Timing of surgery and bevacizumab therapy in neurosurgical patients with recurrent high grade glioma

Malignant gliomas continue to have a dismal prognosis despite all available treatments and advances made in understanding molecular mechanisms and signaling pathways. Conventional treatments, such as surgery, chemotherapy and radiation, have been used with limited success. Bevacizumab is a recently described molecule, which inhibits endothelial proliferation and prevents formation of new blood vessels in tumor. However, this treatment confers increased hemorrhage risk and impairs wound healing. Therefore, the timing of surgery for patients receiving bevacizumab, who are in need of surgery, is critical. We performed a literature review to establish the appropriate timing between the cessation of bevacizumab therapy and surgical intervention. Our literature review indicated that the optimum time between cessation of bevacizumab therapy and surgery was 4 weeks. The timing for re-initiation of bevacizumab post-surgery was at least 2 weeks. The duration of preoperative cessation of bevacizumab treatment is critical in preventing life threatening surgical complications. The interval between the surgery and re-initiation of bevacizumab can be shortened. However, more studies are needed to ascertain the exact timing of preoperative and postoperative therapy.