Phase II study of temozolomide without radiotherapy in newly diagnosed glioblastoma multiforme in an elderly populations

Management of glioblastoma in elderly patients: A review of the literature

High grade gliomas are the most common primary aggressive brain tumours with a very poor prognosis and a median survival of less than 2 years. The standard management protocol of newly diagnosed glioblastoma patients involves surgery followed by radiotherapy, chemotherapy in the form of temozolomide and further adjuvant temozolomide. The recent advances in molecular profiling of high-grade gliomas have further enhanced our understanding of the disease. Although the management of glioblastoma is standardised in newly diagnosed adult patients there is a lot of debate regarding the best treatment approach for the newly diagnosed elderly glioblastoma patients. In this review article we attempt to summarise the findings regarding surgery, radiotherapy, chemotherapy, and their combination in order to offer the best possible management modality for this group of patients. Elderly patients 65-70 with an excellent functional level could be considered as candidates for the standards treatment consisting of surgery, standard radiotherapy with concomitant and adjuvant temozolomide. Similarly, elderly patients above 70 with good functional status could receive the above with the exception of receiving a shorter course of radiotherapy instead of standard. In elderly GBM patients with poorer functional status and MGMT promoter methylation temozolomide chemotherapy can be considered. For elderly patients who cannot tolerate chemotherapy, hypofractionated radiotherapy is an option. In contrast to the younger adult patients, it seems that a careful individualised approach is a key element in deciding the best treatment options for this group of patients.

NUTMEG: A randomized phase II study of nivolumab and temozolomide versus temozolomide alone in newly diagnosed older patients with glioblastoma

Background

There is an immunologic rationale to evaluate immunotherapy in the older glioblastoma population, who have been underrepresented in prior trials. The NUTMEG study evaluated the combination of nivolumab and temozolomide in patients with glioblastoma aged 65 years and older.

Methods

NUTMEG was a multicenter 2:1 randomized phase II trial for patients with newly diagnosed glioblastoma aged 65 years and older. The experimental arm consisted of hypofractionated chemoradiation with temozolomide, then adjuvant nivolumab and temozolomide. The standard arm consisted of hypofractionated chemoradiation with temozolomide, then adjuvant temozolomide. The primary objective was to improve overall survival (OS) in the experimental arm.

Results

A total of 103 participants were randomized, with 69 in the experimental arm and 34 in the standard arm. The median (range) age was 73 (65-88) years. After 37 months of follow-up, the median OS was 11.6 months (95% CI, 9.7-13.4) in the experimental arm and 11.8 months (95% CI, 8.3-14.8) in the standard arm. For the experimental arm relative to the standard arm, the OS hazard ratio was 0.85 (95% CI, 0.54-1.33). In the experimental arm, there were three grade 3 immune-related adverse events which resolved, with no unexpected serious adverse events.

Conclusions

Due to insufficient evidence of benefit with nivolumab, the decision was made not to transition to a phase III trial. No new safety signals were identified with nivolumab. This complements the existing series of immunotherapy trials. Research is needed to identify biomarkers and new strategies including combinations.

Stepwise crosstalk between aberrant Nf1, Tp53 and Rb signalling pathways induces gliomagenesis in zebrafish

The molecular pathogenesis of glioblastoma indicates that RTK/Ras/PI3K, RB and TP53 pathways are critical for human gliomagenesis. Here, several transgenic zebrafish lines with single or multiple deletions of nf1, tp53 and rb1 in astrocytes, were established to genetically induce gliomagenesis in zebrafish. In the mutant with a single deletion, we found only the nf1 mutation low-efficiently induced tumour incidence, suggesting that the Nf1 pathway is critical for the initiation of gliomagenesis in zebrafish. Combination of mutations, nf1;tp53 and rb1;tp53 combined knockout fish, showed much higher tumour incidences, high-grade histology, increased invasiveness, and shortened survival time. Further bioinformatics analyses demonstrated the alterations in RTK/Ras/PI3K, cell cycle, and focal adhesion pathways, induced by abrogated nf1, tp53, or rb1, were probably the critical stepwise biological events for the initiation and development of gliomagenesis in zebrafish. Gene expression profiling and histological analyses showed the tumours derived from zebrafish have significant similarities to the subgroups of human gliomas. Furthermore, temozolomide treatment effectively suppressed gliomagenesis in these glioma zebrafish models, and the histological responses in temozolomide-treated zebrafish were similar to those observed in clinically treated glioma patients. Thus, our findings will offer a potential tool for genetically investigating gliomagenesis and screening potential targeted anti-tumour compounds for glioma treatment.

Congress of neurological surgeons systematic review and evidence-based guidelines update on the role of chemotherapeutic management and antiangiogenic treatment of newly diagnosed glioblastoma in adults

QUESTION

What is the role of temozolomide in the management of adult patients (aged 65 and under) with newly diagnosed glioblastoma?

TARGET POPULATION

These recommendations apply to adult patients diagnosed with newly diagnosed glioblastoma.

RECOMMENDATION

Level I: Concurrent and post-irradiation Temozolomide (TMZ) in combination with radiotherapy and post-radiotherapy as described by Stupp et al. is recommended to improve both PFS and OS in adult patients with newly diagnosed GBM. There is no evidence that alterations in the dosing regimen have additional beneficial effect.

QUESTION

Is there benefit to adjuvant temozolomide treatment in elderly patients (> 65 years old?).

TARGET POPULATION

These recommendations apply to adult patients diagnosed with newly diagnosed glioblastoma.

RECOMMENDATION

Level III: Adjuvant TMZ treatment is suggested as a treatment option to improve PFS and OS in adult patients (over 70 years of age) with newly diagnosed GBM.

QUESTION

What is the role of local regional chemotherapy with BCNU biodegradable polymeric wafers in adult patients with newly diagnosed glioblastoma?

TARGET POPULATION

These recommendations apply to adult patients diagnosed with newly diagnosed glioblastoma.

RECOMMENDATION

Level III: There is insufficient evidence for the use of BCNU wafers following resection in patients with newly diagnosed glioblastoma who undergo the Stupp protocol after surgery. Further studies of higher quality are suggested to understand the role of BCNU wafer and other locoregional therapy in the setting of Stupp Protocol.

QUESTION

What is the role of bevacizumab in the adult patient with newly diagnosed glioblastoma?

TARGET POPULATION

These recommendations apply to adult patients diagnosed with newly diagnosed glioblastoma.

RECOMMENDATION

Level I: Bevacizumab in general is not recommended in the initial treatment of adult patients with newly diagnosed GBM. It continues to be strongly recommended that patients with newly diagnosed GBM be enrolled in properly designed clinical trials to assess the benefit of novel chemotherapeutic agents compared to standard therapy.

Management of glioblastomas in the elderly population

Glioblastoma multiforme (GBM) is the most common primary brain tumor in adults. The incidence of malignant gliomas is growing in the elderly population. Unfortunately, increasing age is one of the most important negative prognostic factors for this tumor. For a long time, the treatment of elderly patients with GBM was controversial. Currently, more active strategies are the rule. Indeed, as in the younger population, prospective randomized studies have recently established the benefit of radiotherapy associated with concomitant and adjuvant chemotherapy by temozolomide in older patients suffering from malignant gliomas with good functional status. The application of chemotherapy alone may be especially useful in patients with poor functional status and O-6-methylguanine-DNA methyltransferase (MGMT) promotor methylation. For the portion of the elderly population identified as frail, treatment decisions should be made in the context of a comprehensive geriatric evaluation while also taking into account quality of life and concomitant pathologies. The willingness of the patient and his or her caregivers will also be key to the therapeutic decision. Symptomatic treatments such as corticosteroids and antiepileptic drugs may be less tolerated in this population compared to younger patients and should be used only if requested. In the future, it will be necessary to continue to develop specific schedules of treatment in the frail population. For this reason, prospective randomized clinical trials are still needed to pursue improvements in the pattern of care of malignant glioma in elderly individuals.

