Neuro-Oncology&nbsp;&nbsp;&nbsp;

What is your strategy for treating headaches in patients with history of brain tumor?

Specifically, headaches thought not to be related to increased ICP.

How do you approach anti-seizure medication management when it was started by another team for a seizure-naive patient before/after craniotomy for a tumor?

Do you refer all patients with new findings of CNS or epidural mets/tumor to ED for evaluation or are there some that can be managed completely outpatient?

E.g., patients with small CNS mets without vasogenic edema or symptoms. Epidural disease without epidural spinal cord compression or asymptomatic low-...

How do you approach a recurrence of grade 3 anaplastic astrocytoma after initial treatment with gross total resection followed by RT/adjuvant temozolomide?

Guidelines do not provide strong guidance on who will benefit from temozolomide vs PCV or when to consider re-challenging with temozolomide.

When is the best time to try targeted therapy in adult-type diffuse non-IDH glioma?

I have seen targeted therapies used (and studied) more often in the recurrent setting. However, there may also be some rationale for trying BRAF/MEK E...

Is there a role for intravenous temozolomide in place of oral for the 5-day dosing q 28 days after surgery/XRT+Temozolomide for glioblastoma multiforme?

For patients with newly diagnosed brain metastases without a history of seizure activity, do you routinely start anti-seizure medication?

If so, how long do you continue medication and when do you discontinue? Does treatment with surgical resection versus radiation alone change your mana...

How do you manage glioblastoma presenting with leptomeningeal dissemination?

How do you time CSF analysis for suspected CNS lymphoma in patients who are on steroids?

How do different inflammatory markers like CRP and ferritin contribute differently, if at all, to the monitoring of CART neurotoxicity?

Under what circumstances would you consider irradiation for brain metastases with active or recent bleeding?

How do factors such as the stability of the bleed, tumor histology, and patient condition influence your decision?

What is the expected timeframe for the development of radiation myelitis and therapies that have helped with neurologic symptoms?

4 Answers available

How would you manage a patient less than 40 years old with an incidentally found LGG, IDH mutated, 1p19q intact, s/p STR?

Would you offer radiation and chemotherapy, vorasidenib, or observation?

4 Answers available

How would you approach treatment for a glioblastoma from a radiation standpoint that was initially thought to be a metastases and therefore treated with multiple courses of SRS over the past few years?

For recurrent glioblastoma treated with combined re-irradiation and bevacizumab, how long do you continue bevacizumab?

Would you continue it until progression of disease? Or would you switch immediately to next line systemic therapy?

For patients with primary CNS lymphoma and less than a CR to chemotherapy, in what situation would you consider partial or focal radiation?

For patients with metastatic cancer on a systemic therapy regimen that includes bevacizumab, are you comfortable treating brain metastases (SRS or WBRT) without holding bevacizumab?

Why does this differ when treating extracranial sites (lung, pelvis) where we hold bevacizumab prior to RT?

What approach do you use when treating adult diffuse gliomas with H3-G34 mutations, now classified into their own category under the 2021 glioma guidelines?

Do you treat this similarly to IDH-Wildtype GBM with the STUPP regimen? Is there any role of less-intensive paradigms, such as 59.4 Gy/33 fx?

What is your approach to management of a subtotally resected pineal parenchymal tumor of intermediate differentiation (CNS WHO grade 2)?

Is there a role for adjuvant chemotherapy or radiation?

How do you manage an intramedullary benign nerve sheath tumor post sub-total resection seen on post-operative MRI?

Would you consider radiation following surgical resection of an intramedullary benign nerve sheath tumor with a small amount of residual tumor (9 mm) ...

How do you approach treatment of sub-total resected ZFTA fusion ependymoma after radiation therapy in a young adult?

Do you recommend adjuvant chemotherapy after radiation treatment?

How do you use Boswellia for radiation necrosis?

With the recent publication in IJROBP showing a greater than 50% response rate, have you started integrating this into your practice?

For those rare patients now out 5 years post GBM treatment and continuous Optune, is there a point one would stop Optune?

How would you approach a patient over the age of 40 with a sub-totally resected frontal oligodendroglioma, WHO Grade II, 1p/19q co-deleted, IDH mutant, with imaging concerning for second site in the pontomedullary junction?

In a young patient with recurrent low-grade glioma s/p gross total resection, is there any role for further observation instead of radiation and chemotherapy?

What is the harm of waiting for another recurrence after a second GTR to delay the toxicity of radiation and chemotherapy? The patient is a woman <...

How do you approach the management of a patient with lumbar spinal metastasis with neurologic symptoms but without evidence of spinal cord compression?

