Department of Neurosurgery, Inova Neuroscience and Spine Institute, 3300 Gallows Rd, NPT 2nd Floor, Suite 200, Falls Church, VA, USA.
Department of Neurosurgery, The UT at MD Anderson Cancer Center, Houston, TX, USA.
J Neurooncol. 2020 Nov;150(2):215-267. doi: 10.1007/s11060-020-03612-7. Epub 2020 Nov 19.
These recommendations apply to adult patients diagnosed with newly diagnosed glioblastoma. QUESTION 1 : In adult patients (aged 65 and under) with newly diagnosed glioblastoma, is the addition of radiation therapy (RT) more beneficial than management without RT in improving survival?
Level I: Radiation therapy (RT) is recommended for the treatment of newly diagnosed malignant glioblastoma in adults. QUESTION 2 : In adult patients (aged 65 and under) with newly diagnosed glioblastoma, is the RT regimen of 60 Gy given in 2 Gy daily fractions more beneficial than alternative regimens in providing survival benefit while minimizing toxicity?
Level I: Treatment schemes should include dosage of up to 60 Gy given in 2 Gy daily fractions that includes the enhancing area. QUESTION 3 : In adult patients (aged 65 and under) with newly diagnosed glioblastoma, is a tailored target volume superior to regional RT for reduction of radiation-induced toxicity while maintaining efficacy?
Level II: It is recommended that radiation therapy planning include 1-2 cm margin around the radiographically T1 weighted contrast-enhancing tumor volume or the T2 weighted abnormality on MRI. Level III: Recalculation of the radiation volume during RT treatment may be necessary to reduce the radiated volume of normal brain since the volume of surgical defect will change during the long period of RT. QUESTION 4 : In adult patients (aged 65 and under) with newly diagnosed glioblastoma, does the addition of RT of the subventricular zone to standard tumor volume treatment improve tumor control and overall survival?
No recommendation can be formulated as there is contradictory evidence in favor of and against intentional radiation of the subventricular zone (SVZ) QUESTION 5 : In elderly (age > 65 years) and/or frail patients with newly diagnosed glioblastoma, does the addition of RT to surgical intervention improve disease control and overall survival?
Level I: Radiation therapy is recommended for treatment of elderly and frail patients with newly diagnosed glioblastoma to improve overall survival. QUESTION 6 : In elderly (age > 65 years) and/or frail patients with newly diagnosed glioblastoma, does modification of RT dose and fractionation scheme from standard regimens decrease toxicity and improve disease control and survival?
Level II: Short RT treatment schemes are recommended in frail and elderly patients as compared to conventional 60 Gy given in 2 daily fractions because overall survival is not different while RT risk profile is better for the short RT scheme. Level II: The 40.05 Gy dose given in 15 fractions or 25 Gy dose given in 5 fractions or 34 Gy dose given in 10 fractions should be considered as appropriate doses for Short RT treatments in elderly and/or frail patients. QUESTION 7 : In adult patients with newly diagnosed glioblastoma is there advantage to delaying the initiation of RT instead of starting it 2 weeks after surgical intervention in decreasing radiation-induced toxicity and improving disease control and survival?
Level III: It is suggested that RT for patients with newly diagnosed GBM starts within 6 weeks of surgical intervention as compared to later times. There is insufficient evidence to recommend the optimal specific post-operative day within the 6 weeks interval to start RT for adult patients with newly diagnosed glioblastoma that have undergone surgical resection. QUESTION 8 : In adult patients with newly diagnosed supratentorial glioblastoma is Image-Modulated RT (IMRT) or similar techniques as effective as standard regional RT in providing tumor control and improve survival?
Level III: There is no evidence that IMRT is a better RT delivering modality when compared to conventional RT in improving overall survival in adult patients with newly diagnosed glioblastoma. Hence, IMRT should not be preferred over the Conventional RT delivery modality. QUESTION 9 : In adult patients with newly diagnosed glioblastoma does the use of radiosensitizers with RT improve the efficacy of RT as determined by disease control and overall survival?
