Brain Tumors A Pocket Guide Mohile 1 Ed 2023

Brain
Tumors
A Pocket Guide
Nimish A. Mohile
Alissa A. Thomas
Editors
123
Brain Tumors
Nimish A. Mohile
Alissa A. Thomas
Editors
Brain Tumors
A Pocket Guide
Editors
Nimish A. Mohile Alissa A. Thomas
Department of Neurology Department of Neurological
University of Rochester Medical Sciences
Center University of Vermont Larner
Rochester, NY, USA College of Medicine
Burlington, VT, USA
ISBN 978-3-031-41412-1 ISBN 978-3-031-41413-8 (eBook)

https://doi.org/10.1007/978-3-031-41413-8
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Contents
Part I Brain Tumor Primer
1 Malignant Glioma�� 3
Shannon Fortin Ensign and Alyx B. Porter
2 Diffuse Astrocytoma�� 21
Donna Molaie and Phioanh (Leia) Nghiemphu
3 Oligodendroglioma�� 39
Oluwatosin Akintola
4 BRAF-Mutated Glioma �� 51
Karisa C. Schreck and Jean M. Mulcahy Levy
5 Treatment of Meningioma�� 67
Rimas V. Lukas, Timothy J. Kruser,
and Adam M. Sonabend
6
Treatment of Primary CNS Lymphoma�� 83
Ugur Sener and Lauren Schaff
7 Adult Medulloblastoma ��103
Tresa McGranahan and Sonia Partap
8 Treatment of Ependymoma��119
Jing Wu and Surabhi Ranjan
v
vi Contents
Part II Supportive Care Primer
9 Brain
Edema and Corticosteroid Toxicity ��141
Maninder Kaur and Reena Thomas
10 T
umor Related Epilepsy��153
Thomas Wychowski
11 Treatment
and Prevention of Venous
Thromboembolism ��165
Shiao-Pei Weathers and Alexander Ou
12 Management
of Neurocognitive Symptoms��177
Christina Weyer-Jamora and Jennie W. Taylor
13 C
hemotherapy-Related Toxicities
and Management��195
Haroon Ahmad and David Schiff
14 Radiation
Related Toxicities and Management��211
Sara J. Hardy and Michael T. Milano
15 Neurosurgical
Complications in Brain Tumor
Patients��235
Tyler Schmidt
16 Management
of Older Patients with Brain
Tumors��249
Andrea Wasilewski
17 P
alliative Care in Neuro-oncology��267
Young-Bin Song and Lynne P. Taylor
Index��283
Part I
Brain Tumor Primer
Malignant Glioma
1
Shannon Fortin Ensign
and Alyx B. Porter
WHO CNS Classification:

Glioblastoma, IDH-wildtype
Astrocytoma, IDH-mutant Grade 3 and 4
Clinical Scenario
A 58 year old right handed man came to medical attention due to

a focal motor seizure of the left lower extremity. He was found to
have a 3 × 3 cm right parieto-occipital homogeneously enhancing
cystic mass. He was taken to the operating room where a gross
total resection was achieved by right occipital craniotomy. Post-
operatively, he had a left homonymous hemianopia. Pathology
demonstrated glioblastoma, IDH-wild type, MGMT methylated,
ATRX retained. He received chemoradiation to a total dose of
60 Gy over 30 fractions with concomitant temozolomide 75 mg/
m2 days 1 through 42. He completed a total 6 cycles of adjuvant
chemotherapy and chose not to wear tumor treating fields.
S. F. Ensign
Department of Hematology and Oncology, Mayo Clinic,
Phoenix, AZ, USA
A. B. Porter (*)
Department of Neurology, Mayo Clinic, Phoenix, AZ, USA
e-mail: Porter.alyx@mayo.edu
© The Author(s), under exclusive license to Springer Nature 3

Switzerland AG 2023
N. A. Mohile, A. A. Thomas (eds.), Brain Tumors,
https://doi.org/10.1007/978-3-031-41413-8_1
4 S. F. Ensign and A. B. Porter
He developed distant disease recurrence 7 months after com-

pletion of treatment. Neuroimaging revealed a new left parietal
lesion and the previously treated right occipital lesion was stable.
Since that area was not the primary target of previous radiation, he
was presented to tumor board to discuss the safety and feasibility
of re-irradiation. A multi-disciplinary team decided to proceed
with radiation at a dose of 40 Gy over 15 fractions.
Six months later, an MRI demonstrated further growth of the
left parietal mass with increased enhancement and surrounding
edema. Additionally, he had more clinical symptoms including
hemiparesis, aphasia and intractable focal seizures. He underwent
resection of the left temporo-parietal mass to relieve pressure,
improve symptoms, treat seizures and to determine the extent to
which this was recurrent tumor or necrosis. The pathology was
consistent with tumor recurrence. He was planned for therapy
with bevacizumab beginning 28 days after surgery, but developed
a saddle pulmonary embolism requiring hospitalization and sub-
sequent decline in performance status. As a result of progressive
clinical decline, the patient elected to enroll in hospice care. He
spent 5 months in hospice and passed away 28 months from his
original diagnosis of glioblastoma.
Making the Diagnosis
Gliomas arise from glial cells and neuronal precursors. They con-
stitute 80% of all malignant primary brain and CNS tumors.
Glioblastoma (GBM) is the most invasive, aggressive (grade 4)
and common form. Patients can present with various symptoms
including seizures, headaches, neurological deficits, and altered
mental status. Magnetic Resonance Imaging (MRI) is the diag-
nostic modality of choice when a brain lesion is suspected.
Computed Tomography (CT) scans are appropriate in emergent
situations to evaluate for intracranial hemorrhage or hydrocepha-
lus. While certain imaging characteristics are highly suggestive of
GBM (heterogeneously enhancing expansile lesion), none are
pathognomonic. In fact, many non-neoplastic processes can
mimic gliomas, including multiple sclerosis, granulomatous dis-
1 Malignant Glioma 5
eases, infections, and radiation necrosis. Tissue diagnosis is

essential to confirming the suspected diagnosis. Surgical
approaches can range from a minimally invasive stereotactic
biopsy to a craniotomy with gross total resection. A flowchart
describing the diagnostic and treatment approach for these tumors
is included in Fig. 1.1.
The current tenet of glioma surgery is to achieve maximal safe
resection [1]. As diffusely infiltrating lesions, the oncologic con-
cept of negative-margin resections applicable to other tumor types
cannot be applied. Multiple studies over the past decades have
demonstrated a survival benefit with gross total resection.
Mathematical models applied to retrospective studies revealed a
progressive improvement in survival with the extent of resection
increasing between 78 and 98%. A systematic review and meta-
analysis of the literature revealed a significant improvement in
overall and progression-free survival with gross total resection
compared to subtotal resection. In glioma surgery, the definition
of gross total resection remains controversial. Achieving true
gross total resection is impossible due to the far-reaching invasion
of tumor cells into the normal brain parenchyma. Therefore, the
consensus is that this terminology refers to the enhancing compo-
Fig. 1.1 Glioblastoma Treatment Flowchart

nent. The controversy lies in the extent of resection of the T2

hyperintense portion. Subtotal resection and biopsy (open or ste-
reotactic) are reserved for tumors in eloquent areas of the brain,
for patients with a poor performance status or multiple medical
co-morbidities and cannot medically tolerate resective surgery.
Once the importance of maximal safe resection was estab-
lished, multiple surgical adjuncts promising to optimize efficacy
were introduced [2]. These include intraoperative imaging modal-
ities such as intraoperative ultrasound and intraoperative MRI. The
quality of available data is at best moderate. However, all imaging
modalities were found to improve the rate of gross total resection.
Intraoperative ultrasound is inexpensive, readily available, easy to
use and can localize small areas of residual that might not be vis-
ible to the naked eye. Intraoperative MRI on the other hand,
requires an expensive infrastructure but can be very helpful in
determining the need for further resection.
Fluorescence in brain tumor surgery was developed in the
1990s but its use became mainstream only recently.
5-Aminolevulinic acid (5-ALA) is an imaging agent used to detect
glioma cells. It is given to patients orally 3 h prior to anesthesia
induction at the dose of 20 mg/kg. 5-ALA causes accumulation of
fluorescent porphyrin in tumor cells exclusively. These cells then
emit a red-pink fluorescent light that is visible in the oculars of the
microscope while the normal brain parenchyma appears in blue.
This tool is especially valuable at the normal parenchyma/tumor
interface. The use of 5-ALA has been shown to improve the abil-
ity of to achieve a gross total resection in a randomized study [3].
Another surgical adjunct is direct white matter stimulation.
This technique is particularly important when resecting tumors in
proximity to the corticospinal tract. During resection, the white
matter fibers are directly stimulated at different amplitudes to elicit
a motor evoked potential. Depending on the amplitude of the stim-
ulation, a positive response indicates the presence of the cortico-
spinal tract within a certain distance of the stimulus. Alternatively,
awake surgery can be performed with cortical stimulation to mini-
mize injury to eloquent areas. The combination of all 3 allows us
to safely expand our resection beyond the contrast enhancing por-
tion into what is defined as supramarginal resection.
Beyond cytoreduction, the role of surgery is to provide tissue

for immunohistochemical and genetic analysis. The prognosis is
heavily influenced by the genetics and molecular subtypes.
Isocitrate dehydrogenase (IDH) mutation is ubiquitous in low
grade gliomas. Malignant astrocytoma with IDH mutations are
classified as either grade 3 or grade 4 astrocytomas, depending on
histologic features and molecular signature. IDH-mutant infiltra-
tive gliomas have a better prognosis than IDH-wild-type.
Based on the 2021 WHO Classification of Tumors, the diagno-
sis of glioblastoma is achieved in a high grade glioma that is IDH-
wild-type [4]. For the purposes of this chapter, treatment
recommendations apply to IDH-wild-type glioblastoma and can
be extrapolated for treatment of IDH mutant grade 3 and grade 4
astrocytomas, for which there are few randomized trials to clearly
define therapy. MGMT (O6-methylguanine-DNA methyltransfer-
ase) methylation status is a predictive biomarker that determines
the response to temozolomide. MGMT is a DNA repair enzyme.
It is particularly effective in repairing damage caused by alkylat-
ing agents and therefore confers a resistance to temozolomide.
MGMT promoter gene methylation silences it and enhances
response to temozolomide. IDH and MGMT status are only 2 of
multiple mutations analyzed in GBM tissue. Once the genetic and
molecular signatures of the tumor have been defined, the treat-
ment paradigm, including clinical trial eligibility, are then deter-
mined.
Post-operative Treatment
Radiation
Glioblastoma is characterized by microscopic invasive disease

within the brain parenchyma outside the tumor bulk, and most
high grade glioma recurrences occur within 2 cm of the initial
surgical resection margin. Adjuvant fractionated radiation therapy
(RT) targeting this expected relapse field confers an overall sur-
vival benefit and comprises standard of care post-operative treat-
ment, delivered concurrently with chemotherapy [5]. While there
are several approaches to radiation therapy volume planning

(EORTC vs RTOG recommendations), the accepted standard of
care is the EORTC contouring approach. Radiation dosing of
60 Gy is delivered as 30 × 2 Gy fractions to the clinical target
volumes (CTV), which is comprised of the gross tumor volume
(GTV) + 2 cm. GTV encompasses the tumor resection cavity plus
areas of residual T1 enhancement. Side effects most encountered
include fatigue, cognitive decline, alopecia, and radiation derma-
titis.
Elderly and frail patients may be considered for short course
radiotherapy combined with chemotherapy. GBM survival
decreases with advancing age and treatment is limited by toxic
side effects and underlying coexisting conditions in the elderly
[6], and patients over age 70 were excluded from the initial phase
III study showing a benefit of combined chemoradiation versus
radiotherapy alone using fractionated 60 Gy dosing [7]. Instead
de-escalated treatment with hypofractionated radiation (40 Gy in
15 fractions) with concurrent and adjuvant temozolomide is a
consideration in this population. Alternatively, elderly patients not
fit for this strategy may be considered for hypofractionated radio-
therapy or temozolomide monotherapy alone, with the latter treat-
ment strategy more effective in patients with MGMT promoter
methylation [8, 9].
Chemotherapy
Temozolomide (TMZ), a pro-drug alkylating agent which methyl-

ates DNA at the O6 position of guanine and which is able to pen-
etrate the blood-brain barrier, is the current standard chemotherapy
utilized in the adjuvant postoperative treatment of GBM [7, 10].
TMZ is delivered orally at a dose of 75 mg/m2 daily during con-
current radiotherapy. After completion of RT, TMZ is held for
4 weeks then resumed at 150 mg/m2 and subsequently escalated to
200 mg/m2 days 1–5 of every 28 days for a minimum of 6 months.
No study has demonstrated benefit of adjuvant chemotherapy
beyond 6 months, but it should be noted that in the CATNON
study, 12 months of adjuvant therapy were given to individuals

with anaplastic astrocytomas [11]. Analysis of the CATNON
study also suggested that there may not be additional benefit for
concurrent temozolomide in that population. Specific treatment
regimens used in malignant gliomas are included in Table 1.1.
Given the emetogenicity of TMZ use of ondansetron 8 mg,
granisetron 1 mg or prochlorperazine 10 mg orally 30 min before
each chemotherapy dose is recommended. During concurrent
chemoradiotherapy weekly blood counts may be needed to moni-
tor for cytopenias, and liver function testing monitored midway
through radiation therapy and subsequently. Lymphopenia places
patients at increased risk for Pneumocystis jirovecii pneumonia
(PJP), and prophylaxis should be considered in patients still
requiring corticosteroids. TMZ should be held for platelet count
under 100,000 and ANC <1500/mL until count recovery.
In younger patients (age ≤ 70) with MGMT-methylated tumors
and good performance status a combined lomustine/TMZ regi-
men concurrent with RT and adjuvant may be considered. This is
based on randomized phase III data showing an improved overall
survival compared to TMZ alone (48.1 months versus
31.4 months), however increased side effects were observed in the
dual treatment arm. Younger fit patients may also be considered
for a clinical trial up front.
Tumor Treating Fields
Tumor treating field (TTF) therapy is offered for frontline treat-

ment of GBM in patients who tolerate this adjunctive modality.
TTF technology consists of a portable medical device where elec-
trodes are attached to the patient’s shaved scalp and transduce
alternating electric fields at an optimal intensity and frequency for
maximal tumor cell growth inhibition. TTF are felt to enact an
antimitotic effect on the tumor hindering cell growth as their pri-
mary mechanism of action [12]. TTF are approved for use concur-
rent with monthly TMZ following completion of standard
chemoradiation, and has proven to confer an overall survival ben-
10
Table 1.1 Glioblastoma treatment

