Gliomes de haut grade : astrocytomes anaplasiques et glioblastomes

Malignant gliomas remain a major issue in neuro-oncology, due to their high incidence, their poor prognosis and the challenge of their treatment. Whereas clinical and radiological diagnosis may be easily established on a routine basis via CT or MRI imaging, the gap between the growing understanding of their biology and the lack of any cure benefit for the patients remains a major issue. Neuropathological classification of malignant gliomas is not yet settled, and recent methods based on immuno-histology and molecular genetics provide new data that question the accuracy of pure morphological diagnosis, and modify previous understanding of the morphologically suggested oncogenetic lineage of gliomas. Neurosurgical procedures change: “ total resection” is the aim, and optimal resection of the tumour tissue may be obtained using new per-operative technologies. The development of nano-neurosurgery is already part of many protocols lying upon local depots of cytotoxic or immunomodulatory agents. Radiotherapy has also been improved through three-dimensional dosimetry and conformational irradiation. Chemotherapies have been disappointing, but new drugs and new targets to the autocrine and paracrine loops have initiated an era of combined drug protocols, some to be used via nano-neurosurgical methods and tools. Immunotherapies are currently evaluated either as specific targeting tools or as a true immunological modulation against tumour cells. Gene therapies, after disappointing results of the gancyclovir suicide gene strategy, are now attempting to act upon biological characteristics of tumour cells. In summary, malignant glioma treatments remain unsatisfactory, despite considerable amount of clinical research. This review emphasizes the progress made especially in clinical diagnosis, in understanding the oncogenesis and the biological basis of new ongoing protocols.