CNS Tumors Flashcards
What CNS tumor should you not perform surgical resection, even when technically feasible?
Primary CNS lymhoma
What are the idnications for seizure prevention in those with CNS tumors?
If they’ve had a seizure before. No role for prophylaxis if they’ve never had seizures
What is the preferred anti-epileptic prophylactic medication?
Levetiracetam
What is the most common primary brain tumor?
Meningioma
What is the most common malignant primary brain tumor?
Glioblastoma
What are the three types of adult type gliomas? What are the hallmark differentiators between them?
Glioblastoma: IDH wt (grade 4)
Oligodendroglioma: IDH mutant, 1p/19q codeletion (grade 2-3)
Astrocytoma: IDH mutant, ATRX loss, TP53 mutation (Grade 2-4)
Pathologic definition of Glioblastoma
IDH wild type AND
Microvascular proliferation or necrosis or TERT promoter mutation or EGFR amplification or Ch7 gain and loss of Chr10
What are two potential gene abnormalities that are seen in Glioblastoma?
TERT promoter mutation or EGFR amplification
Though actionable mutations are rare
Standard treatment for newly diagnosed Glioblastoma
Focal RT (60 Gy) concomitant with temozolomide with adjuvant temozolomide
What is the use of MGMT promoter methylation?
Predicts response to alkylating agents (like temozolomide)
What predicts for a good response to temozolomide in Glioblastoma?
MGMT promoter methylation
You see a patient who finished concurrent RT with temozolomide for glioblastoma. First MRI 2 months post-treatment shows growing brain lesion. Patient is asymptomatic. What next?
Continue temozolomide. Likely pseudoprogression
What treatment is another option for glioblastoma aside from adjuvant temozolomide?
Tumor Treatment Field
The thing you have to wear on your head, etc.
What is the most commonly used treatment for recurrent GBM after temozolomide?
Bevacizumab
What is the best treatment for recurrent GBM who has MGMT methylation?
Bevacizumab + chemotherapy (irinotecan)
You see an elderly patient with GBM with MGMT methylation. Relatively poor performance status. Best treatment?
Temozolomide alone or with hypofractionated WBRT
You are given a stem with brain tumor with fried egg appearance on histology. Diagnosis?
Oligogendroglioma
Grade 3 oligodendroglioma treatment
Chemotherapy (PCV) and RT
Treatment for grade 2 oligodendroglioma
No standard of care
Follow radiographically after surgery
When progression: RT + PCV
For high-risk (age over 40 or have subtotal resection), can go strait to PCV+RT
Treatment for Grade 3 IDH mutant astrocytoma
Concomitant RT + TMZ and adjuvant TMZ (same as glioblastoma)
Treatment for Grade 2 IDH mut astrocytoma
Wait and see approach vs RT+TMZ and adjuvant TMZ for high risk features (big tumors, etc.)
What mutations are seen in sub=ependymal giant cell astrocytoma
TSC mutation (tuberous sclerosis)
treat with mTOR inhibitor
Mutation seen in pleomorphic xantroastrocytoma
BRAF V600E
Treatment for circumscribed astrocytic gliomas?
Surgery is curative
Treatment for leptomeningeal disease from ependymomas
Craniospinal radiation
Mutation seen and treatment for hemangioblastoma
VHL mutation
HIF 2 alpha blocker Belzutifan
In immunocompromised patients with primary CNS lymphomas, what infection is commonly implicated?
EBV
Treatment for primary CNS lymphoma
High dose MTX based chemo, like R-MPV
Treatment for meningioma
Asymptomatic: Follow radiographically
Symptomatic: surgery. If not resectable, then RT
What molecular feature automatically upgrades an astrocytoma to Grade 4?
CDKN2A deletion
What are two risk stratification criteria for grade 2 gliomas?
Age >40 and subtotal resection are high risk
<40 and gross total resection are low risk
What prophylactic medication is needed to be given to patietns who are undergoing treatment for their GBM with temozolomide?
PJP prophylaxis, usually dapsone
What genetic abnormalities confer a poor prognosis in GBM?
TERT promoter mutation
EGFR amplification
Patient with a large symptomatic meningioma undergoes complete resection. Pathology shows grade III meningioma. What now?
Postoperative RT
What two treatments can be used for radiation necrosis?
Steroids
Bevacizumab
