title: Therapeutic options for recurrent malignant glioma.
abstract: OBJECTIVE
  Despite the given advances in neuro-oncology most patients with high grade malignant glioma ultimately fail locally or locoregionally. In parallel with improvements of initial treatment options, several salvage strategies have been elucidated and already entered clinical practice. Aim of this article is to review the current status of salvage strategies in recurrent high grade glioma.
  
  
  METHODS
  Using the following MESH headings and combinations of these terms the pubmed database was searched: "Glioma", "Recurrence", "Neoplasm Recurrence, Local", "Radiosurgery", "Brachytherapy", "Neurosurgical Procedures" and "Drug Therapy". For citation crosscheck the ISI web of science database was used employing the same search terms. In parallel, the abstracts of ASCO 2008-2009 were analyzed accordingly.
  
  
  RESULTS
  Currently the following options for salvage entered clinical practice: re-resection, re-irradiation (stereotactic radiosurgery, (hypo-)fractionated (stereotactic) radiotherapy, interstitial brachytherapy) or single/poly-chemotherapy schedules including new dose-intensified or alternative treatment protocols employing targeted drugs. Re-operation is associated with high morbidity and mortality, however, is an option in a highly selected patient cohort. Since toxicity has been overestimated, re-irradiation is an increasingly used option with precise fractionated radiotherapy being the most optimal technique. On average, time to secondary progression is in the range of several months. Conventional chemotherapy regimens also improve time to secondary progression; however the efficacy is only modest and treatment-related toxicities like myelo-suppression occur very frequently. Molecular targeted agents/kinases are undergoing clinical testing; however no final recommendations can be made.
  
  
  CONCLUSIONS
  Currently, several re-treatment options with only modest efficacy exist. The relative value of each approach compared to other options is unknown as well as it remains open which sequence of modalities should be chosen.
authors.affiliation: Department of Radiation Oncology, Ludwig-Maximilians-University Munich, München, Germany.
authors.forename: Maximilian
authors.initials: M
authors.lastname: Niyazi
authors.forename: Axel
authors.initials: A
authors.lastname: Siefert
authors.forename: Silke Birgit
authors.initials: SB
authors.lastname: Schwarz
authors.forename: Ute
authors.initials: U
authors.lastname: Ganswindt
authors.forename: Friedrich-Wilhelm
authors.initials: FW
authors.lastname: Kreth
authors.forename: Jörg-Christian
authors.initials: JC
authors.lastname: Tonn
authors.forename: Claus
authors.initials: C
authors.lastname: Belka
mesh_terms: D020533:Angiogenesis Inhibitors / Q000627:therapeutic use; D001918:Brachytherapy; D001932:Brain Neoplasms / Q000628:therapy*; D066246:ErbB Receptors / Q000037:antagonists & inhibitors; D005910:Glioma / Q000628:therapy*; D006801:Humans; D009364:Neoplasm Recurrence, Local / Q000628:therapy*; D016634:Radiosurgery; D011879:Radiotherapy Dosage; D040262:Receptors, Vascular Endothelial Growth Factor / Q000037:antagonists & inhibitors; D016879:Salvage Therapy
chemical_list: D020533:Angiogenesis Inhibitors; D066246:ErbB Receptors; D040262:Receptors, Vascular Endothelial Growth Factor