Dose delays and
Drug Dose Antiemetics Supportive care adjustments
Preferred first line regimens
Concurrent with RT 75 mg/m2 PO daily Ondansetron 8 mg 30 min Consider PCP Hold TMZ for ANC <1500/
& Adjuvant during RT & 150– prior to chemotherapy prophylaxis mm3 or platelet count
Temozolomide 200 mg/m2 PO d1–5, and then up to every 8 h <50,000/mm3
(TMZ) q28 days maintenance as needed
Concurrent with RT TMZ 100 mg/m2 PO Ondansetron 16 mg IV, TMZ as above TMZ as above
& Adjuvant d2–6 Dexamethasone 12 mg Lomustine: monitor Lomustine: Dose
Temozolomide/ Lomustine 100 mg/m2 IV, Emend 125 mg PO PFTs at baseline and adjustment for hematologic
Lomustine PO d1 periodic toxicity. Discontinue
q28 days for up to permanently for pulmonary
6 cycles fibrosis
Subsequent line regimens
Bevacizumab 10 mg/kg IV d1, 15, PRN Monitor for HTN, No adjustments,
q28 days proteinuria, bleeding discontinue if indicated
TMZ 150–200 mg/m2 PO Ondansetron 8 mg 30 min Consider PCP Hold TMZ for ANC <1500/
d1–5, q28 days prior to chemotherapy prophylaxis mm3 or platelet count
maintenance and then up to every 8 h <50,000/mm3
as needed
S. F. Ensign and A. B. Porter
1
Lomustine Lomustine: 110 mg/m2 Ondansetron 8 mg po Monitor PFTs at Monitor for pulmonary
monotherapy q42 days 30 min prior to baseline and periodic toxicity
chemotherapy and then
up to every 8 h as needed
PCV (Procarbazine, Procarbazine: 100 mg/ Ondansetron 16 mg IV, Monitor PFTs as Procarbazine & Vincristine:
Lomustine, m2 PO d1–10 Dexamethasone 12 mg above, & monitor for Hepatic dose adjustment as
Malignant Glioma
Vincristine) Lomustine: 100 mg/m2 IV, Emend 125 mg PO constipation/ileus & indicated
PO d1 peripheral neuropathy
Vincristine: 1.5 mg/m2
IV d1, q42 days
11
efit difference of nearly 5 months (20.9 months vs 16 months)

compared with TMZ alone [13]. Side effects generally are mild
and most prominently include a localized dermatitis under the
placement of the electrodes on the scalp, which has been shown to
respond well to topical steroid treatment [14].
Patients must wear these devices continuously for a goal 18 h
per day, which has prompted concerns on the impact of quality
of life (QoL). Questionnaires designed to assess QoL measures
revealed no significant difference in global health status, emo-
tional, social, physical, and cognitive functioning, as well as
pain or leg weakness, and encouragingly patients receiving TTF
had a significantly longer deterioration-free survival for several
of these measures [15].
Symptom Management
Anti-epileptic therapy. Patients may present with seizures as

their first symptom of GBM or experience seizures during their
disease course, and approximately half of all GBM patients will
be diagnosed with epilepsy during their disease [16]. Patients
who develop seizures should be started on a single anti-seizure
medication (ASM) for treatment using any first-line agent at the
lowest effective doses. Typically levetiracetam is offered first
line as this is well tolerated, though care should be used to mon-
itor for potential neuropsychiatric side effects. While smaller
studies have suggested an overall survival (OS) benefit with the
use of valproate, a larger pooled analysis across four random-
ized trials found no difference in OS among patients on valpro-
ate as compared to other ASMs [17]. Patients who experience
recurrent seizures while on therapy should have ASM levels
monitored prior to dose escalation or consideration of adding a
second drug. Seizure prophylaxis in a patient with no seizure
history is generally not recommended, however perioperative
prophylaxis may be considered with recommendations to taper
and subsequently discontinue the ASM starting at 1–2 weeks
post-operatively [18, 19].
Vasogenic edema management. Vasogenic edema results

from local disruption of the blood-brain barrier from the tumor
and is commonly encountered during disease management of
patients with glioblastoma (see Chap. 10). Vasogenic edema
appears on MRI as hypointense on T1-weighted images and
hyperintense on T2-weighted images. Neurologic symptoms are
variable however symptomatic patients require initiation of sys-
temic steroids, with dexamethasone used as the standard agent,
and clinical response should be monitored. Common starting
doses of dexamethasone are 4–8 mg divided once or twice daily
and subsequently a taper can be initiated once symptoms are sta-
bilized. Bevacizumab, an anti-vascular endothelial growth factor
monoclonal antibody can also be used as a steroid-sparing treat-
ment for edema control, including in the management of edema
related to radiation necrosis. Dosing is typically either 7.5 mg/kg
every 3 weeks or 5 mg/kg every 2 weeks for four doses, with MRI
monitoring mid-way through and at treatment completion.
Surveillance
After the initial concurrent chemoradiotherapy, it is standard prac-

tice to obtain a brain MRI with contrast 4–6 weeks following ther-
apy completion. Thereafter, imaging is obtained every 2–4 months
thereafter for monitoring assessment or earlier based on symp-
toms. The current criteria for imaging evaluation are based on the
Response Assessment in Neuro-Oncology (RANO) Working
Group, which includes guidelines for determination of progressive
disease versus pseudoprogression,with progressive disease based
on at least two sequential studies separated by 4 weeks and show-
ing 25% or more increase in size or 40% or more increase in the
total volume of the enhancing lesion [20, 21]. Moreover patients
who are symptomatic or have tumors harboring MGMT promoter
unmethylated status or IDH-wild-type are more likely to have true
disease progression [22, 23]. Advanced imaging such as MRI per-
fusion and PET may not be widely available but can be helpful in
differentiating pseudoprogression from true progression.
Treatment at Recurrence
After the determination of progressive disease and assessment of

patient performance status, including a trial of steroids for treat-
ment of symptomatic peritumoral edema if indicated, subsequent
treatment can be considered for GBM. With both first and second
recurrences, clinical trials should be considered. For patients with
poor functional status or personal preference to not pursue addi-
tional therapy supportive care should be given. Patients with good
functional status can be considered for reoperation with or with-
out implantation of carmustine (Gliadel wafers) and/or re-
irradiation if indicated. The role of laser thermal ablation in this
setting is evolving. For patients in whom systemic therapy is
being considered typical regimens are single-agent bevacizumab
(10 mg/kg IV days 1, 15), single or combination nitrosourea-
based regimens, or re-challenge with temozolomide (150–200 mg/
m2 days 1–5 every 28 days). No agent has proven superiority to
another or has demonstrated improved overall survival.
Nitrosourea- based regimens typically consist of lomustine
(CCNU) monotherapy (100–130 mg/m2 day 1, every 42 days), or
in combinations such as procarbazine, CCNU and vincristine
(PCV) (Procarbazine 100 mg/m2 PO on days 1–10, Lomustine
100 mg/m2 PO day 1, Vincristine 1.5 mg/m2 IV day 1, every
42 days).
Prognosis/Survivorship
The prognosis of patients with GBM is dependent upon age and

functional status at diagnosis, as well as underlying genomic pro-
file including presence of MGMT promoter methylation and IDH
status, among others. The median overall survival of all GBM
patients treated with standard combined TMZ and radiation is
14.6 months [24]. Table 1.2 includes patient-facing information
including guidance related to prognosis. Moreover, patients on
standard chemoRT who underwent a complete, partial, or biopsy
only resection had median survivals of 18.8 months vs 13.5 months
vs 9.4 months, respectively. Patients under age 50 had a median
OS of 17.4 months versus 10.9 months for those over age 60.
Table 1.2 Glioblastoma patient information

What type of tumor • Glioblastoma, or Glioblastoma Multiforme
do I have? (GBM) is a type of brain cancer
• GBM occurs when normal brain cells become
abnormal and start to grow quickly as cancer
which causes damage and swelling into the
normal brain
How do I treat it? • You will undergo imaging of your brain to
determine where the tumor is, and a surgeon will
first perform surgery to remove as much of the
tumor as possible
• After recovery most patients with GBM will have
both radiation treatment to the brain and
chemotherapy
• Some patients also opt to wear a portable device
that delivers electrical fields to the brain to
further slow the growth of the cancer cells
• Some patients opt to consider enrollment in a
clinical trial to treat GBM if available
What can I expect • Most patients will experience some fatigue
to experience during treatment. Nausea and GI upset may also
during treatment? occur, but doctors are able to help treat many of
these side effects with effective medicines
How will we keep • Doctors will monitor your blood counts, liver and
an eye on this? kidney function regularly during treatment
• You will have periodic imaging of your brain to
monitor the cancer during treatment
• You may need to take steroids if there is any
swelling of your brain during treatment or seizure
medicine if you develop epilepsy from
complications of having the brain tumor
What is my • In most patients with GBM the tumor comes
prognosis? back after treatment
• While there are no treatments that can cure
patients from GBM, the treatments available are
often able to help prolong life and provide a
quality of life which may have become
diminished by having a brain tumor
Patients with MGMT promoter methylation had a median OS of

23.4 months versus 12.6 months in the unmethylated group [24].
Astrocytoma, IDH-mutations are associated with improved over-
all survival as compared to glioblastoma, IDH-wildtype (27.4 ver-
sus 14 months, respectively) [25].
There is limited data on survivor care for patients with GBM

given that most patients succumb to their disease in a short time-
line. However, studies of long term GBM survivors have identi-
fied a need for the continued monitoring of recurrences, with
multiple lines of chemotherapy necessary for disease relapse.
Patients also often require continuation of anti-epileptic medica-
tions, monitoring of their neurocognitive decline, and other neu-
rological sequelae including radiation necrosis, cerebrovascular
accidents, hydrocephalus and VP shunting as well as dementia.
This group of patients thus requires specialized Neuro-Oncologic
care for their continued monitoring [26].
Trends and Future Directions
Glioblastoma is characterized by marked heterogeneity which

underlies treatment resistance, parenchymal invasion and inevi-
table tumor recurrence. Clinical trials utilizing targeted therapies
against known signaling aberrations within GBM have yet to
demonstrate significant benefit for either up-front or salvage ther-
apy [27]. The only FDA approved targeted therapy is bevaci-
zumab for use in recurrent glioma. Trials so far of small molecule
kinase inhibitors, antibodies, or antibody drug conjugates that
target aberrant receptor tyrosine kinase signaling activity have not
proven to yield a PFS or OS benefit. Additionally, the use of his-
tone deacetylase inhibitors, PARP inhibitors, or IDH1mt inhibi-
tors are under early investigation and the effectiveness is yet to be
determined [27].
Immune therapies represent another promising treatment strat-
egy, however to date there are no FDA-approved immune-based
treatments. Investigations are underway exploring immune check-
point inhibitors (ICI), vaccines, adoptive T-cell therapies, and
viral therapy [28]. Of note a subset of TMZ treated glioblastomas
display hypermutation signatures at tumor recurrence [29]. This
has led to the proposal that these gliomas may respond to subse-
quent therapy with ICI, noting that high tumor mutational burden
is predictive of response regardless of disease [30]. However,
early trials to date have not shown significant anti-tumor efficacy
of ICI therapy in recurrent GBM although it remains to be seen

whether there is a subgroup of responders in follow-up analyses,
and moreover, some evidence indicates ICI use in the neoadjuvant
setting may lead to more consistent immune activation [31, 32].
Dendritic cell-based vaccines have been shown to yield durable
responses in a minority of patients in clinical trials to date and
studies remain ongoing [28]. Trials investigating CAR-T mostly
have studied the IL-13Ra2, EGFRvIII and HER2 antigens, how-
ever with most patients not displaying significant tumor regres-
sion [28]. Likewise there has been a lack of durable response from
viral directed anti-GBM therapy to date [33]. Further molecular
studies to understand treatment response patterns are warranted.
The current standard of care treatment for glioblastoma aims to
prolong survival at best, though some patients have minimal ben-
efit, dependent on their performance status and the tumor genet-
ics. In the absence of any curative therapy, clinical trial
participation is encouraged for all eligible patients with glioblas-
toma, with the hope of improving survival and quality of life over
time.
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Diffuse Astrocytoma
2
Donna Molaie and Phioanh
(Leia) Nghiemphu
WHO CNS Classification: Astrocytoma, IDH-mutant, CNS

WHO Grade 2.
Clinical Vignette
A healthy ambidextrous 37 year-old male sustained a head

injury after being hit by a car while riding a bicycle. He was
taken to the local hospital emergency room where a CT scan
demonstrated a hypodensity in the right temporal lobe, and an
MRI with and without Gadolinium contrast revealed a non-
enhancing, T2 hyperintense mass in the medial right temporal
lobe. He was evaluated by a Neuro-Oncologist and additional
history revealed 3 years of stereotyped 30-s episodes of feeling
disassociation and dread, increasing in frequency over 4 months.
D. Molaie
Department of Neurosurgery, Kaiser Permanente,
Redwood City, CA, USA
P. (L.) Nghiemphu (*)
Department of Neurology, David Geffen School of Medicine at UCLA,
Los Angeles, CA, USA
e-mail: pnghiemphu@mednet.ucla.edu

Switzerland AG 2023
https://doi.org/10.1007/978-3-031-41413-8_2
22 D. Molaie and P. (. Nghiemphu
He started levetiracetam 750 mg twice daily and consulted with

Neurosurgery for preoperative planning. He was assessed with
a functional MRI (fMRI), MRI with BrainLab, diffusion tensor
imaging (DTI), and neuropsychological testing which demon-
strated left hemisphere dominance for language. Subsequently,
he underwent a right temporal craniotomy with a near gross
total resection (GTR). The pathology demonstrated a Diffuse
Astrocytoma (DA), WHO grade 2, positive immunoreactivity
for isocitrate dehydrogenase 1 (IDH1) R132H mutation on
immunohistochemistry (IHC), and 1p19q non-codeleted by
fluoresecence in situ hybridization (FISH). Given his age,
extent of resection (EOR), and personal preferences, the deci-
sion was made to monitor with serial imaging.
Clinical Features
The causes of most DAs are unknown. Genetic cancer predis-

position syndromes make up less than 5% of cases and primar-
ily involve germline mutations of NF1, P53, and mismatch
repair genes [1]. The only recognized environmental risk fac-
tor is a remote history of ionizing radiation to the brain, head
or neck.
Focal seizures are the most common clinical presentation.
Other presentations include: incidental finding, focal motor or
sensory symptoms, cognitive changes, aphasia and rarely,
pressure-related headache.
Commonly affected locations are the frontotemporal and insu-
lar regions. Typical features on MRI include a cortically based,
nonenhancing, homogenous T2 hyperintense signal with sulcal
effacement and fullness of gyri; the presence of patchy or punc-
tate enhancement prompts consideration of a more aggressive
phenotype. MRI spectrography may be normal or demonstrate
mild choline elevation, reduced NAA, absent lactate, and elevated
choline: creatinine ratio. MR perfusion generally reveals no ele-
vation of relative cerebral blood volume. On PET, FDG uptake is
similar to normal white matter.
2 Diffuse Astrocytoma 23
Surgical Decision-Making
Watchful Waiting or Surgery: Once a lesion suspicious for low

grade glioma (LGG) has been identified on MRI, there are two
primary approaches: MRI surveillance or surgical intervention
(Fig. 2.1). Neurologic and epileptic symptoms, location, size of
tumor, and patient preference are important factors to consider. In
the past decade, general expert opinion has shifted in favor of
early maximal safe resection. If a patient is symptomatic or the
tumor has significant mass effect, the decision to intervene is
straightforward. However, for some asymptomatic patients with
small incidental lesions, watchful waiting may be acceptable but
Fig. 2.1 Management flowchart for Diffuse Astrocytoma, WHO grade 2,

with IDH mutation, and 1p19q intact. Dashed arrows represent management
options on a case-by-case basis, influenced by patients preferences and prog-
nostic markers
there is no clear evidence to definitively guide decision-making or

to guide frequency of neuroimaging. It is important to always
compare new MRI’s to the baseline MRI as growth can be slow
and difficult to appreciate over a short interval. MRI’s every few
months will appear unchanged, but when looked at over a few
years, increase in size is better appreciated.
Preoperative Planning: A neurosurgeon may order a special-
ized MRI with DTI to guide preoperative planning. fMRI is used
to map motor and sensory function relative to tumor location,
helping neurosurgeons determine the resection margins to mini-
mize deficit. If fMRI does not clearly delineate the language dom-
inant hemisphere or if clarification of memory representation is
necessary, a WADA can be performed. Additionally, neuropsy-
chological testing is used to determine the extent of neurocogni-
tive deficits, candidacy for awake craniotomies, and serve as a
baseline.
Awake vs Open Craniotomy: If regions of critical neurologic
function are not close to or do not involve tumor, awake craniot-
omy is generally not necessary. However, if the lesion is adjacent
to critical regions, awake craniotomy with intraoperative mapping
is critical to preserve neurologic function while obtaining maxi-
mal safe resection.
Resection vs Biopsy: If resection has a high risk of neurologic
deficit or tumor is located in the deep structures or brainstem,
biopsy may be advised. The decision between open versus needle
biopsy is also based on surgical risk. Though, it is important to
recognize that under-sampling with needle biopsy is common and
can lead to misdiagnosis.
Pathology
According to WHO 2021 guidelines, DAs are graded as 2, 3, or

