Glioblastoma Multiforme Follow-up

Updated: Jun 14, 2017
  • Author: Jeffrey N Bruce, MD; Chief Editor: Herbert H Engelhard, III, MD, PhD, FACS  more...
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Follow-up

Further Inpatient Care

Patients with glioblastomas who undergo surgical resection typically spend the night after surgery in an intensive care unit, followed by an inpatient stay of 3-5 days. The final length of stay depends on each patient's neurological condition.

Postoperative antibiotics usually are continued for 24 hours, and deep vein thrombosis prophylaxis is continued until patients are ambulatory.

Anticonvulsants are maintained at therapeutic levels throughout the inpatient stay, while steroids are reduced gradually, tailored to each patient's clinical status.

Many patients benefit from occupational therapy and physical therapy or rehabilitation.

While patients are in the hospital, they should receive postoperative imaging to determine the extent of surgical resection. Surgical resection is evaluated best within 3 days of surgery by using contrast-enhanced MRI. Contrast enhancement during this period accurately reflects residual tumor.

If not performed preoperatively, complete evaluations by consulting physicians, including a neurooncologist and radiation oncologist, should be considered postoperatively.

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Inpatient & Outpatient Medications

Anticonvulsant medications are usually maintained, and levels are checked intermittently.

Steroids are tapered to lower doses for radiation therapy and then tapered further if possible. While taking steroids, patients should be maintained on an antiulcer agent.

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Transfer

At some institutions, transferring the patient to another facility may be necessary if the proper consultations cannot be obtained.

In most cases, surgical resection can be performed on an urgent, but not emergent, basis.

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Complications

Brain tumor resection has an overall mortality rate of 1-2%.

Approximately 40% of patients have no or minimal deficits after surgery, 30% manifest no postoperative change relative to preoperative deficits, and 25% sustain an increased postoperative deficit that usually improves.

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Prognosis

Despite extensive clinical trials, individual prediction of clinical outcome has remained an elusive goal. Glioblastomas are among the most malignant human neoplasms, with a median survival despite optimal treatment of less than 1 year. In a series of 279 patients receiving aggressive radiation and chemotherapy, only 5 of 279 patients (1.8%) survived longer than 3 years. [110]

Patient survival depends on a variety of clinical parameters. Younger age, higher Karnofsky performance scale (a standard measure of the ability of patients with cancer to perform daily tasks) score at presentation, radiotherapy, and chemotherapy all correlate with improved outcome. Clinical evidence also suggests that a greater extent of resection favors longer survival. [111, 101, 100, 99, 112] Tumors that are deemed unresectable due to location (eg, in the brainstem) also portend a poorer prognosis. [113]

A review by Perrini et al of 48 patients with recurrent glioblastoma found that preoperative performance status at recurrence and subtotal versus gross-total repeat resection were independent predictors of survival. These authors concluded that gross-total resection at repeat craniotomy is associated with longer overall survival and should be performed whenever possible in patients with recurrent glioblastoma who have good performance status. [114]

Survival has not been shown to correlate with p53, EGFR, or MDM2 mutations. [115]

Two separate reviews of outcomes in elderly patients have been published. One found that although elderly patients have a poor prognosis, gross-total resection confers a modest survival benefit and bevacizumab significantly increased the overall survival. Older age and preoperative Karnofsky Performance Scale score also were significant prognostic factors. [116]

The results of the second study concurred that there is a survival advantage for those who undergo maximal safe resection. The review also found that radiotherapy extends survival in selected patients and temozolomide chemotherapy is safe and extends the survival of patients with tumors that harbor O(6)-methylguanine-DNA methyltransferase (MGMT) promoter methylation. [117]

A study by Li et al used an updated Radiation Therapy Oncology Group (RTOG) GBM database to produce a simplified original recursive partitioning analysis (RPA) model combining classes V and VI. This resulted in 3 distinct prognostic groups defined by performance status, age, neurologic function, and extent of resection. This classification will be used in future RTOG GBM trials. [118]

Clearly, new approaches for the management of glioblastomas are necessary. Enrollment of patients into clinical trials will generate new information regarding investigational therapies. Novel approaches, such as the use of gene therapy and immunotherapy, as well as improved methods for the delivery of antiproliferative, antiangiogenic, and noninvasive therapies, provide hope for the future.

A study by Kaur et al determined that the presence of a large cyst in patients with GBM does not affect overall survival compared with those who do not have a cyst. [119]

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Patient Education

For patient education resources, see the Cancer Center as well as the patient education article Brain Cancer.

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