However, it is also becoming evident that some myeloid-directed glioma therapies may only be beneficial for distinct subclasses of gliomas and that a more cell-type specific manipulation of either microglia or macrophages may improve therapeutic outcome.
2
Neuropathological features of gliomasGlial tumours constitute approximately 50% of all newly diagnosed primary brain tumours, with low-grade gliomas accounting for roughly 15% of all brain tumours in adults [106]. The morphology and the cellular markers for gliomas share some similarities with the main macroglial cell-types (i.e. astrocytes, oligodendrocytes) [75].Histopathologically, gliomas are divided into four different grades (according to the classification scheme by the world health organization, WHO), in which low-grade tumours are defined as grade-I/-II and high-grade gliomas as grade-III and-IV [87]. The presence of mitotic activity is a key feature for distinguishing low-grade from high-grade gliomas [75]. Statistically, low-grade astrocytomas arise roughly in proportion to the relative mass of the different lobes with most common location within the frontal lobes, followed by temporal and parietal lobe lesions [107]. Overall, 5-and 10-year survival rates of ~70% and 50% for grade-I and grade-II gliomas, respectively, have been reported in the literature [25]. The tumour tissue has no obvious signs of neoangiogenesis, infiltrative invasion or inflammation [75]. On the contrary, the outlook for patients with high-grade gliomas is grim. The majority of individuals diagnosed with a grade-IV glioma, which are very heterogeneous tumours and therefore also named glioblastoma multiforme (GBM), have a median progression-free survival of just over half a year and median overall survival of 15-18 months [17], only some subpopulations of patients show median survivals of almost 2 years [54]. GBM is a fast growing, highly angiogenic and invasive tumour and the diffuse growth is a major obstacle for GBM therapy. Other hallmarks of malignant gliomas are break-down of the blood-brain barrier (BBB), many hypoxic areas and necrotic centres [75]. Gliomas are usually diagnosed by neurorimaging (i.e. magnetic resonance imaging) and visualisation of the uptake of a contrast-enhancing agent within the tissue indicates BBB-leakage/breakdown [159]. GBM typically presents as a ragged contrast-enhanced and complex multi-cystic structure. GBM may be diagnosed de novo, i.e. in patients without a clinical history for brain tumours (then named primary GBM) or may evolve from lower grade gliomas (secondary GBM) [103].3
Multi-modal glioma therapyGlioma therapy comprises very different strategies. For patients with deep-seated lesions or lesions located in eloquent regions which are clinically and radiographically indicated as low-grade glioma a conservative management including regular neuroimaging (after obtaining a histological diagnosis) [165], see also [130,150]. Individuals with high-grade gliomas undergo multi-modal treatment combining cytoreductive surgery, radiation-and ch...