Recurrent Glioblastoma Multiforme: A Review of Natural History and Management Options.

Lewis C. Hou, M.D.; Anand Veeravagu, B.S.; Andrew R. Hsu, B.S.; Victor C. K. Tse, M.D., Ph.D.

Disclosures

Neurosurg Focus. 2006;20(4):E5 

In This Article

Abstract and Introduction

Glioblastoma multiforme (GBM) is one of the most aggressive primary brain tumors, with a grim prognosis despite maximal treatment. Advancements in the past decades have not significantly increased the overall survival of patients with this disease. The recurrence of GBM is inevitable, its management often unclear and case dependent. In this report, the authors summarize the current literature regarding the natural history, surveillance algorithms, and treatment options of recurrent GBM. Furthermore, they provide brief discussions regarding current novel efforts in basic and clinical research. They conclude that although recurrent GBM remains a fatal disease, the literature suggests that a subset of patients may benefit from maximal treatment efforts. Nevertheless, further research effort in all aspects of GBM diagnosis and treatment remains essential to improve the overall prognosis of this disease.

Glioblastoma multiforme is a World Health Organization Grade IV tumor that represents 15 to 20% of all primary intracranial tumors.[2] It is the most malignant astrocytic tumor, with histopathological features that include cellular polymorphism, brisk mitotic activity, microvascular proliferation, and necrosis. Despite advances in imaging techniques and multi-modal treatment options, the overall prognosis of patients with GBM remains grim. The median duration of patient survival is estimated to be between 12 and 18 months with maximal treatment, but those without any intervention die soon after diagnosis.[23,46] To date, very few cases of curative outcome or long-term survival have been reported.[55,58,72] In a large retrospective study, Scott, et al.,[58] estimated that 2.2% of the cohort survived for more than 2 years. Overall, the 5-year survival rate is less than 10%, with a final mortality rate of close to 100%.[24,38]

Glioblastoma has an unfavorable prognosis mainly due to its high propensity for tumor recurrence. It has been suggested that GBM recurrence is inevitable after a median survival time of 32 to 36 weeks.[1,19] The natural history of recurrent GBM, however, is largely undefined for the following reasons: 1) lack of uniform definition and criteria for tumor recurrence; 2) institutional variability in treatment philosophy; and 3) the heterogeneous nature of the disease, including location of recurrence and distinct mechanisms believed to contribute to known subtypes of GBM. For this report, we performed a PubMed-based literature search focusing on the terms "recurrent glioblastoma" and "management." We summarize various published studies to provide insight into the currently used surveillance algorithm and treatment strategies for recurrent GBM (Fig. 1). Furthermore, we discuss novel research that may potentially aid in preventing or controlling GBM progression and recurrence.

Management algorithm for recurrent GBM. MRS = MR spectroscopy.

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