Hypofractionated radiation therapy versus chemotherapy with temozolomide in patients affected by RPA class V and VI glioblastoma: a randomized phase II trial

INTRODUCTION

In RPA V-VI glioblastoma patients both hypofractionated radiotherapy and exclusive temozolomide can be used; the purpose of this trial is to compare these treatment regimens in terms of survival and quality of life.

METHODS

Patients with histologic diagnosis of glioblastoma were randomized to hypofractionated radiotherapy (RT-30 Gy in 6 fractions) and exclusive chemotherapy (CHT-emozolomide 200 mg/m²/day 5 days every 28 days). Overall (OS) and progression free survival (PFS) were evaluated with Kaplan Maier curves and correlated with prognostic factors. Quality- adjusted survival (QaS) was evaluated according to the Murray model (Neurological Sign and Symptoms-NSS) RESULTS: From 2010 to 2015, 31 pts were enrolled (CHT: 17 pts; RT: 14pts). Four pts were excluded from the analysis. RPA VI (p = 0.048) and absence of MGMT methylation (p = 0.001) worsened OS significantly. Biopsy (p = 0.048), RPA class VI (p = 0.04) and chemotherapy (p = 0.007) worsened PFS. In the two arms the initial NSS scores were overlapping (CHT: 12.23 and RT: 12.30) and progressively decreased in both group and became significantly worse after 5 months in CHT arm (p = 0.05). Median QaS was 104 days and was significantly better in RT arm (p = 0.01).

CONCLUSIONS

The data obtained are limited by the poor accrual. Both treatments were well tolerated. Patients in RT arm have a better PFS and QaS, without significant differences in OS. The deterioration of the NSS score would seem an important parameter and coincide with disease progression rather than with the toxicity of the treatment.

Glioblastoma in Elderly Patients: Current Management and Future Perspectives

The incidence of glioblastoma (GBM) in the elderly population is slowly increasing in Western countries. Current management includes surgery, radiation therapy (RT) and chemotherapy; however, survival is significantly worse than that observed in younger patients and the optimal treatment in terms of efficacy and safety remains a matter of debate. Surgical resection is often employed as initial treatment for elderly patients with GBM, although the survival benefit is modest. Better survival has been reported in elderly patients treated with RT compared with those receiving supportive care alone, with similar survival outcome for patients undergoing standard RT (60 Gy over 6 weeks) and hypofractionated RT (25⁻40 Gy in 5⁻15 daily fractions). Temozolomide, an alkylating agent, may represent an effective and safe therapy in patients with promoter methylation of O⁶-methylguanine-DNA-methyltransferase (MGMT) gene which is predictor of responsiveness to alkylating agents. An abbreviated course of RT, 40 Gy in 15 daily fractions in combination with adjuvant and concomitant temozolomide has emerged as an effective treatment for patients aged 65 years old or over with GBM. Results of the National Cancer Institute of Canada Clinical Trials Group (NCIC CTG CE6) and European Organization for Research and Treatment of Cancer (EORTC 26062/22061) randomized study of short-course RT with or without concurrent and adjuvant temozolomide have demonstrated a significant improvement in progression-free survival and overall survival for patients receiving RT and temozolomide over RT alone, without impairing either quality of life or functional status. Although combined chemoradiation has become the recommended treatment in fit elderly patients with GBM, several questions remain unanswered, including the survival impact of chemoradiation in patients with impaired neurological status, advanced age (>75⁻80 years old), or for those with severe comorbidities. In addition, the efficacy and safety of alternative therapeutic approaches according to the methylation status of the O⁶-methylguanine-DNA methyl-transferase (MGMT) gene promoter need to be explored in future trials.

Treatment of Glioblastoma in Elderly Patients: An Overview of Current Treatments and Future Perspective

Current treatment of glioblastoma in the elderly includes surgery, radiotherapy and chemotherapy, but the prognosis remains extremely poor, and its optimal management is still debated. Longer survival after extensive resection compared with biopsy only has been reported, although the survival advantage remains modest. Radiation in the form of standard (60 Gy in 30 fractions over 6 weeks) and abbreviated courses of radiotherapy (30–50 Gy in 6–20 fractions over 2–4 weeks) has been employed in elderly patients with glioblastoma, showing survival benefits compared with supportive care alone. Temozolomide is an alkylating agent recently employed in older patients with newly diagnosed glioblastoma. The addition of concomitant and/or adjuvant chemotherapy with temozolomide to radiotherapy, which is currently the standard treatment in adults with glioblastoma, is emerging as an effective therapeutic option for older patients with favorable prognostic factors. The potential benefits on survival, improvement in quality of life and toxicity of different schedules of radiotherapy plus temozolomide need to be addressed in future randomized studies. Free full text available at www.tumorionline.it

Short-term Radiotherapy followed by Adjuvant Chemotherapy in Poor-Prognosis Patients with Glioblastoma

Objectives

The optimal treatment for patients with glioblastoma with unfavorable prognostic factors, such as old age and low performance status, remains controversial. We conducted a prospective study to assess the effect of temozolomide and short-course radiation versus short-course radiation alone in the treatment of poor-prognosis patients with newly diagnosed glioblastoma.

Patients and methods

Forty-five patients with a newly diagnosed glioblastoma, older than 70 years or aged 50–70 years and with a Karnofsky performance score ≤70 were enrolled in this prospective study. Twenty-three patients were treated with an abbreviated course of radiotherapy (30 Gy in 6 fractions over 2 weeks) and 22 patients with the same radiotherapy schedule plus adjuvant temozolomide at the dose of 150–200 mg/m2 for 5 days every 28-day cycle. The primary end point was overall survival. Secondary end points included progression-free survival and toxicity.

Results

Median overall survival was 7.3 months in the radiotherapy group and 9.4 months in the radiotherapy plus temozolomide group (P = 0.003), with respective 6-month overall survivals of 78% and 95%, respectively. Median progression-free survival was 4.4 months in the radiotherapy group and 5.5 months in the radiotherapy plus temozolomide group (P = 0.01), and respective 6-month progression-free survival rates were 22% and 45%. In multivariate analysis, Karnofsky performance score was the only significant independent predictive factor of survival (P = 0.03). Adverse effects of radiotherapy were mainly represented by neurotoxicity (24%), which resolved in most cases with the use of steroids. Grade 3-4 hematologic toxicity occurred in 36% of patients treated with temozolomide.

Conclusions

The addition of temozolomide to short-term radiotherapy resulted in a statistically significant survival benefit with minimal additional toxicity in poor-prognosis patients with newly diagnosed glioblastoma. Future studies need to define the best combined regimens of radiotherapy and temozolomide on survival and quality of life in this subgroup of patients.

Gliosarcomas in the Elderly: Analysis of 7 Cases and Clinico-Pathological Remarks

Aims and Background

Gliosarcomas are rare malignant primary brain tumors that usually affect the fifth or sixth decades of life. The purpose of this study was to describe our experience with such lesions in elderly patients and to establish their prognosis factors.

Methods

Between 1993 and 2001, 7 patients over 60 years of age were treated at our institute for cerebral gliosarcomas. All patients underwent surgery for total or at least sub-total removal of a neoplastic mass.

