Malignant Glioma

• Understanding the disease
• Treatment options
• Side effects of treatment

Stephen Shamp, MD MSEE

David Bloom, MD PhD

Matthew Culbert, MD

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Brain primary: a normal brain cell (glial cell) becomes malignant and is called a glioma

Brain metastases: cancer that started elsewhere in the body (e.g. lung or breast) and spread to the brain

Brain Imaging

Prognostic Factors

Grade – how aggressive and rapidly growing the cells have become

• Lower grade (grade I or II) tumors tend to grow more slowly and are less likely to grow into (invade or infiltrate) nearby tissues.
• Higher grade (grade III or IV) tumors tend to grow quickly and are more likely to grow into nearby tissues. These tumors often require more intense treatment.

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 IDH1 mutation – Mutation of IDH1 gene is associated with a more favorable prognosis.

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 1p/19q Co-deletion - Codeletion of 1p/19q gene is associated with a more favorable prognosis

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 MGMT Methylation - Methylation of MGMT is associated with improved response to temodar chemotherapy, and therefore more favorable prognosis

Molecular Subtyping

Molecular subtype is critical in making estimates of prognosis

MGMT Methylation and Temodar (TMZ)

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JCO December 1, 2009 vol. 27no. 34 5743-5750

Brain Surgery

Regardless of tumor type, the best outcome if the surgeon removes as much tumor as possible, keeps the surgical morbidity (complications) low and an ensures an accurate diagnosis

PostOp MRI to evaluate the success of the surgery in removing the obvious tumor

Brain Radiation

Most patients receive radiation after healing from surgery to the region around the original tumor. This is often combined with oral temodar chemotherapy at the same time

www.nccn.org

CT simulation (planning session)

• We will build a cradle to hold you in the same position with each treatment.
• Temporary or permanent marks will be made
• CT images are obtained and then imported into the treatment planning computer
• Your MRI may be fused to help with targeting

Logistics of External Beam Radiation:

• Usually 30-33 daily treatments
• Treatment days are Monday-Friday 5 days per week, 6 - 6.5 weeks in total
• You will start radiation on the same day as oral temodar chemotherapy if it is recommended by your medical oncologist
• Daily treatment takes 15 minutes or less. You will be given a schedule
• You do not feel anything during treatment, you will not be radioactive

• Lasers and/or imaging is used to precisely deliver the daily radiation treatment.
• Expect to be on the treatment table less than 15 minutes.
• You will not feel any immediate effects.

Side Effects of Brain Radiation

• Common:
• Fatigue
• Hair Loss - localized
• Scalp Irritation
• Possible:
• Headaches
• Nausea
• Worsening Neurological symptoms

Risks of Brain Radiation

• Radiation Necrosis (Injury to surrounding brain)
• Memory / Neurocognitive Decline

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• Depending on area treated other structures may be at risk of rare but serious injury including optic nerves/chiasm, brainstem, cochlea, brainstem, pituitary, secondary malignancy

After treatment you will be followed with serial MRI’s

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Sometimes the MRI will look worse after treatment due to radionecrosis of the cancer but with time this should fade away

Further Treatment

• There may be additional treatment after chemoradiation at the discretion of your medical oncologist
• Additional cycles of oral temodar chemotherapy
• Clinical Trials
• Optune Device