**4.3 Patient evaluation**

The patients were assessed weekly for tolerability and toxicity during the radiation therapy. The baseline examination included cranial MRI (with and without contrast), physical and

Ultrafractionated Radiation Therapy (3 daily doses of 0.75 Gy) -

**4.7 Response to treatment** 

B- At the end of radiotherapy.

**4.8 Commentaries** 

line.

A New and Promising Radiotherapy Schedule for Glioblastoma Patients 407

months for > 55 years (Beauchesne et al., 2010). The trial design allowed the use of fotemustine, a nitrosourea component, as first line of chemotherapy at tumor progression, but patients were treated at the physician's discretion. At the cut-off date, 16 patients had received chemotherapy; fotemustine was given in 14 cases, and temozolomide in 2 (Beauchesne et al., 2010). One patient underwent surgery, and radio-surgery was performed in one case. The response to salvage chemotherapy was not recorded as part of our study.

Tumor response was analyzed (at the end of the ultrafractionated regimen and then 2 months later) using the WHO criteria. Eight stabilizations (corresponding to a decrease of less than 25 % of perpendicular transversal diameters – no cerebral edema and mass effect) were observed among the patients who had received the ultrafractionated radiation therapy (Fig. 5) (Beauchesne et al., 2010). In addition, the doses of corticosteroids were stable or decreased for these patients. Stabilization of tumor responses was observed either at the end of radiation therapy or in the following months. In the remaining cases, the tumor was nonprogressive (Beauchesne et al., 2010). In most cases, corticosteroids were decreased and stopped for several weeks. Half of the long term survivors did not receive a chemotherapy

A MRI scan B MRI scan. Fig. 5. A stabilisation response was seen on a cranial MRI. A- At the beginning of treatment.

Before this study was conducted, the safety and tolerability of this new regimen of radiation therapy, three doses per day administered at intervals at least 4 hours, were unknown. This was the first time that such an ultrafractionated radiation therapy regimen was clinically

neurological examination and included Mini-Mental-Status score (MMS) and a quality-oflife questionnaire (EORTC – QLQ-C30, Brain Cancer Module BN-20) (Beauchesne et al., 2010). Baseline examination was performed at the end of radiation therapy regimen (within the first 10 days after completion of ultrafractionated irradiation) and then every 2 months until death. The first MRI (at the end of radiation therapy) constituted the baseline imaging to evaluate tumor response keeping in mind that radiation therapy artifacts if present should be taken into account when interpreting the images (Beauchesne et al., 2010). Tumor progression was defined according to the modified WHO criteria (Macdonald criteria) as an increase in tumor size by 25 percent (size of the product of the largest perpendicular diameters of contrast-enhancing tumor), the appearance of new lesions, or an increased need for corticosteroids (MacDonald et al., 1990). When there was tumor progression, patients were treated at the investigator's discretion, and the type of subsequent therapy (usually chemotherapy) was recorded (Beauchesne et al., 2010).
