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

How do you interpret CSF pleocytosis in the context of significant leukocytosis on CBC?

For example, a patient with 100 WBCs in CSF with a peripheral WBC 43k/mm3 due to AML.

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-...

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?

What workup do you consider for a developmentally typical child with multiple large café au lait macules but no other signs of neurofibromatosis?

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

4 Answers available

Do you prescribe prophylactic steroids to patients receiving radiosurgery for AVMs?

Would you consider combining tovorafenib and trametinib as dual therapy?

In pediatric patients with low-grade gliomas showing prolonged response or stable disease on tovorafenib, how would you adjust the duration of therapy?

Are there specific safety concerns or long-term risks that should be accounted for when considering drug holidays or overall treatment duration?

Based on the FIREFLY-1 data, would you consider using tovorafenib monotherapy front-line in pediatric patients who have low grade gliomas that are only amenable to subtotal resection or are unresectable?

What was the rationale behind using RANO-HGG criteria instead of RAPNO criteria for the primary endpoint in the FIREFLY-1 trial for pLGG?

How will you implement response assessments in patients starting tovorafenib given potential for pseudoprogression vs true progression?

How has the recent FDA approval of tovorafenib impacted your treatment decisions for pediatric patients with relapsed/refractory low-grade glioma?

Is it merely another option to try or will it become the standard choice for patients experiencing relapsed/refractory disease?

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

Do you recommend adjuvant chemotherapy after radiation treatment?

Would you offer adjuvant radiotherapy for a gross totally resected WHO grade 2 hemangiopericytoma/MFT of the brain in a patient with active multiple sclerosis?

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?

Is it reasonable to delay radiation therapy following surgical decompression for a patient with spinal cord compression if systemic therapy must be started as soon as possible?

Do you ever allow patients to receive a couple of cycles of systemic therapy first if there is high burden of disease? What is the maximum time after ...

4 Answers available

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 there a time interval after which you would not offer adjuvant radiotherapy for a malignant, grade 3 meningioma?

Is there diminished radiotherapy efficacy in tumor control after certain timeframe has passed for malignant meningiomas with no signs of recurrent dis...

Do you wait to treat small asymptomatic brain metastases until they reach a certain size?

For example a 1 or 2 mm brain metastasis? Would you consider waiting for these to enlarge slightly for reasons such as more certainty they are real, l...

If memantine were started 6 weeks after completion of radiation to base of skull, would you expect any potential benefit?

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

Is there a role for unilateral hippocampal sparing?

If a patient has a metastatic lesion in close proximity to one hippocampus, would you offer sparing of the contralateral hippocampus? Do your dose con...

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...

In patients with low grade gliomas that are older than 40 y/o or have subtotal resections, do you ever withhold upfront RT off protocol?

How does 1p/19q co-deletion and IDH mutation status influence your decision?

What is your approach to a completely resected WHO grade II meningioma?

When do you consider observation?

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 approach the workup of a patient with incidentally found pachymeningitis?

Would you recommend upfront radiosurgery for trigeminal neuralgia caused by AVM abutment at the entry root zone?

If not, then what is your preferred treatment and would you integrate SRS into it?

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?

When would you recommend standard of care over hypofractionated treatment in an elderly patient diagnosed with Glioblastoma?

Is there any evidence that radiotherapy can worsen balance, dizziness, or vertigo in patients treated for vestibular schwannoma due to transient edema?

If so, what percent likelihood do you quote patients for this risk with SRS, SRT and fully fractionated therapy?

How do you manage TTFields for a patient with glioblastoma in the setting of disease progression?

Do you routinely discontinue the device or continue if they are otherwise tolerating the treatment well?

Would you consider spinal cord biopsy for an intramedullary cord lesion with disabling neurological deficits and no diagnosis despite a comprehensive workup?

What is the diagnostic yield and complication rate in your experience?

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...

How would you approach treatment of a brainstem AVM after hemorrhage in a patient not a candidate for surgery or embolization?

What would be your preferred technique and dose/fractionation?

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 approach patients with suspected CNS lymphoma who have been treated with steroids?

Do you biopsy immediately, stop treatment, biopsy at a later time, or depend solely on the data you already have?

How do you manage a symptomatic meningioma and associated vasogenic edema in a poor performance status patient?

Is there any additional benefit to radiation in addition to steroids in a patient who is not a surgical candidate?

How do you manage multiple cavernous malformations that have bled and enlarged over time?

How do you counsel patients on control of glioma-related seizures following radiation?

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?

Is placing a VP shunt a major risk to spread medulloblastoma or other malignant brain tumors into the gut?

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

How would you manage leptomeningeal disease of the spine in the setting of prior WBRT?

What factors play into your decision whether to re-treat the brain with craniospinal radiotherapy vs irradiation of the spine only vs other measures (...

In what situations would you consider memantine when treating multiple brain metastases with SRS?

What is the optimal management for a patient with Tourette Syndrome with severe tics that preclude the patient from lying still for radiation?

E.g. The case in question is for a patient planned for thoracic RT for LS-SCLC. Any medications that may help or just give much bigger expansions to c...

How do you approach treatment of a spinal meningioma?

When do you favor RT? What is your preferred dose/fractionation?

How do you do approach treatment of a recurrent gliosarcoma?

How does length of time from prior chemoradiotherapy influence your management?

How do you manage cranial radiotherapy in the setting of an acute CVA?

In a palliative setting, how long would you wait to initiate WBRT?