Management of Progressive Glioblastoma Clinical Practice Guidelines (CNS, 2022)

Congress of Neurological Surgeons

These are some of the highlights of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

May 31, 2022

Updated guidelines for the management of progressive glioblastoma were published in May 2022 by the Congress of Neurological Surgeons (CNS) in Neurosurgery.[1]


Gadolinium contrast-enhanced magnetic resonance imaging (MRI) is recommended for diagnosis of progressive glioblastoma multiforme (pGBM). Diffusion-weighted imaging should be considered as part of the standard MRI sequences used.

18-Fluorodeoxyglucose (FDG) is not recommended for routine diagnosis. Techniques using newer radiotracers may assist in the diagnosis.

Role of Cytoreductive Surgery

Cytoreductive surgery is recommended for patients with symptomatic pGBM. It is also recommended to improve overall survival in pGBM patients.

Pathology Testing

Repeat assessment of 06-methylguanine-DNA methyltransferase (MGMT) methylation and isocitrate dehydrogenase status is not indicated.

Programmed death ligand (PDL) 1/mismatch repair enzyme activity is not a useful component of standard diagnostic testing.

If epidermal growth factor receptor amplification was not previously measured, its assessment at progression may be of diagnostic value.

Large panel sequencing may be considered in patients who are eligible for or interested in molecularly guided therapy or clinical trials.

Use of Cytotoxic Agents

Benefit may be derived from treatment with temozolomide (TMZ; especially with progression after > 5 months off TMZ).

Fotemustine is suggested in elderly patients with methylated MGMT promoter status.

Tumor treatment fields (TTFs) with other chemotherapy may be considered for adult patients.

The following are not suggested: (1) TMZ combined with other cytotoxic agents as standalone therapy; (2) other chemotherapeutic agents (including platinum compounds and topoisomerase inhibitors); (3) other cytotoxic therapies (eg, perillyl alcohol or ketogenic diet) as standalone therapy; and (4) oncolytic virotherapy.

Role of Radiation Therapy

Reirradiation should be considered for patients with pGBM; it can be safely used in elderly patients.

Value of Targeted Therapy and Immunotherapy

Bevacizumab does not provide increased overall survival when used to treat pGBM. There is not sufficient evidence to identify benefits and harms associated with its use in combination with other agents.

For more information, please go to Glioblastoma Multiforme.


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