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Glioma Treatment Guide
As a service to our community, BTSS medical advisors have compiled a summary of Treatments for Gliomas.
NeuroOncology
Systemic and Targeted Therapies for Glioma Management
| Clinically Available in Singapore | ||
|---|---|---|
Treatment | Efficacy | Some Known Adverse Effects |
| Temozolomide | Standard first-line treatment/ may also be used in the recurrent setting. Survival benefit in the first-line setting when added to radiotherapy | Fatigue, hair loss, nausea, vomiting, constipation, suppression of immunity, low platelet, liver toxicity, loss of fertility |
| Procarbazine, Lomustine, Vincristine | First-line treatment of oligodendrogliomas, Treatment in the recurrent setting | Fatigue, hair loss, nausea, vomiting, suppression of immunity, low platelet, liver toxicity, lung toxicity, loss of fertility, numbness |
| Lomustine | Treatment in the recurrent setting | Fatigue, nausea, vomiting, suppression of immunity, low platelet, liver toxicity, lung toxicity, loss of fertility |
| Bevacizumab | Mainly used in the recurrence setting, in the first-line setting under special circumstances | Hypertension, protein in the urine, blood clots, bleeding, wound healing issues |
| Tumor Treating Fields (TTF, Optune) | First-line treatment. May also be used in the recurrent setting | Scalp irritation, headaches |
| Platinum-based Regimens (Carboplatin) | Treatment in the recurrent setting | Fatigue, nausea, vomiting, suppression of immunity, low platelet, renal toxicity, loss of fertility |
| Etoposide | Treatment in the recurrent setting | Fatigue, alopecia, nausea, vomiting, suppression of immunity, low platelet |
| Larotrectinib | Presence of NTRK gene fusion tumours in recurrent setting | Fatigue, nausea, vomiting, anaemia, suppression of immunity, liver toxicity |
| Dabrafenib / Trametinib | Presence of BRAF V600E activation mutation in recurrent setting | Hair loss, skin conditions, headache, constipation, joint aches, anaemia, bleeding |
| Vemurafenib / Cobimetinib | Presence of BRAF V600E activation mutation in recurrent setting | Hair loss, skin conditions, headache, constipation, joint aches, anaemia, bleeding |
| Vorasidenib | Treatment for grade 2 astrocytoma or oligodendroglioma with IDH1/2 mutation following surgery | Fatigue, nausea, diarrhoea, abnormal liver function |
| Clinical Trials Available in Singapore | ||
|---|---|---|
Treatment | Rationale of Trial | Target Population |
| Proof-of-concept study of ACT001 NCT06894225 | Study the effectiveness of ACT001 in Adult patients with recurrent Glioblastoma. Harbouring STAT3 - High Signature. | Glioblastoma harbouring STAT3 - High signature. After standard of care treatment with at least radiation therapy. |
| Continuation of Proof-of-concept study | Testing patient-derived organoids against a panel of therapies used to treat recurrent GBM, in order to determine the combination which would be most efficacious for the individual patient at the point of relapse | GBM patients - patient-derived organoid is harvested at the time of first surgery or biopsy |
| ONC201 | Evaluation of diffuse H3 K27M-mutant gliomas following completion of radiation therapy | Newly diagnosed H3 K27M-mutant Diffuse Glioma |
| Treatment That Maybe Helpful But Not Available in Singapore | ||
|---|---|---|
Treatment | Efficacy | Some Known Adverse Effects |
| Modeyso (ONC201) | In Aug 2025, FDA granted accelerated approval of Dordavirprone for treatment of patients with recurrent H3K27M-mutant diffuse midline glioma | Fatigue, headache, vomiting, nausea, musculoskeletal pain, increased liver enzymes, decreased lymphocyte counts, decreased calcium, prolonged QTc interval (risk of heart arrhythmia) |
| Novel Treatments and Summary Evaluation | ||
|---|---|---|
Treatment | Rationale of Trial | Target Population |
| VAL083 | Oral chemotherapy which can overcome resistance associated with MGMT | MGMT unmethylated GBM patients |
| Immunotherapy, mainly vaccine therapies | • PVSRIPO (intratumoral delivery of recombinant poliovirus) • CMV-targeted vaccines • Personalised cancer vaccines | Mainly recurrent GBM populations |
RadioOncology
Radiation-Based Strategies for Tumor Control and Recurrence Prevention
| Clinically Available in Singapore | ||
|---|---|---|
Treatment | Efficacy | Some Known Adverse Effects |
| Image Guided Radiotherapy (IGRT) | Uses daily imaging to verify tumor positioning within the treatment volume. Most useful when anatomical changes are expected within the treatment volume or when critical organs (e.g., optic nerves) are in close proximity to the tumor target. | Short term: lethargy, headache, nausea/vomiting, skin irritation, hair thinning/loss. Medium-long term: increased risk of brain scarring (Radiation necrosis), possible cognitive changes, changes in vision/hearing (depending on tumor location). Risk of secondary malignancies: <1% every 10 years for patients surviving >10 years. |
| Intensity Modulated Radiotherapy (IMRT) | Allows shaping of the radiation dose around the target. Provides better coverage of the tumor target while sparing surrounding normal organs. Can be delivered with or without image guidance (IGRT) based on precision needs. | Short term: lethargy, headache, nausea/vomiting, skin irritation, hair thinning/loss. Medium-long term: increased risk of brain scarring (Radiation necrosis), possible cognitive changes, changes in vision/hearing (depending on tumor location). Risk of secondary malignancies: <1% every 10 years for patients surviving >10 years. |
