Glioblastoma and Other Primary Brain Malignancies in Adults

Abstract

ImportanceMalignant primary brain tumors cause more than 15 000 deaths per year in the United States. The annual incidence of primary malignant brain tumors is approximately 7 per 100 000 individuals and increases with age. Five-year survival is approximately 36%.ObservationsApproximately 49% of malignant brain tumors are glioblastomas, and 30% are diffusely infiltrating lower-grade gliomas. Other malignant brain tumors include primary central nervous system (CNS) lymphoma (7%) and malignant forms of ependymomas (3%) and meningiomas (2%). Symptoms of malignant brain tumors include headache (50%), seizures (20%-50%), neurocognitive impairment (30%-40%), and focal neurologic deficits (10%-40%). Magnetic resonance imaging before and after a gadolinium-based contrast agent is the preferred imaging modality for evaluating brain tumors. Diagnosis requires tumor biopsy with consideration of histopathological and molecular characteristics. Treatment varies by tumor type and often includes a combination of surgery, chemotherapy, and radiation. For patients with glioblastoma, the combination of temozolomide with radiotherapy improved survival when compared with radiotherapy alone (2-year survival, 27.2% vs 10.9%; 5-year survival, 9.8% vs 1.9%; hazard ratio [HR], 0.6 [95% CI, 0.5-0.7]; P < .001). In patients with anaplastic oligodendroglial tumors with 1p/19q codeletion, probable 20-year overall survival following radiotherapy without vs with the combination of procarbazine, lomustine, and vincristine was 13.6% vs 37.1% (80 patients; HR, 0.60 [95% CI, 0.35-1.03]; P = .06) in the EORTC 26951 trial and 14.9% vs 37% in the RTOG 9402 trial (125 patients; HR, 0.61 [95% CI, 0.40-0.94]; P = .02). Treatment of primary CNS lymphoma includes high-dose methotrexate-containing regimens, followed by consolidation therapy with myeloablative chemotherapy and autologous stem cell rescue, nonmyeloablative chemotherapy regimens, or whole brain radiation.Conclusions and RelevanceThe incidence of primary malignant brain tumors is approximately 7 per 100 000 individuals, and approximately 49% of primary malignant brain tumors are glioblastomas. Most patients die from progressive disease. First-line therapy for glioblastoma is surgery followed by radiation and the alkylating chemotherapeutic agent temozolomide.

Multi-b-value diffusion stretched-exponential model parameters correlate with MIB-1 and CD34 expression in Glioma patients, an intraoperative MR-navigated, biopsy-based histopathologic study

“…Gliomas are the most common primary malignant central nervous system cancer, accounting for 80%-85% of malignant brain tumors ( 1 ), being highly aggressive and having the highest mortality and morbidity. The current standard of care treatment for glioma is maximal safe surgical resection followed by radiation therapy and concomitant chemotherapy ( 2 ).…”

A Review of Glioblastoma and Other Primary Brain Malignancies—Reply

“…In Reply In response to our recent Review, Dr Wang raises several interesting points regarding the use of prophylaxis against P jirovecii pneumonia in patients with glioma, but conflates 2 different clinical scenarios. The first is P jirovecii pneumonia prophylaxis in the setting of long-term steroid use (>4 weeks), as discussed in our Review . The second scenario is empirical P jirovecii pneumonia prophylaxis in the setting of chemoradiation, which is the scenario addressed in the article cited by Wang.…”

“…In our Review, we discussed the indication for P jirovecii pneumonia prophylaxis in patients taking long-term steroids, defined as prednisone, 20 mg/d or greater, for more than 4 weeks. This recommendation is shared by the National Comprehensive Cancer Network, the American Thoracic Society, and the American Society of Clinical Oncology in concert with the Infectious Diseases Society of America .…”

A Review of Glioblastoma and Other Primary Brain Malignancies

“…To the Editor The recent Review about primary brain malignancies in adults recommended that “patients receiving the equivalent of prednisone 20 mg daily for more than a month…should receive prophylaxis for Pneumocystis jirovecii pneumonia.” In Table 1 in the article, the authors listed the 4 recommended P jirovecii pneumonia prophylaxis medications with their doses and highlighted sulfamethoxazole-trimethoprim as the “preferred” agent with the justification that it “reduces incidence of P jirovecii pneumonia in non-HIV immunocompromised individuals from 6.2% to 0.2%.” Although they provided 1 corresponding citation, the reference is a 2014 Cochrane review that included only trials of leukemia, solid organ transplant, and autologous bone marrow transplant and included only 1 sentence that mentioned patients with brain tumors: “Patients receiving corticosteroids for primary or metastatic brain tumours may be at a higher risk warranting prophylaxis.” There is an accompanying citation to a single center’s experience of P jirovecii pneumonia among patients without AIDS from 1963 to 1992, which reported that some patients had solid tumors; brain tumors were not specifically studied, but the article stated: “An emerging group at risk were patients with a primary or secondary brain neoplasm.” A reference was then provided to an earlier article by the same author that calculated a P jirovecii pneumonia incidence rate of 1.3% (8 of 595 patients with brain tumors developed P jirovecii pneumonia) …”

“…Therefore, the recommendation from the Review on glioblastoma and other primary brain malignancies was based on 30- to 60-year-old data from 1 institution. In more recent medical literature, the issue of P jirovecii pneumonia prophylaxis remains controversial.…”