8 december 2016: Bron: American Society for Radiation Oncology (ASTRO)

Bij wie de diagnose van een hersentumor glioblastoma wordt geconstateerd krijgt meestal als behandeling voorgesteld radiotherapie - bestraling plus een chemokuur met temodal. Echter ook deze behandeling is bij zelfs een volledige operatieve verwijdering zelden of nooit genezend. Toch lijkt bestraling - radiotherapie wel het leven te verlengen. Maar lang niet altijd. Bovendien kan radiotherapie - bestraling ook de kwaliteit van leven ernstig aantasten, zowel op korte als lange termijn. Zie ook literatuurlijsten hoe die bijwerkingen van o.a. radiotherapie - bestraling of specifiek bij hersentumoren te verminderen.

De ASTRO (American Society for Radiation Oncology) heeft nu op basis van beschikbare literatuur richtlijnen opgesteld hoe en wanneer radiotherapie - bestraling in te zetten. Als u klikt op deze PDF : Radiation therapy for glioblastoma: Executive summary of an American Society for Radiation Oncology Evidence-Based Clinical Practice Guideline kunt u het volledige studierapport in PDF inzien of downloaden.

Tekst gaat verder onder foto

bestraling van het hoofd

Bron foto: https://rfclipart.com/head-profile-silhouette-with-radiation-sign-inside-16277-vector-clipart.html

Hier de voornaamste conclusies die ik maar niet vertaal. Gebruik anders google translation rechts bovenaan dit artikel:

Hoofdpunten van de aanbevelingen

  • Fractionated radiotherapy improves overall survival compared with chemotherapy or best supportive care alone after biopsy or resection of newly diagnosed glioblastoma (HQE). Whether radiotherapy is indicated in a particular individual may depend on patient characteristics, such as performance status (Strong recommendation).

  • Radiation should be initiated as soon as it is safely permissible. Clinical trials have typically initiated treatment 3 to 6 weeks after surgery.

  • The addition of concurrent and adjuvant temozolomide to fractionated radiotherapy improves overall survival and progression-free survival compared with fractionated radiotherapy alone, with a reasonably low incidence of early adverse events and without impairing quality of life (HQE). The guideline panel endorses fractionated radiotherapy with concurrent and adjuvant temozolomide as the standard of care after biopsy or resection of newly diagnosed glioblastoma in patients up to 70 years of age (Strong recommendation).

  • The addition of bevacizumab (Avastin) to standard therapy for newly diagnosed glioblastoma (ie, fractionated radiotherapy with concomitant and adjuvant temozolomide) does not improve overall survival and is associated with a higher incidence of early adverse events (HQE). Bevacizumab may, however, prolong progression-free survival (MQE). The panel does not recommend the routine addition of bevacizumab to standard therapy for newly diagnosed glioblastoma outside a clinical trial (Strong recommendation).

  • The impact of adding bevacizumab to standard therapy on health-related quality of life requires further validation.

  • The addition of other systemic therapies to conventional radiotherapy with or without temozolomide remains investigational (Strong recommendation).

  • For patients younger than 70 years of age with a good performance status (Karnofsky performance score ≥ 60), the optimal-dose fractionation schedule for external-beam radiation therapy after resection or biopsy is 60 Gy in 2-Gy fractions delivered over 6 weeks (HQE). Numerous other dose schedules have been explored without definitive benefit. Care should be taken to keep dose to critical structures (eg, brainstem, optic chiasm/nerves) within acceptable limits (Strong recommendation).

  • Older age and poor performance status are associated with shorter survival in patients with glioblastoma (MQE). Prognostic considerations should help to guide treatment recommendations for individual patients (Strong recommendation).

  • Among elderly patients (≥ 70 years old) with fair to good performance status (Karnofsky performance score ≥ 50), the panel recommends external-beam radiation therapy after biopsy or resection because radiotherapy (compared with supportive care alone) improves overall survival without impairing quality of life or cognition (HQE). The efficacy of concurrent and adjuvant temozolomide in this population has not been evaluated in a randomized trial but may be considered for selected patients (LQE; Strong recommendation).

  • Among elderly patients, no evidence shows that conventionally fractionated radiotherapy (60 Gy in 30 fractions over 6 weeks) is more efficacious than hypofractionated radiotherapy (eg, 40 Gy in 15 fractions over 3 weeks; HQE). Compared with conventionally fractionated radiotherapy, hypofractionated radiotherapy has been associated with superior survival and less corticosteroid requirement (MQE; Strong recommendation).