Results

Owing to poor clinical conditions (Karnofsky performance score = 40), one patient was not treated postoperatively. Remaining patients were treated with whole-brain radiotherapy, whereas concomitant chemotherapy (temozolomide) was administrated only to 4 patients. Histological examination showed the prevalence of sarcomatous aspects in 3 patients; the gliomatous aspect prevailed in 4 patients.

Conclusions

Sarcomatous aspects and multimodality treatment (surgery, radiotherapy and chemotherapy) were associated with a better prognosis and showed in these elderly patients a trend similar to that of young people.

Radiation therapy for older patients with brain tumors

The incidence of brain tumors in the elderly population has increased over the last few decades. Current treatment includes surgery, radiotherapy and chemotherapy, but the optimal management of older patients with brain tumors remains a matter of debate, since aggressive radiation treatments in this population may be associated with high risks of neurological toxicity and deterioration of quality of life. For such patients, a careful clinical status assessment is mandatory both for clinical decision making and for designing randomized trials to adequately evaluate the optimal combination of radiotherapy and chemotherapy.

Several randomized studies have demonstrated the efficacy and safety of chemotherapy for patients with glioblastoma or lymphoma; however, the use of radiotherapy given in association with chemotherapy or as salvage therapy remains an effective treatment option associated with survival benefit. Stereotactic techniques are increasingly used for the treatment of patients with brain metastases and benign tumors, including pituitary adenomas, meningiomas and acoustic neuromas. Although no randomized trials have proven the superiority of SRS over other radiation techniques in older patients with brain metastases or benign brain tumors, data extracted from recent randomized studies and large retrospective series suggest that SRS is an effective approach in such patients associated with survival advantages and toxicity profile similar to those observed in young adults. Future trials need to investigate the optimal radiation techniques and dose/fractionation schedules in older patients with brain tumors with regard to clinical outcomes, neurocognitive function, and quality of life.

Short-Course Radiation plus Temozolomide in Elderly Patients with Glioblastoma

BACKGROUND

Glioblastoma is associated with a poor prognosis in the elderly. Survival has been shown to increase among patients 70 years of age or younger when temozolomide chemotherapy is added to standard radiotherapy (60 Gy over a period of 6 weeks). In elderly patients, more convenient shorter courses of radiotherapy are commonly used, but the benefit of adding temozolomide to a shorter course of radiotherapy is unknown.

METHODS

We conducted a trial involving patients 65 years of age or older with newly diagnosed glioblastoma. Patients were randomly assigned to receive either radiotherapy alone (40 Gy in 15 fractions) or radiotherapy with concomitant and adjuvant temozolomide.

RESULTS

A total of 562 patients underwent randomization, 281 to each group. The median age was 73 years (range, 65 to 90). The median overall survival was longer with radiotherapy plus temozolomide than with radiotherapy alone (9.3 months vs. 7.6 months; hazard ratio for death, 0.67; 95% confidence interval [CI], 0.56 to 0.80; P<0.001), as was the median progression-free survival (5.3 months vs. 3.9 months; hazard ratio for disease progression or death, 0.50; 95% CI, 0.41 to 0.60; P<0.001). Among 165 patients with methylated O⁶-methylguanine-DNA methyltransferase (MGMT) status, the median overall survival was 13.5 months with radiotherapy plus temozolomide and 7.7 months with radiotherapy alone (hazard ratio for death, 0.53; 95% CI, 0.38 to 0.73; P<0.001). Among 189 patients with unmethylated MGMT status, the median overall survival was 10.0 months with radiotherapy plus temozolomide and 7.9 months with radiotherapy alone (hazard ratio for death, 0.75; 95% CI, 0.56 to 1.01; P=0.055; P=0.08 for interaction). Quality of life was similar in the two trial groups.

CONCLUSIONS

In elderly patients with glioblastoma, the addition of temozolomide to short-course radiotherapy resulted in longer survival than short-course radiotherapy alone. (Funded by the Canadian Cancer Society Research Institute and others; ClinicalTrials.gov number, NCT00482677 .).

Impact of standard care on elderly glioblastoma patients

Background

Uncertainty persists about the survival advantage of concomitant and adjuvant temozolomide (TMZ) plus radiotherapy (RT) in elderly patients with newly diagnosed glioblastoma (GBM). We compared the clinical outcome of unselected elderly GBM patients treated with 4 adjuvant treatment modalities, including the Stupp protocol.

Methods

From 2010 to 2014, retrospective chart review was performed on 171 GBM patients aged ≥55 who received either concurrent chemoradiation therapy (CCRT) with standard 60 Gy/30 (SRT); CCRT with hypofractionated 40 Gy/15 (HRT); HRT alone; or TMZ alone. Stratification is by age (55-69, ≥70), KPS (<70, ≥70), and resection status (biopsy, resection).

Results

Out of 171 patients identified, 128(75%) had surgical resection, median age was 66(55-83), and median overall survival (mOS) 11.4mo. Majority (109/171) were treated according to the Stupp protocol (CCRT-SRT), and 106/171 received post-CCRT adjuvant TMZ (median of 3 cycles). In our population, age <70yo was a significant prognostic factor (mOS of patients aged 55-69 vs ≥70 yo = 13.3 vs 6.6 mo; P = .001). However, among the population receiving the Stupp regimen, there was no difference in survival between patients aged 55-69 and those ≥70 (respectively, 14.4 vs 13.2 mo; P = .798). Patients ≥70 yo had similar survival when treated with CCRT-HRT and CCRT-SRT (P = .248), although numbers were small.

Conclusions

Our data suggests that, despite having a worse global prognostic than their younger counterparts, GBM patients ≥70yo with a good performance status could be treated according to the Stupp protocol with similar survival. Theses results need prospective confirmation.

Radiotherapy with or without temozolomide in elderly patients aged ≥ 70 years with glioblastoma

Introduction

Although the recommended optimal treatment of glioblastoma multiforme (GBM) is adjuvant chemoradiotherapy, trials in GBM have excluded patients older than 70 years. In this study, we aimed to assess overall survival (OS) and prognostic factors in elderly patients (≥ 70 years) with newly diagnosed GBM treated with radiotherapy (RT) ± concurrent/adjuvant temozolomide (TMZ).

Material and methods

Inclusion criteria were patients ≥ 70 years, pre-RT Karnofsky performance status (KPS) ≥ 60, and time between diagnosis and start of RT ≤ 2 months. A total of 40 patients aged ≥ 70 years, 12 female and 28 male, treated between January 2004 and December 2012, were evaluated. Median age was 73.5 years (range, 70–83 years). The median RT dose was 60 Gy (range, 30–62 Gy). Twenty-one (52.5%) received concurrent TMZ, and of those 12 (30%) went on to receive adjuvant TMZ.

Results

The median OS was 7 months (95% CI: 5.45–8.54). One- and two-year OS for the whole cohort was 38% and 16%, respectively. Sex, type of surgery, tumor size, and RT dose did not significantly affect the OS. Presence of concurrent TMZ (p < 0.005) and presence of adjuvant TMZ (p < 0.001) were associated with longer OS in our cohort.

Conclusions

RT ± TMZ seems to be a well-tolerated treatment in patients ≥ 70 years with GBM. Even though no superiority was found between conventional or hypofractionated RT regimens (p = 0.405), the addition of concurrent and adjuvant TMZ to RT increased the OS in our study.