Level III: Iododeoxyuridine is not recommended to be used as radiosensitizer during RT treatment for patients with newly diagnosed GBM QUESTION 10 : In adult patients with newly diagnosed glioblastoma is the use of Ultrafractionated RT superior to standard fractionation regimens in improving disease control and survival?
There is insufficient evidence to formulate a recommendation regarding the use of ultrafractionated RT schemes and patient population that could benefit from it. QUESTION 11 : In patients with poor prognosis with newly diagnosed glioblastoma is hypofractionated RT indicated instead of a standard fractionation regimen as measured by extent of toxicity, disease control and survival?
Level I: Hypofractionated RT schemes may be used for patients with poor prognosis and limited survival without compromising response. There is insufficient evidence in the literature for us to be able to recommend the optimal hypofractionated RT scheme that will confer longest overall survival and/or confer the same overall survival with less toxicities and shorter treatment time. QUESTION 12 : In adult patients with newly diagnosed glioblastoma is the addition of brachytherapy to standard fractionated RT indicated to improve disease control and survival?
Level I: Brachytherapy as a boost to external beam RT has not been shown to be beneficial and is not recommended in the routine management of patients with newly diagnosed GBM. QUESTION 13 : In elderly patients (> 65 year old) with newly diagnosed glioblastoma under what circumstances is accelerated hyperfractionated RT indicated instead of a standard fractionation regimen as measured by extent of toxicity, disease control and survival?
Level III: Accelerated Hyperfractionated RT with a total RT dose of 45 Gy or 48 Gy has been shown to shorten the treatment time without detriment in survival when compared to conventional external beam RT and should be considered as an option for treatment of elderly patients with newly diagnosed GBM. QUESTION 14 : In adult patients with newly diagnosed glioblastoma is the addition of Stereotactic Radiosurgery (SRS) boost to conventional standard fractionated RT indicated to improve disease control and survival?
