low-grade glioma

Background: WHO grade II Low-grade gliomas (LGGs) need multi-disciplinary treatment from different specialties, directed by new molecular classifications and prognostic markers. Yet regional practice patterns and obstacles are not reported, especially in MENA countries.Method: A cross-sectional survey of physicians from MENA countries (including neurosurgeons, radiation oncologists, and medical oncologists) was conducted. An electronic anonymous survey, including clinical scenarios and evidence-based treatment choices, was distributed at professional conferences. The feedback included responses regarding surgical interventions, adjuvant treatment preferences, and barriers to adoption of IDH-mutant inhibitors.Results: 137 physicians (37.23% neurosurgery, 32.85% radiation oncology, 29.93% medical oncology). Most had 6–15 years of experience (56.21%) and worked in government (51.82%) or academic hospitals (25.55%). Maximal safe resection (MSR), if applicable, was preferred over biopsy (89.05% vs. 10.95%). For residual Astrocytoma, concurrent radiotherapy (RT) with temozolomide (TMZ) (42.34%) was the preferred adjuvant, while 44.53% prefer observation after gross total resection (GTR). For residual Oligodendroglioma, RT followed by PCV (45.99%) was preferred, with 59.85% offered observation post-GTR. Most (96.35%) agreed that resection extent impacts outcomes, while 72.99% objected to extending TMZ beyond six cycles. High-risk stratification varied: 46.72% used age ≥40 years, and 88.32% prioritized residual tumor volume. Although 64.96% supported IDH-mutant inhibitors, 58.39% cited limited availability as a barrier, followed by cost (40.88%) and insufficient long-term data (31.39%). Specialty-specific differences emerged: radiation oncologists tend more to provide adjuvant radiotherapy in the context of persistent seizure post-operatively (χ² = 20.50, p < 0.05), and medical/radiation oncologists more often used age ≥40 for high-risk stratification (χ² = 10.10, p = 0.038).Conclusion: There is a wide variation in the WHO grade II LGGs management among physicians in MENA Countries. These data highlight the importance of locally derived guidelines, the increased availability of molecularly directed therapies, and ongoing collaboration between multiple disciplines to ensure optimal patient outcomes.Key points:•    Maximal safe resection (89.05%) is the dominant surgical approach for WHO grade II LGGs, taking into consideration the location and extent of infiltration, among specialists in MENA Countries, reflecting global consensus on resection extent impacting outcomes (96.35% agreement).•    Adjuvant therapy preferences vary: concurrent RT+TMZ for astrocytomas (42.34%) and sequential RT+PCV for oligodendrogliomas (45.99%), with 59.85% observing post-GTR in oligodendrogliomas.•    IDH-mutant inhibitors (e.g., Vorasidenib) are supported by 64.96% of oncologists, but limited availability (58.39%) and cost (40.88%) hinder adoption.Importance of the study: This multicenter survey is the first to evaluate real-world management trends and barriers for WHO grade II low-grade gliomas (LGGs) among physicians in MENA Countries. While all specialists align with international guidelines in surgical strategies (e.g., maximal safe resection), significant heterogeneity exists in adjuvant therapy choices, particularly for astrocytomas versus oligodendrogliomas. Crucially, we identify systemic barriers—such as limited access to molecular therapies (IDH inhibitors) and cost constraints—that disproportionately affect WHO grade II LGGs care in the MENA Countries. Our findings underscore the urgent need for regionally adapted guidelines and multidisciplinary collaboration to standardize practices aligned with international guidelines. By highlighting disparities in resource availability and specialty-specific decision-making (e.g., radiation oncologists prioritizing post-resection seizures, p < 0.05), this study provides a roadmap for optimizing WHO grade II LGGs management in resource-limited settings and advocates for the inclusion of Arab populations in global trials of novel agents like Vorasidenib.