4, based on histological and molecular findings. A DA, WHO
grade 2, histologically may demonstrate: nuclear atypia and
increased cellularity, but without necrosis, mitoses, and endo-
thelial proliferation [2]. Typical molecular findings include IDH
mutations and no co-deletion of chromosomal arms 1p and 19q.
If IDH mutation is negative by IHC, genetic sequencing should
be performed to evaluate for noncanonical mutations, especially

in younger patients. IDH1 R132H is the most common.
Mutations involving IDH2 have also been detected (though less
frequent than IDH1) and are more common in oligodendroglio-
mas. Other common alterations include loss of function muta-
tions of ATRX and TP53. Though MGMT promoter methylation
is prognostic and predictive for high grade gliomas, it’s role in
DAs is unclear.
In regards to astrocytic tumors with normal IDH genes, also
called “IDH-wildtype,” additional molecular features are neces-
sary to classify their behavior. The first and most common, is a
glioblastoma [3]; an IDH-wild-type tumor that often has muta-
tions in the TERT promoter or EGFR amplification [4, 5]. A sec-
ond and more aggressive subtype is a diffuse glioma with H3 K27
mutation, typical of midline tumors. Third, genetic alterations of
BRAF (V600E mutation or duplication), especially in a well cir-
cumscribed tumor, should prompt consideration of low grade
variants (Pilocytic Astrocytomas or Glioneuronal tumors) [2].
isk Stratification and Selection of Patients

R
for Treatment
Patients can be stratified by age and EOR into risk groups, which
are helpful for guiding postoperative management. From the pre-
molecular era, age <40 with a GTR is considered low risk, while
age ≥40 and any patient with incomplete resection are considered
high risk. Additional factors to consider when selecting patients
for immediate postoperative chemotherapy are the presence of
risk factors for poor outcome: preoperative neurologic functional
deficit, preoperative tumor size ≥5 cm, and tumor crossing the
corpus callosum [6, 7].
Traditionally, watchful waiting or observation has been accept-
able for low risk patients, while immediate postoperative chemora-
diotherapy is recommended for high risk. Since the recognition of
IDH mutational status’s positive impact on survival, watchful wait-
ing may also be considered in IDH-mutant DA patients <40 with
incomplete resection but small residual tumor in non-eloquent loca-
tions, or ≥40 with GTR who also have other favorable markers.
The optimal management remains controversial with respect to:

initiation time, treatment type, and chemotherapy regimen (temo-
zolomide (TMZ) versus combination procarbazine, CCNU/
lomustine, vincristine (PCV)). The key points are: (1) Traditional
low risk patients, and those <40 with incomplete resection but
small residual tumor in non-eloquent locations or ≥40 with GTR
who also have other low risk features (pre-operative tumor size
<5 cm and not involving the corpus callosum, no functional defi-
cits), may opt for watchful waiting. (2) The decision to treat
should trigger radiotherapy (RT) and chemotherapy together:
combination therapy is superior to either treatment alone. (3)
Despite RTOG 9802 demonstrating a clear survival benefit with
the use of RT with PCV for DA, TMZ and RT remain a popular
alternative due to its ease of use and better toxicity profile. (4)
Current data is derived from the pre-molecular era. The selection
of treatment should be done on a case-by-case basis, and represent
a balance between the patient’s goals, preferences, symptoms,
risk of malignant transformation, and treatment-related toxici-
ties (Fig. 2.1).
Timing of RT: For low risk patients, an initial watch and wait,
or observe only, approach is reasonable. This is supported by the
results of EORTC 22845, where low risk DA patients age < 40
with GTR were randomized to receive RT immediately after
resection or at progression after watchful waiting; median overall
survival (OS) was equivalent between the groups [8]. During the
observation only period, patients should be followed with serial
imaging, ideally with MRIs of the brain with and without con-
trast, every 3-6 months for the first 5 years, and gradually increase
imaging intervals after that.
RT Doses: Early prospective randomized studies comparing
lower doses (45–50.4 Gy) to higher doses (59.4–64 Gy) in
1.8–2 Gy daily fractions demonstrated no significant difference in
OS with less toxicity [7, 9]. Subsequent studies incorporated the
use of 54 Gy [10], a dose representing a compromise between
EORTC and RTOG data. As of current, typical doses range from
45 to 54 Gy based on these results.
RT-Related Toxicities: Acute side effects present during and

immediately after the completion of RT. These include fatigue, local
alopecia, skin irritation, and symptomatic perilesional edema. Fatigue
may persist for 3 months after completing RT, and hair growth typi-
cally resumes at 6 months. The timing of long-term neurocognitive
deficits is less certain. Data suggest neurocognitive impairment may
present >5 years after RT [11, 12]. Other long-term toxicities include
risk of vascular damage and secondary malignancies.
Chemotherapy & Chemoradiotherapy: The matured results of
RTOG 9802 demonstrate a clear median survival benefit of 5.5 years
for high risk DA patients when PCV was administered after standard
RT (RT/PCV), as compared to RT alone [13]. Despite these compel-
ling results, RT and TMZ remains more popular amongst practitio-
ners because of its better toxicity profile and presumption that
alkylating therapies have similar efficacies [14] concurrent. This can
be including concurrent and adjuvant TMZ or adjuvant TMZ alone.
Notably, TMZ monotherapy is not sufficient for treating IDH-
mutant DA patients: the initial results of EORTC 22033 showed
inferior PFS for patients treated with dose-dense TMZ versus
RT. Similarly, preliminary results from RTOG 0424 suggested RT
alone was not sufficient: high risk DA patients treated with RT/TMZ
and adjuvant TMZ had improved OS as compared to historical con-
trols treated with RT only [15]. Cumulatively, these studies suggest
combination therapy is superior to chemo or RT monotherapy.
The decision to treat with RT/PCV versus RT/TMZ is different
for different providers and patients; it is based on potential toxic-
ity for a patient while considering age, co-morbidities, concurrent
medications, and history of peripheral neuropathy.
As of the writing of this chapter, a phase 3 randomized trial
evaluating the efficacy of vorasidenib, on oral inhibitor or IDH1
and IDH2 enzymes, in patients with residual or recurrent grade 2
IDH-mutant tumors has been published [16]. The study focused
on patients who had not been previously treated with radiation or
chemotherapy and demonstrated an improvement in progression-
free survival and a delay to next therapeutic intervention. If
approved by the FDA, Vorasidenib will be one additional drug in
our arsenal and will be a particularly appealing option for patients
who may want to defer radiotherapy.
Chemotherapy Dosing and Symptom Management
MZ
T
1. Regimens:
(a) Concurrent: 75 mg/m2 oral daily concurrent with RT
(b) Adjuvant: 150 mg/m2–200 mg/m2* oral on days 1–5 (D1–
5) of a 28 day cycle for 12 cycles. If no or mild toxicity at
150, escalate to 200 for next cycle. (Table 2.1 describes
toxicities, monitoring and dose modifications for com-
monly used regimens)
2. Symptom management:
(a) Nausea: Ondansetron (or other 5-HT3 serotonin receptor
antagonist) on D1–42 (dose-dense) and D1–5 (adjuvant),
1 h before TMZ
(b) Constipation: Polyethylene glycol
(c) Drug rash: Combination of anti-H1 and anti-H2 histamine
receptor antagonists on D1–5; if severe, add
Methylprednisolone dose pack
(d) Consider Pneumocystis Jiroveci Prophylaxis in patients
with lymphopenia
PCV
This is typically initiated after RT. Cycle length is 42 days, with a
goal of 6 cycles. Note: Average cycle length was 3–4 in RTOG
9802 [13] due to dose-limiting toxicities and still effective in
terms of survival.
1. Regimen:
D1: CCNU 90–110 mg/m2 oral
D8 &D29: Vincristine 1.4 mg/m2 IV (round to nearest
0.1 mg, max 2 mg)
D8–21: Procarbazine 60 mg/m2/day oral (Available in
50 mg tabs which are given as combination of tabs over
14 days to average 60 mg/m2/day or as a compounded
medication)
2. Symptom management:
2
Table 2.1 Chemotherapies, toxicities, monitoring, and dose modifications

Regimen Considerations Side effects Monitoring toxicity Dose modificationsa, b
TMZ-dose • Food reduces Fatigue, Moderately emetogenic, • Weekly CBC w/ • ANC < 1.5, Plt < 100
Diffuse Astrocytoma
dense absorption NPO 1 h Constipation, Myelosuppression diff, CMP 25% dose reduction
TMZ- before and after (nadir D14–21), Allergic-like rash • D21 CBC w/ • ANC = 1.5–1.0,
adjuvant • Renally excreted (Hives), Liver toxicity, Renal toxicity, diff Plt = 100–75 & count
PCP Pneumoniac, Teratogenic, • D28 CBC w/ recovery <2 weeks stay
Carcinogenic, Gonadotoxic, diff, CMP at 150 mg/m2 daily
Infertility • ANC = 1.5–1.0,
Plt = 100–75 & count
recovery >2 weeks 25%
dose reduction
• ANC = <1.0, Plt = <75
25% dose reduction
(continued)
29
Table 2.1 (continued)
30

Procarbazine • Activated by liver Moderately emetogenic, • D28 CBC w/ • ANC = 1.5–1.0,
P450 Myelosuppression (nadir D28), diff Plt = 100–50 & count
• Weak MAO inhibitor Diarrhea, Flu-like symptoms, • D35 CBC w/ recovery <3 weeks
• Drug/Food Allergic-like rash (Hives), diff continue when normal
interactions Neurotoxic, Gonadotoxic, Infertility, • D42 CBC w/ • ANC = 1.5–1.0,
(Alcohol, Tyramine- Carcinogenic diff, CMP Plt = 100–50 & count
containing productd, • Neurological recovery >3 weeks 20%
Antihistamines, sensory exam dose reduction
Levodopa, TCAs) every clinical • ANC = <1.0, Plt = <50
CCNU aka • Food reduces Fatigue, Anorexia, Moderately visit 20% dose reduction
Lomustine absorption NPO 1 h emetogenic, Myelosuppression (nadir
before and after D28–42), Interstitial lung disease (if
>6 cycles), Impotence, Gonadotoxic,
Infertility, Renal toxicity
D. Molaie and P. (. Nghiemphu
2

Vincristine • Metabolized by liver Neurotoxic (Peripheral neuropathy, • New neuropathic
P450 Cranial nerve palsies), Jaw/parotid/ symptoms and/or exam
• Excreted in bile and bone/back pain, Constipation, change (areflexia,
feces Paralytic ileus, SiADH, pinprick and/or
Hypersensitivity reaction, Minimally vibration/
emetogenic, Gonadotoxic, Infertility proprioception) 50%
Diffuse Astrocytoma
dose reduction
• Progressive &/or severe
neuropathic symptoms
discontinue
CBC w/diff Complete blood count with differential, CMP Comprehensive metabolic panel, ANC Absolute neutrophil count, Plt Plate-
let, MAO Monoamine oxidase, TCA Tricyclic anti-depressant
a
Chemotherapies, TMZ, Procarbazine, & CCNU, should not be started until ANC > 1.5, Platelets >100
b
Lab values are based on the lowest count, regardless of day
c
Risk of PCP Pneumonia when TMZ concurrent with radiation, advise appropriate prophylaxis
d
Food rich in tyramine have commonly undergone fermenting and aging, and include cheese, sourdough, smoked/pickled/fermented
meats/fish, fava beans, soy sauce, etc.
31
(a) Nausea: Ondansetron (or other 5-HT3 serotonin receptor

antagonist) on D1 and D8–21, 1 h before CCNU and
Procarbazine respectively; if severe, add Aprepitant tri-
pack D1–3 (or other anti-NK1 receptor antagonist)
(b) Drug rash: Combination of anti-H1 and anti-H2 histamine
receptor antagonists on D8–21; if severe, add
Methylprednisolone dose pack
Fertility Preservation (FP)
Alkylating agents, such as TMZ, CCNU, and procarbazine can

impair fertility, and this risk is heightened with combination
regimens such as PCV. For patients interested in having chil-
dren, FP is recommended prior to initiation of chemotherapy.
Practitioners should refer interested patients to reproductive
endocrinologists. Several options exist including cryopreserv-
ing oocytes or embryos using donor sperm, and for males,
sperm banking. Additionally, patients should wait 6 months
after last treatment to eliminate chemotherapy toxicity prior to
trying to conceive.
Of note, as the risk of infertility is less for TMZ than PCV,
there are case reports of both men and women who had healthy
children following treatment with TMZ and RT [17].
Surveillance
An MRI brain with and without contrast should be obtained

within 2–4 weeks after completing RT and this should serve as
a baseline for response assessment [18]. Thereafter, imaging
should be coordinated with chemotherapy cycles, every
12 weeks. After completing treatment, patients should continue
to undergo imaging surveillance at every 3 months for 1–2 years,
with gradual lengthening to every 6 months after 5 years. New
or worsened neurologic and/ or epileptic symptoms warrant
earlier imaging.
Options for treatment at recurrence include: surgery, RT, chemo-

therapy, clinical trials, and off-label use of experimental therapies.
Repeat resection should be considered if it can be done safely. If
sufficient time has elapsed from prior RT or the patient is RT-
naïve, RT can also be performed. Chemotherapy options include a
re-challenge of the initial regimen if significant time has elapsed
since last treatment, or initiation of a new regimen if recurrence is
sooner. Note, these recommendations are derived from general
expert opinion as there are no prospective randomized studies
evaluating the efficacy and timing of chemotherapy re-challenge.
Other experimental options with no clear benefit include clinical
trial participation or off-label use of IDH inhibitors and immuno-
therapy.
Prognosis and Survivorship
The median OS and progression free survival for DA patients with

aggressive treatment is 7.8–13.3 and 4.0–10.4 years, respectively,
and depends on tumor biomarkers and treatment [13]. Prognostic
factors of poor survival and increased risk of malignant transfor-
mation include: age ≥ 40 years, preoperative tumor diameter of
≥5 cm, tumor involving corpus callosum and eloquent cortex,
incomplete resection, and preoperative neurologic functional def-
icits [6, 7, 19, 20].
Epilepsy, cognitive function, and QOL, are important aspects
of survivorship care. Epilepsy occurs in 75% of patients with
LGGs [21], and is more common in cortically-based tumors,
especially the mesotemporal and insular regions. EOR and post-
operative chemoradiotherapy are associated with increased sei-
zure control [22]. Seizures are typically well-controlled with
anti-epileptic therapy (AED), and their frequency reduces with
increased progression-free survival [23]. Once stable, tapering
AED can be considered. Weaning after a 2-year seizure free
period predicts a 15–40% risk of seizure recurrence [24, 25];
experts also recommend waiting a minimum of 1 year after last

