The Royal Marsden

Women's cancers Breast cancer introduction 1

Case study session

High grade gliomas: Dilemmas in the

decision making process and new

radiotherapy options

Dr Frank Saran,

Consultant Clinical Oncologist

Head of Neuro-Oncology

The Royal Marsden

Management of glioblastoma

GBM

Radical

RT and TMZ

Palliative

RT (short) or

TMZ

Best supportive

care

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Management of glioblastoma

KPS <40 40-70 >70

Age 70yrs Palliative or

BSC

Radical or

palliative

Radical

Age 70 yrs Best supportive

care

Palliative or

best supportive

care

Palliative or

radical

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Management of glioblastoma

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Management of glioblastoma

– Male in his fifties

– PMH of hypertension

– Maternal history of GBM

– Married with children, professional

– Presented with partial seizure

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Management of glioblastoma

Diagnostic MRI

– Contrast enhancing

isolated lesion

– Radiological Diagnosis:

Glioblastoma

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Management of glioblastoma

Post Surgical MRI

– Awake craniotomy

– Near total resection

– Glioblastoma, WHO

Grade IV

– MGMT methylated

– EGFRvIII positive

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Management of glioblastoma

Post Surgical MRI

Radiotherapy, 60Gy/30#

Concomitant temozolomide

Treated on ACT-IV Phase III

Trial

4 cycles of adjuvant

temozolomide with

vaccine/placebo

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Management of glioblastoma

– 54 years old male

– No PMH of note

– Married, 2 children, teacher, lives in South London

– Debulking of GBM right frontal lobe

– PS 0, no deficits

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Management of glioblastoma

– 54 years old male

– PMH: iv drug abuser on methadone, Hep C pos

– unemployed, no permanent address, no reg. family

contacts

– Debulking of GBM right frontal lobe

– PS 0, no deficits

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Management of glioblastoma

– 54 years old male

– No PMH of note

– Married, 2 children, teacher, lives in South London

– Complete excision of posterior left frontal GBM

– PS 2, right sided hemiparesis

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Management of glioblastoma

– 54 years old female

– No PMH of note

– Married, 2 children, teacher, lives in South London

– Biopsy of frontal GBM (butterfly glioma)

– PS 1, “frontal” poor short term memory

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Management of glioblastoma

– 54 years old male

– No PMH of note

– Married, 2 children, journalist, lives in Surrey

– Biopsy of left temporo-parietal GBM

– PS 1, severe expressive and receptive dysphasia

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Management of glioblastoma

– 34 years old female

– No PMH of note

– Married, 2 children, housewife, lives in Croydon

– Complete excision of posterior left frontal GBM

– PS 0

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Women's cancers Breast cancer introduction 15

New therapeutic approaches

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Intensity modulated radiotherapy (IMRT)

IMRT involves the production of a non-uniform beam

intensity across a field using advanced planning,

verification and delivery techniques.

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IMRT LINAC

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IMRT example

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RADIOTHERAPY RapidArc HGG

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RADIOTHERAPY RapidArc LGG

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Cyberknife

1 fraction

Radiosurgery

Small volumes (brain/neck)

1 - 7 fractions

hypofractionated RT

small to medium volumes

1 - ∞ fractions

radiosurgery, hypo~, conventionally ~,

hyper-fractionated RT

any volume

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Cyberknife – “Linac on a stick”

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CYBERKNIFE – CNS Indications

Brain metastases

–Recurrent spinal metastases

–Menigiomas

–Pituitary adenomas

–AVMs

–Acoustic neuromas

–Spinal/paraspinal tumours

–Craniopharyngiomas

–Small, localised recurrences

–“Functional” radiosurgery (e.g. trigeminal neuralgia etc.)

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Cyberknife - Skull

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Cyberknife – brain metastasis

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Cyberknife – Pituitary adenoma

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Cyberknife – Ependymoma

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Summary

– Glioblastomas are a rare tumour

– Treatment paradigms exist but MUST be tailored to

individual patients

– Clinical assessment is vital for treatment decisions

– Newer techniques in radiotherapy available and

applicable in specific indications

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Acknowledgement

Radiotherapy Department

The Royal Marsden NHS Foundation Trust

Joint Department of Physics

Institute of Cancer Research

Cancer Research UK

Children’s Cancer Unit

NHS Executive