Meaningful palliation is possible for selected patients with recurrent
malignant glioma (
glioblastoma multiforme,
anaplastic astrocytoma,
anaplastic oligodendroglioma, or anaplastic
mixed oligoastrocytoma) using aggressive treatment. Although long-term disease-free survival occurs in fewer than 10% of patients, most who achieve such survival have been treated for multiple recurrences. Surgical resection with the placement of
lomustine-releasing wafers is the only
therapy proven in randomized trials to be beneficial for recurrent
malignant gliomas. Reoperation is indicated when local mass effect limits the quality of life. Reoperation may make other treatments more effective by removing treatment-resistant hypoxic cells and thereby prolonging high-quality survival.
Combination chemotherapy (including
procarbazine and a nitrosourea) provides dramatic benefit for many recurrent anaplastic or aggressively behaving
oligodendrogliomas and anaplastic
mixed oligoastrocytomas. For other recurrent
malignant gliomas, single-
agent cytotoxic chemotherapy (eg, intravenous
lomustine or platinums, oral
carmustine,
temozolomide, or
procarbazine) appears to provide equivalent results and better quality of life at a lower cost than do the combinations of cytotoxic drugs. A randomized phase II trial demonstrates that
temozolomide provides longer progression-free survival and better quality of life than standard-dose
procarbazine in patients with recurrent
glioblastoma multiforme. Because benefits of available cytotoxic
chemotherapy for
anaplastic astrocytoma and
glioblastoma are small, participation in clinical trials is appropriate for most patients.
Reirradiation (using stereotactic or three-dimensional conformal techniques with or without concomitant cytotoxic
chemotherapy) as radiation sensitization can prolong high-quality survival in selected patients. Specific examples include radiosurgery with the gamma knife or with
linear accelerators, intracavitary radiation with the newly US Food and Drug Administration-approved GliaSite (Proxima
Therapeutics, Alpharetta, GA)
radiation therapy system, low dose rate permanent-seed
brachytherapy, and high dose rate stereotactic
brachytherapy.
Dexamethasone (used for the shortest time in the lowest effective doses) can provide symptomatic benefits.
Osmotic diuretics such as
mannitol reduce cytotoxic
edema more rapidly.