OpenOnco · Treatment Plan

Treatment plan — DIS-GBM

PLAN-BMA-TERT_GLIOMA-V1 · v1 · 2026-05-04

Patient

BMA-TERT_GLIOMA · Algorithm: ALGO-GBM-NEWLY-DIAGNOSED-1L

Clinical significance of mutations (ESCAT)

Tumor-board context — the engine does not use these tiers to rank tracks

Biomarker	Variant	ESCAT	Evidence	Clinical significance	Drugs	Sources
BIO-TERT	TERT promoter mutation (C228T or C250T) — WHO CNS tumor classification context: GBM (IDH-wild-type; required for molecular diagnosis), oligodendroglioma (IDH-mutant + 1p/19q co-deletion + TERT = canonical)	IIB	SRC-NCCN-CNS-2025: Level Category 1 (Supports, Poor Outcome) SRC-EANO-GBM-2024: Level A (Supports, Poor Outcome)	TERT promoter mutations are central to WHO CNS tumor classification (2021 5th edition): (1) GBM (IDH-wildtype, WHO grade 4): TERT promoter mutation is one of three molecular defining features (together with EGFR amplification and chromosome +7/-10 copy number changes). An IDH-wildtype diffuse astrocytoma with any of these features meets criteria for molecular GBM diagnosis regardless of histologic grade. TERT alone: ~70–80% of GBM. TERT mutation identifies the most aggressive tumor biology within IDH-wildtype astrocytomas. No TERT-directed therapy available. (2) Oligodendroglioma (IDH-mutant, 1p/19q co-deleted): TERT promoter mutation is present in ~70% and is part of the canonical molecular definition. TERT testing is used to confirm oligodendroglioma classification (IDH + 1p/19q + TERT triple positive). (3) IDH-mutant astrocytoma (grade 2–4): TERT promoter mutation is less common (~20%) and associated with worse prognosis within IDH-mutant tumors; CDKN2A/B homozygous deletion is the main grade 4 determinant in IDH-mutant astrocytoma. Standard treatment for GBM is unchanged by TERT status: Stupp protocol (RT + temozolomide, followed by temozolomide maintenance). MGMT promoter methylation — not TERT — determines temozolomide sensitivity. ESCAT IIB: TERT is a diagnostic molecular classifier in glioma with strong prognostic significance but no actionable therapeutic target.	Stupp protocol: RT 60 Gy/30 fr + temozolomide 75 mg/m² PO QD during RT, then temozolomide 150–200 mg/m² PO days 1–5 q28d × 6 cycles (MGMT-guided; not TERT-guided) Tumor treating fields (TTF; Optune) — FDA-approved for GBM maintenance (EF-14 trial); not TERT-specific	SRC-NCCN-CNS-2025 SRC-EANO-GBM-2024

Treatment options (3 tracks)

Standard plan

★ DEFAULT

Indication

IND-GBM-NEWLY-DIAGNOSED-STUPP

Regimen

Stupp protocol — Temozolomide concurrent + adjuvant

Drugs + NSZU

Temozolomide (DRUG-TEMOZOLOMIDE) Concurrent: 75 mg/m² PO daily during RT 6 weeks; Adjuvant: 150 mg/m² PO days 1-5 cycle 1 (escalate to 200 if tolerated) every 28 days × 6 cycles · Concurrent daily × 42 days then 4-week break then adjuvant cycles 1-6 · PO ✓ NSZU covered

Reason

Engine default per algorithm ALGO-GBM-NEWLY-DIAGNOSED-1L: {'step': 1, 'outcome': False, 'branch': {'result': None, 'notes': 'IDH-mutant glioma grade 4: not GBM per WHO 2021. Manage as astrocytoma IDH-mutant (vorasidenib INDIGO). Separate disease pathway.'}, 'fired_red_flags': [], 'winner_red_flag': None}

Standard plan

Indication: IND-GBM-NEWLY-DIAGNOSED-ELDERLY-TMZ
Regimen: —
Reason: Alternative track presented for HCP consideration

IND-GBM-NEWLY-DIAGNOSED-ELDERLY-HYPORT

Indication: IND-GBM-NEWLY-DIAGNOSED-ELDERLY-HYPORT
Regimen: —
Reason: Alternative track presented for HCP consideration

Pre-treatment investigations

Investigations before treatment start · critical / standard / desired · merged across tracks

