Combined salvage therapies for recurrent glioblastoma multiforme: evaluation of an interdisciplinary treatment algorithm

Abstract

Glioblastoma multiforme patients presenting with recurrence following multimodality therapy have limited palliative treatment options when the major modalities of therapy including surgery, radiochemotherapy and adjuvant chemotherapy have been exhausted. The authors introduce a clinical and radiological indication-solving algorithm and provide outcome rates of a glioblastoma recurrence cohort. Sixty six consecutive adult patients with recurrent glioblastoma who underwent a combined scheme of salvage treatments consisting of reoperation, high dose rate (HDR) brachytherapy and chemotherapy were included in this prospective study and were compared to a historical control group of 24 recurrent glioblastoma patients who have been treated with intensive temozolomide chemotherapy as the only treatment modality. Median follow-up was 32 months (range 28-36 months). Median survival was 9 months for the entire cohort after salvage treatment and can be translated into a 3-month improvement in survival compared to the control group of patients with glioblastoma recurrence treated with temozolomide alone (P = 0.043). Toxicity and adverse events of reoperation, HDR brachytherapy combined with chemotherapy were quite favourable compared to intensive temomozolomide chemotherapy as the only treatment. Our experience suggests that a combined salvage treatment plan appears to be both feasible and effective and can be considered in selected patients affected by recurrent high grade gliomas. The authors' clinical and radiological indication-solving algorithm may assist in providing the best possible salvage treatment for this difficult population.

Patterns of recurrence and outcomes of glioblastoma multiforme treated with chemoradiation and adjuvant temozolomide

“…After RT treatment, up to 80% of patients experience recurrence inside of the RT field ( 11 ); in this setting, there is currently no consensus regarding the best option for salvage treatment ( 12 ). Several studies have described the outcomes of different salvage treatments in progressive or recurrent GBM ( 12 - 15 ). A phase II study including 35 cases with recurrent GBM tested the combination of bevacizumab and irinotecan.…”

“…Therefore, in our institution, metronomic TMZ has been employed as a salvage therapy in this clinical scenario, either alone or in combination with a local treatment. The role of local therapy is also not well established, being reserved for patients with significant neurological symptoms when the disease and patients are operable ( 12 ). In the last decade, the use of re-irradiation has significantly increased mainly because of improvements in the accuracy of image-guided radiotherapy and knowledge regarding radiation tolerability by the brain ( 19 ).…”

Attitude and practice of brachytherapy in India: a study based on the survey amongst attendees of Annual Meeting of Indian Brachytherapy Society

“…The data on decline of brachytherapy use [ 2 ] needs to be interpreted with caution as sometimes the data from registry or population database could be misleading due to changes in coding and reporting patterns [ 3 ]. Apart from established indications [ 4 , 5 ], brachytherapy has expanded wings to novel and innovative indications like brain, liver, penile, lung, and intra-thoracic brachytherapy [ 6 , 7 , 8 , 9 ]. Brachytherapy planning has also evolved from point based prescription to volume based and from X-ray based to magnetic resonance imaging (MRI) based planning [ 10 , 11 ].…”

Combined Salvage Therapies for Recurrent Glioblastoma Multiforme: Treatment Options in Multifocal and Multicentric Patterns of Recurrence

“…Another drawback of the study that undermines reliability is the small number of patients included. Large number of patients could be adopted in a multicenter study which we are planning in the near future [44][45][46][47][48].…”