CNS

Question 1

Adult Low-Grade Infiltrative Supratentorial Astrocytoma/ Oligodendroglioma (excluding pilocytic astrocytoma)

Answer 1

Adjuvant Treatment:

• Combination PCV (lomustine + procarbazine + vincristine) (category 1)
• Temozolomide

• Recurrence or Progressive, Low-grade Disease:

• Temozolomide
• Lomustine or carmustine
• Combination PCV
• Platinum-based regimens

Question 2

Anaplastic Gliomas

Answer 2

• Adjuvant Treatment:

• Temozolomide or PCV with deferred RT
• Concurrent (with RT) temozolomide 75 mg/m2 daily

• Recurrence Therapy Temozolomide

• Lomustine or carmustine
• Combination PCV
• Bevacizumab
• Bevacizumab + chemotherapy (irinotecan,carmustine/lomustine,temozolomide, carboplatin [category 2B for carboplatin])
• Irinotecan
• Cyclophosphamide (category 2B)
• Platinum-based regimens
• Etoposide

Question 3

Anaplastic Oligoastrocytoma/Anaplastic Oligodendroglioma

Answer 3

• Adjuvant Treatment

- RT and PCV for 1p19q co-deleted (category 1)

Question 4

Glioblastoma

Answer 4

• Adjuvant Treatment:

• Concurrent (with RT) temozolomide 75 mg/m2 daily
• Post RT temozolomide 150–200 mg/m2 5/28 schedule
• Temozolomide 150–200 mg/m2 5/28 schedule

• Recurrence Therapy

• Bevacizumab
• Bevacizumab + chemotherapy(irinotecan, carmustine/lomustine,temozolomide,carboplatin [category 2B for carboplatin])
• Temozolomide
• Lomustine or carmustine
• Combination PCV Cyclophosphamide (category 2B)
• Platinum-based regimens

Question 5

Adult Intracranial and Spinal Ependymoma (excluding subependymoma)

Answer 5

• Recurrence

• Platinum-based regimens: Single agent or combination
• Etoposide Lomustine or carmustine
• Bevacizumab
• Temozolomide

Question 6

Adult Medulloblastoma and Supratentorial PNET

Answer 6

• Adjuvant Treatment
- Weekly vincristine during craniospinal radiation therapy followed by either of the following regimens:
◊ Cisplatin, cyclophosphamide, and vincristine
◊ Cisplatin, lomustine, and vincristine

• Recurrence Therapy
- No prior chemotherapy
◊ High-dose cyclophosphamide ± etoposide
◊ Carboplatin, etoposide, and cyclophosphamide
◊ Cisplatin, etoposide, and cyclophosphamide
◊ Consider high-dose chemotherapy with autologous stem cell reinfusion in patients who achieve a CR with conventional doses of chemotherapy or have no residual disease after re-resection Prior chemotherapy
◊ High-dose cyclophosphamide ± etoposide
◊ Oral etoposide
◊ Temozolomide
◊ Consider high-dose chemotherapy with autologous stem cell reinfusion in patients who achieve a CR with conventional doses of chemotherapy or have no residual disease after re-resection

Question 7

Meningiomas

Answer 7

• Interferon alfa (category 2B)
• Somatostatin analogue, if octreotide scan positive
• Sunitinib (category 2B)

Question 8

Primary CNS Lymphoma

Answer 8

• Induction Therapy
- High-dose methotrexate 3.5 g/m2 combined with the following plus RT:
◊ Vincristine, procarbazine, cytarabine ± rituximab
◊ Cytarabine
◊ Ifosfamide ± RT

• High-dose methotrexate 8 g/m2 combined with the following plus deferred RT
  ◊ Rituximab
  ◊ Rituximab and temozolomide
• Consider urgent glucarpidase (carboxypeptidase G2) for prolonged methotrexate clearance due to methotrexate-induced renal toxicity

• Consolidation Therapy

• High-dose chemotherapy with stem cell rescue
• High-dose cytarabine ± etoposide

• Recurrence or Progressive

• Disease Retreat with high-dose methotrexate
• Temozolomide
• Rituximab ± temozolomide
• Topotecan
• Consider high-dose chemotherapy with autologous stem cell reinfusion in patients who achieve a CR with conventional doses of chemotherapy
• High-dose cytarabine
• Dexamethasone, high-dose cytarabine, cisplatin
• Pemetrexed

Question 9

Limited (1–3) Metastatic or Multiple (>3) Metastatic Lesions

Answer 9

• Recurrent Disease
- Treatment as per the regimens of the primary tumor
- Carmustine wafer
- Temozolomide 5/28 schedule
- High-dose methotrexate(breast and lymphoma)
- Capecitabine ± lapatinib,cisplatin,etoposide (breast)
- Topotecan (small cell lung) Ipilimumab (melanoma)
- BRAF inhibitors (melanoma)
◊ Dabrafenib
◊ Vemurafenib

Question 10

Leptomeningeal metastasis

Answer 10

Treatment : Organ-specific systemic chemotherapy, emphasizing drugs with good CNS penetration
- Intra-CSF chemotherapy
◊ Liposomal cytarabine [lymphoma/leukemias]
◊ Methotrexate [lymphoma/leukemias, breast]
◊ Cytarabine [lymphoma/leukemias]
◊ Thiotepa
◊ Rituximab (lymphoma)
◊ Topotecan
◊ Etoposide
◊ Interferon alfa (category 2B)
◊ Trastuzumab (breast)

• High-dose methotrexate for lymphoma and breast
• Weekly pulse erlotinib for EGFR exon 19 deletion or exon 21 L858R mutation (non-small cell lung cancer) (category 2B)