Nano-structures mediated co-delivery of therapeutic agents for glioblastoma treatment: A review

Glioblastoma is a malignant brain tumor and leads to death in most patients. Chemotherapy is a common method for brain cancer in clinics. However, the recent advancements in the chemotherapy of brain tumors have not been efficient enough. With the advancement of nanotechnology, the used drugs can enhance chemotherapy efficiency and increase the access to brain cancers. Combination of therapeutic agents has been recently attracted great attention for glioblastoma chemotherapy. One of the early benefits of combination therapies is the high potential to provide synergistic effects and decrease adverse side effects associated with high doses of single anticancer drugs. Therefore, brain tumor treatments with combination drugs can be considered as a crucial approach for avoiding tumor growth. This review investigates current progress in nano-mediated co-delivery of therapeutic agents with focus on glioblastoma chemotherapy prognosis.

Glioblastoma care in the elderly

Glioblastoma is common among elderly patients, a group in which comorbidities and a poor prognosis raise important considerations when designing neuro-oncologic care. Although the standard of care for nonelderly patients with glioblastoma includes maximal safe surgical resection followed by radiotherapy with concurrent and adjuvant temozolomide, the safety and efficacy of these modalities in elderly patients are less certain given the population's underrepresentation in many clinical trials. The authors reviewed the clinical trial literature for reports on the treatment of elderly patients with glioblastoma to provide evidence-based guidance for practitioners. In elderly patients with glioblastoma, there is a survival advantage for those who undergo maximal safe resection, which likely includes an incremental benefit with increasing completeness of resection. Radiotherapy extends survival in selected patients, and hypofractionation appears to be more tolerable than standard fractionation. In addition, temozolomide chemotherapy is safe and extends the survival of patients with tumors that harbor O(6)-methylguanine-DNA methyltransferase (MGMT) promoter methylation. The combination of standard radiation with concurrent and adjuvant temozolomide has not been studied in this population. Although many questions remain unanswered regarding the treatment of glioblastoma in elderly patients, the available evidence provides a framework on which providers may base individual treatment decisions. The importance of tumor biomarkers is increasingly apparent in elderly patients, for whom the therapeutic efficacy of any treatment must be weighed against its potential toxicity. MGMT promoter methylation status has specifically demonstrated utility in predicting the efficacy of temozolomide and should be considered in treatment decisions when possible. Cancer 2016;122:189-197. © 2015 American Cancer Society.

Glioblastoma in the elderly: the effect of aggressive and modern therapies on survival

OBJECTIVE

The prognosis of elderly patients with glioblastoma (GBM) is universally poor. Currently, few studies have examined postoperative outcomes and the effects of various modern therapies such as bevacizumab on survival in this patient population. In this study, the authors evaluated the effects of various factors on overall survival in a cohort of elderly patients with newly diagnosed GBM.

METHODS

A retrospective review was performed of elderly patients (≥ 65 years old) with newly diagnosed GBM treated between 2004 and 2010. Various characteristics were evaluated in univariate and multivariate stepwise models to examine their effects on complication risk and overall survival.

RESULTS

A total of 120 patients were included in the study. The median age was 71 years, and sex was distributed evenly. Patients had a median Karnofsky Performance Scale (KPS) score of 80 and a median of 2 neurological symptoms on presentation. The majority (53.3%) of the patients did not have any comorbidities. Tumors most frequently (43.3%) involved the temporal lobe, followed by the parietal (35.8%), frontal (32.5%), and occipital (15.8%) regions. The majority (57.5%) of the tumors involved eloquent structures. The median tumor size was 4.3 cm. Every patient underwent resection, and 63.3% underwent gross-total resection (GTR). The vast majority (97.3%) of the patients received the postoperative standard of care consisting of radiotherapy with concurrent temozolomide. The majority (59.3%) of patients received additional agents, most commonly consisting of bevacizumab (38.9%). The median survival for all patients was 12.0 months; 26.7% of patients experienced long-term (≥ 2-year) survival. The extent of resection was seen to significantly affect overall survival; patients who underwent GTR had a median survival of 14.1 months, whereas those who underwent subtotal resection had a survival of 9.6 months (p = 0.038). Examination of chemotherapeutic effects revealed that the use of bevacizumab compared with no bevacizumab (20.1 vs 7.9 months, respectively; p < 0.0001) and irinotecan compared with no irinotecan (18.0 vs 9.7 months, respectively; p = 0.027) significantly improved survival. Multivariate stepwise analysis revealed that older age (hazard ratio [HR] 1.06 [95% CI1.02-1.10]; p = 0.0077), a higher KPS score (HR 0.97 [95% CI 0.95-0.99]; p = 0.0082), and the use of bevacizumab (HR 0.51 [95% CI 0.31-0.83]; p = 0.0067) to be significantly associated with survival.

CONCLUSION

This study has demonstrated that GTR confers a modest survival benefit on elderly patients with GBM, suggesting that safe maximal resection is warranted. In addition, bevacizumab significantly increased the overall survival of these elderly patients with GBM; older age and preoperative KPS score also were significant prognostic factors. Although elderly patients with GBM have a poor prognosis, they may experience enhanced survival after the administration of the standard of care and the use of additional chemotherapeutics such as bevacizumab.

Management of high-grade gliomas in the elderly

The incidence of glioblastoma (GBM) has been increasing over the past several decades with majority of this increase occurring in patients older than 70 years. In spite of the growing body of evidence in this area, it is still unclear as to the optimal management of elderly patients with GBM. The elderly are a heterogeneous population with a range of comorbid conditions, and functional, cognitive, and physiological changes, and ideally treatment decisions should be made in the context of a comprehensive geriatric assessment. Patients with a poor performance status or assessed as "frail" might be considered for less aggressive therapy such as hypofractionated radiotherapy or single-agent temozolomide, whereas those with a good functional status may still benefit from maximum resection followed by combined radiation and chemotherapy. Recent randomized trials suggest molecular markers such as O(6)-methylguanine-DNA-methyltransferase promoter methylation testing could help guide these decisions, particularly when considering monotherapy with temozolomide vs radiotherapy. Ongoing studies seek to clarify the role of concurrent treatment in this population. Clinical judgment and discussion with patients and families, weighing all the options, are necessary in each case. Ultimately, patients and the neuro-oncology community should be encouraged to participate in clinical trials focused specifically on caring for the elderly patient with GBM.

Treating glioblastoma in the elderly

The incidence of glioblastoma (GBM) is increasing among the elderly, who now account for up to half of all the adult cases of GBM. This trend has resulted in the recent development of clinical research specifically dedicated to this fragile population. Some studies have investigated surgical resection, radiotherapy and chemotherapy with temozolomide, and ongoing research is currently addressing the use of combined radiochemotherapy in this population. Although older patients with GBM have a significantly worse life expectancy compared with their younger counterparts, etiologic treatments should not be withheld from these patients solely because of their age. On the contrary, results from prospective studies suggest that active care of these patients has a significant positive impact on survival without affecting quality of life or cognition. To optimize both symptomatic and etiologic treatment, neuro-oncology multidisciplinary teams must take into account performance and cognitive status, the resectability of the tumor, and associated comorbidities.

Biopsy versus partial versus gross total resection in older patients with high-grade glioma: a systematic review and meta-analysis

BACKGROUND

Optimal extent of surgical resection (EOR) of high-grade gliomas (HGGs) remains uncertain in the elderly given the unclear benefits and potentially higher rates of mortality and morbidity associated with more extensive degrees of resection.

METHODS

We undertook a meta-analysis according to a predefined protocol and systematically searched literature databases for reports about HGG EOR. Elderly patients (≥60 y) undergoing biopsy, subtotal resection (STR), and gross total resection (GTR) were compared for the outcome measures of overall survival (OS), postoperative karnofsky performance status (KPS), progression-free survival (PFS), mortality, and morbidity. Treatment effects as pooled estimates, mean differences (MDs), or risk ratios (RRs) with corresponding 95% confidence intervals (CIs) were determined using random effects modeling.