ID	Name	Priority	Category	Where to order	Needed for
TEST-IDH-MUTATION	IDH1/IDH2 mutation	Critical	histology	CSD Lab ✓ (code TBC)	standard
TEST-MGMT-METHYLATION	MGMT methylation	Critical	histology	CSD Lab ✓ (code TBC)	standard
CBC, LFTs, creatinine baseline	CBC, LFTs, creatinine baseline	Standard	—	—	standard
Geriatric assessment (frailty scoring)	Geriatric assessment (frailty scoring)	Standard	—	—	desired (standard)
IDH mutation status (mandatory — WHO 2021 classification)	IDH mutation status (mandatory — WHO 2021 classification)	Standard	—	—	standard
KPS / ECOG performance status formal assessment	KPS / ECOG performance status formal assessment	Standard	—	—	desired (standard)
MGMT methylation status (mandatory — drives treatment choice in elderly)	MGMT methylation status (mandatory — drives treatment choice in elderly)	Standard	—	—	standard
MRI brain with contrast (baseline; post-resection within 48h)	MRI brain with contrast (baseline; post-resection within 48h)	Standard	—	—	standard
NGS comprehensive panel (TERT, EGFR, CDKN2A — prognostic)	NGS comprehensive panel (TERT, EGFR, CDKN2A — prognostic)	Standard	—	—	desired (standard)
TEST-MRI-BRAIN-CONTRAST	MRI brain with contrast	Standard	imaging	—	standard
TEST-NGS-COMPREHENSIVE	Comprehensive NGS tumor panel (DNA + RNA, ≥300 genes)	Desired	histology	CSD Lab: M065	desired (standard)

Red flags — PRO / CONTRA aggressive

PRO-AGGRESSIVE

Triggers that push toward the aggressive track

Symptomatic raised intracranial pressure / mass effect in glioblastoma: declining GCS, new focal deficit, papilledema, midline shift on imaging, or seizure cluster. Mandates immediate neurosurgical / corticosteroid intervention BEFORE oncologic systemic therapy. RF-GBM-INTRACRANIAL-PRESSURE-EMERGENCY

CONTRA-AGGRESSIVE

Hard contraindications to escalation

What NOT to do

Explicit prohibitive rules, each grounded in a regimen / supportive care / contraindication entity

Standard plan (IND-GBM-NEWLY-DIAGNOSED-STUPP)

Do NOT delay starting RT beyond 6 weeks post-resection
Do NOT skip MGMT testing — defines elderly (≥70) regimen choice
Do NOT skip PJP prophylaxis (universal lymphopenia → opportunistic infection)
Do NOT use enzyme-inducing AEDs (phenytoin, carbamazepine) — accelerate TMZ clearance; use levetiracetam

Standard plan (IND-GBM-NEWLY-DIAGNOSED-ELDERLY-TMZ)

Do NOT use TMZ alone in MGMT-unmethylated GBM ≥70 — minimal benefit; prefer hypofractionated RT
Do NOT use full Stupp (60 Gy/30 fx) in patients ≥70 or KPS <60 — excessive toxicity
Do NOT skip MGMT testing before choosing TMZ vs RT — this is the key biomarker in elderly
Do NOT skip PJP prophylaxis (co-trimoxazole) — lymphopenia risk applies to TMZ mono too

Timeline

Treatment timeline — derived from regimen + monitoring schedule

Standard plan

Induction · Stupp protocol — Temozolomide

28-day cycles × Concurrent phase 6 weeks + adjuvant 6 cycles (~7 months total)

MDT brief

Skills (recommended) — for consideration (1)

Molecular geneticist / molecular oncologist recommended
Indication references an actionable genomic biomarker — mutation / target / actionability interpretation needed.
skill: molecular_geneticistv0.1.0reviewed 2026-04-25STUBsign-offs: 0lead: TBD

Data quality

Unevaluated RedFlags: RF-GBM-FRAILTY-AGE, RF-GBM-HIGH-RISK-BIOLOGY, RF-GBM-INFECTION-SCREENING, RF-GBM-INTRACRANIAL-PRESSURE-EMERGENCY, RF-GBM-TRANSFORMATION-PROGRESSION

Skill catalog (1/16 activated in this plan)

All registered virtual specialists. ✓ — activated for this case; ○ — not activated (available for other clinical scenarios).

