Opakované ozařování u high-grade gliomů – stále diskutované téma

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Authors: C. C. Mirestean ¹; R. I. Iancu ^2,3; D. P. T. Iancu ^1,2
Published in: Cesk Slov Neurol N 2025; 88(2): 89-94
Category: Review Article
doi: https://doi.org/10.48095/cccsnn202589

Overview

I po maximální standardní léčbě, která zahrnuje maximální chirurgickou resekci, adjuvantní radioterapii a souběžnou a následně adjuvantní chemoterapii alkylační látkou temozolomidem (TMZ), což je režim ověřený klinickými studiemi fáze III, zůstává celkové přežití u glioblastomu (GB), nejčastějšího a nejmalignějšího podtypu gliomu vysokého stupně, omezené. Pětileté přežití je nižší než 10 %, přičemž obvyklou příčinou úmrtí je lokální recidiva. Nejčastěji navrhovanými alternativami čistě paliativní léčby jsou reoperace, opětovné podání alkylačních látek včetně TMZ nebo léčba relapsu lomustinem a opakované ozařování. Opakované ozařování se jeví být možností pro GB v pečlivě vybraných případech a volba ozařovací metody mezi standardní frakcionací, stereotaktickou hypofrakcionovanou radioterapií a stereotaktickou radiochirurgií musí zohledňovat technické a s pacientem související faktory a průběh relapsu. Použití alkylačních látek TMZ a lomustinu v kombinaci s opakovaným ozařováním se zdá být strategií s přínosem zejména po výběru terapie na základě metylačního stavu promotoru O6-metylguanin-DNA-metyltransferázy. Budoucími směry výzkumu jsou neoadjuvantní imunoterapie a identifikace molekulárních biomarkerů, přesnější vymezení cílového objemu na základě pozitronové emisní tomografie/výpočetní tomografie s aminokyselinami, ale také použití inhibitorů glykolýzy ve spojení s látkami proti cévnímu endoteliálnímu růstovému faktoru. Omezení kumulativních ekvivalentních dávek po 2 Gy (EQD2) na mozkovou tkáň parenchym do výše 100 Gy v případě ultrahypofrakcionovaných režimů a do výše < 120 Gy EQD2 v případě jiných frakcionačních schémat by mohlo omezit riziko mozkové radionekrózy pod 10 %.

Klíčová slova:

radioterapie – glioblastom – stereotaktická radiochirurgie – opakované ozařování – O6-methyl-guanin-DNA-metyltransferáza – temozolomide – lomustin – hypofrakcionovaná stereotaktická radioterapie – radionekróza

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