Recurrent GBM

[Haybrant]

I have a 62 yo M with right frontal GBM treated per STUPP (gross total then RT+TMZ and adjuvant TMZ), completed RT 9 months ago, 46 w conedown to 60. Started to develop balance issues and fatigue. Attached is his current scan with recurrence in the 46 field edge tracking down the corpus. What can be offered for retreatment in this setting if anything? Hes being started on avastin by neuro-onc

---

Members don't see this ad.

 

[Mandelin Rain]

Avastin, Optune, hospice.

I wouldn't do it, but pulsed low dose rate XRT has shown some response.

Bummer.

 

[Haybrant]

thanks mandelin - is it a matter of disease extent now and location (corpus extension); like is there any consideration that can be give to fractionated srs. its a bit out of my realm so appreciate the explanation

 

[seper]

IMHO, re-irradiation my help with symptom control much better than other modalities mentioned. Probably does not improve survival so I'd use short schedules.

 

[Haybrant]

IMHO, re-irradiation my help with symptom control much better than other modalities mentioned. Probably does not improve survival so I'd use short schedules.

GTV with small margin - what dose would be reasonable, like 250 x 10?

 

[seper]

3Gy X 10, 3.5Gy X 10, 5-6 Gy X 5 -- doubt there is any significant difference in therapeutic ratio

 

[medgator]

Optune is approved in the adjuvant setting after chemo tmz and recurrent setting.

Would consider it here

 

[Haybrant]

thanks all, do you need to wait an interval without avastin before giving fractionated palliative rt

 

[nkmiami]

thanks all, do you need to wait an interval without avastin before giving fractionated palliative rt

no- i wouldnt. there have even been some gbm studies giving it concurrently.

 

[BobbyHeenan]

We routinely gave 25-30 Gy in 5 fractions with concurrent bevacizumab in these cases to GTV plus 2-3 mm margin in training. I do this out in practice as well in cases where failure is at least 6 months from completion of XRT. There are two phase I/II studies with similar re-irradiation SBRT-ish schedules (Duke and MSKCC) utilizing this technique. I was enrolling in RTOG 1205 (35 in 10) previously but this trial is closed I believe. I actually like to have bev on board here because it cuts down on steroid usage and anecdotally I think the re-XRT is tolerated better with bev on board - it cuts down on significant edema at least for a little while.

Obviously, optune is an option here as well.

 

[Haybrant]

We routinely gave 25-30 Gy in 5 fractions with concurrent bevacizumab in these cases to GTV plus 2-3 mm margin in training. I do this out in practice as well in cases where failure is at least 6 months from completion of XRT. There are two phase I/II studies with similar re-irradiation SBRT-ish schedules (Duke and MSKCC) utilizing this technique. I was enrolling in RTOG 1205 (35 in 10) previously but this trial is closed I believe. I actually like to have bev on board here because it cuts down on steroid usage and anecdotally I think the re-XRT is tolerated better with bev on board - it cuts down on significant edema at least for a little while.

Obviously, optune is an option here as well.

thanks bobby, interesting phase I study. looks like they excluded pts w corpus callosum involvement which makes sense, esp in pretreated region. location of this recurrence is unfortunate. Probably would not feel comfortable w more than 3-3.5 x 10 palliation. Neuroonc has decided to hold off right now on RT referral

 

[evilbooyaa]

No good solutions. Do whatever you feel is reasonable. Rest of the posts in this thread are all reasonable options. Certainly agree with Optune. No survival benefit (which in this patient population, is all that matters, IMO) with any additional RT.

 

[Mandelin Rain]

In this case, I think the location is pretty limiting. No chance for re-operation, or likely any meaningful XRT dose. I think Optune is really the only treatment beyond avastin that could improve survival. If the neuro-onc hasn't already, one could consider Caris (or other similar) testing.

 

[Palex80]

We've treated quite a few patients with a combination of bevacizumab and hypofractionated RT. We havent's seen any toxicity so far and bevacizumab may actually protect the patients from side-effects, since it's known to reduce edema and can be used to treat radionecrosis. I prefer giving 39.9/2.66 in otherwise fit patients, who won't bother coming an extra few times, but any other schedule is probably at least as good.

 

[CFO]

Best data on re-irradiation for high grade glioma recurrence is likely "Hypofractionated stereotactic radiation therapy: an effective therapy for recurrent high-grade gliomas" paper from Jefferson

 

[thecarbonionangle]

i'd do 6x5, 8x3, 9x3 and call it a day.

 

[firewicket]

I know there is data for treatment of radionecrosis with Bev but does anyone know of data for prophylactic treatment with bev in the re-irradiation setting to prevent radionecrosis. I have heard this approach at several conferences and it totally makes sense, but when it comes to finding published data for it I came up empty handed. Is there a paper I can give the hem-onc/neuro-onc to push administration prophylactically (other than extrapolation of data)?

 

[BobbyHeenan]

I know there is data for treatment of radionecrosis with Bev but does anyone know of data for prophylactic treatment with bev in the re-irradiation setting to prevent radionecrosis. I have heard this approach at several conferences and it totally makes sense, but when it comes to finding published data for it I came up empty handed. Is there a paper I can give the hem-onc/neuro-onc to push administration prophylactically (other than extrapolation of data)?

I too am not aware of a paper, but for re-irradiation of GBM I push for it concurrently; I think there's good data of steroid sparing effects, and my gut feeling is that radionecrosis risk is less than GBM, but it's just that - a gut feeling.

I trained at a center with a very active neuro oncology/CNS site, and our attendings (both rad onc and neuro onc) too liked bevacizumab on board for crazy CNS re-irradiation and off the top of my head I can think of a spine radiosurgery case where used it as well.

It's probably really hard to find any meaningful data about "prevention" of radionecrosis...your best bet is just showing them all the series of cases where it is used and seems to be tolerated well (MSK, Duke, UAB et al). There is also some data that it may have activity in meningioma, so for re-irradiation there I've had it approved.