The role of steroids in the management of brain metastases: a systematic review and evidence-based clinical practice guideline

Do steroids improve neurologic symptoms in patients with metastatic brain tumors compared to no treatment? If steroids are given, what dose should be used? Comparisons include: (1) steroid therapy versus none. (2) comparison of different doses of steroid therapy. Target population These recommendations apply to adults diagnosed with brain metastases. Recommendations Steroid therapy versus no steroid therapy Asymptomatic brain metastases patients without mass effect Insufficient evidence exists to make a treatment recommendation for this clinical scenario. Brain metastases patients with mild symptoms related to mass effect Level 3 Corticosteroids are recommended to provide temporary symptomatic relief of symptoms related to increased intracranial pressure and edema secondary to brain metastases. It is recommended for patients who are symptomatic from metastatic disease to the brain that a starting dose of 4–8 mg/day of dexamethasone be considered. Brain metastases patients with moderate to severe symptoms related to mass effect Level 3 Corticosteroids are recommended to provide temporary symptomatic relief of symptoms related to increased intracranial pressure and edema secondary to brain metastases. If patients exhibit severe symptoms consistent with increased intracranial pressure, it is recommended that higher doses such as 16 mg/day or more be considered. Choice of Steroid Level 3 If corticosteroids are given, dexamethasone is the best drug choice given the available evidence. Duration of Corticosteroid Administration Level 3 Corticosteroids, if given, should be tapered slowly over a 2 week time period, or longer in symptomatic patients, based upon an individualized treatment regimen and a full understanding of the long-term sequelae of corticosteroid therapy. Given the very limited number of studies (two) which met the eligibility criteria for the systematic review, these are the only recommendations that can be offered based on this methodology. Please see “Discussion” and “Summary” section for additional details

The role of chemotherapy in the management of newly diagnosed brain metastases: a systematic review and evidence-based clinical practice guideline

TARGET POPULATION: This recommendation applies to adults with newly diagnosed brain metastases; however, the recommendation below does not apply to the exquisitely chemosensitive tumors, such as germinomas metastatic to the brain. RECOMMENDATION: Should patients with brain metastases receive chemotherapy in addition to whole brain radiotherapy (WBRT)? Level 1 Routine use of chemotherapy following WBRT for brain metastases has not been shown to increase survival and is not recommended. Four class I studies examined the role of carboplatin, chloroethylnitrosoureas, tegafur and temozolomide, and all resulted in no survival benefit. Two caveats are provided in order to allow the treating physician to individualize decision-making: First, the majority of the data are limited to non small cell lung (NSCLC) and breast cancer; therefore, in other tumor histologies, the possibility of clinical benefit cannot be absolutely ruled out. Second, the addition of chemotherapy to WBRT improved response rates in some, but not all trials; response rate was not the primary endpoint in most of these trials and end-point assessment was non-centralized, non-blinded, and post-hoc. Enrollment in chemotherapy-related clinical trials is encouraged

The role of retreatment in the management of recurrent/progressive brain metastases: a systematic review and evidence-based clinical practice guideline

QUESTION: What evidence is available regarding the use of whole brain radiation therapy (WBRT), stereotactic radiosurgery (SRS), surgical resection or chemotherapy for the treatment of recurrent/progressive brain metastases? TARGET POPULATION: This recommendation applies to adults with recurrent/progressive brain metastases who have previously been treated with WBRT, surgical resection and/or radiosurgery. Recurrent/progressive brain metastases are defined as metastases that recur/progress anywhere in the brain (original and/or non-original sites) after initial therapy. RECOMMENDATION: Level 3 Since there is insufficient evidence to make definitive treatment recommendations in patients with recurrent/progressive brain metastases, treatment should be individualized based on a patient\u27s functional status, extent of disease, volume/number of metastases, recurrence or progression at original versus non-original site, previous treatment and type of primary cancer, and enrollment in clinical trials is encouraged. In this context, the following can be recommended depending on a patient\u27s specific condition: no further treatment (supportive care), re-irradiation (either WBRT and/or SRS), surgical excision or, to a lesser extent, chemotherapy. Question If WBRT is used in the setting of recurrent/progressive brain metastases, what impact does tumor histopathology have on treatment outcomes? No studies were identified that met the eligibility criteria for this question

The role of whole brain radiation therapy in the management of newly diagnosed brain metastases: a systematic review and evidence-based clinical practice guideline

QUESTION: Should patients with newly-diagnosed metastatic brain tumors undergo open surgical resection versus whole brain radiation therapy (WBRT) and/or other treatment modalities such as radiosurgery, and in what clinical settings? TARGET POPULATION: These recommendations apply to adults with a newly diagnosed single brain metastasis amenable to surgical resection. RECOMMENDATIONS: Surgical resection plus WBRT versus surgical resection alone Level 1 Surgical resection followed by WBRT represents a superior treatment modality, in terms of improving tumor control at the original site of the metastasis and in the brain overall, when compared to surgical resection alone. Surgical resection plus WBRT versus SRS + or - WBRT Level 2 Surgical resection plus WBRT, versus stereotactic radiosurgery (SRS) plus WBRT, both represent effective treatment strategies, resulting in relatively equal survival rates. SRS has not been assessed from an evidence-based standpoint for larger lesions (\u3e3 cm) or for those causing significant mass effect (\u3e1 cm midline shift). Level 3 Underpowered class I evidence along with the preponderance of conflicting class II evidence suggests that SRS alone may provide equivalent functional and survival outcomes compared with resection + WBRT for patients with single brain metastases, so long as ready detection of distant site failure and salvage SRS are possible. Note The following question is fully addressed in the WBRT guideline paper within this series by Gaspar et al. Given that the recommendation resulting from the systematic review of the literature on this topic is also highly relevant to the discussion of the role of surgical resection in the management of brain metastases, this recommendation has been included below

