Multifocal low-grade astrocytoma successfully treated with volumetric modulated arc therapy and concurrent temozolomide

Multifocal gliomas comprise an uncommon clinical entity with challenging diagnostic and therapeutic ramifications. In this article, we present the case of a young man with progressive memory loss that was found to have numerous space-occupying lesions masquerading as secondary metastases in his brain MRI. Histopathological examination revealed a diffuse low-grade astrocytoma. The patient was successfully treated with radical chemoradiotherapy and adjuvant temozolomide and has been recurrence-free during three years of regular follow-up. While we review the contemporary diagnostic and therapeutic options, we emphasize the necessity of stereotactic biopsy to 1. exclude brain metastases, 2. provide tissue for further molecular characterization, which is helpful for prognostication, and 3. guide an individualized treatment plan. We also contend against using whole-brain radiotherapy based on its well-recognized detrimental neurocognitive effects and its inability to allow dose escalation. Instead, targeted radiotherapy with IMRT/VMAT should be the preferred irradiation technique. As our imaging technology advances, so does our ability to diagnose multifocal lesions that would have been classified as unifocal in the past. Hence, we expect that we will, more often, be finding ourselves confronted with this clinical scenario in the future.