treatment to ensure tumor stability.
Neurocognitive impairment is a common long-term side effect,
typically presenting >5 years after RT. [11, 12, 26] Patients may
experience a measurable decline in attention, memory, executive
function, language, and information processing speed. The degree
of impairment can be mild to severe, and contributing factors
include: tumor location/ size, surgical intervention, RT dose, che-
motherapy, tumor-related epilepsy, and potentially the tumor
itself. Imaging may demonstrate increased white matter changes.
Attention and memory are commonly impacted; the latter is more
frequently impaired when a tumor involves the temporal lobe
[27], and the hippocampus, corpus callosum, and fornix are in the
RT field. The use of stimulants may modestly improve cognitive
function [28].
QOL is also an important factor in patient survivorship. In a
prospective case-control study for LGG patients with stable tumor
for 12 years, 38.5% experienced decline in health-related QOL,
and had worse physical role functioning and physical QOL at 6
and 12 years respectively when compared to matched healthy
controls [23]. Extrapolating from long-term QOL data of 27 sur-
vivors with stable anaplastic oligodendroglioma treated with RT
or RT/PCV, 30% had severe cognitive impairment while 26% did
not, 81% lived independently, and 41% were employed [29].
Note, interpretation of long-term data is inherently limited due to
the attrition of patients with a longer survival. Other important
aspects of survivorship care include management of anxiety,
depression, sleep-wake disturbances, and neurologic deficits such
as weakness, neuropathic sensory disturbance, and gait instability.
Patient Information
What type of tumor do I have? A diffuse astrocytoma is an

uncommon primary brain tumor arising from the brain’s support-
ive cells. They grow slowly and have a risk of malignant transfor-
mation. Astrocytomas are commonly located in the cortex, or
outer layer of the brain. Growth or progression outside of the
brain is extremely rare.
How do I treat it? The management of an astrocytoma may

include a combination of regular imaging, surgical resection, RT,
chemotherapy, and clinical trial participation. Timing and type of
intervention needs to be assessed via a case-by-case basis, consid-
ering a patient’s age, symptoms, molecular markers, and their
goals and preferences.
What can I expect to experience during treatment and
how will we monitor my disease? Chemoradiotherapy most
commonly causes fatigue, nausea, constipation, improved sei-
zure control, and reduced white blood cells and platelets. Side
effects are typically well-managed with supportive medica-
tions and patients need to be monitored with regular blood
tests and MRIs to monitor toxicity and treatment response,
respectively.
What is my prognosis? With treatment, survival for patients
with astrocytoma can range from 5 years to at least 15 years. This
depends on: age, neurologic symptoms, tumor size and location,
molecular markers, and type of treatment. To date, patients
age < 40, with normal neurologic function, and pre-operative
tumor <5 cm not involving the midline, who have undergone
maximal safe resection followed by postoperative chemoradio-
therapy have better survival. Note, these cut-offs are relative and
each factor exists on its own continuum, therefore, patients should
be counseled on case-by-case basis by specialized practitioners.
References
1. Kyritsis AP, Bondy ML, Rao JS, Sioka C. Inherited predisposition to
glioma. Neuro Oncol. 2010;12:104–13.
2. Louis DN, et al. The 2016 World Health Organization classification of
tumors of the central nervous system: a summary. Acta Neuropathol.
2016;131:803–20.
3. Baumert BG, et al. Temozolomide chemotherapy versus radiotherapy in
high-risk low-grade glioma: a randomized phase III Intergroup study by
EORTC/NCIC-CTG/TROG/MRC-CTU (EORTC 22033-26033). Lancet
Oncol. 2016;17:1521–32.
4. Hasselblatt M, et al. Diffuse astrocytoma, IDH-wildtype: a dissolving
diagnosis. J Neuropathol Exp Neurol. 2018;77:422–5.
5. Tesileanu CMS, et al. Survival of diffuse astrocytic glioma, IDH1/2-

wildtype, with molecular features of glioblastoma, WHO grade IV: a con-
firmation of the cIMPACT-NOW criteria. Neuro Oncol. 2019;22:515–23.
6. Pignatti BF, et al. Cerebral low-grade glioma. 2020;20:2076–2084.
7. Karim ABMF, et al. A randomized trial on dose-response in radiation
therapy of low-grade cerebral glioma: European Organization for
Research and Treatment of Cancer (EORTC) study 22844. Int J Radiat
Oncol Biol Phys. 1996;36:549–56.
8. Van Den Bent MJ, Witte D, Hassel MB. Long-term efficacy of early ver-
sus delayed radiotherapy for low-grade. Lancet. 2005;366:985–90.
9. Shaw E, et al. Prospective randomized trial of low-versus high-dose radi-
ation therapy in adults with supratentorial low-grade glioma: initial report
of a North Central Cancer Treatment Group/Radiation Therapy Oncology
Group/Eastern Cooperative Oncology Group Study. J Clin Oncol.
2002;20:2267–76.
10. Karim ABMF, et al. Randomized trial on the efficacy of radiotherapy for
cerebral low-grade glioma in the adult: European Organization for
Research and Treatment of Cancer Study 22845 with the Medical
Research Council study BRO4: an interim analysis. Int J Radiat Oncol
Biol Phys. 2002;52:316–24.
11. Laack NN, et al. Cognitive function after radiotherapy for supratentorial
low-grade glioma: a North Central Cancer Treatment Group prospective
study. Int J Radiat Oncol Biol Phys. 2005;63:1175–83.
12. Douw L, et al. Cognitive and radiological effects of radiotherapy in
patients with low-grade glioma: long-term follow-up. Lancet Neurol.
2009;8:810–8.
13. Buckner JC, Shaw EG, Pugh SL, et al. Radiation plus Procarbazine,
CCNU, and Vincristine in low- grade glioma. N Engl J Med.
2016;374:1344–55. https://doi.org/10.1016/j.physbeh.2017.03.040.
14. Darlix A, et al. Chemotherapy and diffuse low-grade gliomas: a survey
within the European Low-Grade Glioma Network. Neurooncol Pract.
2019;6:264–73.
15. Fisher BJ, Hu C, Macdonald DR, et al. Phase 2 study of Temozolomide-
based chemoradiation therapy for high-risk low-grade gliomas: prelimi-
nary results of radiation therapy oncology group 0424. Int J Radiat Oncol
Biol Phys. 2015;91:497–504. https://doi.org/10.1038/jid.2014.371.
16. Mellinghoff IK, van den Bent MJ, Blumenthal DT, et al. Vorasidenib in
IDH1- or IDH2-mutant low grade glioma. N Engl J Med. 2023;389:589–
601.
17. Strowd RE, et al. Impact of temozolomide on gonadal function in patients
with primary malignant brain tumors. J Oncol Pharm Pract. 2013;19:321–
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response assessment in glioblastoma clinical trials. Neurotherapeutics.
2017;14:307–20.
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therapy for low-grade astrocytoma and oligodendroglioma in adults: the
EORTC 22845 randomised trial. Lancet. 2005;366:985–90.
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spheric low-grade gliomas in adults: clinical article. J Neurosurg.
2008;109:817–24.
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history, pathogenesis, and outcome after treatments. Neuro Oncol.
2012;14 Suppl 4(Suppl 4):iv55–64.
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Oligodendroglioma
3
Oluwatosin Akintola
The Clinical Scenario
A healthy 75-year-old male was brought into the hospital after a

transient episode of confusion during which he was unable to shift
gears in a rental car. His confusion lasted several minutes and
required his spouse to take over driving. He had a fall with loss of
consciousness and rhythmic right lower extremity shaking one
month prior. He also noted forgetfulness and word finding diffi-
culty over the past year. He initially underwent stroke work up
with a CT/CT Angiogram head and neck. The scans showed left
parieto-occipital edema concerning for an underlying mass lesion.
MRI Brain confirmed presence of a large, infiltrative, multi region
mass involving the parietal, temporal and occipital lobe. This
tumor did not demonstrate any enhancement. Neurosurgical con-
sultation was obtained, and a biopsy was performed. Pathology
showed Oligodendroglioma, IDH-mutant, 1p19q-codeleted, CNS
WHO grade 2. Functional MRI showed involvement of the mass
within areas of motor activity in the precentral gyrus and diffusion
tractography showed the corticospinal tract located within the
O. Akintola (*)
Department of Neurological Sciences, University of Vermont, Larner
College of Medicine, Burlington, VT, USA
e-mail: Oluwatosin.akintola@uvmhealth.org

Switzerland AG 2023
https://doi.org/10.1007/978-3-031-41413-8_3
40 O. Akintola
anterior aspect of the mass. The case was reviewed by the multi-
disciplinary brain tumor board. Shared decision making was initi-
ated with the patient. The patient proceeded with radiotherapy and
chemotherapy, given the risk of debilitating neurological deficits
if a resection of the mass was attempted.
The approach to patients with a brain tumor includes the history,

examination and neuroimaging. Oligodendrogliomas are most
often situated in the frontal and temporal lobes. Patients may pres-
ent with cognitive impairment, aphasia, behavioral changes, and
seizures. The symptoms at presentation are often related to the
anatomic location of the tumor. Brain magnetic resonance imag-
ing (MRI) with contrast is the preferred imaging modality.
Oligodendrogliomas are diffusely infiltrating tumors with expans-
ile changes noted in the white matter and cerebral cortex. Low
grade oligodendrogliomas (grade 2) are less likely to demonstrate
enhancement on MRI scans. Accurate diagnosis requires tissue
sampling for histopathologic and molecular genetic testing.
Stereotactic biopsy or maximally safe resection should be offered
to patients depending on the location of these tumors. The local-
ization of eloquent areas on functional MRI (fMRI) is useful for
patients suffering from tumors involving brain regions important
for language, motor, sensory, and visual processing. MRI diffu-
sion tensor imaging (DTI) sequences and tractography are impor-
tant tools for surgical decision making and surgical planning.
The Role of Surgery
Gross total resection is the preferred treatment if tumor location,

eloquence, comorbidities, and functional status considerations
favor this approach. Biopsies and partial resections are often
offered based on unfavorable patient or tumor characteristics
(advanced age, deep location of tumor, multi-region involvement
3 Oligodendroglioma 41
of tumor, significant neurological deficits, comorbidities contrib-

uting to high operative risk). A post operative MRI brain scan is
required 24–48 hours following resection for baseline monitoring,
treatment planning and detection of progression. Management
with radiotherapy and chemotherapy is often required following
surgery. After surgery, surveillance is a reasonable approach for
patients with grade 2 Oligodendrogliomas who have had a gross
total resection and are younger than 40 years old. MRI head scans
are typically obtained every 3–6 months for 5 years, every
6 months indefinitely, or as clinically indicated.
Integrated Histopathologic-Molecular Diagnosis
Oligodendrogliomas are classified as grade 2 or grade 3 CNS

tumors only [1]. Grade 2 Oligodendrogliomas are often diagnosed
in younger adults aged 25–45 years old and only occasionally
diagnosed in people older than age 60 [2]. Following surgical
sampling via biopsy or resection, a histopathologic diagnosis of
infiltrating glioma is made. The classic pathological features of
oligodendrogliomas are sheet-like isomorphic round nuclei sur-
rounded by clear cytoplasm (“fried egg” appearance) with a deli-
cate network of branching capillaries (“chicken wire” appearance).
However, IDH mutation and loss of both chromosomal arms 1p
and 19q are required to make a diagnosis of oligodendroglioma
[1], regardless of histological features.
The IDH mutation status may be determined using immuno-
histochemistry staining and/or gene sequencing. Fluorescence in
situ hybridization (FISH) is often performed to assess loss of 1p
and 19q [3]. However, next generation sequencing is more accu-
rate in detecting whole-arm 1p/19q codeletion. While the desig-
nation of oligodendroglioma is molecularly defined, grade 2 or
grade 3 designations are dependent on histological features.
Grade 3 oligodendrogliomas (previously known as anaplastic oli-
godendrogliomas) are characterized by hyper cellularity, pleo-
morphism, elevated mitotic activity, and microvascular
proliferation [1]. Oligodendrogliomas without these features are
42 O. Akintola
classified as Grade 2 tumors. Homozygous deletion of CDKN2A/B

occurs in less than 10% of oligodendrogliomas and is associated
with reduced survival [4]. While CDKN2A/B deletion may sug-
gest a higher-grade tumor, this finding is not required to designate
grade 3 oligodendrogliomas.
Radiation
Involved field radiation therapy is often required following

surgery. The goal of radiotherapy is to delay tumor recurrence
while minimizing neurotoxicity. Radiotherapy should be
offered within 3–6 weeks after surgery [5]. Nearly all patients
with Grade 3 oligodendrogliomas should receive radiotherapy
regardless of extent of resection [6]. Patients with grade 2 oli-
godendrogliomas with gross total resection of their tumors
who are younger than age 40 may delay radiation in favor of
radiologic and clinical observation, until evidence of recur-
rence [6]. High-risk profile patients (age > 40, subtotal resec-
tion or biopsy) with grade 2 tumors should proceed with
radiation. Observing patients with grade 2 oligodendrogliomas
and high-risk profile (age > 40, subtotal resection) may be rea-
sonable in select cases. However, this approach should only be
applied after careful consideration with the patient [7]. Clinical
trials may be offered to patients with either grade 2 or 3 tumors
if the patient is eligible. Radiotherapy doses of 54 Gy in frac-
tions of 1.8 Gy are often administered to grade 2 oligodendro-
gliomas and other low-grade gliomas [8]. Grade 3
oligodendrogliomas receive 59.4 Gy in fractions of 1.8 Gy [9].
The target volume includes a 1–2 cm margin around the gross
tumor volume as defined on fluid attenuated magnetic reso-
nance imaging (MRI) to account for microscopic infiltration of
the tumor [10].
Chemotherapy
Radiotherapy is often followed by chemotherapy. However, che-

motherapy may also precede radiotherapy. Two large phase III
trials showed that the receiving procarbazine, lomustine (aka
CCNU), and vincristine (PCV), either prior to or after radio-
therapy, nearly doubled the overall survival compared with radi-
ation alone [9, 11]. Chemotherapy should begin 4–6 weeks after
radiotherapy. The PCV regimen or temozolomide are both rea-
sonable options for adjunctive therapy after completion of radio-
therapy in patients with oligodendrogliomas. The PCV regimen
is detailed in a table below. There is no consensus on the supe-
rior choice between PCV and temozolomide at this time [6].
Choice of chemotherapy in patients with oligodendrogliomas
often depends on the age, functional status and physiologic
reserve to tolerate chemotherapy. Temozolomide is generally
better tolerated with PCV being associated with increased toxic-
ity—myelosuppression (lomustine), pulmonary fibrosis (lomus-
tine), drug-drug and drug-food interactions (procarbazine), and
peripheral neuropathy (vinctrisine) [7]. Temozolomide is aas-
sociated with myelosuppression to a lesser extent than lomus-
tine. Both regimens require regular laboratory work up with
complete blood count (CBC) with differential, serum creatinine,
alanine aminotransferase (ALT), aspartate aminotransferase
(AST), and total bilirubin. Temozolomide, lomustine and pro-
carbazine are emetic. Patients receive premedication with an
orally administered anti-emetic (usually ondansetron 8 mg or
granisetron 1 mg) before each dose.
Surveillance
Neuroimaging with Brain MRIs is the method of choice for sur-

veillance in patients with oligodendroglioma. Imaging intervals
depend on the grade of the tumor and extent of resection.
44 O. Akintola
• Grade 2 Oligodendroglioma with gross total resection—Brain

