The role of cytoreductive surgery in the management of progressive glioblastoma : a systematic review and evidence-based clinical practice guideline.

QUESTION: Should patients with previously diagnosed malignant glioma who are suspected of experiencing progression of the neoplasm process undergo repeat open surgical resection? TARGET POPULATION: These recommendations apply to adults with previously diagnosed malignant glioma who are suspected of experiencing progression of the neoplastic process and are amenable to surgical resection. RECOMMENDATIONS LEVEL II: Repeat cytoreductive surgery is recommended in symptomatic patients with locally recurrent or progressive malignant glioma. The median survival in these patient diagnosed with glioblastoma is expected to range from 6 to 17 months following a second procedure. It is recommended that the following preoperative factors be considered when evaluating a patient for repeat operation: location of recurrence in eloquent/critical brain regions, Karnofsky Performance Status and tumor volume.

The role of targeted therapies in the management of progressive glioblastoma : a systematic review and evidence-based clinical practice guideline.

QUESTION: What is the influence of targeted medical therapies on disease control and survival in the adult patient with progressive glioblastoma? TARGETED POPULATION: This recommendation applies to adult patients with progressive glioblastoma RECOMMENDATIONS: Level III Treatment with bevacizumab is recommended as it provides improved disease control compared to historical controls as measured by best imaging response and progression free survival at 6 months. Given that there are a large number of therapies are available for progressive glioblastoma that may be applied under selected circumstances dependent on patient characteristics and treating physician judgment, it is strongly recommended that patients with progressive glioblastoma be enrolled in properly designed clinical investigations to provide convincing evidence of therapeutic value.

The role of radiotherapy in the management of progressive glioblastoma : a systematic review and evidence-based clinical practice guideline.

QUESTION: Can re-irradiation (by using conventional radiotherapy, fractionated radiosurgery, or single fraction radiosurgery) be used in patients with progressive glioblastoma multiforme after the first adjuvant combined multimodality treatment with radiation and chemotherapy? TARGET POPULATION: These recommendations apply to adult patients with progressive glioblastoma after first line combined multimodality treatment with chemotherapy and radiation. RECOMMENDATIONS LEVEL III: When the target tumor is amenable for additional radiation, re-irradiation is recommended as it provides improved local tumor control, as measured by best imaging response. Such re-irradiation can take the form of conventional fractionation radiotherapy, fractionated radiosurgery, or single fraction radiosurgery. LEVEL III: Re-irradiation is recommended in order to maintain or improve a patient's neurological status and quality of life prior to any further tumor progression.

The role of imaging in the management of progressive glioblastoma : a systematic review and evidence-based clinical practice guideline.

QUESTION: Which imaging techniques most accurately differentiate true tumor progression from pseudo-progression or treatment related changes in patients with previously diagnosed glioblastoma? TARGET POPULATION: These recommendations apply to adults with previously diagnosed glioblastoma who are suspected of experiencing progression of the neoplastic process. RECOMMENDATIONS LEVEL II: Magnetic resonance imaging with and without gadolinium enhancement is recommended as the imaging surveillance method to detect the progression of previously diagnosed glioblastoma. LEVEL II: Magnetic resonance spectroscopy is recommended as a diagnostic method to differentiate true tumor progression from treatment-related imaging changes or pseudo-progression in patients with suspected progressive glioblastoma. LEVEL III: The routine use of positron emission tomography to identify progression of glioblastoma is not recommended. LEVEL III: Single-photon emission computed tomography imaging is recommended as a diagnostic method to differentiate true tumor progression from treatment-related imaging changes or pseudo-progression in patients with suspected progressive glioblastoma.

The role of neuropathology in the management of progressive glioblastoma : a systematic review and evidence-based clinical practice guideline.

QUESTION: 1. What are the most important diagnostic considerations in reporting progressive glioblastoma? TARGET POPULATION: These recommendations apply to adults with progressive glioblastoma LEVEL III: For patients who undergo biopsy or neurosurgical resection at the time of radiologic or clinical progression, it is recommended that the pathologist report the presence and extent of progressive neoplasm as well as the presence and extent of necrosis within the pathologic material examined. Furthermore, to ensure the proper interpretation of progressive glioblastoma, it is recommended that the pathologist take into account the patient's previous diagnosis and treatment, as well as the current clinical and neuroimaging features that have led to a second biopsy or resection. QUESTION: 2. What techniques and ancillary studies are most useful in separating malignant progression from treatment effect? TARGET POPULATION: These recommendations apply to adults with progressive glioblastoma LEVEL III: In the setting of prior radiation and chemotherapy, it is recommended to adhere to strict histologic criteria for microvascular proliferation and necrosis in order to establish a diagnosis of a glioblastoma. Immunohistochemistry and genetic studies are selectively recommended for distinguishing neoplastic cells from atypical reactive cells in progressive glioblastoma.