What is the recommended treatment for a 63-year-old male with newly diagnosed glioblastoma multiforme (GBM) stage 4 in the left frontal lobe?

Treatment Recommendations for a 63-Year-Old Male with Newly Diagnosed Glioblastoma Multiforme in Left Frontal Lobe

The standard of care for this 63-year-old male with newly diagnosed glioblastoma multiforme (GBM) in the left frontal lobe should be maximal safe surgical resection followed by concurrent radiotherapy and temozolomide chemotherapy, and then adjuvant temozolomide. 1

Initial Management

Surgical Approach

• Maximal safe surgical resection should be attempted whenever feasible 1
• Extent of resection is of prognostic value 1
• Evaluation of residual tumor should be performed within 24-48 hours after surgery 1

Post-Surgical Treatment

The following should be initiated within 4-6 weeks after surgery:

1. Radiation Therapy:

   • Standard fractionated focal radiotherapy: 60 Gy delivered in 30 fractions (2 Gy per fraction) 1
   • Treatment should include a 1-2 cm margin around the T1-weighted contrast-enhancing tumor volume or T2-weighted abnormality on MRI 2

2. Concurrent Chemotherapy:

   • Temozolomide 75 mg/m² daily throughout radiotherapy (including weekends) 3

3. Adjuvant Chemotherapy:

   • Following completion of radiotherapy, continue with 6 cycles of maintenance temozolomide
   • Initial cycle at 150 mg/m² for 5 days of a 28-day cycle
   • If well tolerated, increase to 200 mg/m² for subsequent cycles 3

Prognostic Factors and Considerations

Several factors influence prognosis in this patient:

• Age (63 years) - intermediate risk (not elderly by most trial definitions)
• Tumor location (frontal lobe) - more favorable than deep structures
• MGMT promoter methylation status should be tested as it predicts response to temozolomide 1
• IDH mutation status should be determined (though likely IDH-wildtype given age and primary GBM) 1

Supportive Care

• Anticonvulsants: Only indicated if the patient has had seizures; prophylactic use is not recommended 1
• Steroids: Should be tapered as early as possible to minimize side effects 1
• Thromboprophylaxis: Recommended due to high risk of thromboembolic events 1
• Pneumocystis pneumonia prophylaxis: Required during concurrent chemoradiotherapy 3

Monitoring During Treatment

• Complete blood count should be obtained prior to treatment initiation and weekly during concurrent chemoradiotherapy 3
• For adjuvant cycles, CBC should be checked on Day 1 and Day 22 of each cycle 3
• Liver function tests should be performed at baseline, midway through first cycle, and prior to each subsequent cycle 3
• MRI evaluation approximately 4 weeks after completion of chemoradiotherapy (note that pseudoprogression may occur 4-8 weeks after radiotherapy) 1

Special Considerations

• If the patient develops significant toxicity or poor performance status during treatment, dose modifications or alternative regimens may be considered
• For patients with MGMT promoter methylation, temozolomide provides greater benefit 1
• Bevacizumab is not recommended for newly diagnosed GBM as it does not improve overall survival 1

Expected Outcomes

Despite optimal therapy, prognosis remains guarded. The median survival for patients with GBM receiving standard treatment is approximately 14-15 months, with 2-year survival rates around 25-30% 4. However, individual outcomes may vary based on molecular markers and response to treatment.

Follow-up

• Clinical evaluation with attention to neurological function every 3-6 months 1
• Regular MRI surveillance to monitor for disease recurrence 1
• Assessment of steroid requirements and management of treatment-related toxicities

This treatment approach represents the current standard of care based on high-quality evidence and is associated with the best outcomes in terms of survival and quality of life for patients with newly diagnosed GBM.