  • The optimal-dose fractionation schedule has not yet been determined for elderly patients, although recent randomized trials have suggested that shorter regimens may be equivalent to longer-duration treatment.

  • Given the absence of proven superiority for conventionally fractionated radiotherapy, the panel recommends hypofractionated radiotherapy for elderly patients with a fair to good performance status (HQE). Temozolomide monotherapy is an efficacious alternative for elderly patients with O6-methylguanine DNA methyltransferase gene (MGMT) promoter methylation (HQE), but the panel does not recommend temozolomide monotherapy as first-line therapy for patients with unmethylated MGMT promoters (MQE). Temozolomide monotherapy confers a higher risk of adverse events than radiotherapy, particularly with respect to hematologic toxicity, nausea, and vomiting (MQE; Strong recommendation).

  • Among elderly patients with a good performance status, the addition of concurrent and adjuvant temozolomide to hypofractionated radiotherapy seems to be safe and efficacious without impairing quality of life (LQE). In such patients, the panel recommends consideration of concurrent and adjuvant temozolomide. The combination of hypofractionated radiotherapy and temozolomide may be particularly efficacious in those with a methylated MGMT promoter (LQE; Strong recommendation).

  • Reasonable options for patients with a poor performance status include hypofractionated radiotherapy alone, temozolomide alone, or best supportive care (LQE; Strong recommendation).

  • Although glioblastoma is believed to be diffusely infiltrative, partial-brain radiation therapy leads to no worse survival than whole-brain radiation therapy (HQE). The panel endorses partial-brain radiation therapy as the standard treatment paradigm for glioblastoma (Strong recommendation).

  • Several strategies for target volume definition produce similar outcomes (LQE). All confer a low risk of isolated marginal or distant failure, with a high risk of local failure as a component of disease progression (MQE). Acceptable strategies include, but are not limited to, the following (Strong recommendation):
    • Two phase: (1) Primary target volume encompasses edema (hyperintense region on T2 or fluid-attenuated inversion recovery on magnetic resonance imaging) and gross residual tumor/resection cavity, and (2) boost target volume encompasses gross residual tumor/resection cavity. A range of acceptable clinical target volume margins exists.
    • One phase: Single target volume includes gross residual tumor/resection cavity with wide margins, without specifically targeting edema.

  • Reduction of target volumes allows less radiation to be delivered to radiographically normal brain. Delivery of less radiation to normal brain should result in less late toxicity (LQE), but this remains to be validated (Weak recommendation).

  • In younger patients with a good performance status, focal re-irradiation (eg, stereotactic radiosurgery, hypofractionated stereotactic radiotherapy, brachytherapy) for recurrent glioblastoma may improve outcomes compared with supportive care or systemic therapy alone (LQE). Tumor size and location should be taken into account when deciding whether re-irradiation would be safe (LQE; Weak recommendation).

  • No prospective evidence supports re-irradiation in any patient subgroup.

Het volledige studierapport: Radiation therapy for glioblastoma: Executive summary of an American Society for Radiation Oncology Evidence-Based Clinical Practice Guideline  kunt u gratis inzien.

Hier het abstract van deze studie met referentielijst:

Radiation therapy occupies an integral role in treating glioblastoma. Whether and how radiation therapy should be applied depends on characteristics specific to tumor and patient, including age and performance status.

Radiation therapy for glioblastoma: Executive summary of an American Society for Radiation Oncology Evidence-Based Clinical Practice Guideline

Alvin R. Cabrera, MDcorrespondencePress enter key for correspondence information
,
John P. Kirkpatrick, MD, PhD
,
John B. Fiveash, MD
,
Helen A. Shih, MD
,
Eugene J. Koay, MD, PhD
,
Stephen Lutz, MD
,
Joshua Petit, MD
,
Samuel T. Chao, MD
,
Paul D. Brown, MD
,
Michael Vogelbaum, MD, PhD
,
David A. Reardon, MD
,
Arnab Chakravarti, MD
,
Patrick Y. Wen, MD
,
Eric Chang, MD

DOI: http://dx.doi.org/10.1016/j.prro.2016.03.007

Abstract

Purpose

To present evidence-based guidelines for radiation therapy in treating glioblastoma not arising from the brainstem.

