Three-dimensional conformal radiotherapy, temozolomide chemotherapy, and high-dose fractionated stereotactic boost in a protocol-driven, postoperative treatment schedule for high-grade gliomas

ABSTRACT Aimsandbackground. Noavailablescientificreportdealswithhigh-dose(≥70 Gy)ra -diotherapyplustemozolomidechemotherapy(TMZCHT)inhigh-gradegliomas.Thesurvival results of a protocol-driven, postoperative treatment schedule are reportedhere to contribute to the discussion on this issue.Methods and study design. Uniform criteria were prospectively adopted for case se -lection during the period 1993-2006 in the management of 123 patients, and we pro -gressively introduced three-dimensional conformal radiotherapy (3D-CRT, 60 Gy),TMZ CHT and a high-dose (70 Gy) stereotactic boost (HDSRT) in the treatment sched -ule. Palliative radiotherapy was delivered by whole brain irradiation (WBI, 50 Gy) forbulky tumors, whereas radical irradiation was performed with 3D-CRT throughout thestudy period.Two periods of accrual are considered: 36 patients were treated before 31December 1999 (29.25%) and 87 (70.75%) after 1 January 2000. This subdivision wasdue to the implementation of HDSRT hardware and TMZ CHT from January 2000.Results. The median overall survival was 13 months and the 1-, 2- and 3-year survivalrates were 53%, 19.5% and 11.6%, respectively. The differences in survival related tothe treatment variables were highly significant, both in univariate and multivariateanalysis.The median survival and 1-, 2- and 3-year survival rates in the palliativeWBIgroup were 9.75 months and 37%, 2%, and 0%, respectively; in the 3D-CRT group17.25 months and 64%, 34%, and 15%, respectively; in the TMZ CHT concomitantwith radiotherapy group 20 months and 61%, 39%, and 21%, respectively; in theTMZCHT concomitant with and sequential to radiotherapy group 25.75 months and 84%,54%, and 26%, respectively, and in the HDSRT group 22 months and 72%, 48%, and37%, respectively. No symptomatic radiation necrosis occurred in any of the groups.Conclusions. The results reported here are generally better than those reported in theliterature. The selection of patients on the basis of favorable prognostic factors andsuitability to the currently available, aggressive postoperative treatment resourcescan be the mainstay for improving therapeutic results. In particular, the new treat -ment option reported here (HDSRT in association with TMZ CHT) proved to be safeand ef cti v obg r ly u m .IntroductionIn the last decades there has been no evidence-based demonstration of an im -provement in the therapeutic results obtained with radiation therapy in high-grade