Glioma

Question 1

Median overall survival for Gliomas

Answer 1

Question 2

Adult Diffuse Gliomas

Answer 2

1) Astrocytoma, IDH Mutant
2) Oligo, IDH Mutant & 1p19codeleted
3) GBM, IDH Wild type

Question 3

Tumor Characteristics that reduced the risk of progression

Answer 3

1) Any Oligo
2) IDH 1/2 Mutations
3) MGMT Methylation

Question 4

Worse prognostic factors for low grade glioma

Answer 4

1) Age >40
2) Astrocytoma histology
3) Tumor diameter >6cms
4) Tumor crossing the midline
5) Presence of neuro deficit prior surgery

Question 5

Oligo fav prognostic factors

Answer 5

1p19q co deletion

Question 6

WHO classification for Oligo

Answer 6

1) 1p19q co deletion
2) IDH 1R132H mutation

Question 7

RTOG post op Low grade glioma dose

Answer 7

RTOG guidelines say 50.4-54 Gy
NCCN guidelines say 45-54 Gy

mnemonic: N-4 C-5: NCCN: 4554!

Question 8

Low risk LGG 5 year PFS post GTR

Answer 8

50%

Question 9

Optic nerve dose constrains

Answer 9

55Gy for std Fx

Question 10

Optic Chiasm Dose Constrains

Answer 10

56Gy as per RTOG 08-25

Question 11

Brainstem Dose constrains

Answer 11

54Gy for std fx
60Gy as per RTOG 08-25

RTOG 08-25 has higher dose constrain that what we remember

Question 12

Retina Dose constrains

Answer 12

50Gy

Question 13

5 year OS for Grade II

Answer 13

60-70%

Question 14

RTOG 04-24

Remember as April 24Th

Answer 14

Phase 2 randomized trial
Q: If TMZ is beneficial for high risk LGG
54Gy + TMZ for high risk LGG
High risk factors: 3 out of 5 factors
3 year OS: 73.1%

Question 15

RTOG 98-02

Remember as Feb 1998 (98-02)

Answer 15

Q: If PCV + RT is beneficial for LGG
Arm 1 RT alone, Arm 2 RT + PCV
PFS was improved.

Question 16

Believers Trial: EORTC 22844

Answer 16

Q: Dose response relationship and efficacy of RT
Arm 1 45Gy vs Arm 2 59.4Gy
DFS and OS were equal in both arms
47 vs 50% & 58 vs 59%
Tumor size appeared to be an important factor

Question 17

Non-Believers Trial: EORTC 22845

Answer 17

Q: If RT can be delayed till time of progression post surgery for LGG.
Post surgery pts were randomized between early or late RT
RT dose used was 54Gy (45Gy to CTV + 9 Gy boost to tumor cavity)
.
.
MPF Survival Better in early RT 5.3 yrs vs 3.4 yrs (sig p)
5 yr PFS was better in early RT 55% vs 35%
Median OS was similar 7.4 yrs vs 7.2 yrs
.
.
RT helped control post surgery neuro symptoms so early RT was beneficial for this group of pts

Question 18

Stupp trial
EORTC.NCIC

Answer 18

Q: Adding TMZ to adjuvant RT is it beneficial?
.
.
2Year OS:
RT: 11%
RT + TMZ: 27%
.
.
.
5 year OS:
RT: 2%
RT + TMZ: 10%
.
.

.
5 year OS MGMT Methylated
RT: 5%
RT + TMZ: 14%
.
.

5 year OS MGMT unmethylated
RT: 0%
RT + TMZ: 8%

Question 19

TMZ Mechanism of action

Answer 19

Alkylating agent
MGMT unmethylated means more MGMT in the system so that MGMT removes the alkyl groups deposited on DNA by TMZ. So it reduces the cellular toxicity of TMZ

Question 20

RTOG 93-05

Remember as May 1993

Answer 20

Q: Adding SRS Boost for GBM pats who get 60Gy in 30 Fxs.
Arm 1: EBRT 60Gy + chemo (carmustine)
Arm 2: 60Gy + Chemo + SRS Boost (15-24Gy)
.
.
No benefit on local control or overall survival.

Question 21

RTOG 08-25

remember Aug-25

Answer 21

Q: Whether the addition of bevacizumab would improve survival among patients with newly diagnosed glioblastoma who are getting std of care: RT + TMZ.
.
.
Volumes:
46 Gy to post op T2/flair
14Gy boost to post op contrast enhanced T1
CTV can be cropped out of ventricles: natural barriers

Question 22

TMZ Dosage

Answer 22

75mg/m2 daily during RT
150-200mg/m2 during 1-5 days of 28 day cycle for 6-12 months adjuvant to RT

Question 23

DIPG

Answer 23

1st line of treatment is RT to shrink the mass.
RT Dose: 54Gy std fx or 39Gy in 13 fractions

Question 24

Pseudo progression rates for Grade IV GBM

Answer 24

20-30%

Question 25

OS between 60Gy in 30 Fx and 40Gy in 15 fx

Answer 25

5.1 vs 5.6 mnths

Question 26

Alopecia

Answer 26

Max Dose of 43Gy
Single fraction 7Gy