title: Metabolic management of glioblastoma multiforme using standard therapy together with a restricted ketogenic diet: Case Report.
abstract: BACKGROUND
  Management of glioblastoma multiforme (GBM) has been difficult using standard therapy (radiation with temozolomide chemotherapy). The ketogenic diet is used commonly to treat refractory epilepsy in children and, when administered in restricted amounts, can also target energy metabolism in brain tumors. We report the case of a 65-year-old woman who presented with progressive memory loss, chronic headaches, nausea, and a right hemisphere multi-centric tumor seen with magnetic resonance imaging (MRI). Following incomplete surgical resection, the patient was diagnosed with glioblastoma multiforme expressing hypermethylation of the MGMT gene promoter.
  
  
  METHODS
  Prior to initiation of the standard therapy, the patient conducted water-only therapeutic fasting and a restricted 4:1 (fat: carbohydrate + protein) ketogenic diet that delivered about 600 kcal/day. The patient also received the restricted ketogenic diet concomitantly during the standard treatment period. The diet was supplemented with vitamins and minerals. Steroid medication (dexamethasone) was removed during the course of the treatment. The patient was followed using MRI and positron emission tomography with fluoro-deoxy-glucose (FDG-PET).
  
  
  RESULTS
  After two months treatment, the patient's body weight was reduced by about 20% and no discernable brain tumor tissue was detected using either FDG-PET or MRI imaging. Biomarker changes showed reduced levels of blood glucose and elevated levels of urinary ketones. MRI evidence of tumor recurrence was found 10 weeks after suspension of strict diet therapy.
  
  
  CONCLUSIONS
  This is the first report of confirmed GBM treated with standard therapy together with a restricted ketogenic diet. As rapid regression of GBM is rare in older patients following incomplete surgical resection and standard therapy alone, the response observed in this case could result in part from the action of the calorie restricted ketogenic diet. Further studies are needed to evaluate the efficacy of restricted ketogenic diets, administered alone or together with standard treatment, as a therapy for GBM and possibly other malignant brain tumors.
authors.affiliation: Radiology Department, Arcispedale Santa Maria Nuova, Reggio E, 42100, Italy. giulio.zuccoli@gmail.com.
authors.forename: Giulio
authors.initials: G
authors.lastname: Zuccoli
authors.forename: Norina
authors.initials: N
authors.lastname: Marcello
authors.forename: Anna
authors.initials: A
authors.lastname: Pisanello
authors.forename: Franco
authors.initials: F
authors.lastname: Servadei
authors.forename: Salvatore
authors.initials: S
authors.lastname: Vaccaro
authors.forename: Purna
authors.initials: P
authors.lastname: Mukherjee
authors.forename: Thomas N
authors.initials: TN
authors.lastname: Seyfried