Glioblastoma Treatment Guidelines

Initial Treatment for Patients Under 70 with Good General Condition

The American College of Neurology recommends maximal safe surgical resection followed by concurrent radiotherapy with temozolomide and six cycles of maintenance temozolomide as the standard treatment for glioblastoma patients under 70 with good general condition 1, 2, 3
The protocol includes surgery with total macroscopic resection whenever possible, radiotherapy with 60 Gy in 30 fractions of 2 Gy over 6 weeks, concurrent temozolomide at 75 mg/m² daily during radiotherapy, and maintenance temozolomide at 150-200 mg/m² on days 1-5 of each 28-day cycle for 6 cycles 1, 3

The European Association of Neuro-Oncology states that the benefit of temozolomide is largely limited to patients with methylated MGMT promoter, and patients with methylated MGMT benefit substantially from temozolomide 1, 3
Patients with unmethylated MGMT have a marginal or absent benefit from temozolomide, according to the National Comprehensive Cancer Network 1, 2, 3

The American Society of Clinical Oncology recommends that treatment for elderly patients who are not candidates for standard chemoradiotherapy should be guided by MGMT status 1, 2, 3
For patients with methylated MGMT, temozolomide alone (5 days out of 28 until progression or for 12 months) is recommended, while for those with unmethylated MGMT or unknown status, hypofractionated radiotherapy alone (40 Gy in 15 fractions) is suggested 1, 3

The European Society for Medical Oncology states that a clinical decision without tissue diagnosis should only be considered in exceptional situations, and surgery should be performed in high-volume specialized centers 4
Biopsy should be performed when microsurgical resection is not feasible, and serial samples should be taken along the needle trajectory to avoid sampling bias 4

The College of American Pathologists recommends that diagnostic and therapeutic decisions rely on the evaluation of relevant molecular markers, including IDH status, MGMT promoter methylation, and ATRX and 1p/19q status 1, 3, 4

The National Institute for Health and Care Excellence states that standards of care at recurrence are less well-defined, but surgery and radiotherapy may be considered, and bevacizumab may be an option according to national authorization, although its impact on overall survival is unproven 1, 2, 5

The American Academy of Neurology recommends clinical evaluation with attention to neurological function, seizures, and corticosteroid use, as well as MRI every 3-4 months in standard practice outside clinical trials 6, 1
Gradual tapering of corticosteroids should be done as soon as possible, as prolonged use is a negative prognostic factor 1, 2

The American Society of Clinical Oncology advises against administering corticosteroids to treat asymptomatic or minimally symptomatic edema, as their use has been demonstrated to be a negative prognostic factor in three large distinct cohorts 1, 2
Corticosteroids may interfere with the effectiveness of radiotherapy, chemotherapy, and immunotherapy, and should be avoided whenever possible 1, 2