Neuro-onc

Question 1

location of meningiomas

Answer 1

“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”

Question 2

Clinical presentation of meningioma

Answer 2

Clinically – asymptomatic (most often) OR seizures (30%) + focal findings (broad array depending on location)

Question 3

Management of meningioma

Answer 3

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

Question 4

What defines oligodendroglioma?

Answer 4

Mutation in isocitrate dehydrogenase (IDH) type 1 or type 2 AND codeletion of chromosomes 1p and 19q

Question 5

What defines GBM?

Answer 5

IDH wildtype + grade 4 glioma

Question 6

What defines astrocytoma?

Answer 6

1p19q intact
Low grade – Frequently IDH mutant
Grade 4 astrocytoma – IDH mutant in minority

Question 7

Grade 2 and Grade 3 astrocytoma management

Answer 7

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)

Question 8

Ependymoma 1) Additional required workup 2) G1-G4 management

Answer 8

1) LP
3) 2) Upfront surgery
IF G1 AND gross total resection, observation
*IF incompletely resected G2 or G3 – adjuvant XRT

Question 9

Postop management of ependymoma

Answer 9

IF high grade (G2-G3) involved-field radiation therapy
IF G1, surveillance

Question 10

Medulloblastoma management

Answer 10

upfront gross total resection with adjuvant radiation and adjuvant chemo

Question 11

Answer to patient symptomatic several weeks after XRT for GBM (within first 3 months)

Answer 11

• pseudoprogression

Question 12

Management of pseudoprogression in GBM

Answer 12

PO dexamethasone

Question 13

additional workup required for CNS lymphoma

Answer 13

Fundoscopic exam with slit lamp evaluation

Question 14

Drugs that need to be held with high dose MTX

Answer 14

• antibiotics (reduce clearance)
• duiretics (renal protection)
• PPIs

Question 15

Next step in workup for classifying astrocytoma

Answer 15

CDK2A/B testing (homozygous deletion = Grade 4)

Question 16

Poor prognostic feature of astrocytoma

Answer 16

Homozygous deletion of CDKN2A/B

Question 17

Poor risk feature of medulloblastoma

Answer 17

MYC activation

Question 18

Next step after debulking surgery of medulloblastoma

Answer 18

• second look surgery for maximal tumor debulking

Question 19

Adjuvant mgmt of oligodendroglioma

Answer 19

IF no prior chemo or RT AND not on steroids, vorasidenib
IF residual disease, RT + PCV

Question 20

Clinical benefit of TTF for GBM

Answer 20

PFS and OS benefit

Question 21

What defines astrocytoma?

Answer 21

IDH mutant + intact 1p/19q locus

Question 22

What defines oligodendroglioma?

Answer 22

IDH mutant + 1p/19q co-deletion

Question 23

What defines GBM?

Answer 23

IDH wildtype + molecular features of GBM (TERT mutation, EGFR amplification, chromosome +7/-10) or histopath features (necrosis and/or microvascular proliferation)

Question 24

Next step in mgmt for path after resection showing G3 astrocytoma + TERT promotor and wild-type IDH

Answer 24

• GBM management (histopath with astrocytoma but GBM features (TERT) = GBM

Question 25

Molecular features of GBM

Answer 25

TERT mutation, EGFR amplification, chromosome +7/-10

Question 26

Standard of care adjuvant for astrocytoma

Answer 26

• radiation therapy followed by adjuvant temozolomide

Question 27

temozolomide mechanism

Answer 27

Alkylating drug

Question 28

median OS for oligodendroglioma

Answer 28

G3 = 3-5 yrs
G2 = 10-15 years

Question 29

Adjuvant mgmt of G3 oligodendroglimoa

Answer 29

• XRT w/ PCV
  OR
• XRT w/ concurrent and adjuvant temodar

Question 30

Advanced age or borderline PS GBM management

Answer 30

• hypofractionated XRT - 45 Gy over 3 weeks with concomitant and adjuvant temodar

Question 31

Small lesion within the fourth ventricle in asymptomatic patient is typically

Answer 31

subependymoma

Question 32

meningioma location + radiographic features

Answer 32

• supratentorial
• intense and homogenous contrast enhancement

Question 33

mutation that confers better prognosis in primary brain tumors

Answer 33

• IDH

Question 34

EGFR amplification prognostic significance

Answer 34

Poor

Question 35

adjuvant management of ependymoma

Answer 35

IF G3 or incompletely resected G2, involved-field radiation therapy
IF G1, surveillance

Question 36

Most common radiation-induced lesions

Answer 36

Meningioma