RESULTS

A total of 12 607 participants from 34 studies met eligibility criteria, including our current cohort of 211 patients. When comparing overall resection (of any extent) with biopsy, in favor of the resection group were OS (MD 3.88 mo, 95% CI: 2.14-5.62, P < .001), postoperative KPS (MD 10.4, 95% CI: 6.58-14.22, P < .001), PFS (MD 2.44 mo, 95% CI: 1.45-3.43, P < .001), mortality (RR = 0.27, 95% CI: 0.12-0.61, P = .002), and morbidity (RR = 0.82, 95% CI: 0.46-1.46, P = .514) . GTR was significantly superior to STR in terms of OS (MD 3.77 mo, 95% CI: 2.26-5.29, P < .001), postoperative KPS (MD 4.91, 95% CI: 0.91-8.92, P = .016), and PFS (MD 2.21 mo, 95% CI: 1.13-3.3, P < .001) with no difference in mortality (RR = 0.53, 95% CI: 0.05-5.71, P = .600) or morbidity (RR = 0.52, 95% CI: 0.18-1.49, P = .223).

CONCLUSIONS

Our findings suggest an upward improvement in survival time, functional recovery, and tumor recurrence rate associated with increasing extents of safe resection. These benefits did not result in higher rates of mortality or morbidity if considered in conjunction with known established safety measures when managing elderly patients harboring HGGs.

Management of elderly patients with gliomas

The current progressive aging of the population is resulting in a continuous increase in the incidence of gliomas in elderly people, especially the most frequent subtype, glioblastoma (GBM). This sociohealth shift, known as the "silver tsunami," has prompted the neuro-oncology community to investigate the role of specific antitumor treatments, such as surgery, radiotherapy, chemotherapy, and other targeted therapies, for these traditionally undertreated patients. Advanced age, a widely recognized poor prognostic factor in both low-grade glioma (LGG) and high-grade glioma patients, should no longer be the sole reason for excluding such older patients from receiving etiologic treatments. Far from it, results from recent prospective trials conducted on elderly patients with GBM demonstrate that active management of these patients can have a positive impact on survival without impairing either cognition or quality of life. Although prospective studies specifically addressing the management of grade 2 and 3 gliomas are lacking and thus needed, the aforementioned tendency toward acknowledging a therapeutic benefit for GBM patients might also apply to the treatment of patients with LGG and anaplastic gliomas. In order to optimize such etiologic treatment in conjunction with symptomatic management, neuro-oncology multidisciplinary boards must individually consider important features such as resectability of the tumor, functional and cognitive status, associated comorbidities, and social support.

The future of glioblastoma therapy: synergism of standard of care and immunotherapy

The current standard of care for glioblastoma (GBM) is maximal surgical resection with adjuvant radiotherapy and temozolomide (TMZ). As the 5-year survival with GBM remains at a dismal <10%, novel therapies are needed. Immunotherapies such as the dendritic cell (DC) vaccine, heat shock protein vaccines, and epidermal growth factor receptor (EGFRvIII) vaccines have shown encouraging results in clinical trials, and have demonstrated synergistic effects with conventional therapeutics resulting in ongoing phase III trials. Chemoradiation has been shown to have synergistic effects when used in combination with immunotherapy. Cytotoxic ionizing radiation is known to trigger pro-inflammatory signaling cascades and immune activation secondary to cell death, which can then be exploited by immunotherapies. The future of GBM therapeutics will involve finding the place for immunotherapy in the current treatment regimen with a focus on developing strategies. Here, we review current GBM therapy and the evidence for combination of immune checkpoint inhibitors, DC and peptide vaccines with the current standard of care.

Concomitant treatment with temozolomide enhances apoptotic cell death in glioma cells induced by photodynamic therapy with talaporfin sodium

BACKGROUND

Photodynamic therapy (PDT) induces selective cell death of neoplastic tissue and connecting vasculature by combining photosensitizers with light. We have previously reported that PDT induces apoptotic cell death in glioma cells when the photosensitizer talaporfin sodium (NPe6) is used. Here, we investigated the combined effect of NPe6-PDT with temozolomide, a DNA-alkylating drug used in glioma therapy.

METHODS

Human glioblastoma T98G cells and human glioma U251 cells were used as glioma cells. Cell viability was evaluated by WST-8 assay. Apoptosis was evaluated by measurement of caspase-3 activity and DNA-fragmentation. Intracellular reactive oxygen species were evaluated by dihydrorhodamine assay.

RESULTS

While the degree of NPe6-PDT induced cell death unchanged in T98G and U251 cells when temozolomide treatment was adjuvant, it was dose-dependently increased by concomitant treatment with temozolomide. Further, concomitantly administered temozolomide dose-dependently increased caspase-3 activity and DNA-fragmentation, while adjuvant-temozolomide did not. These results are suggesting that concomitantly administered temozolomide potentiates the effect of NPe6-PDT to facilitate apoptotic cell death. Additionally, concomitantly administered temozolomide increased intracellular NPe6-fluorescence and reactive oxygen species, suggesting that the augmentation effect of combined treatment may be due to increased intracellular accumulation of NPe6.

CONCLUSION

These results suggest that concomitant treatment with NPe6-PDT and temozolomide is a potentially useful therapy for glioma.

[Management of gliomas]

Gliomas are the most frequent primary brain tumors. Their care is difficult because of the proximity of organs at risk. The treatment of glioblastoma includes surgery followed by chemoradiation with the protocol of Stupp et al. The addition of bevacizumab allows an increase in progression-free survival by 4 months but it does not improve overall survival. This treatment is reserved for clinical trials. Intensity modulation radiotherapy may be useful to reduce the neurocognitive late effects in different types of gliomas. In elderly patients an accelerated radiotherapy 40 Gy in 15 fractions allows a similar survival to standard radiotherapy. O(6)-methylguanine-DNA methyltransferase (MGMT) status may help to choose between chemotherapy and radiotherapy. There is no standard for the treatment of recurrent gliomas. Re-irradiation in stereotactic conditions allows a median survival of 8 to 12.4 months. Anaplastic gliomas with 1p19q mutation have a greater sensibility to chemotherapy by procarbazine, lomustine and vincristine. Chemoradiotherapy in these patients has become the standard treatment. Many studies are underway testing targeted therapies, their place in the therapeutic management and new radiotherapy techniques.

Radiation therapy for older adults with glioblastoma: radical treatment, palliative treatment, or no treatment at all?

The incidence of glioblastoma in older adults has increased over the last few decades. Current treatment includes surgery, radiotherapy, and chemotherapy, but optimal disease management remains a matter of debate. Both standard (60 Gy in 30 daily fractions) and hypofractionated radiotherapy (30-40 Gy in 10-15 daily fractions) have been employed with a similar survival benefit. Recent randomized studies indicate that chemotherapy with the alkylating agent temozolomide is a safe and effective therapeutic option for patients aged 60 years or older with newly diagnosed glioblastoma, suggesting that it should be a sufficient treatment for patients presenting with a methylated O6-methylguanine-DNA methyltransferase (MGMT) promoter gene. The addition of concomitant temozolomide chemotherapy, adjuvant temozolomide chemotherapy, or both to postoperative radiotherapy, which is the standard treatment for adults with glioblastoma, has been associated with a survival benefit for older patients with a good performance status; however, aggressive treatment in this population may be associated with a high risk of neurological toxicity and deterioration of quality of life. Survival stratification according to age, MGMT promoter methylation status, and neurological status may be useful for clinical decision making and designing randomized trials for adequately evaluating the optimal combination of radiotherapy and chemotherapy for older patients with glioblastoma.

