Glioblastoma: Treatment

Glioblastoma: overview

This algorithm outlines treatment of IDH-wildtype glioblastoma. For newly diagnosed disease, the first step is maximal safe resection, followed by radiotherapy with concurrent temozolomide and then adjuvant temozolomide, the Stupp protocol (STUPP), which improved overall survival and identified MGMT promoter methylation as a key predictive biomarker. Tumor-treating fields may be added to adjuvant temozolomide, based on EF-14 (TTFields).

For elderly patients or those with poor performance status, the chart shows hypofractionated radiotherapy plus temozolomide, with the greatest benefit in MGMT-methylated tumors, or temozolomide alone for MGMT-methylated disease. At recurrence, options include re-resection or re-irradiation in selected patients, bevacizumab, or a clinical trial.

Step by step

• Newly diagnosed: maximal safe resection, then radiotherapy with concurrent temozolomide (Stupp protocol, STUPP).
• After chemoradiation: adjuvant temozolomide with or without tumor-treating fields (EF-14).
• Elderly or poor performance status: hypofractionated radiotherapy plus temozolomide, with MGMT-methylated tumors benefiting most.
• Elderly or poor performance status with MGMT-methylated tumor: temozolomide alone is an option.
• Recurrence: re-resection or re-irradiation in selected patients, bevacizumab, or a clinical trial.

Trials behind this algorithm

• STUPP Stupp R et al, NEJM, 2005; PMID: 15758009