Temozolomide: realizing the promise and potential

PURPOSE OF REVIEW: The discovery of temozolomide in the 1980s was expected to be an important advance in improving survival for patients with malignant brain tumors. Numerous clinical studies have demonstrated the activity of temozolomide against recurrent or refractory gliomas and noncentral nervous system malignancies. In the last 2 years, studies have focused on exploring strategies to optimize the efficacy of temozolomide, including evaluating different temozolomide dosing schedules and combining temozolomide with other antineoplastic agents, radiation therapy, or drug resistance-modifying agents. RECENT FINDINGS: A critical review of these studies suggests that temozolomide, as currently used, has limited efficacy in treating refractory malignant infiltrative brain tumors, and survival benefit is, at best, a few weeks longer than that with procarbazine. There is enthusiasm about the activity of temozolomide in the treatment of recurrent low-grade gliomas and advanced malignant melanomas. Temozolomide has activity and a favorable safety profile in all dosing schedules tested. Nevertheless, the trials evaluating the efficacy of temozolomide suffer from being uncontrolled, with short follow-up periods. SUMMARY: Despite the advantages of a favorable safety profile and oral administration, temozolomide has yet to realize its initial promise and full potential. Studies of temozolomide combined with novel drug resistance-modifying agents will likely improve disease control while minimizing toxicities, leading to improved survival benefit. Larger, randomized trials comparing temozolomide with standard therapy are needed to confirm the suggested benefit from temozolomide in malignant brain tumors. Temozolomide will continue to be attractive as an agent in the treatment of brain tumors because of its desirable features and safety.