Congress of Neurological Surgeons systematic review and evidence-based guidelines update on the role of cytotoxic chemotherapy and other cytotoxic therapies in the management of progressive glioblastoma in adults.

Mateo Ziu,Patrick Wen,Isabelle M Germano,D Ryan Ormond,Jeffrey J Olson

doi:10.1007/s11060-021-03900-w

Abstract

These recommendations apply to adult patients diagnosed with progressive glioblastoma (pGBM). QUESTION (Q1): In adult patients with pGBM does the use of temozolomide (TMZ) with alternative dosing or the use of TMZ in combination with other cytotoxic treatments result in increased overall survival compared to other chemotherapy? Level III: Adult patients with pGBM might derive benefit in treatment with TMZ, especially those who progress after more than 5months of TMZ-treatment free interval. Combination of TMZ with other cytotoxic agents such as nitrosourea, cisplatin, electrohyperthermia, or tamoxifen is not suggested in adult patients with pGBM as a stand-alone therapy. There is insufficient data to make a recommendation about which alternative TMZ dosing provides the best benefits. QUESTION (Q2): In adult patients with pGBM does the use of systemic or in situ nitrosourea result in increased overall survival compared to other chemotherapy? Level III: In the setting of pGBM, fotemustine is suggested in elderly patients with methylated MGMT promoter status. There is insufficient evidence to compare fotemustine to other nitrosoureas. There is insufficient evidence to make a recommendation about the use of in situ nitrosourea in patients with pGBM who underwent the Stupp regimen. QUESTION (Q3): In adult patients with pGBM does the use of platinum compounds and topoisomerase result in increased survival compared to other chemotherapy? Level III: Other chemotherapy including platinum compounds and topoisomerase inhibitors are not suggested to be used in adult patients with pGBM. Other cytotoxic therapies like perillyl acohol or ketogenic diet are not suggested for use in adult patients with pGBM as a stand-alone therapy. QUESTION (Q4): In adult patients with pGBM does the use of tumor treating field (TTF) result in increased overall survival compared to chemotherapy? Level III: The use of TTF with other chemotherapy may be considered when treating adult patients with pGBM. There is insufficient evidence to recommend TTF to increase overall survival in adult patients with pGBM. QUESTION (Q5): In adult patients with pGBM does the use of oncolytic virotherapy result in increased survival compared to chemotherapy? Level III: Oncolytic virotherapy is not suggested in patients with pGBM.

Highlights

RationaleChemotherapy and other cytotoxic therapies play a key role in the management of patients with progressive glioblastoma multiforme
Question (Q1) In adult patients with progressive glioblastoma multiforme (pGBM) does the use of temozolomide (TMZ) with alternative dosing or the use TMZ in combination with other cytotoxic treatments result in increased overall survival compared to other chemotherapy?
In patients treated with TMZ and Treatment Free Interval (TFI) ≥ 5 months overall survival (OS) was 17.7 and 11.6 months respectively for patients treated with TMZ or Nitrosoureas Patients with TFI ≥ 5 months benefit from TMZ re- challenge at the time of recurrence Authors Conclusions: TMZ rechallenge is a treatment option to be considered for patients with TFI > 5 months irrespective of MGMT status since it may prolong Progression Free Survival (PFS) and OS compared to NU Comments and Conclusions: Retrospective study as such classified as class III evidence

Summary

Introduction

Chemotherapy and other cytotoxic therapies play a key role in the management of patients with progressive glioblastoma multiforme (pGBM). The term “progressive” has been chosen as preferential, consistent with the previous guidelines, to underscore the reality that few or no GBM are truly eradicated with the initial therapy and evidence of new disease represents progression of the original disease. In the published literature the term “recurrent GBM” is often encountered. In this chapter these terms are used interchangeably. The previous guidelines focused on review of the published peer- reviewed English literature for the period January 1, 1990 to June 30, 2012 on cytotoxic chemotherapy used for adult patients with pGBM. Cytotoxic therapies other than chemotherapy have been used to treat adult patients with pGBM

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