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Glioblastoma

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of glioblastoma are prepared by our editorial team based on guidelines from the American Association of Neurological Surgeons (AANS/CNS 2022,2014), the European Association of Neuro-Oncology (EANO 2021,2017), the European Association of Neuro-Oncology (EANO/SNO 2021), the Spanish Association of Medical Oncology (SEOM 2018), the American Society for Radiation Oncology (ASTRO 2016), and ...
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Screening and diagnosis

Indications for screening
As per EANO 2021 guidelines:
Recognize that screening and prevention have no major role for patients with gliomas.
B
Refer patients with relevant germline variants or suspected hereditary cancer syndromes for genetic counseling and, subsequently, for possible molecular genetic testing.
B
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Classification and risk stratification

Classification: as per EANO 2021 guidelines, use the most recent WHO Classification of Tumors of the CNS for glioma classification, complemented by cIMPACT-NOW.
B

Diagnostic investigations

Clinical assessment: as per EANO 2021 guidelines, assess the Karnofsky performance score and neurological function, as well as the patient's age, individual risks, and benefits for clinical decision-making.
B
Karnofsky Performance Scale
Patient description
Normal, no complaints, no evidence of disease
Able to carry on normal activity, minor signs or symptoms of disease
Normal activity with effort, some signs or symptoms of disease
Cares for self, unable to carry on normal activity or to do active work
Requires occasional assistance but is able to care for most personal needs
Requires considerable assistance and frequent medical care
Disabled, requires special care and assistance
Severely disabled, hospital admission is indicated, death not imminent
Very sick, hospital admission necessary, active supportive treatment necessary
Moribund
Dead
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  • Diagnostic imaging

Diagnostic procedures

Tumor biopsy
As per EANO 2021 guidelines:
Perform biopsy or resection as the standard of care in < 70 years old patients with IDH-wild-type glioblastoma and a Karnofsky performance status > 70.
B
Make clinical decisions without obtaining a tissue diagnosis only in very exceptional situations.
B

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  • Molecular testing (IDH mutation, MGMT promoter methylation, and 1p/19q co-deletion)

  • Molecular testing (further testing)

  • Molecular testing (repeat testing)

Medical management

Management of initial disease, surgical resection
As per EANO 2021 guidelines:
Perform surgical resection as feasible or biopsy followed as the standard of care in < 70 years old patients with IDH-wild-type glioblastoma and a Karnofsky performance score > 70.
A
Attempt to obtain complete resection
B
while prioritizing prevention of new permanent neurological deficits over the extent of resection.
B

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  • Management of initial disease (radiotherapy)

  • Management of initial disease (concomitant chemoradiotherapy)

  • Management of initial disease (target volumes for radiotherapy)

  • Management of initial disease (tumor-treating fields)

  • Management of progressive disease (repeat cytoreductive surgery)

  • Management of progressive disease (carmustine-impregnated wafers)

  • Management of progressive disease (repeat radiotherapy)

  • Management of progressive disease (chemotherapy)

  • Management of progressive disease (targeted therapy)

  • Management of symptoms (headache)

  • Management of symptoms (seizure)

  • Management of symptoms (fatigue)

  • Management of symptoms (psychological and cognitive disorders)

  • Management of symptoms (delirium)

Perioperative care

Postoperative thromboprophylaxis: as per EANO 2017 guidelines, initiate VTE prophylaxis with LMWH postoperatively within 24 hours, as the perioperative risk of intracranial hypertension increases when prophylaxis is initiated before induction of anesthesia.
B
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  • Postoperative imaging

Patient education

Genetic counseling: as per EANO 2021 guidelines, refer patients with relevant germline variants or suspected hereditary cancer syndromes for genetic counseling and, subsequently, for possible molecular genetic testing.
B

Follow-up and surveillance

Rehabilitation
As per EANO 2017 guidelines:
Consider offering early postoperative rehabilitation and rehabilitation after tumor-specific treatment.
C
Consider offering cognitive rehabilitation in patients with glioma, especially in young patients with relatively favorable prognoses. (III) Consider offering cognitive rehabilitation in patients with stable glioma and cognitive complaints and/or deficits.
E

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  • Surveillance after curative-intent therapy (MRI/MRS)

  • Surveillance after curative-intent therapy (PET/SPECT)

  • Management of recurrent disease