Brain Cancer Treatment Protocols

Question 1

Primary tx for all grades of gliomas:

Answer 1

Safe surgical resection.

Question 2

The surgical goal is …?

Answer 2

Gross total resection.

==> Less aggressive resection is employed for tumor potentially involving eloquent brain.

==> Under certain circumstances, weighing risk versus benefit, expectant monitoring with serial imaging is used.

Question 3

There is significant divergence of opinion on treatment approaches, particularly …?

Answer 3

For grade II lesions, such as grade II astrocytoma.

==> Radiation and chemotherapy regimens may vary among institutions.

Question 4

Grade I (pilocytic astrocytomas):

Answer 4

These lesions are typically uncommon and noninvasive and are considered benign and potentially curable by surgery.

==> When total surgical removal is not possible, radiation therapy or expectant management is typically employed.

Question 5

Grade II (low-grade infiltrative astrocytomas, oligodendroglioma, mixed gliomas) - Surgery:

Answer 5

Recommended for grade II with maximal safe resection.

Question 6

Grade II (low-grade infiltrative astrocytomas, oligodendroglioma, mixed gliomas) - Unfavorable prognostic factors:

Answer 6

1. > 40y.
2. Astrocytoma histology.
3. Largest dimension of tumor >6cm.
4. Tumor crossing midline.
5. Presence of neurologic deficit before resection.
6. Pts with up to 2 of these are considered low risk, while pts with 3 or more are high risk.

Question 7

Grade II (low-grade infiltrative astrocytomas, oligodendroglioma, mixed gliomas) - Low-risk pts should undergo …?

Answer 7

Observation, as well as pts who are <40y.

Question 8

Grade II (low-grade infiltrative astrocytomas, oligodendroglioma, mixed gliomas) - High-risk pts:

Answer 8

Should be treated with fractionated external-beam RT (EBRT) or adjuvant chemo.

Question 9

The standard radiation dosage for low-grade astrocytomas is …?

Answer 9

45-54 Gy, delivered in 1.8-2.0 Gy fractions.

Question 10

Adjuvant chemo includes:

Answer 10

Temozolomide 150-200 mg/m2/day PO on days 1-5 of a 28d cycle for 6-8 cycles.

Question 11

Grade II (low-grade infiltrative astrocytomas, oligodendroglioma, mixed gliomas) - Recurrence or progressive, low-grade disease (previously untreated):

Answer 11

Temozolomide 75 mg/m2 PO daily on days 1-21 or 150-200 mg/m2 PO on days 1-5 of a 28d cycle until disease progression or for a max of 24 cycles.

Question 12

Grade II (low-grade infiltrative astrocytomas, oligodendroglioma, mixed gliomas) - Post-op RT:

Answer 12

Post-op RT is often employed for UNRESECTABLE, residual, or recurrent tumor.

Question 13

Grade II (low-grade infiltrative astrocytomas, oligodendroglioma, mixed gliomas) - Chemo:

Answer 13

Often used for low-grade oligodendrogliomas, particularly tumors with the 1p, 19q del, which is a marker for tumor susceptibility to chemo.

Question 14

Grade III (anaplastic astrocytoma, oligoastrocytoma) - Standard of care is …?

Answer 14

Surgical resection followed by EBRT (60Gy in 30-35 fractions) + Adjuvant temolozomide, 75 mg/m2/day PO on days 1-42, usually 1-1.5h before radiation.

Question 15

Grade III (anaplastic astrocytoma, oligoastrocytoma) - Port-RT:

Answer 15

1. Continue temozolomide at higher doses of 150-200 mg/m2/day PO on days 1-5 every 28d OR
2. PCV (procarbazine, lomustine, vincristine): lomustine (CCNU) 90-130 mg/m2 PO on day 1 + Procarbazine 60-75 mg/m2 PO on days 8-21 + Vincristine 1.4mg/m2 IV (not to exceed 2mg/dose) on days 8 and 29. Administer every 6 wk for up to 4 cycles with deferred RT.

Question 16

Grade IV (glioblastoma) - The standard of care:

Answer 16

Surgical resection followed by EBRT (60 Gy in 30-35 fractions) + Adjuvant temozolomide 75 mg/m2/day PO on days 1-42, usually 1-1.5h before radiation.

Question 17

Grade IV (glioblastoma) - Post-RT:

Answer 17

Continue temozolomide at higher doses of 150-200mg/m2/day PO on days 1-5 every 28d.

Question 18

Recommendations for recurrent tumors - Consider the following:

Answer 18

1. There is no standard therapy for recurrent glioma.
2. Pts who were spared RT or chemo commonly receive these therapies at recurrence.
3. Numerous agents are used in cases of primary Tx failure.
4. Many clinical trials are ongoing.

Question 19

Current avenues available include the following:

Answer 19

1. Anti-angiogenic agents.
2. Tyrosine kinase inhibitors.
3. Cancer vaccines.
4. Stereotactic radiosurgery.