Malignant astrocytoma in elderly patients: where do we stand?

PURPOSE OF REVIEW

Age is inversely correlated with clinical outcome and a strong prognostic factor for the course of most primary brain tumors including malignant astrocytoma, i.e. anaplastic astrocytoma and glioblastoma. We here review available clinical outcome data and discuss future directions of clinical research.

RECENT FINDINGS

The standard of care in patients with malignant astrocytoma above the range of 65-70 years was considered radiotherapy, preferentially using a hypofractionated regimen (15 × 2.66 Gy). Two phase III clinical trials, the NOA-08 and Nordic trials, demonstrated that temozolomide (TMZ) therapy alone was not inferior to radiotherapy alone, and methylation of the O-methylguanine-DNA-methyltransferase (MGMT) gene promoter was predictive with a methylated MGMT promoter indicating a benefit from TMZ chemotherapy. Ongoing clinical trials in this patient population include the National Cancer Institute of Canada/European Organisation for Research and Treatment of Cancer intergroup trial, investigating the combination of hypofractionated radiotherapy and TMZ chemotherapy, and the Swiss ARTE trial, investigating the combination of bevacizumab and hypofractionated radiotherapy. Recent translational studies indicate that prognostically favorable factors in malignant astrocytoma from younger patients are virtually absent in the elderly.

SUMMARY

Current standard of care for elderly patients with malignant astrocytoma involves a treatment strategy based on the MGMT gene promoter methylation status. The role of combined radiotherapy and TMZ chemotherapy and a potential role for the addition of anti-VEGF therapy to radiotherapy are currently addressed in ongoing trials. The lack of favorable prognostic factors in tumor tissue might in part explain the poorer clinical outcome of elderly patients.

Elderly patients aged 65-75 years with glioblastoma multiforme may benefit from long course radiation therapy with temozolomide

To determine the outcome of elderly patients with glioblastoma managed with hypofractionated [40 Gray (Gy)] or long-course (60 Gy) radiation therapy (RT). Patients aged >60 years diagnosed with WHO grade IV glioma managed with RT between October 2006 and July 2012 were retrospectively identified. Baseline data including ECOG performance status, RT dose and use of temozolomide (TMZ) were recorded. Overall survival was calculated in months from date of diagnosis. 109 patients were included with age distribution from 61 to 88 years (13 % <65, 63 % 65-75, and 24 % >75). Median survival (MS) of total group was 12 months (95 % CI 11-13) with 12 % surviving beyond 2 years. For age groups <65, 65-75, >75 the survival was 17, 12, and 9 months respectively (p = 0.001). Near total resection (p = 0.027), but not ECOG 0-1 (p = 0.34) was associated with improved MS. For the 69 patients aged 65-75, 55 % were managed with 40 Gy and 45 % 60 Gy. Longer survival was associated with the use of 60 Gy (15 vs. 9 months, p < 0.0001), and use of TMZ (13 vs. 7 months, p < 0.0001). In the 48 patients (70 %) managed with TMZ, the MS was 15 months with 60 Gy (95 % CI 13-17) compared with 11 months (95 % CI 9-13) in those with 40 Gy. Performance status with ECOG 0-1 was not associated with improved survival (p = 0.25). Within the limitations of a retrospective study, we demonstrate improved MS in the elderly population when TMZ is added to RT. Those in the age group 65-75 may benefit from long-course RT with TMZ.

Treating glioblastoma patients with poor performance status: where do we go from here?

Approximately one third of all glioblastoma patients exhibit an impaired functional status in the perioperative setting. Their optimal management is difficult to define. The only available prospective study in poor performance status (PS) patients has been performed in elderly patients (≥ 70 years). In this population, treatment with temozolomide was shown to be safe and to be associated with a clinically significant improvement of PS in one third of patients. In young patients (<70 years), daily clinical experience and retrospective data show that some patients can benefit from temozolomide radiochemotherapy, abbreviated radiation courses, upfront chemotherapy or early use of bevacizumab. However, prospective studies are needed to correctly evaluate these strategies, namely their impact on functional status and quality of life.

Treatment of malignant gliomas in elderly patients: a concise overview of the literature

Gliomas are the most frequent primary brain tumors and the incidence data has increased in the elderly population. Unfortunately, prospective studies on this population are few and so the right treatment is unknown. In the elderly patients no standard treatment has been established and therefore the optimal treatment should be individualized. We performed a review analyzing the prognostic and predictive factors, the clinical studies, and the correct management of this population.

Outcome of conventional treatment and prognostic factor in elderly glioblastoma patients

BACKGROUND

Glioblastoma (GBM) is the most life-threatening primary brain tumour. Especially in elderly patients, a poorer outcome is noticeable. Until now, the effectiveness of the conventional active treatment has been controversial. The purpose of this study is to find the optimal treatment for elderly patients with newly diagnosed GBM.

METHOD

The authors retrospectively reviewed 301 patients who were diagnosed with GBM at a single centre from January 2006 to December 2010. All patients were divided into younger and elderly groups based on the cut-off age of 65 years, and the treatment outcome was analysed.

RESULTS

Of 301 patients, 67 (23.3 %) patients were 65 years old or older, and 234 (77.7 %) patients were younger than 65 years. In the elderly group, 49 patients received surgical resection and 18 patients received biopsy. Forty-seven patients (70.1 %) underwent concomitant chemoradiotherapy (CCRT) and 38 patients (56.7 %) underwent adjuvant temozolomide (TMZ) chemotherapy. The median overall survival (OS) of elderly patients was 12.0 months and the progression-free survival (PFS) was 8.5 months. The median OS of elderly patients who underwent CCRT and adjuvant TMZ chemotherapy increased to 16.2 months. On the multivariate analysis, tumour infiltration (p = 0.005), and resection (p = 0.001) were significant independent prognostic factors in elderly patients. The grade 3 or 4 complication rate was not statistically different between the younger group (n = 22, 9.4 %) and the elderly group (n = 8, 12 %).

CONCLUSION

Elderly patients diagnosed with GBM had a survival benefit and a low complication rate with the conventional treatment. Therefore, elderly patients should be encouraged to receive the conventional active treatment.

High-grade glioma in elderly patients: can the oncogeriatrician help?

Gliomas are the most frequent primary brain tumors in adults. As the population ages in Western countries, the number of people being diagnosed with glioblastoma is expected to increase. Clinical management of elderly patients with primary brain tumors is difficult, owing to multiple comorbidities, polypharmacy, decreased tolerance to chemotherapy, and an increased risk of radiation-induced neurotoxicity. A few specific randomized studies have shown a benefit for radiotherapy in elderly patients with good performance status. For patients with poor performance status, chemotherapy (temozolomide) has been shown to be associated with prolonged duration of response. Patients with methylated O⁶-alkylguanine deoxyribonucleic acid alkyltransferase promoter seem to have better outcomes. Oncogeriatrics proposes the geriatric evaluation of elderly patients to improve therapeutic choices and optimize the management of treatment toxicities and comorbidities.

