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Case History

Image not available. A 62-year-old man presents with a short history of headaches and unsteadiness. He had no neurological signs. A computed tomography (CT) scan demonstrated a rim-enhancing lesion in his left parietal lobe and magnetic resonance imaging (MRI) (Figure 47.1) showed strong enhancement with gadolinium, with appearances typical of a glioblastoma multiforme. His symptoms reduce with corticosteroids.

What are the important prognostic features and likely outcome?

What is the role of surgery?

Is there any benefit for radiotherapy?

Is chemotherapy beneficial?

Are any treatments available for relapse?

What experimental approaches are being explored?

Figure 47.1

Axial T1-weighted MRI with gadolinium showing enhancing left parietal lesion.

Background

What are the important prognostic features and likely outcome?

Image not available. High-grade gliomas (HGGs) are locally invasive, incurable and have a poor prognosis in terms of survival, quality of life and social functioning. HGGs include grade IV glioma or glioblastoma multiforme with a median survival of about 6–12 months, and the less common grade III or anaplastic gliomas which have a median survival of 2–3 years. Increasing age and reduced performance status (PS) are key poor prognostic factors in the Medical Research Council (MRC) and Radiation Therapy Oncology Group (RTOG) trials, and this patient's age (over 60) is not in his favour. Other prognostic factors include a history of fits (patients with >3 months history of fits do better), mental status and extent of surgery.

Discussion

What is the role of surgery?

Image not available. Resection as opposed to biopsy allows complete histological examination and grading, which is important for the selection of postoperative treatment. Debulking can also provide rapid symptom improvement. However, tumour infiltrates well beyond the enhancing rim seen on cross-sectional imaging and because of this surgical resection is not curative. Although maximal cytoreductive surgery would usually be the preferred option for this patient if he is fit and the tumour does not involve a critical structure, there is little randomized trial evidence for a survival benefit. In patients with poorer prognosis, a biopsy may be preferred or it may even be most appropriate to accept a clinical and radiological diagnosis and adopt a best supportive approach.

Is there any benefit for radiotherapy?

HGGs are relatively radioresistant, and dose is limited by the sensitivity of surrounding brain tissue. Early trials of radical radiotherapy suggested an improved outcome, with survival of about 3 months with supportive care, and 9 months with radiotherapy.1 Survival benefit can be inferred from dose fractionation studies. In an MRC trial2 60 Gy in 30 fractions was associated with longer median survival compared with 45 Gy in 20 fractions (12 months versus 9 months). Recurrence is inevitable following radiotherapy, and is predominantly in-field. Attempts to improve outcome using accelerated, ...

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