GBM

Question 1

Significance of TERT promotor

Answer 1

bad prognosticator

Question 2

General treatment of resectable GBM

Answer 2

Upfront surgery
4-6 weeks after surgery, CRT started (same protocol as for unresectable disease)

Question 3

Adjuvant chemoradiation protocol for GBM

Answer 3

Given MGMT methylated tumor AND age <70 AND ECOG 0-1, plan for concurrent chemoradiation for 6 weeks (XRT M-F) with daily oral temozolomide 75 mg/m2 (x 42 days) as radiosensitizer based on BSA and radiation (PFS 7-9 months)

Question 4

Second line for GBM

Answer 4

IF no mass effect AND fit AND no VEGF contraindication OR significant surrounding edema, avastin 10 mg/kg D1/D15 q28 days until progression or as tolerated (more likely) (Cachia – limit to 1 yr given tolerance and little evidence of prolonged benefit) (ORR 30-40%, 3 month PFS benefit, NO OS benefit, reduced steroid requirements but you don’t have other good options in GBM)
*Low threshold for dose reduction (Observational data that lower dose 7.5 mg/kg may be associated with improved survival)
IF intolerance, switch to q3 bev dosing
IF on blood thinner, monitor closely for ICH (11% risk of ICH)
IF stable for 1 year AND MGMT methylated, temodar rechallenge 50 mg/m2 daily (RESCUE - 6 month PFS 15-29%)
IF mass effect AND fit, Lomustine 90 mg/m2 (Cachia – always use 90 as starting dose) every 6 weeks until progression/intolerance BUT not more than 6 cycles typically (Decreased vasogenic edema well, basically supersteroid, but doesn’t do much for tumor control – ORR 9-14%, mPFS 1.5-2.7 months, mOS 9.6 months) (difficult to tolerate)