Summary Recommendations

Guidelines

Recommendations for Frontline Systemic Therapy for Anaplastic Glioma

NCCN Guidelines:

- 1p/19q deletion should be tested on all anaplastic oligodendroglioma or oligoastrocytoma.

- For patients with good PS, and anaplastic astrocytoma, anaplastic oligodendroglioma or oligoastrocytoma without 1p19q co-deletion, fractionated external beam radiation therapy (EBRT) remains the standard after surgical intervention. Temozolomide or PCV with deferred RT is a reasonable choice. Fractionated RT concurrent with temozolomide is another reasonable option but has not been shown to be beneficial in a small local retrospective study.

- For patients with good PS, and anaplastic oligoastrocytoma or anaplastic oligodendroglioma harbouring 1p19q co-deletion, we recommend RT with adjuvant PCV after surgical intervention. Fractionated RT concurrent with temozolomide is a reasonable option after discussion with patients regarding current limited phase III clinical data.

- For patients with poor PS, hypofractionated RT, temozolomide or best supportive care alone is reasonable.

Recommendations for Frontline Systemic Therapy for Glioblastoma

NCCN Guidelines:

- Fractionated RT concurrent with temozolomide followed by adjuvant temozolomide is the standard of care for glioblastoma patients age 70 years with good PS, defined by WHO PS 2 (Category I). Dose-dense therapy is not recommended.

- For glioblastoma patients age >70 years with good PS, options of treatment include hypofractionated RT, temozolomide with deferred RT or RT with concurrent temozolomide followed by adjuvant temozolomide. We suggest checking MGMT promoter methylation status in this group, and recommend temozolomide therapy if positive.

- The routine addition of bevacizumab as upfront therapy is not recommended.

- The role of nimotuzumab as front-line therapy was debated. One of the workgroup members felt that the randomised phase II Cuban trial provided sufficient evidence to recommend nimotuzumab, in addition to RT, as front-line therapy in rare situations where myelosuppression of temozolomide cannot be tolerated. The rest of the workgroup members argued that the trial was conducted with small patient numbers with results not reproduced in other trials, had also not been supported by other national guidelines committees and that given its additional cost and lack of confirmatory trial data, nimotuzumab cannot be recommended as standard front-line therapy.

- Given the lack of data on front-line therapy in patients with poor PS, combination therapy with PCV, temozolomide monotherapy, RT alone or best supportive care is reasonable.

Recommendations for Systemic Therapy for Recurrent Malignant Gliomas

NCCN and ESMO Guidelines:

- For patients with good PS, reasonable chemotherapy options include temozolomide, lomustine, combination PCV, cyclophosphamide, platinum-based agents and irinotecan.

- Bevacizumab, as monotherapy or in combination with other chemotherapy, may also be considered in recurrent glioblastoma.

- For patients with poor PS, best supportive care is reasonable.

ESMO: European Society for Medical Oncology; MGMT: 0-6-methylguanine-DNA methyltransferase; NCCN: National Cancer Comprehensive Network; PCV: Procarbazine, lomustine and vincristine; PS: Performance status; RT: Radiation therapy; WHO: World Health Organization