| Volumetric Modulated Arc Therapy (VMAT) | A different form of IMRT. Main advantage is continuous radiation dose delivery as the treatment gantry rotates, leading to shorter treatment couch time. | Short term: lethargy, headache, nausea/vomiting, skin irritation, hair thinning/loss. Medium-long term: increased risk of brain scarring (Radiation necrosis), possible cognitive changes, changes in vision/hearing (depending on tumor location). Risk of secondary malignancies: <1% every 10 years for patients surviving >10 years. |
| Tomotherapy | A different form of IMRT that incorporates daily imaging with 'slice by slice' radiation dose delivery. Most useful for treating lengthy volumes, such as in craniospinal irradiation. | Short term: lethargy, headache, nausea/vomiting, skin irritation, hair thinning/loss. Medium-long term: increased risk of brain scarring (Radiation necrosis), possible cognitive changes, changes in vision/hearing (depending on tumor location). Risk of secondary malignancies: <1% every 10 years for patients surviving >10 years. |
| Stereotactic Radiotherapy/Radiosurgery (SRT/SRS) | Allows delivery of radiotherapy doses with sub-millimeter precision. Improved precision is most useful for treating smaller tumor targets, enabling dose intensification (larger daily radiotherapy doses). | Side effects depend on target location and prescribed dose. A 10% risk of radiation necrosis can cause symptoms like headaches, nausea, and changes in power/sensation/vision, depending on dose intensification. |
| Proton Beam Therapy (PBT) | Uses protons that stop within the target, reducing radiation to surrounding tissues. May lower side effects, especially in children and young adults, though no proven survival benefit for gliomas. Approved by MOH for many pediatric CNS conditions (including gliomas). For patients >25 years, approved only if delivered concurrently with chemotherapy. Doses are similar to x-ray radiotherapy. | Side effect profile is similar to conventional x-ray radiotherapy, but overall intensity is generally reduced due to sparing of normal tissues beyond the target volume, especially for low to moderate dose splash. Benefit depends on factors like proximity of organs-at-risk, dose, and tumor type. Protons can reduce side effects in craniospinal radiotherapy. Users are advised to consult their doctor for more information. |
| Treatment That Maybe Helpful But Not Available in Singapore | ||
|---|---|---|
Treatment | Efficacy | Some Known Adverse Effects |
| Proton beam therapy - In lieu of IMRT/VMAT, at the same dose | Conformal radiotheraphy delivered using proton particles may potentially reduce the dose to normal tissue. The degree of benefit is dependent on factors such as tumour type, prescription dose and the proximity of the target to normal organs. Please consult your radiation oncologist for further details. | - |
| Boron Neutron Capture Therapy (BNCT) | Generally, patients with newly diagnosed or recurrent high grade gliomas, who are unsuitable for standard treatment, and who are fit for overseas travels, can be considered for BNCT. Centres may have different criteria for accepting patients for BNCT, based on the countries' and centres' regulations and availability. | The most common side effect reported has been mild erythema of the skin over the irradiated area. This is usually self-limiting. |
| Clinical Trials That Maybe Helpful But Not Available in Singapore | ||
|---|---|---|
Treatment | Rationale of Trial | Target Population |
| External beam RT | Ph 1/2 study studying the role of TLX101as a radiosensitizer in combination with external beam RT | Recurrent GBM in patients 18 years and above |
| Concurrent TTF with chemoradiotherapy (TMZ + 60Gy RT) | The TheraSphere GBM device utilizes yttrium-90 (Y-90) glass microsphere therapy for selective internal radiation therapy (endovascular radiotherapy) in recurrent GBM patients. The TheraSphere GBM treatment utilizes intra-arterial delivery and takes advantage of blood flow and direct tumor delivery. TheraSphere GBM could achieve a high tumor response rate based on delivery of a tumor absorbed dose that is not currently possible with external radiation. | Adult patients 18 years and above with newly diagnosed GBM following surgery and biopsy |
NeuroSurgery
Surgical Approaches for Diagnosis, Resection, and Tumor Management
| Clinically Available in Singapore | ||
|---|---|---|
Treatment | Efficacy | Some Known Adverse Effects |
| Neuro-navigation for guided resection of tumours | For common and routine use for accurate localisation of tumours | - |
| Awake surgery | Useful for gliomas in eloquent areas of the brain | - |
| Brain Mapping Surgery (with patient asleep) | For patients who cannot tolerate awake conditions or with severe deficits | - |
| Stereotactic biopsy | Minimally invasive surgery to obtain tissue sample for histology | - |
| Use of intra- operative MRI for Glioma resection | Useful to ensure maximum safe removal of tumours. Used in conjunction with the other modalities - awake surgery. | - |
| LITT - Laser interstitial thermal therapy (pending acquisition in Singapore) | Potential use in select cases of low grade and high grade glioma. | - |
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