First: is it really recurrence?
In the months after chemoradiation, up to a third of worrying scans are pseudoprogression: inflammation and treatment effect that looks like tumor and settles on its own. Later, radiation necrosis can do the same. Before any decision, the team should look at the timing, the pattern on perfusion or spectroscopy MRI, the symptoms and, where possible, a repeat scan in four to six weeks. The RANO criteria exist to make this judgment consistent. A biopsy or second surgery is sometimes the only way to be sure, and it provides new tissue for molecular testing and for treatments that need it.
- 1Treatment effectInflammation after chemoradiation enlarges the enhancing area, then settles over weeks. Common in the first three months.
- 2True progressionThe tumor itself grows from scan to scan. Perfusion MRI, timing and sometimes biopsy tell the two apart.
Schematic. One worrying scan is rarely acted on alone; a repeat in four to six weeks is usual.
- Repeat MRI in 4–6 weeks
- Perfusion or spectroscopy MRI
- Biopsy if it matters for the next step
- Second surgery, if accessible and fit
- Re-irradiation for small recurrences
- Lomustine · bevacizumab · regorafenib
- Clinical trial or authorized program
Second surgery
If the recurrence is accessible and the patient is fit, a second resection relieves pressure, improves symptoms and can extend survival when most of the tumor can be removed. It also yields fresh tissue, which matters for sequencing-based treatments. The decision rests with an experienced neurosurgical team; this is one of the situations where a high-volume center makes a difference.
Re-irradiation
Focused re-irradiation, usually stereotactic radiosurgery or hypofractionated radiotherapy, is used for small, well-defined recurrences. It can control the local tumor for months with manageable toxicity. Larger or diffuse recurrences are not suitable.
Drugs: lomustine, bevacizumab, regorafenib, temozolomide re-challenge
- Lomustine (CCNU) is the most commonly used chemotherapy at recurrence and the usual control arm in trials; median survival with it is about seven to nine months in trial populations, better in MGMT-methylated tumors.
- Bevacizumab reduces swelling, lets steroids be lowered and lengthens progression-free survival, but has not been shown to lengthen overall survival. It is valuable for symptom control.
- Regorafenib showed a survival benefit over lomustine in one Phase 2 trial (REGOMA) that has not been confirmed in a larger study; availability varies.
- Temozolomide re-challenge is an option for MGMT-methylated tumors that recurred late.
| Option | Best suited to | What it offers | Main limit |
|---|---|---|---|
| Second surgery | Accessible recurrence, good performance status | Symptom relief, fresh tissue, longer survival if most is removed | Not possible for deep or diffuse recurrence |
| Re-irradiation | Small, well-defined recurrence | Months of local control | Not for large or diffuse disease |
| Lomustine | Most patients; MGMT-methylated do better | The usual second-line chemotherapy | Median survival about 7–9 months in trials |
| Bevacizumab | Swelling, high steroid need | Symptom control, longer PFS | No overall survival benefit shown |
| Trial or program | Fit patients with measurable disease | Access to new treatments | Eligibility rules; results unproven |
Clinical trials and authorized programs
Recurrence is where most new treatments are first tested: oncolytic viruses, CAR-T cells, checkpoint inhibitors in combinations, targeted drugs for specific mutations, and vaccines. Trials for recurrent disease have their own eligibility rules, usually requiring measurable tumor on MRI, a stable steroid dose and a performance score of 60 or 70 or above. Our guide to finding trials explains how to search. Authorized programs abroad, including ours, accept recurrent patients subject to fitness and tissue availability; expectations should be set accordingly, because recurrent disease is harder to treat on every route.
Supportive care is treatment
Steroid management, seizure control, physiotherapy, and early involvement of a palliative-care team improve quality of life and sometimes survival, and they do not mean giving up. Decide early, and in writing, what matters most to the patient: more time, more function, less time in hospital. That decision should guide the choice among the options above.
Questions families ask
How long do people live after glioblastoma recurs?
In trial populations treated with lomustine or bevacizumab, median survival after recurrence is roughly six to nine months, with wide variation. Patients who can have a second resection and have good performance status do better.
Can I enter a trial if I am on bevacizumab?
Many trials exclude patients who have received bevacizumab, because it changes how tumors look on MRI. If a trial is a goal, ask about this before starting bevacizumab.
Is a vaccine useful at recurrence?
Vaccines work best with a small tumor burden and a recovering immune system, so recurrence is a harder setting. Programs that accept recurrent patients should say what their data at recurrence show; ours are mostly in newly diagnosed and post-operative patients, and we say so.
Related guides
- Standard treatment for glioblastoma explained: surgery, radiotherapy, temozolomide and TTFields
- How to find and judge a glioblastoma clinical trial
- Dendritic-cell and mRNA vaccines for glioblastoma: how they work and what is proven
Sources
- Wen PY, et al. Glioblastoma in adults: a Society for Neuro-Oncology and European Society of Neuro-Oncology consensus review. Neuro-Oncology 2020 doi.org
- Lombardi G, et al. Regorafenib compared with lomustine in relapsed glioblastoma (REGOMA). Lancet Oncology 2019 doi.org
- Wick W, et al. Lomustine and bevacizumab in progressive glioblastoma (EORTC 26101). NEJM 2017 doi.org
Considering treatment in China?
Send the patient's records for a remote review. A coordinator confirms receipt within one business day; the multidisciplinary team's report and a written estimate follow in about a week, before any decision or payment.