Treatment outcomes in glioblastoma patients aged 76 years or older: a multicenter retrospective cohort study

Age is one of the most important prognostic factors in glioblastoma patients, but no standard treatment has been established for elderly patients with this condition. We therefore conducted a retrospective cohort study to evaluate treatment regimens and outcomes in elderly glioblastoma patients. The study population consisted of 79 glioblastoma patients aged ≥ 76 years (median age 78.0 years; 34 men and 45 women). The median preoperative Karnofsky performance status (KPS) score was 60. Surgical procedures were classified as biopsy (31 patients, 39.2 %), <95 % resection of the tumor (21 patients, 26.9 %), and ≥ 95 % resection of the tumor (26 patients, 33.3 %). Sixty-seven patients (81.0 %) received radiotherapy and 45 patients (57.0 %) received chemotherapy. The median overall progression-free survival time was 6.8 months, and the median overall survival time was 9.8 months. Patients aged ≥ 78 years were significantly less likely to receive radiotherapy (p = 0.004). Patients with a postoperative KPS score of ≥ 60 were significantly more likely to receive maintenance chemotherapy (p = 0.008). Multivariate analyses identified two independent prognostic factors: postoperative KPS score ≥ 60 (hazard ratio [HR] = 0.531, 95 % confidence interval [CI] 0.315-0.894, p = 0.017) and temozolomide therapy (HR = 0.442, 95 % CI 0.25-0.784, p < 0.001).The findings of this study suggest that postoperative KPS score is an important prognostic factor for glioblastoma patients aged ≥ 76 years, and that these patients may benefit from temozolomide therapy.

Outcomes in newly diagnosed elderly glioblastoma patients after concomitant temozolomide administration and hypofractionated radiotherapy

This study aimed to analyze the treatment and outcomes of older glioblastoma patients. Forty-four patients older than 70 years of age were referred to the Paul Strauss Center for chemotherapy and radiotherapy. The median age was 75.5 years old (range: 70–84), and the patients included 18 females and 26 males. The median Karnofsky index (KI) was 70%. The Charlson indices varied from 4 to 6. All of the patients underwent surgery. O₆-methylguanine–DNA methyltransferase (MGMT) methylation status was determined in 25 patients. All of the patients received radiation therapy. Thirty-eight patients adhered to a hypofractionated radiation therapy schedule and six patients to a normofractionated schedule. Neoadjuvant, concomitant and adjuvant chemotherapy regimens were administered to 12, 35 and 20 patients, respectively. At the time of this analysis, 41 patients had died. The median time to relapse was 6.7 months. Twenty-nine patients relapsed, and 10 patients received chemotherapy upon relapse. The median overall survival (OS) was 7.2 months and the one- and two-year OS rates were 32% and 12%, respectively. In a multivariate analysis, only the Karnofsky index was a prognostic factor. Hypofractionated radiotherapy and chemotherapy with temozolomide are feasible and acceptably tolerated in older patients. However, relevant prognostic factors are needed to optimize treatment proposals.

Malignant astrocytomas of elderly patients lack favorable molecular markers: an analysis of the NOA-08 study collective

BACKGROUND

The number of patients age >65 years with malignant gliomas is increasing. Prognosis of these patients is worse compared with younger patients. To determine biological differences among malignant gliomas of different age groups and help to explain the survival heterogeneity seen in the NOA-08 trial, the prevalence and impact of recently established biomarkers for outcome in younger patients were characterized in elderly patients.

METHODS

Prevalences of mutations of isocitrate dehydrogenase 1 (IDH1) and histone H3.3 (H3F3A), the glioma cytosine-phosphate-guanine island methylator phenotype (G-CIMP), and methylation of alkylpurine DNA N-glycosylase (APNG) and peroxiredoxin 1 (PRDX1) promoters were determined in a representative biomarker subset (n = 126 patients with anaplastic astrocytoma or glioblastoma) from the NOA-08 trial.

RESULTS

IDH1 mutations (R132H) were detected in only 3/126 patients, precluding determination of an association between IDH mutation and outcome. These 3 patients also displayed the G-CIMP phenotype. None of the IDH1 wild-type tumors were G-CIMP positive. Mutations in H3F3A were absent in all 103 patients sequenced for H3F3A. MassARRAY analysis of the APNG promoter revealed generally low methylation levels and failed to confirm any predictive properties for benefit from alkylating chemotherapy. Neither did PRDX1 promoter methylation show differential methylation or association with outcome in this cohort. In a 170-patient cohort from The Cancer Genome Atlas database matched for relevant prognostic factors, age ≥65 years was strongly associated with shorter survival.

CONCLUSIONS

Despite an age-independent stable frequency of O(6)-methylguanine-DNA methyltransferase (MGMT) promoter hypermethylation, tumors in this age group largely lack prognostically favorable markers established in younger glioblastoma patients, which likely contributes to the overall worse prognosis of elderly patients. However, the survival differences hint at fundamental further differences among malignant gliomas of different age groups.

[Adjuvant radiochemotherapy in the elderly affected by glioblastoma: single-institution experience and literature review]

PURPOSE

Radiochemotherapy (RCT) is the standard adjuvant treatment for patients affected by glioblastoma (GBM). As there is no evidence in elderly patients with GBM, combined, single modality or best supportive care is used. The aim of this retrospective study was to evaluate acute toxicity and outcome of elderly patients with GBM treated with RCT with temozolomide (TMZ).

MATERIALS AND METHODS

Patients >65 years with newly diagnosed GBM who underwent surgery or biopsy and RCT were evaluated. Recursive Partitioning Analysis (RPA) class and National Cancer Institute--Common Toxicity Criteria (NCI-CTC) version 3 were used to classify patients and evaluate acute toxicity, respectively.

RESULTS

From April 2005 to January 2011, 35 patients (18 women and 17 men) with GBM were treated at our institution. Only 31.43% of cases underwent complete resection. Median progression-free survival (PFS) was 8 months and median overall survival (OS) 13 months. At univariate and multivariate analysis, only RPA class correlated with OS (p=0.01, p=0.03, respectively). During RCT, toxicity was mild (thrombocytopaenia G3-4, 11.43%; neurological toxicity, G3-4, 8.57%).

CONCLUSIONS

Our data suggest that RCT with TMZ seems to produce a better outcome with a mild toxicity profile in elderly patients affected by GBM.

SEOM guideline for the treatment of malignant glioma

High-grade gliomas are an infrequent disease diagnosed usually in the fifth or sixth decade. Careful histopathological diagnosis is essential because tumour grade and type condition the treatment. Magnetic resonance with gadolinium is considered the standard radiologic exploration and should be followed by tissue sampling. Treatment of these patients should be decided in a multidisciplinary committee. Surgery, radiotherapy and chemotherapy are the basis of patients' treatment, with the best results obtained when the three of them can be used.

Temozolomide versus standard 6-week radiotherapy versus hypofractionated radiotherapy in patients older than 60 years with glioblastoma: the Nordic randomised, phase 3 trial

BACKGROUND

Most patients with glioblastoma are older than 60 years, but treatment guidelines are based on trials in patients aged only up to 70 years. We did a randomised trial to assess the optimum palliative treatment in patients aged 60 years and older with glioblastoma.

METHODS

Patients with newly diagnosed glioblastoma were recruited from Austria, Denmark, France, Norway, Sweden, Switzerland, and Turkey. They were assigned by a computer-generated randomisation schedule, stratified by centre, to receive temozolomide (200 mg/m(2) on days 1-5 of every 28 days for up to six cycles), hypofractionated radiotherapy (34·0 Gy administered in 3·4 Gy fractions over 2 weeks), or standard radiotherapy (60·0 Gy administered in 2·0 Gy fractions over 6 weeks). Patients and study staff were aware of treatment assignment. The primary endpoint was overall survival. Analyses were done by intention to treat. This trial is registered, number ISRCTN81470623.

