Neuro-Oncology   

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

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

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

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

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

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

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?

Is there a role for adjuvant chemotherapy or radiation?

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

Do you recommend adjuvant chemotherapy after radiation treatment?

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

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

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...

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

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...

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

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

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

Louis et al., PMID 34185076

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

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

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

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...

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...

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

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

If so, when do you consider this? 

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

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

Length of temozolomide course when given with adjuvant radiotherapy

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

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

Assuming the patient is not a candidate for SRS

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

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

Would this be any different for whole brain radiotherapy?

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

Provided patient is tolerating treatment well. 

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...

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

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

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

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

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

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

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?