Under the 2021 WHO classification, the diagnosis depends on both what the cells look like under a microscope and the tumor’s molecular profile. The most important markers for Grade 2 gliomas include:

IDH mutation status. The presence of an IDH1 or IDH2 mutation defines a true Grade 2 glioma under current classification. Tumors without IDH mutation are classified differently and treated differently.

1p/19q codeletion. The loss of specific portions of chromosomes 1 and 19 defines oligodendroglioma, which has a more favorable outlook and responds especially well to certain chemotherapy regimens.

ATRX status. A marker that helps distinguish astrocytoma from oligodendroglioma.

CDKN2A/B deletion. An important marker because its presence in an IDH-mutant astrocytoma can reclassify the tumor as Grade 4, with different treatment implications.

MGMT methylation status. A marker that can influence chemotherapy decisions.

Molecular profiling is central to modern low-grade glioma classification and management. At NCI-designated cancer centers, including Rutgers Cancer Institute, the only NCI-designated comprehensive cancer center in New Jersey, full molecular testing is part of the routine diagnostic workup.

Low-grade glioma treatment has evolved significantly over the past several years, with the introduction of new targeted therapies and a better understanding of when aggressive early treatment helps and when it’s better to preserve options for later. The right plan depends on the tumor’s molecular profile, size, location, the patient’s symptoms and overall health, and long-term considerations about cognitive function and quality of life.

Surgery: The Foundation

Surgery is almost always the first step for a low-grade glioma. The goal is maximal safe resection, which means removing as much of the visible tumor as possible without damaging the parts of the brain that control speech, movement, memory, and other essential functions. For low-grade gliomas, evidence is particularly strong that more complete surgical removal is associated with better long-term outcomes and with delayed progression to higher-grade disease.

Because low-grade gliomas often occur in or near areas of the brain that control critical functions, awake craniotomy plays a particularly important role. During an awake craniotomy, the patient is awake for parts of the procedure, and brain function is tested in real time while the surgeon works, allowing maximum tumor removal while preserving speech, motor function, and other essential abilities. This is one of the most important techniques for safely treating low-grade gliomas in eloquent brain regions.

Observation (For Some Low-Risk Patients)

For a carefully selected group of patients with low-risk features, including younger age, complete surgical resection, smaller tumor size, and absence of neurologic deficits, initial observation with close imaging surveillance may be appropriate. This approach has become less common over the past several years as evidence has grown for earlier treatment in most patients, but it remains a reasonable option in specific situations and is most relevant for Grade 2 oligodendrogliomas with favorable features.

Vorasidenib: Targeted Therapy for IDH-Mutant Gliomas

One of the most significant advances in low-grade glioma treatment came with the FDA approval in August 2024 of vorasidenib, an oral drug that directly targets the mutant IDH1 and IDH2 enzymes that drive most low-grade gliomas. Vorasidenib is approved for adults with Grade 2 IDH-mutant astrocytoma or oligodendroglioma following surgical resection. In the INDIGO clinical trial, vorasidenib significantly delayed tumor progression compared to placebo and offered the potential to postpone the need for radiation and chemotherapy for many patients.

This is a meaningful shift in how low-grade glioma is treated. For younger patients especially, delaying radiation can help preserve long-term cognitive function, which is one of the most important quality-of-life considerations for a disease that patients may live with for many years. Vorasidenib is not a cure, but it is a well-tolerated, once-daily oral therapy that has changed what’s possible in the early period after surgery for many patients with residual or recurrent tumors.

Radiation Therapy

Radiation therapy has been a standard part of low-grade glioma treatment for decades, particularly for patients with high-risk features such as older age, larger tumor size, incomplete surgical removal, or significant neurologic symptoms. Radiation is typically delivered in small daily doses over several weeks. The decision about whether and when to use radiation is increasingly individualized, weighing disease control benefits against long-term cognitive effects, and incorporating newer options like vorasidenib into the long-term plan.

Chemotherapy

Chemotherapy, either as part of initial treatment along with radiation or as a later option, is used in many patients with low-grade glioma. The specific regimen depends on the tumor’s molecular profile. For oligodendrogliomas with 1p/19q codeletion, a specific three-drug chemotherapy combination has been shown to be particularly effective. For astrocytomas, an oral chemotherapy drug is more commonly used. Chemotherapy may be recommended along with radiation for patients with high-risk features, or as an alternative to radiation in specific situations.