FINDINGS

342 patients were enrolled, of whom 291 were randomised across three treatment groups (temozolomide n=93, hypofractionated radiotherapy n=98, standard radiotherapy n=100) and 51 of whom were randomised across only two groups (temozolomide n=26, hypofractionated radiotherapy n=25). In the three-group randomisation, in comparison with standard radiotherapy, median overall survival was significantly longer with temozolomide (8·3 months [95% CI 7·1-9·5; n=93] vs 6·0 months [95% CI 5·1-6·8; n=100], hazard ratio [HR] 0·70; 95% CI 0·52-0·93, p=0·01), but not with hypofractionated radiotherapy (7·5 months [6·5-8·6; n=98], HR 0·85 [0·64-1·12], p=0·24). For all patients who received temozolomide or hypofractionated radiotherapy (n=242) overall survival was similar (8·4 months [7·3-9·4; n=119] vs 7·4 months [6·4-8·4; n=123]; HR 0·82, 95% CI 0·63-1·06; p=0·12). For age older than 70 years, survival was better with temozolomide and with hypofractionated radiotherapy than with standard radiotherapy (HR for temozolomide vs standard radiotherapy 0·35 [0·21-0·56], p<0·0001; HR for hypofractionated vs standard radiotherapy 0·59 [95% CI 0·37-0·93], p=0·02). Patients treated with temozolomide who had tumour MGMT promoter methylation had significantly longer survival than those without MGMT promoter methylation (9·7 months [95% CI 8·0-11·4] vs 6·8 months [5·9-7·7]; HR 0·56 [95% CI 0·34-0·93], p=0·02), but no difference was noted between those with methylated and unmethylated MGMT promoter treated with radiotherapy (HR 0·97 [95% CI 0·69-1·38]; p=0·81). As expected, the most common grade 3-4 adverse events in the temozolomide group were neutropenia (n=12) and thrombocytopenia (n=18). Grade 3-5 infections in all randomisation groups were reported in 18 patients. Two patients had fatal infections (one in the temozolomide group and one in the standard radiotherapy group) and one in the temozolomide group with grade 2 thrombocytopenia died from complications after surgery for a gastrointestinal bleed.

INTERPRETATION

Standard radiotherapy was associated with poor outcomes, especially in patients older than 70 years. Both temozolomide and hypofractionated radiotherapy should be considered as standard treatment options in elderly patients with glioblastoma. MGMT promoter methylation status might be a useful predictive marker for benefit from temozolomide.

FUNDING

Merck, Lion's Cancer Research Foundation, University of Umeå, and the Swedish Cancer Society.

Temozolomide and other potential agents for the treatment of glioblastoma multiforme

This article provides historical and recent perspectives related to the use of temozolomide for the treatment of glioblastoma multiforme. Temozolomide has quickly become part of the standard of care for the modern treatment of stage IV glioblastoma multiforme since its approval in 2005. Yet despite its improvements from previous therapies, median survival remains approximately 15 months, with a 2-year survival rate of 8% to 26%. The mechanism of action of this chemotherapeutic agent, conferred advantages and limitations, treatment resistance and rescue, and potential targets of future research are discussed.

Impact of age and co-morbidities in patients with newly diagnosed glioblastoma: a pooled data analysis of three prospective mono-institutional phase II studies

To analyse the impact of age and co-morbidities on compliance and outcomes in GBM patients enrolled in three prospective phase II trials. GBM patients (≥ 18 years) were treated with radiotherapy (60 Gy) or enrolled in a Fractionated Stereotactic Conformal-Radiotherapy Phase II trial (69.4 Gy). Concomitant and adjuvant chemotherapy with Temozolomide (TMZ) was administered. Charlson Index Co-morbidity (CCI) was used to assess co-morbidity. Toxicity was evaluated according to RTOG score. Survival analysis was performed by the Kaplan-Maier. Influence of age and co-morbidity was evaluated using log-rank test. From 2001 to 2008, 146 patients were enrolled: 56 (38.4 %) aged over 65 and 90 under 65. CCI ≥ 1 was observed in 41 % of elderly and 22 % of young group. Patients' compliance was 97.9 % for radio-chemotherapy. Acute toxicity was mild with no difference between the groups. Global median progression-free survival (PFS) and overall survival (OS) were 12 and 18 months, respectively. Age, surgery and radiation dose correlated with survival (p = 0.01, p = 0.04 and p = 0.03). CCI ≤ 2 did not show any influence on OS. Our data show that elderly with a good performance status and few co-morbidity may be treated as younger patients; moreover, age confirms a negative impact on survival while CCI ≤ 2 did not correlated with OS.

Temozolomide chemotherapy alone versus radiotherapy alone for malignant astrocytoma in the elderly: the NOA-08 randomised, phase 3 trial

BACKGROUND

Radiotherapy is the standard care in elderly patients with malignant astrocytoma and the role of primary chemotherapy is poorly defined. We did a randomised trial to compare the efficacy and safety of dose-dense temozolomide alone versus radiotherapy alone in elderly patients with anaplastic astrocytoma or glioblastoma.

METHODS

Between May 15, 2005, and Nov 2, 2009, we enrolled patients with confirmed anaplastic astrocytoma or glioblastoma, age older than 65 years, and a Karnofsky performance score of 60 or higher. Patients were randomly assigned 100 mg/m(2) temozolomide, given on days 1-7 of 1 week on, 1 week off cycles, or radiotherapy of 60·0 Gy, administered over 6-7 weeks in 30 fractions of 1·8-2·0 Gy. The primary endpoint was overall survival. We assessed non-inferiority with a 25% margin, analysed for all patients who received at least one dose of assigned treatment. This trial is registered with ClinicalTrials.gov, number NCT01502241.

FINDINGS

Of 584 patients screened, we enrolled 412. 373 patients (195 randomly allocated to the temozolomide group and 178 to the radiotherapy group) received at least one dose of treatment and were included in efficacy analyses. Median overall survival was 8·6 months (95% CI 7·3-10·2) in the temozolomide group versus 9·6 months (8·2-10·8) in the radiotherapy group (hazard ratio [HR] 1·09, 95% CI 0·84-1·42, p(non-inferiority)=0·033). Median event-free survival (EFS) did not differ significantly between the temozolomide and radiotherapy groups (3·3 months [95% CI 3·2-4·1] vs 4·7 [4·2-5·2]; HR 1·15, 95% CI 0·92-1·43, p(non-inferiority)=0·043). Tumour MGMT promoter methylation was seen in 73 (35%) of 209 patients tested. MGMT promoter methylation was associated with longer overall survival than was unmethylated status (11·9 months [95% CI 9·0 to not reached] vs 8·2 months [7·0-10·0]; HR 0·62, 95% CI 0·42-0·91, p=0·014). EFS was longer in patients with MGMT promoter methylation who received temozolomide than in those who underwent radiotherapy (8·4 months [95e% CI 5·5-11·7] vs 4·6 [4·2-5·0]), whereas the opposite was true for patients with no methylation of the MGMT promoter (3·3 months [3·0-3·5] vs 4·6 months [3·7-6·3]). The most frequent grade 3-4 intervention-related adverse events were neutropenia (16 patients in the temozolomide group vs two in the radiotherapy group), lymphocytopenia (46 vs one), thrombocytopenia (14 vs four), raised liver-enzyme concentrations (30 vs 16), infections (35 vs 23), and thromboembolic events (24 vs eight).

INTERPRETATION

Temozolomide alone is non-inferior to radiotherapy alone in the treatment of elderly patients with malignant astrocytoma. MGMT promoter methylation seems to be a useful biomarker for outcomes by treatment and could aid decision-making.

FUNDING

Merck Sharp & Dohme.