Re-irradiation for recurrent GBM

[Kroll2013]

Dear colleagues,
I need your opinion for this case:

63 yo right handed gentleman who was diagnosed in June 2014 with a fairly large 5.2 x 3.8 x 3.5 cm left temporo-Parietal, irregular multilobulated, contrast enhancing lesion with extensive vasogenic edema , mass effect and central necrosis, this was deeply seated in its necrotic part and extends superficially behind the motor strip. A biopsy was obtained and final pathology reported a GBM.
He received concurrent chemoradiation and did fairly well , followed by Adjuvant TMZ on a 5/28 schedule until he failed in May 2016. He was therefore started on Bevacizumab for salvage and following an excellent initial response and clinical improvement, has developed worsening neurological status and progression on MRI scan repeat. The tumor recurred locally (5cm) with increase of the peritumoral edema.
Clinically he presents right hemicorps deficit.

1- what are his chances with re-irradiation?
2- how many fractions and what dose per fraction?
3- is there any recent litterature review that can justify RT vs no RT?

Tx a lot


Sent from my iPhone using SDN mobile

---

Members don't see this ad.

 

[seper]

I think survival here is < 8 weeks and hospice is appropriate.
There are probably some published phase I studies on 3d line chemo if you want to quote accurate survival data to the family.
Re-irradiation can be used to try to palliate weakness, and if I treat I do 5 Gy X 5 with tight margin.

 

[evilbooyaa]

My institution has done at least 5 re-irradiations in the past 4 to 6 months. All of them have been on hospice if not during treatment, then within 1 month. One attending is not enthusiastic about doing them anymore.

Especially if it's locally recurrent (within previous high-dose field). We do always review the previous plan (which 9/10 times happens at an outside hospital so we need to get DICOMs and recreate the plan) and if it's outside of the boost field we'll consider it, but it's generally squarely within the high-dose field.

Patient initially had a unilateral, unifocal (albeit multilobulated) GBM, it sounds like. Would he have been better off with an attempt at a resection?

OP, any reason he had just a biopsy? We generally see that with completely inaccessible locations or some sort of multifocal disease with bilateral involvement.

 

[scarbrtj]

How about Optune? Don't boo me.
http://www.abta.org/brain-tumor-treatment/treatments/ttfields.html?

 

[kimplera]

our institution has used PRDR for these patients with reasonable effects:
https://www.ncbi.nlm.nih.gov/pubmed/24469853
we have a current phase II study recruiting patients combining bev with PRDR
https://clinicaltrials.gov/ct2/show/NCT01743950?term=reirradiation+gbm&rank=16

 

[Gfunk6]

Tough case. Agree with Optune. Other options include adding CCNU to Avastin. Re-irradiation per RTOG 1205 excluded patients with > 5 cm disease, but may be considered too


Sent from my iPhone using SDN mobile

 

[Palex80]

Optune is an option, CCNU is an option (although the randomited trial was negative), reirradiation is also an option.

Do you know what his MGMT-status is?

I presume the patient has a PS 2 right now? Is he on steroids already?
His neurological symptoms are unlikely to recover irrelevant of what treatment he will get, if he is already on steroids. In my opinion, BSC is a good option in this case.

 

[Neuronix]

1- what are his chances with re-irradiation?
2- how many fractions and what dose per fraction?
3- is there any recent literature review that can justify RT vs no RT?

1. Poor.
2. I'd still consider RTOG 1205 (35 Gy / 10 fractions +/- bev) despite the size. I'd be clear with the patient that the odds are not good that it will help, but it can be tried.
3. Literature in this setting is not great. Phase II prospective and retrospective series.

Optune is worth a try--the EF-11 trial was helmet vs. dealer's choice chemo in GBM recurrences. No survival benefit, but improved QoL vs. chemo.

 

[Kroll2013]

1. Poor.
2. I'd still consider RTOG 1205 (35 Gy / 10 fractions +/- bev) despite the size. I'd be clear with the patient that the odds are not good that it will help, but it can be tried.
3. Literature in this setting is not great. Phase II prospective and retrospective series.

Optune is worth a try--the EF-11 trial was helmet vs. dealer's choice chemo in GBM recurrences. No survival benefit, but improved QoL vs. chemo.

tx a lot

 

[nkmiami]

I also perform pulsed dose rate external beam for almost any re-irradiation site where a definitive dose is being given. Although, it has been around for 50 years, most docs seem to be unaware of it

 

[hot sauce]

I also perform pulsed dose rate external beam for almost any re-irradiation site where a definitive dose is being given. Although, it has been around for 50 years, most docs seem to be unaware of it

Pulsed is certainly an option. I am selective in when I will recommend it because of the huge time commitment in a patient with a poor prognosis.