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CNS: Elderly glioblastoma

Free question published 15 August 2026

Central nervous systemElderly glioblastoma

A 74-year-old man presents with confusion and a fall. MRI and biopsy confirm glioblastoma, IDH-wildtype, WHO grade 4, with a methylated MGMT promoter. Resection was not feasible; biopsy only was performed. His Karnofsky performance status is 80 and he lives independently. Which adjuvant treatment is most appropriate?

  1. ABest supportive care alone
  2. BRadiotherapy 40 Gy in 15 fractions alone, without temozolomide
  3. CRadiotherapy 60 Gy in 30 fractions with concomitant and adjuvant temozolomide
  4. DRadiotherapy 40 Gy in 15 fractions with concomitant and up to 12 cycles of adjuvant temozolomide
  5. ETemozolomide monotherapy with no radiotherapy

Why D is correct

For patients aged around 70 or over with KPS 70 or more and MGMT-methylated glioblastoma, NICE NG99 (recommendation 1.2.20) recommends hypofractionated radiotherapy 40 Gy in 15 fractions with concomitant and up to 12 cycles of adjuvant temozolomide. This is supported by the Perry CCTG CE.6 trial, in which adding temozolomide to short-course radiotherapy improved median survival (9.3 versus 7.6 months overall), with the greatest benefit in MGMT-methylated tumours.

And why the others are not

  • AIncorrect: best supportive care alone is reserved for elderly patients with KPS under 70.
  • BIncorrect: omitting temozolomide forgoes the survival benefit demonstrated in the Perry trial, which was greatest in methylated tumours.
  • CIncorrect: 60 Gy in 30 fractions is the schedule for fit patients aged around 70 or under, not an elderly patient.
  • EIncorrect: temozolomide alone without radiotherapy is not the NICE-recommended pathway for a fit elderly patient with KPS 80.

Source NICE NG99 — Brain tumours (primary) and brain metastases in adults — National Institute for Health and Care Excellence. Brain tumours (primary) and brain metastases in over 16s. NICE guideline NG99. Published 11/07/2018, updated 29/01/2021.

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