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CNS: Glioblastoma standard of care

Free question published 24 July 2026

Central nervous systemGlioblastoma standard of care

A 58-year-old man presents with a three-week history of expressive dysphasia and headache. MRI shows a heterogeneously enhancing right temporal lobe mass with central necrosis. He undergoes maximal safe resection; histology confirms glioblastoma, IDH-wildtype, WHO grade 4, with an unmethylated MGMT promoter. His Karnofsky performance status is 90 and he has made a good postoperative recovery. Which is the most appropriate adjuvant treatment plan?

  1. ARadiotherapy 60 Gy in 30 fractions with concomitant temozolomide, then up to 6 cycles of adjuvant temozolomide
  2. BHypofractionated radiotherapy 40 Gy in 15 fractions with concomitant and adjuvant temozolomide
  3. CAdjuvant PCV chemotherapy followed by radiotherapy
  4. DRadiotherapy 60 Gy in 30 fractions alone, omitting temozolomide because the MGMT promoter is unmethylated
  5. EBest supportive care alone

Why A is correct

For a fit patient aged 70 or under with KPS 70 or more after maximal safe resection, NICE NG99 (recommendation 1.2.19) and the EANO glioma guideline recommend the Stupp protocol: 60 Gy in 30 fractions with concomitant temozolomide followed by up to 6 cycles of adjuvant temozolomide. MGMT methylation is prognostic and predictive but does not, in current UK practice, justify withholding temozolomide in an otherwise fit younger patient.

And why the others are not

  • BIncorrect: 40 Gy in 15 fractions is the hypofractionated schedule reserved for patients aged around 70 or over, not a 58-year-old.
  • CIncorrect: PCV is the chemotherapy used in 1p/19q-codeleted oligodendroglioma and low-grade glioma, not glioblastoma.
  • DIncorrect: although unmethylated tumours derive less benefit, NICE does not recommend omitting temozolomide in fit younger patients, so radiotherapy alone is undertreatment.
  • EIncorrect: best supportive care alone is considered only for patients aged around 70 or over with KPS under 70.

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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