In a patient with metastatic cancer to the lumbar spine and epidural disease on CT who presents back pain and leg weakness: Is a whole spine MRI in...

Is it reasonable to extrapolate data from Glioblastoma and discuss Tumor Treating Fields in patients with Grade 4, IDH Mutant, astrocytomas?

What criteria do you use to decide whether to start anticonvulsants in patients with brain metastases?

Do all patients with brain metastases get started on anticonvulsants? Do you decide based on extent of edema, tumor size, or something else?&nb...

How do you manage incidentally identified pituitary lesions on brain imaging?

What workup do you typically recommend?

Is it acceptable to treat newly diagnosed small cell lung cancer with limited brain metastasis with upfront SRS?

This has become standard practice at our institution for patients with a good performance status, with whole brain radiotherapy given after the comple...

12 Answers available

Why do we use dexamethasone for CNS edema and prednisone for pneumonitis?

Is this an artifact of what agent prior clinical trials used or something to do with the mechanism of action (i.e., less mineralocorticoid effect of d...

What are some alternatives to dexamethasone for brain edema in patients who are allergic, have an intolerance, or refuse the medication?

How would you treat an essential-like tremor secondary to tumor (e.g. glioma)?

Is your approach different than that to a primary essential tremor?

How would you approach treatment of a patient with recurrent choroid plexus papilloma with intraventricular dissemination?

History of 4th ventricle choroid plexus papilloma s/p GTR, now with recurrent disease in the 4th ventricle and the left lateral ventricle (7 nodules i...

How do you manage multiple brain metastases from small cell lung cancer?

Do you have a number/volume threshold for SRS vs WBRT?

4 Answers available

How would you manage a new suspected brain metastasis in a patient with a distant cancer history?

Would you consider empiric SRS if biopsy/resection is not feasible? When would you consider liquid biopsy?

How do you approach treatment of a grade 4 IDH-mutant astrocytoma, a diagnosis now distinct from glioblastoma according to the 2021 WHO Classification for CNS Tumors?

What is your treatment approach for a recurrent brainstem glioma?

What is your preferred dose/fractionation following a previous course of radiotherapy?

What would your next line treatment be for a patient previously treated with repeat resection, craniospinal irradiation, and initial cisplatin/vincristine/CCNU with medulloblastoma?

What would be your next treatment for a young adult patient with medulloblastoma refractory to repeat resection, craniospinal irradiation, and initial...

How do you discuss curative vs palliative treatment intent for patients with favorable risk 1p/19q co-deleted oligodendrogliomas?

How does the updated classification system of gliomas impact your recommendations for radiation?

Louis et al., PMID 34185076

How do you manage AEDs in patients with malignant brain tumors?

Do you ever add prophylactic Keppra (levetiracetam) for glioblastoma patients without a seizure history based on data such as this study (nature.com) ...

What is your surveillance strategy in patients with brain metastases who are getting systemic therapy?

How often are you scanning the brain and what is your trigger to treat?

Is it safe to give large fraction stereotactic irradiation for brain metastases concurrently with VEGF inhibitors?

0 Answers available

How do you manage new brain mets in a patient with a history of RT necrosis after prior SRS?

Assuming no overlap with prior RT doses, would a history of necrosis cause you to hypofractionate rather than deliver single fraction SRS?

What schedule and type of antiemetics do you provide for patients receiving PCV for co-deleted oligodendrogliomas?

How do you choose between adjuvant PCV vs temozolomide in high risk oligodendroglioma with IDH mutation and 1p/19q co deletion?

NCCN lists PCV as category 1 (and now with analysis in Abstract 2002 from ASCO 2019 showing benefit in IDH mutated), and temozolomide as 2B, yet temoz...

What are your recommendations for a patient with metastatic non-mutated lung adenocarcinoma who previously had headaches responsive to prednisone but with negative temporal artery biopsy for GCA?

For medical oncologists, would you offer a PD-1/L1 inhibitor? For other subspecialties, how would you counsel the oncologist regarding the risk of usi...

Would you hold off on whole brain radiotherapy for a patient with metastatic NSCLC and multiple asymptomatic brain metastases and will be starting immunotherapy?

How do you approach decision making in terms to adjuvant chemotherapy after CSI in adult medulloblastoma?

What is the appropriate workup and treatment for patients with SMART syndrome following radiation for brain tumors?

For stroke-like migraine attacks after radiation therapy (SMART syndrome), does your management of these patient's change with recurrent episodes? How...

What is the best course of action for a patient with isolated carcinomatous meningitis who is responding well to intrathecal methotrexate but now has MRI findings suspicious for methotrexate leukoencephalopathy?

Can intrathecal methotrexate be continued with close neurologic observation vs switch in treatment now due to findings?