MRI every 3–6 months for 3–5 years, and then every 6 months
indefinitely, or more frequently as clinically indicated. It is
unclear how long annual scans should continue.
• Grade 3 Oligodendroglioma—Brain MRI 4–6 weeks after com-

pleting radiation therapy for post radiation baseline evaluation.
Monitoring proceeds with brain MRI every 2–3 months for
3 years, then every 3–6 months indefinitely [12].
Treatment at Recurrence (Regimens with Dosing)
Treatment after failure of first line chemotherapy is determined by

the initial drug of choice. Therefore, temozolomide is a reason-
able option for patients with recurrence on the PCV regimen and
vice versa [6]. Bevacizumab (an anti-vascular endothelial growth
factor monoclonal antibody) is an option for patients with symp-
tomatically recurrent disease. The role of bevacizumab is limited
to serving as an alternative to glucocorticoids for management of
symptomatic cerebral edema [7]. Other cytotoxic chemotherapies
with penetration of the blood-brain barrier include paclitaxel, eto-
poside plus cisplatin, and carboplatin. However, response rates to
these agents have been discouraging with most patients progress-
ing within 12 months. As oligodendrogliomas are IDH mutant,
clinical trials targeting IDH inhibitors may be offered. Other tar-
geted therapies include PARP inhibitors, CDK4/6 inhibitors [13].
These therapies are generally experimental.
Prognosis
Although patients with oligodendrogliomas survive for several

years, nearly all patients eventually succumb to their tumor.
The overall median survival for low grade oligodendroglioma is
reported as 15–20 years [14, 15]. Survival may exceed this
range for patients with a gross total resection and with an excel-
lent functional status without high-risk features in their tumors.
The historical survival for patients with histologically diag-

nosed anaplastic oligodendroglioma was approximately
5–7 years [16]. However, when isolated for truly 1p19q code-
leted tumors, survival trends suggest 10–14 years [9, 11].
Survival trends are based on studies using histological grade.
Recent studies show that median overall survival for molecu-
larly defined 1p/19 co-deleted oligodendrogliomas is often not
reached, suggesting more prolonged survival than initially
thought. Updated survival data is needed in the context of the
new classification of adult gliomas. Factors that predict worse
survival include older age, poor functional status at diagnosis,
subtotal resection or biopsy and large tumor size greater than
5 cm. Like most gliomas, oligodendrogliomas have profound
effects on cognitive functioning. Many patients demonstrate
impaired memory and report significant difficulty with execu-
tive function at the time of diagnosis and throughout their
course of treatment. with biological evidence of progressive
gray matter and white matter damage. Neurocognitive impair-
ment is often a combined effect of the tumor and neurotoxicity
of treatment with radiotherapy and/or chemotherapy [14].
About 80% of patients with oligodendrogliomas will develop
seizures in their lifetime. They are more vulnerable to the
adverse effects of anti-epileptics and are more likely to report
adverse effects such as fatigue, mood changes and cognitive
slowing on these medications [17].
According to guidelines, patients with oligodendrogliomas

should be considered for clinical trials at each stage of the dis-
ease course [12]. Eligibility is determined by the patient’s func-
tional status, tumor location and pathology/molecular genetic
profile of the tumor. In practice, most patients are offered clinical
trials at the time of recurrence due to the efficacy of first line
treatment. The CODEL clinical trial is expected to compare
radiotherapy plus PCV versus radiotherapy plus temozolomide
[18]. The trial aims to help address lingering questions about the
first line chemotherapy regimen of choice (Fig. 3.1 and Table 3.1).
46 O. Akintola
Symptoms and signs suggestive of a brain tumor
Urgent gadolinium contrast enhanced MRI of the Head (CT

head with contrast if MRI contraindicated)
Brain surgery for maximally section and pathology review of

resected tumor.
WHO Grade 2, 1p19q co-deleted, IDH WHO Grade 3, 1p19q co-deleted, IDH
Mutant Mutant
Gross total resection/Near Subtotal resection/Biopsy Any extent of resection

Gross total resection. Age
<40. No neurological deficits.
• Radiotherapy 54-60Gy
Shared decision making. Proceed to - • Adjuvant PCV x 6 cycles
• Surveillance MRI Head every 3-
6 months for 3-5 years. Expand OR
to 6-12 months if no recurrence.
• Adjuvant temozolomide x 6-12 cycles
OR
• Radiotherapy followed by PCV
Surveillance MRI Head every 3-6

months.
Fig. 3.1 Treatment flowchart. Treatment of newly diagnosed IDH-mutant,

1p/19q-codeleted oligodendroglioma (grade 2 and 3) in adults
Table 3.1 Chemotherapy regimens

Days
Dose/Route of administered
Chemotherapy administration (42-day cycle)
Lomustine 110 mg/m2 orally Day 1
Procarbazine 60 mg/m2 orally Days 8–21
Vincristine 1.4 mg/m2 Day 8 and day
intravenously 20
(maximum 2 mg
per dose)
The PCV regimen is administered in 6- to 8-week cycles for a total of six
cycles. Weekly CBC and CMP are obtained to monitor hematological and
hepatic toxicity. Supportive Care: Ondansetron 8–16 mg orally (PO), given
30 min before lomustine on day 1. Dose modifications are made on
subsequent cycles based on renal, hepatic and hematologic toxicities

Days
Dose/Route of administered
Chemotherapy administration (28-day cycle)
Temozolomide (C1) 150 mg/m2 Day 1–5
orally
Temozolomide (C2–C6) 200 mg/m2 Day 1–5
orally
Temzolomide is administered 4 week cycles for a total of six cycles. Day
21 and day 28 CBC and CMP are obtained to monitor hematological and
hepatic toxicity. Supportive Care: Ondansetron 8–16 mg orally (PO), given
30 min before lomustine on day 1. Dose modifications are made on
subsequent cycles based on renal, hepatic and hematologic toxicities
Patient Information
• Oligodendrogliomas are a rare type of brain tumor arising

from oligodendrocytes within brain tissue. They commonly
occur in young adults.
• Oligodendrogliomas are generally initially suspected on MRI
head scans. Pathology review after surgery is required to con-
firm diagnosis and grade.
• Oligodendrogliomas can be low grade (Grade 2—slower grow-
ing) or high grade (Grade 3—faster growing)
• Surgery is the first level of treatment. The goal is removal of as
much tumor as possible without compromising the patient’s
function. Oligodendrogliomas infiltrate brain tissue, therefore
they are often difficult to remove completely.
• Surgery is often followed by radiation therapy. Radiation ther-
apy is followed by chemotherapy. The order of treatment and
the ability to complete treatment may vary by patient.
• MRI Head scans are obtained at least every 3 months to moni-
tor oligodendrogliomas. If your brain tumor has not grown for
many years, your physician may discuss expanding monitoring
intervals with you.
• Clinical trials with experimental therapies may be on offer at
the time of diagnosis and should be considered particularly at
the time of recurrence.
48 O. Akintola
References
1. Louis DN, et al. The 2021 WHO classification of tumors of the central
nervous system: a summary. Neuro Oncol. 2021;23(8):1231–51.
2. Morshed RA, et al. Molecular features and clinical outcomes in surgi-
cally treated low-grade diffuse gliomas in patients over the age of 60. J
Neurooncol. 2019;141(2):383–91.
3. Pinkham MB, et al. FISHing tips: what every clinician should know about
1p19q analysis in gliomas using fluorescence in situ hybridisation. Clin
Oncol (R Coll Radiol). 2015;27(8):445–53.
4. Appay R, et al. CDKN2A homozygous deletion is a strong adverse prog-
nosis factor in diffuse malignant IDH-mutant gliomas. Neuro Oncol.
2019;21(12):1519–28.
5. Press RH, et al. Optimal timing of chemoradiotherapy after surgical
resection of glioblastoma: stratification by validated prognostic classifi-
cation. Cancer. 2020;126(14):3255–64.
6. Mohile NA, et al. Therapy for diffuse astrocytic and oligodendroglial
tumors in adults: ASCO-SNO guideline. J Clin Oncol. 2022;40(4):403–
26.
7. Weller M, et al. EANO guidelines on the diagnosis and treatment of dif-
fuse gliomas of adulthood. Nat Rev Clin Oncol. 2021;18(3):170–86.
8. Shaw EG, et al. Randomized trial of radiation therapy plus procarbazine,
lomustine, and vincristine chemotherapy for supratentorial adult low-
grade glioma: initial results of RTOG 9802. J Clin Oncol.
2012;30(25):3065–70.
9. van den Bent MJ, et al. Adjuvant procarbazine, lomustine, and vincristine
chemotherapy in newly diagnosed anaplastic oligodendroglioma: long-
term follow-up of EORTC brain tumor group study 26951. J Clin Oncol.
2013;31(3):344–50.
10. Niyazi M, et al. ESTRO-ACROP guideline “target delineation of glio-
blastomas”. Radiother Oncol. 2016;118(1):35–42.
11. Cairncross G, et al. Phase III trial of chemoradiotherapy for anaplastic
oligodendroglioma: long-term results of RTOG 9402. J Clin Oncol.
2013;31(3):337–43.
12. Nabors LB, et al. NCCN guidelines insights: central nervous system can-
cers, version 1.2017. J Natl Compr Cancer Netw. 2017;15(11):1331–45.
13. Miller JJ. Targeting IDH-mutant glioma. Neurotherapeutics.
2022;19:1724–32.
14. Olson JD, Riedel E, DeAngelis LM. Long-term outcome of low-grade
oligodendroglioma and mixed glioma. Neurology. 2000;54(7):1442–8.
15. Iwadate Y, et al. Eighty percent survival rate at 15 years for 1p/19q co-
deleted oligodendroglioma treated with upfront chemotherapy irrespec-
tive of tumor grade. J Neurooncol. 2019;141(1):205–11.
16. Ostrom QT, et al. CBTRUS statistical report: primary brain and other
central nervous system tumors diagnosed in the United States in 2010-
2014. Neuro Oncol. 2017;19(suppl_5):v1–v88.
17. Kerkhof M, et al. Seizures in oligodendroglial tumors. CNS Oncol.
2015;4(5):347–56.
18. Jaeckle KA, et al. CODEL: phase III study of RT, RT + TMZ, or TMZ for
newly diagnosed 1p/19q codeleted oligodendroglioma. Analysis from the
initial study design. Neuro Oncol. 2021;23(3):457–67.
BRAF-Mutated Glioma
4
Karisa C. Schreck
and Jean M. Mulcahy Levy
A 21-year-old young woman presented to the emergency room for

evaluation of persistent vomiting and difficulty walking in a
straight line. An MRI of the brain was obtained and showed a
large right partially solid and partially cystic temporal mass
(Fig. 4.1). The patient underwent a gross total resection and was
diagnosed with an epithelioid glioblastoma. She received stan-
dard of care therapy with daily temozolomide and focal radiation
for 6 weeks followed by six cycles of temozolomide for five out
of every 28 days. Unfortunately, she rapidly relapsed and under-
went a second resection with an expanded genetic analysis of her
tumor. At relapse, a BRAF V600E mutation was identified and
she was started on a BRAF V600E inhibitor (vemurafenib) with
good disease control for approximately 2 years.
K. C. Schreck (*)
Johns Hopkins University, Baltimore, MD, USA
e-mail: Ksolt1@jhmi.edu
J. M. Mulcahy Levy
Children’s Hospital Colorado and University of Colorado Anschutz,
Aurora, CO, USA

Switzerland AG 2023
https://doi.org/10.1007/978-3-031-41413-8_4
52 K. C. Schreck and J. M. Mulcahy Levy
Fig. 4.1 T1-post gadolinium MRI images from a patient with a BRAF
V600E-mutated epithelioid glioblastoma showing a large solid/cystic enhanc-
ing mass of the right temporal region
BRAF Mutations
BRAF is a serine/threonine kinase in the ERK signaling pathway

that dimerizes upon activation and phosphorylates downstream
MEK1 or MEK2, leading to ERK pathway activity and cellular
proliferation and growth. Alterations in BRAF fall into two cate-
gories: single nucleotide variants (SNVs) and rearrangements.
The most common SNV is the point mutation c.1799T>A, lead-
ing to an amino acid substitution of glutamate for valine (BRAF
p.V600E) [1]. The V600E point mutation confers constitutive
activity to BRAF and allows it to signal as a monomer, thereby
dramatically upregulating intracellular ERK signaling. BRAF
V600E and other point mutations are identified on CLIA-
approved next generation sequencing (NGS) solid tumor panels.
BRAF V600E can also be identified by a CLIA-approved immu-
nohistochemistry stain in some laboratories, though the false
negative rate for this test can be high [2]. Rearrangements occur
when BRAF signaling is aberrantly activated through fusions
4 BRAF-Mutated Glioma 53
with another protein. These fusions generally remove the regula-

tory domain from BRAF and replacing it with another protein’s
nterminus, while leaving the kinase domain intact. The most
common BRAF-fusion is with KIAA at different breakpoints
including the most common fusion of KIAA1549-BRAF 16;9.
BRAF-fusions are frequently not detected on DNA-based next
generation sequencing and require specific probes or RNA-based
methods (such as fluorescence in situ hybridization or NanoString
sequencing) for identification [1].
BRAF-Mutation Frequency by Tumor Type
BRAF mutations have been identified in most primary brain

tumor types [3–5]. The frequency of BRAF mutations varies
widely between tumor types and between pediatric and adult
cases of the same histologic diagnosis (see Table 4.1). Pediatric
low grade astrocytoma, in particular, are very likely to have
mutations in the MAPK signaling pathway, of which the major-
ity are in BRAF [6].
Providers should consider sending NGS to evaluate for BRAF
SNVs or fusions in tumors that have a high likelihood of contain-
ing BRAF alterations [7]. As NGS becomes less expensive and
more widely-available, all high grade brain tumors, even those
from older adults, should be evaluated for the presence of a BRAF
mutation given its treatment implications.
Table 4.1 BRAF mutation frequency by tumor type. (Modified with permis-
sion of the authors from Ref. [3])
Tumor type BRAF-SNV (%) BRAF-fusion (%)
Pilocytic astrocytoma 10 60–70
Pediatric low grade astrocytoma 25–35 13
Pediatric high grade astrocytoma 10–20 <1
Adult low grade astrocytoma 5–15 5
Adult high grade astrocytoma 3 <1
Pleomorphic Xanthoastrocytoma 70–80 <1
Ganglioglioma 50 12
Papillary Craniopharyngioma 95 <1
Low Grade Glioma
Standard therapy in adults and children with low grade glioma

