title: The role of imaging in the management of adults with diffuse low grade glioma: A systematic review and evidence-based clinical practice guideline.
abstract: OBJECTIVE
  What is the optimal imaging technique to be used in the diagnosis of a suspected low grade glioma, specifically: which anatomic imaging sequences are critical for most accurately identifying or diagnosing a low grade glioma (LGG) and do non-anatomic imaging methods and/or sequences add to the diagnostic specificity of suspected low grade gliomas?
  
  
  METHODS
  These recommendations apply to adults with a newly diagnosed lesion with a suspected or histopathologically proven LGG.
  
  
  CONCLUSIONS
  
  
  
  METHODS
  In patients with a suspected brain tumor, the minimum magnetic resonance imaging (MRI) exam should be an anatomic exam with both T2 weighted and pre- and post-gadolinium contrast enhanced T1 weighted imaging. CRITICAL IMAGING FOR THE IDENTIFICATION AND DIAGNOSIS OF LOW GRADE GLIOMA:
  
  
  METHODS
  In patients with a suspected brain tumor, anatomic imaging sequences should include T1 and T2 weighted and Fluid Attenuation Inversion Recovery (FLAIR) MR sequences and will include T1 weighted imaging after the administration of gadolinium based contrast. Computed tomography (CT) can provide additional information regarding calcification or hemorrhage, which may narrow the differential diagnosis. At a minimum, these anatomic sequences can help identify a lesion as well as its location, and potential for surgical intervention. IMPROVEMENT OF DIAGNOSTIC SPECIFICITY WITH THE ADDITION OF NON-ANATOMIC (PHYSIOLOGIC AND ADVANCED IMAGING) TO ANATOMIC IMAGING:
  
  
  METHODS
  Class II evidence from multiple studies and a significant number of Class III series support the addition of diffusion and perfusion weighted MR imaging in the assessment of suspected LGGs, for the purposes of discriminating the potential for tumor subtypes and identification of suspicion of higher grade diagnoses.
  
  
  METHODS
  Multiple series offer Class III evidence to support the potential for magnetic resonance spectroscopy (MRS) and nuclear medicine methods including positron emission tomography and single-photon emission computed tomography imaging to offer additional diagnostic specificity although these are less well defined and their roles in clinical practice are still being defined.
  
  
  OBJECTIVE
  Which imaging sequences or parameters best predict the biological behavior or prognosis for patients with LGG?
  
  
  METHODS
  These recommendations apply to adults with a newly diagnosed lesion with a suspected or histopathologically proven LGG.
  
  
  CONCLUSIONS
  Anatomic and advanced imaging methods and prognostic stratification
  
  
  METHODS
  Multiple series suggest a role for anatomic and advanced sequences to suggest prognostic stratification among low grade gliomas. Perfusion weighted imaging, particularly when obtained as a part of diagnostic evaluation (as recommended above) can play a role in consideration of prognosis. Other imaging sequences remain investigational in terms of their role in consideration of tumor prognosis as there is insufficient evidence to support more formal recommendations as to their use at this time.
  
  
  OBJECTIVE
  What is the optimal imaging technique to be used in the follow-up of a suspected (or biopsy proven) LGG?
  
  
  METHODS
  This recommendation applies to adults with a newly diagnosed low grade glioma.
  
  
  CONCLUSIONS
  
  
  
  METHODS
  In patients with a diagnosis of LGG, anatomic imaging sequences should include T2/FLAIR MR sequences and T1 weighted imaging before and after the administration of gadolinium based contrast. Serial imaging should be performed to identify new areas of contrast enhancement or significant change in tumor size, which may signify transformation to a higher grade.
  
  
  METHODS
  Advanced imaging utility may depend on tumor subtype. Multicenter clinical trials with larger cohorts are needed. For astrocytic tumors, baseline and longitudinal elevations in tumor perfusion as assessed by dynamic susceptibility contrast perfusion MRI are associated with shorter time to tumor progression, but can be difficult to standardize in clinical practice. For oligodendrogliomas and mixed gliomas, MRS may be helpful for identification of progression.
authors.affiliation: Swedish Neuroscience Institute, 751 Northeast Blakely Drive, Suite 4020, Seattle, WA, USA. scj_29@hotmail.com.
authors.forename: Sarah Jost
authors.initials: SJ
authors.lastname: Fouke
authors.affiliation: Washington University School of Medicine, St. Louis, MO, USA.
authors.forename: Tammie
authors.initials: T
authors.lastname: Benzinger
authors.affiliation: Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
authors.forename: Daniel
authors.initials: D
authors.lastname: Gibson
authors.affiliation: Department of Neurosurgery, Kansas University Medical Center, Kansas City, KS, USA.
authors.forename: Timothy C
authors.initials: TC
authors.lastname: Ryken
authors.affiliation: Department of Neurosurgery, Henry Ford Health System, Detroit, MI, USA.
authors.forename: Steven N
authors.initials: SN
authors.lastname: Kalkanis
authors.affiliation: Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA.
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Olson
mesh_terms: D000328:Adult; D006801:Humans; D001921:Brain / Q000473:pathology; D001932:Brain Neoplasms / Q000175:diagnosis / Q000473:pathology / Q000628:therapy; D019317:Evidence-Based Medicine; D005910:Glioma / Q000175:diagnosis / Q000473:pathology / Q000628:therapy; D060787:Neoplasm Grading; D059906:Neuroimaging / Q000379:methods
keywords: Diagnostic specificity; Guidelines; Low grade glioma; Magnetic resonance imaging; Prognosis