Methods and materials

The American Society for Radiation Oncology (ASTRO) convened the Glioblastoma Guideline Panel to perform a systematic literature review investigating the following: (1) Is radiation therapy indicated after biopsy/resection of glioblastoma and how does systemic therapy modify its effects? (2) What is the optimal dose-fractionation schedule for external beam radiation therapy after biopsy/resection of glioblastoma and how might treatment vary based on pretreatment characteristics such as age or performance status? (3) What are ideal target volumes for curative-intent external beam radiation therapy of glioblastoma? (4) What is the role of reirradiation among glioblastoma patients whose disease recurs following completion of standard first-line therapy? Guideline recommendations were created using predefined consensus-building methodology supported by ASTRO-approved tools for grading evidence quality and recommendation strength.

Results

Following biopsy or resection, glioblastoma patients with reasonable performance status up to 70 years of age should receive conventionally fractionated radiation therapy (eg, 60 Gy in 2-Gy fractions) with concurrent and adjuvant temozolomide. Routine addition of bevacizumab to this regimen is not recommended. Elderly patients (≥70 years of age) with reasonable performance status should receive hypofractionated radiation therapy (eg, 40 Gy in 2.66-Gy fractions); preliminary evidence may support adding concurrent and adjuvant temozolomide to this regimen. Partial brain irradiation is the standard paradigm for radiation delivery. A variety of acceptable strategies exist for target volume definition, generally involving 2 phases (primary and boost volumes) or 1 phase (single volume). For recurrent glioblastoma, focal reirradiation can be considered in younger patients with good performance status.

Conclusions

Radiation therapy occupies an integral role in treating glioblastoma. Whether and how radiation therapy should be applied depends on characteristics specific to tumor and patient, including age and performance status.

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Presented at the 57th ASTRO Annual Meeting, October 18-21, 2015, San Antonio, TX.

Conflicts of interest: Before initiating work on this guideline, all panelists completed disclosure statements and pertinent disclosures are published within this report. Where potential conflicts are detected, remedial measures to address them are taken and noted here.

Dr Kirkpatrick receives research funding, honoraria, and travel expenses from Varian; is a partner in ClearSight Radiotherapy Products; and received previous research funding from Genentech. Dr Fiveash receives honoraria, travel expenses, and research funding from Varian. Dr Shig serves on an advisory board for Genentech and received previous honoraria and travel expenses from Merck. Dr Koay receives research funding from Phillips and has a pending patent on quantitative pancreatic image analysis. Dr Lutz had previous stock in Tosk and Oculus. Dr Vogelbaum is a consultant for NeuralStem and has stock options, royalties, and patent licensing and copyright fees from Infuseon. Dr Reardon serves on advisory boards for Roche/Genentech, EMD Serono, Novartis, Amgen, Abbvie, Bristol-Myers Squibb, Cavion, Celldex, Juno Pharmaceuticals, Momenta Pharmaceuticals, Novocure, Oxigene, Regeneron, and Stemline; served on a previous advisory board for Apogenix; is on speaker bureaus for Merck/Scherin and Roche/Genentech; and receives research funding from Celldex, Inovio, and Midatech. Dr Wen is on advisory boards for Roche/Genentech, Novartis, Regeneron, Monteris, and Cavion; is a speaker for Merck; is steering committee chair for Vascular Biogenics trial; and was previously on advisory boards for Abbvie, Cubist, Foundation Medicine, Merck, and Midatech. Dr Chang receives honoraria from Abbvie BrainLab, and Elekta.

The panel chairs and American Society for Radiation Oncology Guidelines Subcommittee reviewed these disclosures and took measures to mitigate the impact of potential conflicts. Because of relationships with Merck, Drs Reardon, Shih, and Wen did not write the recommendations and narratives addressing temozolomide and were recused from consensus voting on these recommendations. Because of relationships with Genentech, Drs Reardon, Wen, and Kirkpatrick did not write the recommendations and narratives regarding bevacizumab and were recused from voting on these recommendations. No other disclosures were viewed as affecting guideline content.

Supplementary material for this article (http://dx.doi.org/10.1016/j.prro.2016.03.007) can be found at www.practicalradonc.org.


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