(LGG) is variable and ranges from observation alone to treatment
with radiation and chemotherapy, depending on tumor type and
patient risk factors. In adult LGG, molecular features such as
IDH1/2 mutations and 1p/19q codeletion are associated with a
more indolent clinical course. BRAF mutations in LGG rarely
occur alongside IDH1/2 mutations, but retrospective data sug-
gests the natural history of BRAF V600E-mutated LGG is better
than that of other IDH wild-type diffuse astrocytoma and may be
similar to IDH-mutated LGG [8]. In pediatric patients, a BRAF
V600E mutation is associated with intermediate or high-risk dis-
ease and concurrent loss of CDKN2A conveys higher risk [6, 9].
Alternatively, the presence of BRAF fusions is typically associ-
ated with improved clinical outcomes [6, 10]. In adult patients,
the clinical course is less predictable [3].
The integration of BRAF and MEK inhibitors (BRAFi and
MEKi, respectively) into the treatment of LGG is an emerging
area. As described above, BRAF V600E mutations and fusions
are both common in LGG. Current successful targeted therapy is
specifically directed against glioma with BRAF V600E muta-
tions. There have been case reports documenting successful treat-
ment in patients of all ages, as well as two arms on larger basket
trials for adults [11–16]. Vemurafenib monotherapy in adults with
BRAF V600E-mutated PXA resulted in a response rate of 43% (3
of 7 participants) in one arm of a basket study [12]. Dabrafenib
combined with trametinib in adults with WHO grade I or II
BRAF-mutated glioma (n = 13) resulted in a response rate of 69%
(9 of 13 participants), with median progression free survival of
2 years places [2].
In pediatric patients, BRAF-targeted therapy has been effica-
cious in a range of tumor types [4, 5, 17]. Following the publica-
tion of the first response of a pediatric patient to BRAF inhibition,
additional case studies and clinical trials have shown that response
in pediatric CNS tumors is independent of pathologic diagnosis or
grade [14, 18–21]. In response to dabrafenib monotherapy, pedi-

atric patients with LGG have a response rate of 71%, with a dis-
ease control rate (defined as stable disease or better for at least
6 months) of 88% [22, 23].
For adult and pediatric patients with BRAF V600E-mutated
ganglioglioma, pleomorphic xanthoastrocytoma, or pilocytic
astrocytoma, using BRAFi/MEKi as first-line therapy is reason-
able, although additional clinical trials are needed to fully define
this approach in pediatric patients [24]. In diffuse astrocytoma
(WHO grade 2) the data are less clear, as only two patients were
included in the dabrafenib/trametinib basket study described
above. The conventional approach to patients with BRAF V600E-
mutated diffuse astrocytoma has been to treat first with conven-
tional radiation/chemotherapy and then use targeted therapy at the
time of progression. Given the risk of long-term adverse events
secondary to radiation in patients with diffuse astrocytoma, some
providers and patients are turning to BRAFi/MEKi as first-line
therapy and converting to conventional treatment modalities
should the tumor fail to respond or progress on targeted therapy.
The risk of toxicity associated with BRAFi/MEKi therapy is high,
however, and treatment duration is at least 2 years in patients who
are long-term responders. Long-term, twice-daily treatment may
not be an acceptable quality-of-life to some patients. These com-
peting factors, along with the potentially large financial burden of
targeted therapy, should be considered when deciding when to
initiate targeted therapy.
High-Grade Glioma
Standard first-line therapy for adults with BRAF-mutated high-

grade glioma (HGG) is the same as for non-BRAF-mutated
HGG. This is generally radiation with concomitant temozolomide
followed by adjuvant temozolomide for glioblastoma, unless a
clinical trial is available [25]. In pediatric patients, concurrent
radiotherapy with temozolomide followed by temozolomide and
lomustine has shown promise, although incorporation of up-front
targeted therapy is currently being investigated in pediatric high
grade glioma. The overall survival of patients with BRAF-mutated

glioblastoma may be better than BRAF-wild type glioblastoma
due to the availability of targeted therapy for both young and older
adults, but still necessitates aggressive treatment at the time of
diagnosis [3, 26].
BRAF and MEK inhibitors have efficacy in a subset of
HGG. While case reports have described examples of dramatic
responses to BRAFi/MEKi in treatment-refractory HGG, there
are also reports of non-responders [27, 28]. Sensitivity to targeted
therapy in BRAF V600E-mutated HGG appears lower than in
LGG: the response rate to vemurafenib monotherapy was only
9% (1 of 11 patients), but a clinical benefit (defined as stable dis-
ease for at least 6 months) was observed in 27% of high-grade
glioma [9]. The response rate to dabrafenib/trametinib combina-
tion therapy was better, with a 33% response rate in adults (15 of
45 patients), with a larger subset of patients experiencing a clini-
cal benefit [2]. Both trials primarily enrolled patients who had
already received standard treatment for HGG.
The optimal time to initiate BRAF-targeted therapy is unknown
given the lack of robust efficacy data and the potential toxicity, in
both adult and pediatric patients. The majority of published cases
are patients who have progressed following radiation, and in some
cases have failed multiple lines of therapy. Notably, the toxicities
of BRAFi and MEKi are generally non-overlapping with standard
treatments for HGG. Some patients who respond to BRAFi/MEKi
experience a dramatic clinical improvement as their tumor shrinks
in response to therapy, so it is reasonable to consider a trial of
BRAF-targeted therapy even in patients with a relatively poor
functional status.
Targeted Therapy Regimens and Dosing
The dosing regimens of BRAF-targeted therapy used in adult

glioma are currently the FDA-approved doses. For patients with
BRAF V600E-mutated glioma, BRAFi/MEKi combination ther-
apy is recommended over monotherapy for two reasons: (1)
improved tolerability, (2) increased time to resistance as indicated

in melanoma clinical trials [29, 30].
The combination regimens most commonly used for primary
brain tumors, along with standard dose-reductions are listed in
Table 4.2. Dabrafenib/trametinib should be taken on an empty
stomach. Encorafenib/binimetinib can be taken with or without
food.
Surveillance While on Treatment
BRAFi/MEKi combination therapy is associated with a low risk

of several potentially serious toxicities, necessitating careful
anticipatory guidance and surveillance. The patterns of toxicity
are predictable. Most are class effects, for which all BRAF and/or
MEK inhibitors put the patient at risk, though the incidence of
some toxicities varies between drugs. Surveillance for the follow-
ing potential toxicities of BRAF-targeted therapy is as follows:
1. Cardiomyopathy—Left ventricular function should be

assessed before starting therapy with a BRAFi, after one
month of therapy, and every 2–3 months thereafter.
2. Hyperglycemia—Serum glucose levels should be monitored
in patients with pre-existing diabetes or hyperglycemia who
are taking dabrafenib and trametinib.
3. Liver toxicity—Liver function tests should be monitored regu-
larly while on treatment, particularly with encorafenib and
binimetinib.
4. New primary malignancies—RAF-targeted therapy can pro-
mote the growth of pre-existing or new malignancies with
wild-type BRAF. Patients should be monitored with a full skin
exam at baseline and regularly while on therapy. Patients
should be counseled about the risk of new malignancies and
encouraged to self-monitor as well.
5. Rhabdomyolysis—Creatine phosphokinase (CPK) and creati-
nine should be monitored regularly while on treatment with
encorafenib and binimetinib.
Table 4.2 Treatment regimens and standard dose reductions
58
Adult dosing Pediatric dosing

Dabrafenib Trametinib Encorafenib Binimetiniba Vemurafenib Cobimetinibb Dabrafenib Trametinib
Starting 150 mg 2 mg once 450 mg 45 mg twice 960 mg 60 mg once Age ≥ 12 years: Age ≥ 6 years:
dose twice daily daily once daily daily twice daily daily (21 of 4.5 mg/kg/day 0.025 mg/kg
28 day cycle) div BID once daily
Age < 12 years: Age < 6 years:
5.25 mg/kg/day 0.032 mg/kg
div BID (max once daily
300 mg/day div (max 2 mg/
BID) day)
First Reduce to Reduce to Reduce to Reduce to Reduce to Reduce to Age ≥ 12 years: Age ≥ 6 years:
dose 100 mg 1.5 mg 300 mg 30 mg twice 720 mg 40 mg once 3.75 mg/kg/day 0.02 mg/kg
reduction twice daily once daily once daily daily twice daily daily div BID once daily
div BID once daily
(max 2 mg/
day)
K. C. Schreck and J. M. Mulcahy Levy
Adult dosing Pediatric dosing
Dabrafenib Trametinib Encorafenib Binimetiniba Vemurafenib Cobimetinibb Dabrafenib Trametinib
4
Second Reduce to Reduce to Reduce to Stop Reduce to Reduce to Age ≥ 12 years: Age ≥ 6 years:
dose 75 mg 1 mg once 200 mg binimetinib 480 mg 20 mg once 3 mg/kg/day div 0.015 mg/kg
reduction twice daily daily once daily twice daily daily BID once daily
div BID once daily
(max 2 mg/
day)
BRAF-Mutated Glioma
Third Reduce to Stop Stop Stop Stop Stop dabrafenib Stop trametinib
dose 50 mg trametinib encorafenibc vemurafenib cobimetinib
reduction twice
dailyd
a
Note, if binimetinib is held, reduce encorafenib to a maximum of 300 mg daily until binimetinib is resumed due to increased toxicity
when encorafenib is used as monotherapy
b
Cobimetinib is administered for 21 consecutive days, then held for 7 days during each 28-day cycle
c
If encorafenib or binimetinib is permanently discontinued, discontinue the other targeted therapy (binimetinib or encorafenib) as well
d
Drug is discontinued below this dose level
59
6. QT Prolongation—Patients starting encorafenib and bin-

imetinib should have their QTc measured. Electrolytes should
be monitored and corrected before and during treatment.
7. Vision loss—BRAFi are associated with a low risk of uveitis
or retinal detachment. MEKi are associated with a risk of
serous retinopathy and retinal vein occlusion. An ophthalmo-
logic evaluation should be performed at baseline, at regular
intervals (for binimetinib), and for any visual disturbance.
Specific interval monitoring recommended for dabrafenib and tra-

metinib: dermatologic evaluation, cardiac function tests, hepatic
function tests, complete blood count, serum glucose, retinal eval-
uation, and routine blood pressure measurement.
Specific interval monitoring recommended for encorafenib
and binimetinib: dermatologic evaluation, cardiac function tests,
hepatic function tests, serum chemistries, and CPK.
Specific interval monitoring recommended for vemurafenib
and cobimetinib: dermatologic evaluation, cardiac function tests,
hepatic function tests, complete blood count, serum chemistries,
and CPK.
Management of Common Toxicities

Treatment-related toxicities are very common with BRAFi/MEKi
combination therapy, but the majority are grade 1 or 2 [31]. With
appropriate anticipatory guidance (see Table 4.3) and proactive
toxicity management, many common toxicities can be prevented
or ameliorated, improving overall treatment compliance and qual-
ity-of-life. This is critical as patients who respond may remain on
treatment for years. On clinical trials, approximately 1 in 3
patients require a dose-reduction, but only 10–15% discontinued
the drug entirely due to intolerance [30, 31]. This speaks to the
fact that proactive toxicity management can markedly improve
tolerability. Toxicities generally develop along two timeframes:
within a few days of starting therapy or after a period of time on
chronic therapy.
In general, for mild-moderate symptoms, patients can continue
therapy—possibly on a reduced dose—while receiving supportive
care to alleviate symptoms. For more severe toxicities, the
Table 4.3 Patient information handout

What type of Your brain tumor has a mutation in a certain protein called
tumor do I BRAF. This mutation causes more activity in your tumor
have? cells leading to increased tumor growth
How is it In some people, chemotherapy can specifically target the
treated? mutant protein BRAF or the MEK protein that BRAF is
talking to. These medicines are a combination of two
different pills taken by mouth 1–2 times each day. There
are several different combinations: dabrafenib/trametinib,
encorafenib/binimetinib, vemurafenib/cobimetinib. Please
follow your doctor’s instructions for taking the medicines
carefully and do not skip any doses. These medicines can
make some forms of birth control less effective and can
also interact with some other medicines. You may need to
change some of your normal medicines or the form of
birth control you are using. Please make sure all your
doctors know every medicine you are taking
What can I Your doctor will tell you about the symptoms this type of
expect to treatment can cause as it can be a little different for each
experience particular set of drugs. It is relatively common to
during experience tiredness, nausea, diarrhea, rash, muscle pain,
treatment? joint pain, and sensitive skin. You should tell your doctor
right away if you develop a severe rash, any vision
change, trouble breathing, swelling in one or both legs, or
a new or growing bump or mole on your skin
How will we Your doctor will tell you what regular testing you need to
keep an eye keep healthy on this treatment. In general, you will need
on this? to get your blood drawn regularly, your heart checked
regularly (with an ultrasound test) and have regular
check-ups with your oncologist, an ophthalmologist (eye
doctor) and possibly with a dermatologist (skin doctor)
What is my The type of brain tumor you have is the most important
prognosis? fact your doctor will use to estimate how long you are
likely to live, as the prognosis is very different depending
on what type of tumor you have, where it is located, your
age, and your response to therapy
o ffending BRAFi or MEKi should be held until the adverse event

improves or resolves. With either drug combination, dose reduc-
tions are common and should occur at predetermined intervals
recommended by the manufacturer (Table 4.2). In some scenar-
ios, re-escalation of the drugs can occur after the toxicity has
resolved.
Management strategies for a variety of common toxicities can

be found in Table 4.4. In many situations, toxicities are temporary
and dose re-escalation can be considered once the toxicity reaches
≤ grade 1.
Table 4.4 Management of common toxicities. (Modified with permission of

the authors from Ref. [3])
Adverse
event Management recommendations
Rash Implement preventative measures when initiating therapy:
avoid excessive sunlight, apply sunscreen daily, topical
mild-steroid (e.g. hydrocortisone 1% cream) or topical
antibiotic (e.g. clindamycin cream) applied twice daily.
Consider oral antibiotics (e.g. doxycycline 100 mg BID or
minocycline 100 mg BID). If no improvement within
2 weeks consider holding MEKi until rash improves and
then resuming at a reduced dose
Diarrhea Institute supportive care (dietary modification, hydration,
loperamide). Continue BRAFi/MEKi for uncomplicated
diarrhea, but consider holding both medications for Grade > 2
diarrhea that continues >48 h, or complicated diarrhea
Nausea/ Promptly institute antiemetic measures. If AE is Grade 1–2
Vomiting can generally continue BRAFi/MEKi, but if higher grade
should hold both BRAFi and MEKi until symptoms improve
Arthralgias Use nonsteroidal anti-inflammatory drugs for symptomatic
relief. Consider temporary dose-interruption or the addition
of low-dose corticosteroids (dexamethasone 2 mg daily to
start) for treatment optimization. Rheumatology evaluation
for severe cases
Vision If AE is Grade 1 continue drugs while obtaining
change ophthalmology consultation within a week. If Grade > 2
obtain urgent consult and hold MEKi. Dose-modification or
discontinuation depends on diagnosis (uveitis, serous
neuroretinal detachment, or retinal vein occlusion)
Fevers Clinical evaluation and workup for infection. Implement
anti-pyretics at first occurrence (acetaminophen, NSAID,
etc.) hydration as required. Consider oral corticosteroids
(e.g. dexamethasone 2 mg for 5 days). Consider dose
reduction of BRAFi
Left Hold MEKi and re-evaluate left ventricular ejection fraction
ventricular (LVEF) after 3–4 weeks. Consider resuming MEKi at a
function, reduced dose if LVEF improves, otherwise discontinue
decreased

Adverse
event Management recommendations
Liver Continue BRAFi/MEKi for asymptomatic patients with
enzyme mild elevation and observe closely for improvement. If
elevation Grade 3–4, hold both BRAFi/MEKi, consider workup for
other etiologies of liver injury, and resume drugs at a
reduced dose if patient improves to Grade < 1
Interstitial For AE Grade > 2, hold MEKi while pursuing workup
lung disease (consider chest CT, pulmonary function tests, infection
workup, pulmonology consult). Consider symptomatic
therapy with corticosteroids and resume MEKi at a reduced
dose if the AE improves to Grade < 1
Patients who experience disease progression after discontinuing