Specialist	skill_id	Version	Last reviewed	Domain
Cellular therapy specialist (CAR-T)	`cellular_therapy_specialist`	v0.1.0	2026-04-25	cellular_therapy
Clinical pharmacist	`clinical_pharmacist`	v0.1.0	2026-04-25	clinical_pharmacy
Hematologist / oncohematologist	`hematologist`	v0.1.0	2026-04-25	hematology_oncology
Hematopathologist (lymphoma / leukemia / myeloma)	`hematopathologist`	v0.1.0	2026-04-25	hematopathology
Infectious disease / hepatology	`infectious_disease_hepatology`	v0.1.0	2026-04-25	infectious_diseases
Medical oncologist (solid-tumor chemotherapist)	`medical_oncologist`	v0.1.0	2026-04-25	solid_oncology
Molecular geneticist / molecular oncologist	`molecular_geneticist`	v0.1.0	2026-04-25	molecular_oncology
Palliative care	`palliative_care`	v0.1.0	2026-04-25	palliative_care
Pathologist (general)	`pathologist`	v0.1.0	2026-04-25	pathology
Primary care / family physician	`primary_care`	v0.1.0	2026-04-25	primary_care
Psycho-oncologist	`psychologist`	v0.1.0	2026-04-25	psychosocial
Radiation oncologist	`radiation_oncologist`	v0.1.0	2026-04-25	radiation_oncology
Radiologist	`radiologist`	v0.1.0	2026-04-25	diagnostic_imaging
Social worker / case manager	`social_worker_case_manager`	v0.1.0	2026-04-25	psychosocial
Surgical oncologist	`surgical_oncologist`	v0.1.0	2026-04-25	surgical_oncology
Transplant specialist (BMT)	`transplant_specialist`	v0.1.0	2026-04-25	cellular_therapy

Sources cited

SRC-CCTG-CE6-PERRY-2017: Short-Course Radiation plus Temozolomide in Elderly Patients with Glioblastoma (2017)
SRC-EANO-GBM-2024: EANO Guidelines on Diagnosis and Treatment of Diffuse Gliomas of Adulthood (2024 update)
SRC-NCCN-CNS-2025: NCCN Central Nervous System Cancers (v.3.2025)
SRC-NORDIC-GBM-MALMSTROM-2012: Temozolomide versus Standard 6-Week Radiotherapy versus Hypofractionated Radiotherapy in Patients Older than 60 Years with Glioblastoma (2012)

Experimental options (clinical trials)

Third plan track — open-enrollment trials from ClinicalTrials.gov. Render-time metadata; engine selection is not affected by this block (CHARTER §8.3). Last synced: 2026-05-04.

NCT	Title	Phase	Status	Sponsor	UA	Eligibility (excerpt)
NCT06622434	New Adjuvant Vaccine in Glioblastoma, a Phase 1/2a Study	PHASE1 / PHASE2	RECRUITING	Assistance Publique - Hôpitaux de Paris	—

Verify recruitment status directly with the trial site. ctgov data can lag behind current UA-site status.

Option availability in Ukraine

Per-track UA registration · NSZU · cost · access pathway. Render-time metadata; engine selection does not depend on these fields (CHARTER §8.3).

Option	UA registration	NSZU	Cost orientation	Access pathway
Standard plan Stupp protocol — Temozolomide concurrent + adjuvant (REG-STUPP-TMZ)	✓ registered	✓ covered	₴-? — verify pathway	NSZU formulary
Standard plan — No regimen components on this track — availability unknown	— unknown	— unknown	₴-? — verify pathway	not recorded
IND-GBM-NEWLY-DIAGNOSED-ELDERLY-HYPORT — No regimen components on this track — availability unknown	— unknown	— unknown	₴-? — verify pathway	not recorded
Trial · NCT06622434 New Adjuvant Vaccine in Glioblastoma, a Phase 1/2a Study No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor

Cost information is orientation. Verify with a specific pharmacy / foundation / trial site. Status updated: 2026-05-04.

plan_id: PLAN-BMA-TERT_GLIOMA-V1 | version: 1 | generated: 2026-05-04T14:13:16.667949+00:00

Per FDA non-device CDS positioning (CHARTER §15): Outpatient oncology treatment planning to support tumor-board discussion. Not a medical device; not for autonomous clinical decision-making.

Per FDA non-device CDS positioning (CHARTER §15): Both treatment options below are presented for review. The engine's selection of a 'recommended' default does not constitute a clinical decision. Final treatment selection requires HCP judgment incorporating information not available to the system.

This document is an informational resource supporting tumor-board discussion (per CHARTER §11). It is not a system that makes clinical decisions. Every recommendation must be verified by the treating physician.