Neuro-onc Flashcards
location of meningiomas
“dural based” - anywhere from the dura, most commonly within the skull and at sites of dural reflection (convexity, falx cerebri, tentorium cerebelli, venous sinuses)
- so on imaging referred to as “dural based lesion”
Clinical presentation of meningioma
Clinically – asymptomatic (most often) OR seizures (30%) + focal findings (broad array depending on location)
Management of meningioma
IF young OR symptomatic, consult NSGY for resection evaluation (will need treatment at some point)
IF old OR asymptomatic, monitor – repeat MRI in 6 months
What defines oligodendroglioma?
Mutation in isocitrate dehydrogenase (IDH) type 1 or type 2 AND codeletion of chromosomes 1p and 19q
What defines GBM?
IDH wildtype + grade 4 glioma
What defines astrocytoma?
1p19q intact
Low grade – Frequently IDH mutant
Grade 4 astrocytoma – IDH mutant in minority
Grade 2 and Grade 3 astrocytoma management
Grade 2
If gross total resection →
IF residual disease AND no prior treatment other than surgery AND surgery within 5 years, vorasidenib 40 mg PO once daily
Grade 3
*Higher grade managed like GBM
Immediate postoperative concurrent RT + adjuvant chemotherapy (EORTC 26053 - CATNON trial)
Ependymoma 1) Additional required workup 2) G1-G4 management
1) LP
3) 2) Upfront surgery
IF G1 AND gross total resection, observation
*IF incompletely resected G2 or G3 – adjuvant XRT
Postop management of ependymoma
IF high grade (G2-G3) involved-field radiation therapy
IF G1, surveillance
Medulloblastoma management
upfront gross total resection with adjuvant radiation and adjuvant chemo
Answer to patient symptomatic several weeks after XRT for GBM (within first 3 months)
- pseudoprogression
Management of pseudoprogression in GBM
PO dexamethasone
additional workup required for CNS lymphoma
Fundoscopic exam with slit lamp evaluation
Drugs that need to be held with high dose MTX
- antibiotics (reduce clearance)
- duiretics (renal protection)
- PPIs
Next step in workup for classifying astrocytoma
CDK2A/B testing (homozygous deletion = Grade 4)
Poor prognostic feature of astrocytoma
Homozygous deletion of CDKN2A/B
Poor risk feature of medulloblastoma
MYC activation
Next step after debulking surgery of medulloblastoma
- second look surgery for maximal tumor debulking
Adjuvant mgmt of oligodendroglioma
IF no prior chemo or RT AND not on steroids, vorasidenib
IF residual disease, RT + PCV
Clinical benefit of TTF for GBM
PFS and OS benefit
What defines astrocytoma?
IDH mutant + intact 1p/19q locus
What defines oligodendroglioma?
IDH mutant + 1p/19q co-deletion
What defines GBM?
IDH wildtype + molecular features of GBM (TERT mutation, EGFR amplification, chromosome +7/-10) or histopath features (necrosis and/or microvascular proliferation)
Next step in mgmt for path after resection showing G3 astrocytoma + TERT promotor and wild-type IDH
- GBM management (histopath with astrocytoma but GBM features (TERT) = GBM
Molecular features of GBM
TERT mutation, EGFR amplification, chromosome +7/-10
Standard of care adjuvant for astrocytoma
- radiation therapy followed by adjuvant temozolomide
temozolomide mechanism
Alkylating drug
median OS for oligodendroglioma
G3 = 3-5 yrs
G2 = 10-15 years
Adjuvant mgmt of G3 oligodendroglimoa
- XRT w/ PCV
OR - XRT w/ concurrent and adjuvant temodar
Advanced age or borderline PS GBM management
- hypofractionated XRT - 45 Gy over 3 weeks with concomitant and adjuvant temodar
Small lesion within the fourth ventricle in asymptomatic patient is typically
subependymoma
meningioma location + radiographic features
- supratentorial
- intense and homogenous contrast enhancement
mutation that confers better prognosis in primary brain tumors
- IDH
EGFR amplification prognostic significance
Poor
adjuvant management of ependymoma
IF G3 or incompletely resected G2, involved-field radiation therapy
IF G1, surveillance
Most common radiation-induced CNS lesions
Meningioma