BRAFi or BRAFi/MEKi may experience a response to re-initiation
of targeted therapy [32]. Patients who progress on BRAFi alone
may experience a response to BRAFi/MEKi [33]. For patients who
experience progression while on combined therapy with BRAFi/
MEKi, we recommend changing the treatment approach to one
that involves surgery, radiation, or other chemotherapy.
Prognosis/Survivorship
Prognostic implications of BRAF mutations in glioma are still

unclear and there are no prospective comparative survival data
available. While the overall survival of patients with BRAF
V600E-mutated glioblastoma may be better than BRAF wild-type
glioblastoma, the exact difference and the additional time gained
by targeted therapy are areas of ongoing investigation [3]. Clinical
experience with these drugs has demonstrated that some patients
with progressive glioma treated with BRAF-targeted therapy expe-
rience a profound improvement in their functional status.
Patients with non-V600E single nucleotide mutations are more
likely to harbor passenger BRAF mutations. These patients likely
have a similar prognosis as patients whose tumors have wild-type
BRAF [3].
rends and Future Directions: When Do

T
you Consider a Clinical Trial?
The role of clinical trials in the treatment of patients with BRAF-

mutated or BRAF-fusion glioma is still vitally important.
Questions remain including: Should targeted inhibition be a first-
line therapy for all patients? How long should targeted therapy be
continued? Should targeted therapy be combined with current
standards of radiation and/or chemotherapy? How well do BRAFi
and MEKi penetrate the blood brain barrier and inhibit activated
BRAF? Evidence suggests that movement of targeted therapy up-
front is vital to the care of these patients and that all patients who
are able be invited to participate in a clinical trial to further
advance our understanding of best practices for these drugs.
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Treatment of Meningioma
5
Rimas V. Lukas, Timothy J. Kruser,
and Adam M. Sonabend
Introduction
Clinical Scenario
A 24-year-old man presented with a generalized tonic-clonic sei-

zure. Workup revealed a left parietal dural based lesion with signifi-
cant edema. He underwent a gross total resection and pathology was
R. V. Lukas (*)
Department of Neurology, Northwestern University, Chicago, IL, USA
Lou and Jean Malnati Brain Tumor Institute, Northwestern University,
Chicago, IL, USA
e-mail: rimas.lukas@nm.org
T. J. Kruser
Chicago, IL, USA
Department of Radiation Oncology, Northwestern University,
Chicago, IL, USA
SSM Health, Madison, USA
A. M. Sonabend
Chicago, IL, USA
Department of Neurological Surgery, Northwestern University,
Chicago, IL, USA

Switzerland AG 2023
https://doi.org/10.1007/978-3-031-41413-8_5
68 R. V. Lukas et al.
consistent with a meningioma World Health Organization (WHO)

grade 2. In discussion with his clinical team, he elected to defer
therapy and follow with surveillance imaging with MRI’s every
3–4 months. Two years after surgery, he was found to have recur-
rence of the meningioma in the same location. A repeat resection
was performed and revealed again meningioma WHO grade 2. He
underwent fractionated radiotherapy and has been followed with
surveillance imaging with no evidence of recurrence.
Meningiomas are the most common primary central nervous
system (CNS) tumors. The management of these tumors spans the
disciplines of neurosurgery, radiation oncology, neuro-oncology,
medical oncology, and neurology, and receives input from neuro-
radiology and neuropathology. An overview of the clinical aspects
of the care of these patients will be provided [1–3].
Meningiomas comprise >1/3 of all primary CNS tumors with
the majority of these being WHO grade 1. Incidence increases
with age and is more than twice as high in women compared to
men (2.27:1) [4]. It is higher within the context of some cancer
predisposition syndromes such as neurofibromatosis type 2, a
neurocutaneous syndrome which follows an autosomal dominant
inheritance pattern. A history of prior radiation is also associated
with an increased risk of meningioma development within the
radiation field, with radiation-induced tumors developing years to
decades after radiation exposure. Specific gene rearrangements
involving NF2 have been described in approximately half of radi-
ation-induced meningiomas [5, 6] (Table 5.1).
Meningiomas may be incidentally noted or may be radiograph-
ically diagnosed after imaging performed due to neurologic
symptomatology. Symptoms often correlate with the neuroana-
Table 5.1 Mutations and fusions in meningiomas

Mutation or Neuroanatomic
fusion location Clinical features
NF2 NA • Detected in ~1/2 of sporadic
mutation meningiomas
• Predominantly fibroblastic and/or
transitional subtypes
• Germline mutation in patients with
NF2. These patients have an
increased incidence of meningiomas
5 Treatment of Meningioma 69

Mutation or Neuroanatomic
fusion location Clinical features
NF2 fusion NA • Present in ~1/2 of radiation induced
meningiomas
SMO Olfactory groove • Predominantly meningothelial
mutation subtype
AKT Base of skull • Predominantly meningothelial
mutation subtype
mTOR Base of skull • Predominantly meningothelial
mutation subtype
TERT NA • Confers a more aggressive natural
promoter history
mutation
PTCH1 NA • Germline mutation in Gorlin
mutation syndrome (basal cell nevus
syndrome) which is associated with
increased incidence of meningiomas
• PTCH1 is located upstream of SMO
in the hedgehog pathway
SUFU NA • Germline mutation is also seen in
mutation Gorlin syndrome (basal cell nevus
syndrome) which is associated with
increased incidence of meningioma
• SUFU is located downstream from
PTCH1 and SMO in the hedgehog
pathway
SMARCB1 NA • Germline mutation in
mutation Schwannomatosis and Coffin-Siris
syndrome which is associated with
increased risk of meningiomas
SMARCE1 NA • Germline mutation is also seen in
mutation Coffin-Siris syndrome and is
associated with increased incidence
of meningioma
NF2 neurofibromatosis type 2, NA not applicable, SMO smoothened, AKT
gene for protein kinase B, mTOR mammalian target of rapamycin, TERT
telomerase reverse transcriptase, PTCH1 patched-1, SUFU suppressor of
fused homolog gene, SMARCB1 SWI/SNF-related matrix-associated actin-
dependent regulator of chromatin subfamily B member 1 gene, SMARCE1
SWI/SNF-related matrix-associated actin-dependent regulator of chromatin
subfamily E member 1
tomic location of the tumor. Thus, a careful neurological history

and examination often form part of the initial evaluation.
Subsequent management can range from clinical and radiographic
surveillance to aggressive multi-modality approaches [1–3]. A
number of factors which influence these clinical decisions will be
discussed below.
Diagnostic Evaluation
Neurological symptoms related to meningiomas are usually sub-

acute in onset due to the relatively slow growth of most of these
tumors when compared to other CNS neoplasms. These symp-
toms typically localize to the associated neuroanatomic structures
which are being compressed by the tumor. Patients may also
exhibit non-localizable symptoms such as positional headaches
which may be associated with other symptoms of increased intra-
cranial pressure such as nausea, vomiting, horizontal diplopia,
and somnolence.
The majority of meningiomas are intracranial, arising from the
dura covering the brain. A smaller number arises from the spinal
dura. Occasionally, meningiomas can be found in unexpected
locations such as within the ventricles. Rarely, extra-CNS metas-
tases of meningiomas (including grade 1 meningiomas) are seen.
Common locations for extra-CNS metastases include the lungs.
Extra-CNS staging is not performed as standard of care and is
only a component of symptomatic evaluation or if lesions are
detected incidentally when imaging is performed for other rea-
sons.
Imaging
The diagnostic evaluation of patients with suspected meningioma

involves CNS imaging. Computed tomography (CT) may be the
first modality obtained if the patient undergoes initial evaluation
in an acute care setting such as the emergency department (ED).
It is, however, often possible to move directly to obtaining mag-
netic resonance imaging (MRI) without accompanying CT. If CT

is obtained, a hyperdense extra-axial lesion compressing the
underlying brain raises suspicion for a meningioma. At times
these tumors exhibit calcification, indicative of their slow growth.
MRI similarly reveals an extra-axial mass. These tumors are
usually homogeneously enhancing and may exhibit a dural tail, a
feature suggestive of but not pathognomonic for meningioma. A
delineation between the extra-axial tumor and the underlying
brain (termed a CSF cleft) is sometimes noted. This, however, can
be seen with any extra-axial tumor and is not specific for menin-
giomas. Radiographic findings highly suggestive of meningioma,
when within the appropriate clinical context, are often adequate to
allow for moving forward with next steps in clinical management
without a histologic diagnosis. This is one of the few exceptions
to the rule in neuro-oncology of the need for confirmation of
pathology prior to embarking on therapeutic intervention. There
are a number of potential radiographic mimics of meningioma
which should be considered when developing a differential diag-
nosis for these radiographic abnormalities (Table 5.2).
Finally, a number of advanced imaging studies are undergoing
investigation for meningiomas. These include MR spectroscopy
and advanced positron emission tomography (PET) modalities
[1]. None of these are standard clinical practice at this time.
Pathology
Pathologic evaluation of tissue is necessary to establish a defini-

tive diagnosis of meningioma. Unlike some tumors, a needle
biopsy is rarely used to do so. Often, a surgical resection with an
attempt at a gross total resection (GTR) or at least an extensive
subtotal resection (STR) is performed as this has both diagnostic
and therapeutic value. These tumors are currently classified into
three grades which correlate with their natural histories and guide
clinical management. Most meningiomas (~80%) are grade 1.
Approximately 18% are grade 2 (also termed atypical m eningioma)
and only ~2% are grade 3 (also termed anaplastic or malignant
meningioma) [4].
Table 5.2 Radiographic mimics of meningioma

Diagnostic
entity Clinical features
Dural • Most frequently seen with breast cancer and prostate
metastases cancer
• In about 1/2 of patients with dural metastases skull
metastases are also present
Solitary fibrous • Previously termed hemangiopericytoma
tumor • Has a high potential for local recurrence, recurrence
elsewhere in the CNS, and dissemination outside of
the CNS
Langerhans • A histiocytic infiltrate
histiocytosis • Extra-axial CNS involvement is not a common
manifestation of CNS Langerhans histiocytosis
• More common CNS involvement involves the
hypothalamic-pituitary axis
Rosai-Dorfman • A non-Langerhans cell histiocytosis
disease • Often extra-CNS involvement includes lymph nodes,
skin, sinuses, renal, orbit, and salivary glands
• It is often self-limited
• Treatment may include surgery, radiation, steroids
Erdheim- • A non-Langerhans cell histiocytic neoplasm
Chester disease • Often extra-CNS involvement includes skeletal,
cutaneous, renal, and pulmonary
• Approximately half of Erdheim-Chester cases have
somatic V600E BRAF mutations
• Treatment may include steroids, interferons, and
BRAF targeted therapies
IgG4 related • Both serum and lesional tissue can be evaluated for
disease IgG4
• Often responds readily to steroids
Orbital • Frequently limited to the orbit but in some cases can
pseudotumor extend to the cranial dura
• This is an inflammatory process treated with steroids
and immunosuppressants
Sarcoidosis • This is usually accompanied by extra-CNS
involvement (particularly pulmonary) of sarcoidosis,
but in some instances can be limited to the dura
Rheumatoid • A rare manifestation of rheumatoid arthritis
meningitis

Diagnostic
entity Clinical features
Dural • Often follows a much more indolent course than
lymphoma primary central nervous system lymphoma
Schwannoma • At the base of skull schwannomas arising from
cranial nerves can mimic meningiomas
• CNVIII is the cranial nerve most frequently affected
by schwannoma
Infectious • A range of acute and chronic infections can involve
the pachymeninges and may mimic meningioma
• These infections include but are not limited to viral,
bacterial, fungal, and mycobacterial infections
CNS central nervous system
Histologically meningiomas can be classified into 15 subtypes

[7]. In turn, the pathologist requires familiarity with a range of
histopathologic presentations of meningioma to confidently make
the diagnosis. While most histologic subtypes do not influence the
clinical management, there are a few which when present confer
a more aggressive natural history and in turn increase the grade of
the tumor (Table 5.3). Other features which increase grade include
brain invasion, a higher number of mitoses, high cellularity, a high
nuclear to cytoplasm ratio, prominent nucleoli, necrosis, and
sheet-like growth pattern [8] (Table 5.4). It is likely that in the
near future, methylation profiling may lead to a more robust prog-
nostication for these tumors [9, 10]. At this point in time methyla-
tion profiling is not yet standard of care for meningiomas.
Next generation sequencing (NGS), will likely have a growing
role in the evaluation of meningioma. Some specific findings such
as TERT promoter mutation and CDKN2A/B homozygous dele-
tion confer a WHO grade of 3. In addition, it is known that a
substantial percentage of meningiomas harbor neuroanatomically
exclusive mutations [11] (Table 5.1). Targeting of these mutations
is undergoing investigation in various studies including a phase II
cooperative group study (NCT02523014, Alliance clinical trial
A071401).
Table 5.3 Histologic Histologic subtype Grade

subtypes of meningiomas
Chordoid meningioma 2
Clear cell meningioma 2
Table 5.4 Histologic and molecular features associated with grade

Grade 1 Grade 2 Grade 3
Histologic Chordoid or clear cell
subtypes subtypes
Brain No brain Or Brain invasion Or Brain
invasion invasion invasion
Mitoses 0–3 mitoses per Or 4–19 mitoses per 10 Or 20 or more
10 HPF HPF mitoses per 10
HPF
Aggressive 2 or less Or 3 of the following: Usually
features • Increased present
cellularity
• Small cells with
high nuclear to
cytoplasmic ratio
• Prominent nucleoli
• Sheeting
• Foci of
spontaneous
necrosis
NA not applicable, HPF high-powered fields
Therapeutic Management
The therapeutic management of meningioma most oftentimes uti-

lizes surgery and/or radiation. Systemic therapy at this time does
not have a clearly established role and is primarily used within the
context of clinical trials or for disease which has progressed after
surgery and radiation. It should be emphasized that many (if not
most) meningiomas do not require therapeutic intervention. If

upfront treatment is not recommended, clinical and radiographic
surveillance is usually warranted as these tumors have the poten-
tial to grow over time and can be associated with morbidity and
mortality. Of note only a third of presumed meningiomas that are
discovered incidentally exhibit growth over time. Often, for small
asymptomatic meningiomas the recommendation is to hold off on
treatment until there is clear evidence of growth.
Surgery
Surgery serves both diagnostic and therapeutic purposes. With

respect to the first, it provides diagnostic certainty to a previously
clinical-radiographic diagnosis. The degree of certainty required
depends on the specific clinical scenario. It also allows establish-
ment of grade which informs the natural history and prognosis
associated with the tumor. Finally, it provides tissue for advanced
molecular testing including NGS and methylation profiling. With
regards to therapeutic benefit, it is the one modality which
decreases tumor burden and mass effect. This has the potential to
alleviate at least some of the symptoms associated with the tumor.
The goal of surgery is GTR where feasible and STR when it is
not. GTR may be curative in grade 1 and some grade 2 meningio-
mas [12]. The extent of resection is associated with risk of recur-
rence and progression-free survival. The most frequently utilized
system for assessing extent of resection is the Simpson grading
[13](Table 5.5). A number of factors, predominantly the anatomic
location of tumor, limit the feasibility of a complete resection.
Specific locations in which STR is planned and expected include
the base of skull and the posterior portion of the patent sagittal
sinus. With meningiomas involving the base of the skull there are
critical vessels and cranial nerves which it is often not practical to
Table 5.5 Simpson Simpson grade Extent of resection

grade of resection
1 GTR with removal of involved
dura and bone
2 GTR with dural coagulation
3 GTR without dural coagulation
4 STR
5 Biopsy/decompression
GTR gross total resection, STR subtotal resection
sacrifice or to put at undue risk. In regards to the posterior portion

