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Page 6 of 8 Bellu et al. J Cancer Metastasis Treat 2021;7:29 https://dx.doi.org/10.20517/2394-4722.2021.89

Figure 2. Median progression free survival of 19.1 months (A); and median overall survival of 30.7 months (B).

added that alpha-internexin (INA) expression, in particular when associated with IDH1 mutation, can also
be a good prognostic factor.

Because of its infiltrative and diffuse spreading, the surgical approach is limited to biopsy or the minimal
[7]
debulking of focal areas causing mass effect . Radiotherapy (RT) has historically been used in GC, but its
effectiveness is still unclear: multiple studies were conducted in this regard, but their results do not agree
regarding survival advantage and dose/modalities of treatment; therefore, RT is often used in selected
patients suitable to receive it, while weighing the expected benefits with potential neurocognitive side
effects .
[8]
Conversely, chemotherapy (CT) seems to have an important significance in prolonging survival:
historically, the regimen procarbazine-lomustine-vincristine (PCV) was the most used treatment, as also
[9]
supported by the NOA-05 study . However, this has been replaced, in most cases, by temozolomide, which
has easier administration and better tolerability compared to PCV [10-12] ; CT is usually prescribed as upfront
therapy, but it may also be used after RT with a survival benefit or during RT for GC with more aggressive
[13]
aspects .
[10]
One limitation in our study is the lack of neurocognitive assessment; this should be an important factor to
be analyzed when comparing efficacy results between chemotherapy alone and chemotherapy plus
radiotherapy.

In our cases, it appears that only 67% of patients underwent surgery/biopsy; however, when possible, biopsy
should be mandatory to analyze the molecular aspects of GC for choosing the best treatment; indeed, we
showed that MGMT methylation can be an important prognostic factor in this tumor, and it is known that
patients with MGMT methylation might benefit from temozolomide.

However, in our population, we reported a relatively small number of biopsies, and it could be due to the
poor ECOG PS of the patients or the morphological characteristics of the tumor. A recent study analyzing
78 patients showed that a tumor involving the midline brain structure can correlate with a higher
perioperative morbidity . Hence, the non-surgical approach could also be an appropriate decision. Overall,
[14]
our opinion is that biopsy should be mandatory for patients in good clinical condition to better define the
tumor’s nature, prognosis, and the best treatment.