Glioblastoma
Short Summary

55-year-old female was diagnosed with glioblastoma after suffering increasing headaches, and was treated with radiation with concurrent Temodal. MRI exam that was performed after 2 additional cycles of CCNU showed tumor progression. The expert recommends different further treatment options.

Patient's Questions
1)    Are there different further treatment options concerning chemotherapy?
2)    Are there alternative drugs that could be recommended, may be also as an off-label-use?
 
3)    Does a consultation of a radiooncologist make sense in order to check the opportunity of a stereotactic radiotherapy.
Medical Background

55-year-old female.                                     

Treatment History:
1) Fall 2006: numbness in LUE, CT negative
2) 3/07: increasing headaches, admitted to hospital, CT showed right sided mass
3) 3/07:resection of tumor, pathology reported as glioblastoma
4) 5/07-7/07: Treated with 60Gy radiation with concurrent temodal
5) 8/07: MRI shows new enhancement around resection cavity
6) 8/07: CCNU started, 2 cycles
7) 10/07: MRI progression of tumor

Expert's Opinion

Recommendations:
I have reviewed the notes provided and agree that they are consistent with an aggressive high-grade tumor. Given the patient's age, history, and pathology data, I would recommend the following given the diagnosis of glioblastoma and limited information noted above. The recommendations may clearly change once I have more information regarding treatments since 11/2007 till now.
1. Are there different further treatment options concerning chemotherapy?
-       Would review the initial post-radiation MRI to see if really progression versus pseudoprogression and would consider retrial of temodal. If concern that temodal failed then could consider Carboplatin or BCNU or CPT-11.

-       Would recommend a Brain Tumor Center locally that has clinical trial options to try investigational agents.
Brandsma D, Stalpers L, Taal W, Sminia P, van den Bent MJ. Clinical features, mechanisms, and management of pseudoprogression in malignant gliomas. Lancet Oncol. 2008 May;9(5):453-61. Review.
Brandes AA, Franceschi E, Tosoni A, Blatt V, Pession A, Tallini G, Bertorelle R, Bartolini S, Calbucci F, Andreoli A, Frezza G, Leonardi M, Spagnolli F, Ermani M. MGMT promoter methylation status can predict the incidence and outcome of pseudoprogression after concomitant radiochemotherapy in newly diagnosed glioblastoma patients. J Clin Oncol. 2008 May 1;26(13):2192-7.
2. Are there alternative drugs that could be recommended, may be also as an off-label-use?
-       AVASTIN (bevacizumab) + chemotherapy are the best option currently. A large phase II trial finished recently and the data is positive and available soon. But other earlier trials have already shown benefit as referenced below.
Vredenburgh JJ, Desjardins A, et al, Phase II trial of bevacizumab and irinotecan in recurrent malignant glioma. Clin Cancer Res. 2007 Feb 15;13(4):1253-9.
-       Can also consider Tarceva + rapamycin
Doherty L, Gigas DC, Kesari S, Drappatz J, Kim R, Zimmerman J, Ostrowsky L, Wen PY. Pilot study of the combination of EGFR and mTOR inhibitors in recurrent malignant gliomas. Neurology. 2006 Jul 11;67(1):156-8.
-       Can also consider Gleevec+ hydrea
Desjardins A, Quinn JA, Vredenburgh JJ, Sathornsumetee S, Friedman AH, Herndon JE, McLendon RE, Provenzale JM, Rich JN, Sampson JH, Gururangan S, Dowell JM, Salvado A, Friedman HS, Reardon DA. Phase II study of imatinib mesylate and hydroxyurea for recurrent grade III malignant gliomas. J Neurooncol. 2007 May;83(1):53-60. Epub 2007 Jan 24.
Kesari S, Ramakrishna N, Sauvageot C, Stiles CD, Wen PY. Targeted molecular therapy of malignant gliomas. Curr Oncol Rep. 2006 Jan;8(1):58-70.
3. Does a consultation of a radiooncologist make sense in order to check the opportunity of a stereotactic radiotherapy.
-       Yes reasonable to see radiation oncologist to see if stereotactic radiosurgery is an option if the recurrence if focal and small.

All of these recommendations have to be taken in context of functional status and balancing quality of life and with limited information till 11/2007

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