Level I: Stereotactic Radiosurgery boost to external beam RT has not been shown to be beneficial and is not recommended in patients undergoing routine management of newly diagnosed malignant glioma.
这些建议适用于新诊断为胶质母细胞瘤的成年患者。
问题 1：在新诊断为胶质母细胞瘤的成年患者（年龄在 65 岁及以下）中，与不进行放射治疗（RT）相比，加用 RT 治疗是否能提高生存率？
Ⅰ级：建议对新诊断的成人恶性脑胶质瘤进行 RT 治疗。
问题 2：在新诊断为胶质母细胞瘤的成年患者（年龄在 65 岁及以下）中，与其他方案相比，60 Gy 剂量的 2 Gy 每日分割 RT 方案是否能提供生存获益，同时最小化毒性？
Ⅰ级：治疗方案应包括最大 60 Gy 的剂量，每日 2 Gy，包括增强区。
问题 3：在新诊断为胶质母细胞瘤的成年患者（年龄在 65 岁及以下）中，与区域性 RT 相比，个体化靶区是否能降低放疗诱导的毒性，同时保持疗效？
Ⅱ级：建议在 RT 计划中，使用放射治疗的边界为影像学 T1 加权对比增强肿瘤体积或 MRI 上 T2 加权异常区域外加 1-2 cm。Ⅲ级：由于 RT 治疗期间手术缺损体积会发生变化，因此可能需要重新计算放疗体积，以减少正常脑组织的照射体积。
问题 4：在新诊断为胶质母细胞瘤的成年患者（年龄在 65 岁及以下）中，加用脑室下区 RT 是否能改善肿瘤控制和总生存率？
不能提出建议，因为有支持和反对有针对性地照射脑室下区（SVZ）的证据相互矛盾。
问题 5：在新诊断为胶质母细胞瘤的老年（年龄>65 岁）和/或体弱患者中，与手术干预相比，加用 RT 是否能改善疾病控制和总生存率？
Ⅰ级：建议对新诊断的老年和体弱患者进行胶质母细胞瘤的 RT 治疗，以提高总生存率。
问题 6：在新诊断为胶质母细胞瘤的老年（年龄>65 岁）和/或体弱患者中，是否可以修改 RT 剂量和分割方案，使标准方案降低毒性，改善疾病控制和生存率？
Ⅱ级：与常规 60 Gy 每日 2 次分割方案相比，体弱和老年患者推荐采用较短的 RT 方案，因为总生存率没有差异，而 RT 风险特征对短 RT 方案更好。Ⅱ级：40.05 Gy 剂量 15 次分割、25 Gy 剂量 5 次分割或 34 Gy 剂量 10 次分割应被视为老年和/或体弱患者短 RT 治疗的合适剂量。
问题 7：与立即开始 RT 相比，在新诊断为胶质母细胞瘤的成年患者中，延迟 RT 起始时间是否能降低放疗诱导的毒性，改善疾病控制和生存率？
Ⅲ级：建议新诊断为 GBM 的患者 RT 应在手术干预后 6 周内开始，而不是更晚。对于新诊断为经手术切除的 GBM 的成年患者，术后 6 周内开始 RT 的最佳具体术后天数尚无足够证据推荐。
问题 8：新诊断为幕上胶质母细胞瘤的成年患者，调强放疗（IMRT）或类似技术是否与标准区域性 RT 一样有效，能提供肿瘤控制并改善生存？
Ⅲ级：与常规 RT 相比，在提高新诊断为胶质母细胞瘤的成年患者的总生存率方面，没有证据表明 IMRT 是一种更好的 RT 传递方式。因此，在新诊断为胶质母细胞瘤的成年患者中，不应优先选择 IMRT 而不是常规 RT 传递方式。
问题 9：在新诊断为胶质母细胞瘤的成年患者中，与 RT 联合使用放射增敏剂是否能提高 RT 的疗效，从而提高肿瘤控制和总生存率？
Ⅲ级：不建议在新诊断为 GBM 的患者中使用碘脱氧尿苷作为放射增敏剂。
问题 10：在新诊断为胶质母细胞瘤的成年患者中，超分割 RT 是否优于标准分割方案，以提高疾病控制和生存率？
由于缺乏证据，无法就超分割 RT 方案和可能从中受益的患者人群提出建议。
问题 11：在新诊断为胶质母细胞瘤且预后不良的患者中，与标准分割方案相比，是否应采用 hypofractionated RT 方案，以降低毒性、疾病控制和生存率？
Ⅰ级：对于预后不良和生存时间有限的患者，可以采用 hypofractionated RT 方案而不影响反应。目前，我们还没有足够的文献证据来推荐能够提供最长总生存率和/或毒性最低、治疗时间最短的最佳 hypofractionated RT 方案。
问题 12：在新诊断为胶质母细胞瘤的成年患者中，加用近距离放疗是否能改善疾病控制和生存率？
Ⅰ级：近距离放疗作为外照射 RT 的增敏剂，并没有显示出有益的效果，因此不建议在新诊断的 GBM 患者的常规治疗中使用。
问题 13：在年龄大于 65 岁的老年患者中，在什么情况下加速超分割 RT 比标准分割方案更适合，以衡量毒性、疾病控制和生存率？
Ⅲ级：与常规外照射 RT 相比，45 Gy 或 48 Gy 的总 RT 剂量的加速超分割 RT 已被证明可缩短治疗时间，而不影响生存率，应考虑作为新诊断为 GBM 的老年患者的治疗选择。
问题 14：在新诊断为胶质母细胞瘤的成年患者中，加用立体定向放射外科（SRS）放疗是否能提高疾病控制和生存率？
Ⅰ级：SRS 放疗加外照射 RT 并没有显示出有益的效果，因此不建议在常规管理新诊断的恶性胶质瘤患者中使用。
