Recurrence patterns in patients with high-grade glioma following temozolomide-based chemoradiotherapy

Abstract

There is currently no consensus regarding the optimal radiation volume for high-grade glioma (HGG). The brain volume irradiated is associated with the extent of radiation neurotoxicity. When reducing the treatment volume, the risk of geographic tumor miss should be considered. In such cases, the recurrence patterns and, particularly, the rate of marginal tumor recurrence, are important indices for determining the optimal radiation volume. In the present study, a smaller-target delineation protocol with limited margins was adopted. The postoperative enhancing tumor and resection cavity were defined as gross tumor volume (GTV); 1 and 2 cm were added to the GTV to create clinical target volume (CTV1 and CTV2), which received 60 and 54 Gy, respectively. At a median follow-up of 14 months, 54 HGG patients developed tumor recurrence. The median overall and progression-free survival were 14 and 10.5 months, respectively. A total of 34 patients developed central recurrence, 8 presented with in-field recurrence, 2 developed marginal recurrence, 2 had distant recurrence and 11 patients developed cerebrospinal fluid dissemination, 2 of whom developed central recurrence, with 1 patient simultaneously developing marginal recurrence. Local recurrence (central and in-field) was found to be the main recurrence pattern. As the rate of marginal recurrence was low (<5%), it appears that the smaller irradiated volume in the present study was appropriate. However, clinical trials investigating limited irradiation volume are required to validate our findings.

Keywords: chemoradiotherapy; high-grade glioma; irradiated volume; recurrence patterns.

Figure 1.

Magnetic resonance images of local glioblastoma multiforme (GBM) recurrence in a representative case. Preoperative (A) axial fluid-attenuated inversion recovery image and (B) post-contrast T1-weighted image showing a tumor located in the left temporal lobe. (C) Postoperative axial post-contrast T1-weighted image. (D) Axial post-contrast T1-weighted image at the end of radiotherapy. (E) Axial post-contrast T1-weighted image at 10 months after pathological diagnosis, showing an increasing enhancing lesion at the primary site. The patient underwent re-operation and had the same pathological diagnosis (GBM) as that of the primary tumor. (F) The axial post-contrast T1-weighted image at recurrence was fused with the planning computed tomography image, revealing local recurrence. The blue line indicates the 54-Gy IDL, the green line indicates the 60-Gy IDL and the red line marks the tumor recurrence volume. IDL, isodose line.