Clinical Trials

Low-grade glioma is one of the most active areas in neuro-oncology research, with ongoing trials testing new targeted therapies, combinations of vorasidenib with other treatments, and approaches designed to delay the need for radiation. For patients with IDH-mutant tumors in particular, clinical trial enrollment can offer access to treatments that aren’t yet available as standard care.

How the Plan Gets Made

Low-grade glioma is a long-horizon disease. Treatment decisions are about more than the first few months; they’re about the next 10, 20, or 30 years. The right plan depends on the tumor’s molecular profile, the patient’s age and overall health, the tumor’s specific features on imaging and pathology, and the balance between disease control and cognitive preservation. For most patients, the decisions involve a multidisciplinary team working together: neurosurgery, medical oncology, radiation oncology, and neuropathology, with ongoing input from the patient about their priorities and concerns.

Treatments commonly used for this conditionBrain Tumor Surgery, Awake Craniotomy, Fluorescence-Guided Surgery, and Clinical Trial Enrollment.

Technology

Using XR Technology To Advance Medical Care

Dr. Sherman integrates VR and AR visualization into surgical planning and patient education, giving patients a clearer picture of their diagnosis and the approach to treatment.

Common Questions About Low-Grade Gliomas

Low-grade gliomas are already considered tumors of the central nervous system, and under current classification they are classified as a form of brain cancer, even though they grow more slowly than high-grade gliomas. Over time, many low-grade gliomas progress to higher grades, and this progression is one of the main reasons treatment is often recommended rather than indefinite observation.

For the great majority of patients, surgery is recommended at some point, and there is strong evidence that more complete resection improves long-term outcomes. The timing and extent of surgery depend on the tumor’s location, size, molecular features, and the patient’s symptoms. For a small number of patients with very small, asymptomatic tumors and favorable features, initial observation may be reasonable.

Outcomes vary significantly based on age, molecular features, extent of resection, and treatment. Published outcomes for Grade 2 IDH-mutant gliomas have improved substantially in recent years, and many patients in modern series live for many years after diagnosis. Oligodendrogliomas with 1p/19q codeletion generally have the most favorable outcomes of any diffuse glioma in published data. Individual prognosis depends on the full profile of a tumor, how it responds to treatment, and factors that can only be assessed by a treating physician.

Surgery is generally considered when the tumor is causing symptoms (including seizures that are hard to control), when imaging shows growth, when the tumor is large enough to pose a future risk, or when complete or near-complete resection is achievable safely. The timing of surgery for low-grade glioma depends on multiple factors. In many published series, earlier intervention has been associated with better outcomes than prolonged observation, but the right timing for a specific patient depends on factors that can only be assessed by a treating physician.

Observation remains a reasonable approach for a small group of patients with very favorable features. However, evidence over the past decade has increasingly supported earlier intervention, both with surgery and with adjuvant treatment, for most patients. The introduction of vorasidenib in 2024 has also changed the calculus by offering a well-tolerated treatment option that can be started early without committing to radiation.

Vorasidenib is an oral medication approved by the FDA in August 2024 for adults with Grade 2 IDH-mutant astrocytoma or oligodendroglioma after surgery. It targets the mutant IDH enzyme that drives most low-grade gliomas and has been shown in clinical trials to significantly delay tumor progression. For many patients, it offers a way to extend the time before radiation or chemotherapy becomes necessary, which matters especially for younger patients who want to preserve long-term cognitive function.

Next Step

Newly Diagnosed or Seeking a Second Opinion?

Dr. Sherman is accepting new patients at Rutgers Cancer Institute in New Brunswick, New Jersey. Whether you’ve just been diagnosed or you’re looking for another perspective on a treatment plan, a consultation is the first step toward understanding your options.

Schedule a Consultation 732-235-6333

Low-Grade Glioma

What Is a Low-Grade Glioma?

Symptoms

Diagnosis

Treatment

Using XR Technology To Advance Medical Care

Common Questions About Low-Grade Gliomas

Newly Diagnosed or Seeking a Second Opinion?