Do you ever use bevacizumab in combination with standard radiation and temozolomide in the first-line setting for patients with glioblastoma?

If so, when do you consider this?

How do you manage leptomeningeal carcinomatosis from a metastatic solid tumor?

Do you prefer WBRT, IT chemo or targeted systemic therapy and what is your preference on the sequence of therapies?

How do you approach treatment of 1p19q non-codeleted high grade gliomas?

Has the recently published interim analysis of the CATNON trial altered your utilization of temozolomide?Does IDH status change your treatment approac...

Is it ever appropriate to omit temozolomide in unmethylated glioblastoma?

Do you consider the small, but statistically significant, improvement in OS to outweigh the side effects of treatment?

How do you approach treatment of a glioblastoma in pregnancy?

In a healthy patient >65 years of age with glioblastoma multiforme, what is the recommendation for temozolomide when given concurrently with adjuvant radiation therapy?

Length of temozolomide course when given with adjuvant radiotherapy

Would you use a hippocampal sparing technique when treating with PCI for a limited stage small cell lung cancer?

What treatment would you offer a young pregnant woman with a symptomatic midline low grade glioma?

Discussion of treatment options for midline low-grade glioma causing life-altering symptoms in a pregnant patient to avoid teratogenicity.

How do you decide on the modality of consolidative treatment after a CR in primary CNS lymphoma patients treated with a high-dose methotrexate regimen?

How do you decide between WBRT, maintenance chemotherapy, or stem cell transplantation?

For a patient with HER2+ breast cancer with progressive but asymptomatic disease in the brain, would you hold off on WBRT to do a trial of tucatinib, or proceed with WBRT then tucatinib?

Assuming the patient is not a candidate for SRS

How would you approach a symptomatic patient with with a history of whole brain RT with new bilateral MRI enhancing lesions within the optic nerves?

Would you suspect progressive disease v. radiation necrosis vs optic neuritis due to immunotherapy. Eyes were within radiation field 8 months ago.&nbs...

How do you counsel patients on the neurocognitive effects of whole brain radiation therapy?

Specifically, how do you explain potential cognitive decline in a way that explains what changes they can expect in their daily lives?

Would you deliver SRS/XRT for isolated asymptomatic CNS metastasis before start of immunotherapy for stage IV lung cancer (negative for driver mutation) with high positive PDL1?

After completing SRS for brain mets, how long should the medical oncologist wait before starting chemotherapy?

Would this be any different for whole brain radiotherapy?

Is it acceptable to treat patients with limited, asymptomatic brain metastases and EGFR-mutant NSCLC with upfront TKI?

Can SRS or whole brain radiotherapy be reserved for progression in these young, healthy patients?

8 Answers available

Would you continue consolidation temozolomide for more than 1 year for a patient with grade 3 anaplastic astrocytoma, after gross total resection and daily temozolomide+EBRT?

Provided patient is tolerating treatment well.

How do you manage adult brainstem lesions in the absence of a tissue diagnosis?

For a lesion that appears radiographically consistent with a high grade glioma, would you treat empirically if there is hesitancy to perform a high ri...

How do you decide between re-irradiation, chemotherapy, and alternating electric field therapy in patients with relapsed GBM post chemoradiation with TMZ?

If choosing systemic therapy, do you prefer bevacizumab with or without irinotecan? Have you used anti-PD1 agents (e.g. nivolumab) off label?

Do you use anticonvulsant prophylaxis in patients with multiple CNS metastases absent a history of seizures?

Is there data related to types of metastases (tumor histology, anatomic distribution, hemorrhagic, diffuse, size, edema etc.) and risk for seizure?&nb...

How do you manage anticoagulation for patients with DVT/PE who have brain metastases?

Some medical oncologists tend to hold anticoagulation in patients who develop brain metastases for fear of causing intracranial hemorrhage. Is t...

Do you offer memantine for patients undergoing PCI?

Do you offer memantine for cognitive preservation to glioma patients?

In particular, would you offer memantine to those with WHO II or III gliomas and a good performance status but larger treatment volume?

When do you consider using ALK targeted systemic therapy in lieu of WBRT or SRS for patients with metastatic ALK-positive NSCLC?

The Phase III J-ALEX study and two phase II studies seem to suggest favorable intracranial response rates for alectinib.

How do you taper steroids for patients with symptomatic edema following standard chemoradiation for GBM?

Do you have a preference for specific steroids? Some practices may switch to prednisone during this time. Patients with gliomas are often on d...

In light of the 2 negative bevacizumab trials for up-front GBM, how do you feel about the future of bevacizumab in GBM?

Do you really feel the failure was because people crossed over to bev at progression, or is it simply that bev does not affect overall survival?