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Glioblastoma and Other Malignant Gliomas:  A Clinical Review

Antonio Omuro, MD1; Lisa M. DeAngelis, MD1
[+] Author Affiliations
1Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York
JAMA. 2013;310(17):1842-1850. doi:10.1001/jama.2013.280319.
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Importance  Glioblastomas and malignant gliomas are the most common primary malignant brain tumors, with an annual incidence of 5.26 per 100 000 population or 17 000 new diagnoses per year. These tumors are typically associated with a dismal prognosis and poor quality of life.

Objective  To review the clinical management of malignant gliomas, including genetic and environmental risk factors such as cell phones, diagnostic pitfalls, symptom management, specific antitumor therapy, and common complications.

Evidence Review  Search of PubMed references from January 2000 to May 2013 using the terms glioblastoma, glioma, malignant glioma, anaplastic astrocytoma, anaplastic oligodendroglioma, anaplastic oligoastrocytoma, and brain neoplasm. Articles were also identified through searches of the authors’ own files. Evidence was graded using the American Heart Association classification system.

Findings  Only radiation exposure and certain genetic syndromes are well-defined risk factors for malignant glioma. The treatment of newly diagnosed glioblastoma is based on radiotherapy combined with temozolomide. This approach doubles the 2-year survival rate to 27%, but overall prognosis remains poor. Bevacizumab is an emerging treatment alternative that deserves further study. Grade III tumors have been less well studied, and clinical trials to establish standards of care are ongoing. Patients with malignant gliomas experience frequent clinical complications, including thromboembolic events, seizures, fluctuations in neurologic symptoms, and adverse effects from corticosteroids and chemotherapies that require proper management and prophylaxis.

Conclusions and Relevance  Glioblastoma remains a difficult cancer to treat, although therapeutic options have been improving. Optimal management requires a multidisciplinary approach and knowledge of potential complications from both the disease and its treatment.

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Figure.
Typical Glioblastoma Features on Magnetic Resonance Imaging Studies Used in the Initial Evaluation of a Suspected Brain Tumor

Brain magnetic imaging studies of a patient with a glioblastoma in the right temporal lobe. A, Axial T1-weighted magnetic resonance image (MRI) without contrast showing a poorly delineated right temporal mass lesion. Gadolinium contrast injection (B) reveals a heterogeneously enhancing cystic/necrotic lesion. C, Fluid attenuated inversion recovery sequence shows areas of hypersignal extending beyond the areas of contrast enhancement, corresponding to peritumoral edema, which typically improves with corticosteroids. D, Susceptibility weighted image shows hypointense areas corresponding to small intratumoral hemorrhagic components. E and F, Advanced imaging with dynamic contrast enhanced (DCE) T1 perfusion MRI further characterizes the neoplastic angiogenic process, showing areas of hyperperfusion on the plasma volume map (E) and increased vascular permeability (volume transfer coefficient [Ktrans] map) (F). (Images courtesy of Robert Young, MD, Memorial Sloan-Kettering Cancer Center.)

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