Oligodendroglioma : clinical presentation, pathology, molecular biology, imaging, and treatment /

Oligodendroglioma: Clinical Presentation, Pathology, Molecular Biology, Imaging, and Treatment features the latest "cutting-edge" molecular biology, molecular therapeutics, imaging, immunotherapy, and research methods on the topic of oligodendrogliomas. The most detailed and comprehensive resource on the subject, it provides up-to-date information on clinical presentation, pathology, molecular biology, and treatment methods, including immunotherapy. This book is a critical for students, physicians and researchers in the fields of neuroscience, neuro-oncology, neurosurgery, radiation oncology, medical oncology, and others working in research or with patients.Includes bibliographical references and index.Online resource; title from PDF title page (EBSCO, viewed June 24, 2019).Oligodendroglioma: Clinical Presentation, Pathology, Molecular Biology, Imaging, and Treatment features the latest "cutting-edge" molecular biology, molecular therapeutics, imaging, immunotherapy, and research methods on the topic of oligodendrogliomas. The most detailed and comprehensive resource on the subject, it provides up-to-date information on clinical presentation, pathology, molecular biology, and treatment methods, including immunotherapy. This book is a critical for students, physicians and researchers in the fields of neuroscience, neuro-oncology, neurosurgery, radiation oncology, medical oncology, and others working in research or with patients.SECTION I. CLINICAL PRESENTATION AND QUALITY OF LIFE1. Clinical Presentation in Adults -- Brain2. Clinical Presentation of Spinal Oligodendrogliomas3. Oligodendrogliomas -- Atypical Clinical Presentations4. Clinical Presentation of Pediatric Oligodendrogliomas5. Seizures & Oligo's6. Living with OligodendrogliomaSECTION II. PATHOLOGY AND MOLECULAR BIOLOGY7. Origin and Development of Oligodendroglioma8. Pathology and Molecular Biology Oligo's9. The role of biomarkers in the diagnosis and treatment of oligodendrogliomas10. Prospects of translational proteomics and protein microarrays in oligodendroglioma11. Pathology of Pediatric Oligodendroglioma SECTION III. NEURO-IMAGING 12. CT Imaging of Oligodendroglioma13. Routine and Advanced Magnetic Resonance Imaging of Oligodendrogliomas14. Advanced [11C] Methionine and [18F] FDG Positron Emission Tomography for Diagnosis, Treatment, and Follow Up of Oligodendrogliomas15. Neuroimaging of Pediatric OligodendrogliomasSECTION IV. SURGICAL THERAPY16. Oligodendrogliomas: Basic Techniques in Surgery17. Oligodendrogliomas: Advanced Techniques in Surgery18. Surgical management of 1p/19q co-deleted oligodendrogliomas WHO grade II and III19. Surgical Results in Anaplastic Oligodendroglioma (AO) and Anaplastic Oligoastrocytoma (AOA)20. Surgical Management of Pediatric OligodendrogliomaSECTION V. RADIATION THERAPY 21. Basic Principles of Brain Tumor Radiotherapy22. Standard External Beam Radiation Therapy for Oligodendroglioma23. Stereotactic Radiosurgery in the management of Oligodendroglioma24. Proton Beam Therapy for Oligodendroglioma 25. Interstitial Brachytherapy treatment for Oligodendrogliomas26. The Role of Radiation in Pediatric OligodendrogliomasSECTION VI. CHEMOTHERAPY AND IMMUNOTHERAPY27. Basic Principles of Brain Tumor Chemotherapy28. The use of PCV Chemotherapy in Oligodendrogliomas29. Temozolomide Chemotherapy for Oligodendroglial Tumors30. Miscellaneous Chemotherapy Approaches to Oligodendroglial Tumors31. Molecular Therapy for Oligodendrogliomas32. Bevacizumab for Recurrent Anaplastic Oligodendroglial Tumors33. Pediatric Oligodendroglioma34. Immune Checkpoint Blockade in GliomaElsevie

Rationale and design of the 500-patient, 3-year, and prospective Vigilant ObservatIon of GlIadeL WAfer ImplaNT registry

Implantation of biodegradable wafers impregnated with carmustine (BCNU) is one of the few chemotherapeutic modalities that have been evaluated in Phase III trials and approved by the US FDA for treatment of newly diagnosed high-grade glioma and recurrent glioblastoma. Enrolling up to 500 patients for 3-year follow-up at over 30 sites, the prospective Vigilant ObservatIon of GlIadeL WAfer ImplaNT (VIGILANT) registry (NCT02684838) will evaluate BCNU wafers for treatment of CNS malignancies in contemporary practice and in the new era of molecular tumor analysis. Subgroup analyses will include tumor type, molecular marker status, and treatment combinations. Interim analyses from the VIGILANT registry will be reported until complete results are available in 2024