of the sagittal sinus, if it remains patent and robust collaterals do
not exist, resection which sacrifices the posterior component of
the sinus leads to the substantial risk of impeding the venous out-
flow from the brain and the associate development of a venous
infarction. If GTR is felt unlikely to be feasible (and mass effect
is not problematic) definitive radiation should be entertained. In
cases of STR, postoperative radiation should be considered.
If a tumor recurs, re-resection is often considered as a potential
treatment option. As the number of resections increases the enthu-
siasm for additional resections diminishes, particularly as wound
healing is impaired in the context of multiple previous surgeries
and radiation. However, it is still often contemplated at every
recurrence as it is one of the most effective means of addressing
these tumors.
Radiation
As noted earlier, meningiomas are one of the few CNS tumors in

which treatment may be initiated based upon the radiographic
diagnosis within the appropriate clinical context. This is employed
when the suspicion is that the tumor is a grade 1 meningioma.
When the imaging or rapid onset of symptoms raises concern for
grade 2 and 3 meningiomas, surgery to establish the diagnosis and
grade as well as resect or debulk the tumor is the standard of care.
Radiation for meningiomas can be broadly divided into two cat-

egories, stereotactic radiosurgery (SRS) and focal fractionated
radiotherapy. SRS is a means of delivering a moderate to high dose
of radiation to a relatively limited area often in a single fraction.
This can be delivered via a linear accelerator (LiNac) via the same
device used to deliver standard fractionated radiation or one
designed specifically for SRS (such as the Cyberknife device). It
can also be delivered via a device utilizing a fixed cobalt source of
radiation (ie Gammaknife). Each apparatus for delivery has its
advantages and drawbacks. Recommendations regarding individual
radiation treatment regimens (Table 5.6) are determined by tumor
size, location, histology, and proximity to radiosensitive structures.
Broadly speaking, SRS is the preferred radiation method uti-
lized for relatively small (<3 cm) grade 1 meningiomas. It differs
from standard radiotherapy in that the rigidity of setup is height-
ened, allowing for larger doses per fraction to be delivered in a
more conformal fashion than what can be delivered with standard
radiotherapy. SRS may be used in place of surgery, to treat resid-
ual tumor post-operatively, or to treat progressive/recurrent
disease. It has the ability to provide long-term control in the
majority of patients [14]. If the meningioma is small or moder-
ately sized it is often reasonable to treat with SRS once radio-
graphic growth is demonstrated. This approach is felt to delay the
potential SRS related toxicity while not increasing the risk to the
patient. If the tumor is larger in size or located adjacent to critical
cranial structures with lower radiation tolerability (Table 5.7) then
fractionated SRS (defined as 2–5 fractions) is often employed as
a means of limiting the toxicity, versus a fully fractionated course
of standard radiotherapy. The primary short term toxicity of SRS
is cerebral edema which may worsen neurologic symptoms tran-
Table 5.6 Frequently utilized radiation treatment regimens for meningio-

mas
RT technique Grade I Grade II Grade III
Single fraction 12–16 Gy 16–20 Gy for recurrent Not generally
SRS disease appropriate
Fractionated 45–54 Gy 54–59.4 Gy for adjuvant 60 Gy
RT or salvage indications postoperatively
Table 5.7 Radiation tolerability of critical structures

Structure Single fraction limit Fractionated RT limit
Optic nerves, chiasm 8–9 Gy max point dose 55 Gya
Brainstem <1 cc receiving 12+ Gy 55 Gya
a
Up to 60 Gy may be allowable for high-grade lesions abutting these struc-
tures
siently. In the long term, the primary concern is radiation necrosis

which can develop months after the treatment and may first mani-
fest even years after SRS. The risk of radiation necrosis is
increased by prior radiation therapy in the same treatment field as
well as by some medications such as targeted therapies and immu-
notherapies.
Fractionated radiation is when a substantial number of small
fractions of radiation are administered (typically Monday
through Friday) for a number of weeks to reach a high cumula-
tive dose [15]. This modality is often used when the radiation
field for the meningioma is large as well as with grade 2 and 3
meningiomas. While there is a lack of comparative studies,
when evaluating results across studies fractionated radiation
appears superior to SRS in grade 2/3 meningiomas. Another
indication for fractionated radiation is meningiomas that lie in
close proximity to optic structures, such as optic nerve sheath
meningioma. In this setting the fractionation allows for adequate
tumor dosing, while the small daily fraction allows for optic
structure tolerances to not be exceeded. Outcomes in such cases
show high rates of tumor control, with high rates of visual pres-
ervation [16]. However, these advantages to fractionation must
be weighed against the logistical difficulties of daily transport to
radiation oncology. This is of particular consideration when
patients have neurological deficits or the distance to travel is far.
Fractionated radiation is standard of care for the treatment of all
grade 3 meningiomas regardless of extent of resection as well as
for grade 2 meningiomas post-STR. Post-operative radiation in
grade 2 meningiomas post-GTR is associated with high rates of
local control in prospective studies, and as is currently being
investigated in a randomized cooperative group trial, NRG
BN003 (NCT03180268) [17].
Systemic Therapies
Systemic therapies have a limited role in the management of

meningiomas at this time. It is possible, however, that this may
change in the future. Much of this may be driven by our enhanced
understanding of the molecular characteristics of these tumor sub-
types. A number of systemic therapies have been investigating in
these tumors, and unfortunately thus far none have been overly
successful (Table 5.8). Studies have been predominantly single
Table 5.8 Systemic Hydroxyurea

therapies investigated for Imatinib
the treatment of
Hydroxyurea + imatinib
meningiomas
Temozolomide
Irinotecan
Cyclophosphamide + adriamycin + vincristine
Interferon alpha
Mifepristone
Megestrol
Tamoxifen
Octreotide
Sandostatin LAR
Pasireotide LAR
Erlotinib
Gefitinib
Vatalanib
Sunitinib
Lapatinib
PTK787
Bevacizumab
Bevacizumab + paclitaxel
Bevacizumab + everolimus
(90)Y-DOTATOC
(90)Y-DOTATOC+(177)Lu-DOTATOC
Abemeciclib
Lutetium Lu177 dotatate
arm utilizing no control or historical controls; a single random-

ized clinical trial has been performed examining the anti-progestin
agent mifepristone (given 70% of tumor express progesterone
receptors) which revealed no impact on tumor outcomes [18].
Disappointingly, there have been no systemic regimens which
have demonstrated definitive radiographic responses. In contem-
porary clinical practice, systemic therapies are most often utilized
within the context of clinical trials or as salvage regimens for pro-
gressive disease (particularly when additional surgery or radiation
are not optimal). Specific regimens which are considered include
antiangiogenics, targeted therapies, traditional cytotoxic chemo-
therapies, and immunotherapies.
Ongoing studies which take advantage of mutually exclusive
targetable mutations in subsets of meningiomas hold notable
promise. In its greatest scope this is undergoing evaluation in the
non-randomized multi-arm phase 2 cooperative group trial
A071401 (NCT02523014). This study has separate arms for
tumors with mutations in SMO, AKT, and NF2. Each arm is
treated with a therapeutic targeting the specific aberrant path-
way.
Conclusions
Meningiomas are common tumors which arise from the pachyme-

ningeal coverings of the CNS. The natural history of most of these
tumors reflects a pattern of slow growth, allowing many to be
observed clinically and radiographically without therapeutic
intervention. In those which require treatment, surgery can be
curative and radiation, often delivered as SRS, can provide excel-
lent long-term control. Some meningiomas, however, prove resis-
tant to therapy and can incur both substantial morbidity and
mortality. These oftentimes require repeated interventions with
surgery and radiation serving as the cornerstones of their manage-
ment. Systemic therapies, often within the context of clinical tri-
als, are also added to the armamentarium when meningiomas are
not amenable to further localized therapy. As these tumors are
genomically less complex than other CNS tumors and are not pro-
tected by a blood brain barrier, the likelihood of therapeutic

advances is high as our understanding of the molecular character-
ization and sub-classification improves.
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Treatment of Primary CNS
Lymphoma 6
Ugur Sener and Lauren Schaff
Introduction
Clinical Scenario
A 58 year old woman with no past medical history presented to

her primary care physician with forgetfulness, confusion and
difficulty performing tasks at work. She was referred to a neu-
rologist who found deficits on a mental status examination,
including impaired recall, trouble with calculations, and confu-
sion with multi-step commands. An MRI brain was ordered and
demonstrated homogeneously enhancing lesions in the sple-
nium of the corpus callosum, right temporal lobe and right pari-
etal lobe with restricted diffusion and minimal edema. Due to
concerns for lymphoma, she was not treated with corticoste-
roids. She underwent a staging workup including a slit lamp
examination of the eye, CT chest, abdomen and pelvis and HIV
U. Sener
Department of Neurology, Mayo Clinic, Rochester, MN, USA
L. Schaff (*)
Department of Neurology, Memorial Sloan-Kettering Cancer Center,
New York, NY, USA
e-mail: schaffl@mskcc.org

Switzerland AG 2023
https://doi.org/10.1007/978-3-031-41413-8_6
84 U. Sener and L. Schaff
test, all of which were normal. Two lumbar punctures revealed

elevation in protein and slight elevation in cells, but negative
cytology and absence of a monoclonal population with flow
cytometry. She then underwent a brain biopsy that revealed dif-
fuse large B-cell lymphoma. She began therapy with high-dose
methotrexate, rituxan and temozolomide and after completing
therapy she was found to have a complete imaging response.
She also returned to her neurologic baseline. After induction
therapy, she had an autologous stem cell transplant (ASCT)
with a thiotepa-based conditioning chemotherapy regimen and
has been free of disease for over 2 years.
Primary CNS lymphoma (PCNSL) is a rare form of extrano-
dal non-Hodgkin lymphoma (NHL) of the brain, spinal cord,
cerebrospinal fluid (CSF), and/or eyes without systemic involve-
ment. PCNSL is an aggressive malignancy that can rapidly result
in significant neurologic disability, but it is highly responsive to
chemo and radiation therapies and potentially curable. While
immunosuppression is a risk factor for PCNSL, the disease also
occurs in immunocompetent individuals. Management is not
standardized across institutions and practice patterns are highly
variable. Here, we will review the diagnosis, staging, and com-
mon treatment strategies for PCNSL in immunocompetent
patients.
Epidemiology
PCNSL is a rare malignancy with an average age-adjusted inci-

dence rate of 0.43 per 100,000 per year, representing 4% of newly
diagnosed brain tumors [1, 2]. Median age at diagnosis is approx-
imately 65 though PCNSL can be diagnosed at any stage of adult-
hood [3]. It is typically a B-cell neoplasm with diffuse large B-cell
lymphoma (DLBCL) representing 90% of cases, though Burkitt,
low-grade, and T-cell lymphomas can rarely present with CNS-
only involvement [4].
6 Treatment of Primary CNS Lymphoma 85
Diagnosis and Staging
Diagnosis
Diagnosis of PCNSL requires a high level of clinical suspicion

as presentation is variable depending on areas of involvement.
Up to 70% of patients present with focal neurologic deficits
whereas 43% present with mental status and behavioral changes
[3, 4]. Seizures and symptoms of increased intracranial pressure
such as headache, nausea, or vomiting can also occur. Imaging
typically identifies one or more homogeneously enhancing brain
lesions, often supratentorial and involving deep structures such
as periventricular white matter, basal ganglia, thalamus, and cor-
pus callosum. Magnetic resonance imaging (MRI) of the brain
with and without contrast is the imaging modality of choice. In
immunocompetent individuals, lesions are typically T2 hyperin-
tense on MRI and homogeneously enhancing with contrast
(Fig. 6.1). Restricted diffusion can be seen on diffusion weighted
imaging (DWI) sequences. In individuals unable to undergo
MRI, computed tomography (CT) of the head with and without
contrast is recommended. On CT, PCNSL appears iso- to hyper-
dense on pre-contrast images, sometimes mimicking hemor-
rhage (Fig. 6.1).
Definitive diagnosis of PCNSL requires pathologic confirma-
tion, often obtained by brain biopsy. There is no clear benefit to
lesion resection. Even when a single lesion is noted on imaging,
autopsy studies suggest PCNSL is a whole-brain disease respon-
sive to chemo and radiation therapies, obviating the need for
extensive debulking and associated surgical morbidity [4]. In
cases of CSF or ocular involvement, diagnosis may be made by
lumbar puncture or vitreous biopsy. However, it is generally not
recommended to defer brain biopsy pending these results as there
is urgency to initiation of treatment.
Corticosteroids can obscure pathology and lead to false nega-
tive results. When PCNSL is suspected, use of corticosteroids
should always be deferred until tissue diagnosis is obtained unless
life-threatening mass effect is present.
a b c
d e f
Fig. 6.1 Radiographic Appearance of Primary CNS Lymphoma. PCNSL

involving the left thalamus and splenium of the corpus callosum is illustrated.
On CT head, PCNSL can appear hyperintense (a) to isointense. On MRI
brain, PCNSL typically appears T1 hypointense (b), uniformly enhancing
with contrast (c), and T2 fluid attenuated inversion recovery (FLAIR) hyper-
intense (d). Diffusion restriction can be seen with lesions appearing hyperin-
tense on diffusion weighted imaging (DWI) (e), and hypointense on apparent
diffusion coefficient (ADC) (f)
Staging
Staging is required to determine the extent of disease involvement

and sufficiently rule out systemic lymphoma. In addition to MRI of
the brain, staging should include MRI of the whole spine with and
without contrast. Ocular involvement can occur in up to 25% of cases
and can be asymptomatic. Thus, slit lamp examination is recom-
mended. Leptomeningeal involvement can occur in up to 20% of
cases [3, 4]. Lumbar puncture with CSF analysis including cell
count, measurement of protein and glucose, cytology, and flow
cytometry should be performed if the procedure can be safely com-
pleted. Positron emission tomography (PET) imaging should also be
completed to assess for systemic lymphoma involvement. If PET
imaging is not available, CT of the chest, abdomen, and pelvis along
with bone marrow biopsy and, in appropriate patients, testicular
ultrasound should be completed. All patients should undergo HIV

testing.
First-Line Treatment
Treatment of PCNSL begins with an induction regimen with the

goal of reducing disease burden, followed by consolidation to
eradicate any residual microscopic disease and achieve remission.
While the approach to induction treatment varies across centers,
there is general consensus about the use of high-dose methotrex-
ate (HD-MTX) in a combination regimen.
Methotrexate Therapy
Methotrexate is an inhibitor of dihydrofolic acid reductase, an

enzyme required for purine nucleotide synthesis. In neoplastic
cells, methotrexate interferes with DNA synthesis and cellular
division, leading to cell death. Methotrexate penetrates the blood-
brain barrier when administered as a rapid infusion at doses
greater than 1.5 g/m2 [5, 6]. The optimal dose for treatment of
PCNSL is unknown but data suggests survival benefit with doses
greater than or equal to 3 g/m2 with many regimens calling for
doses between 3.5 and 8 g/m2.
Table 6.1 Guide to high-dose methotrexate treatment

Prior to initiation of methotrexate therapy:
Assess patient for third-space fluids:
• Perform clinical examination and chest x-ray to assess for ascites and
pleural effusion
• If third-space fluids present, delay treatment until fluids removed or
consider dose reduction
• Consider transthoracic echocardiogram to assess cardiac function
Review medication risk for potential drug interactionsa:
• PPI can delay HD-MTX clearance
• NSAIDs can potentiate myelosuppression and GI toxicity
• TMP-SMX is a folate antagonist and should be avoided
(continued)

Laboratory evaluation to ensureb:
• WBC ≥ 1500/μL
• ANC ≥ 200/μL
• Platelet count ≥75,000/μL
• Serum bilirubin <1.2 mg/dL
• ALT <450 U/L
• Normal serum creatinine
• Creatinine clearance >60 mL/min
• Urine pH ≥ 7.0
Supportive measures:
Prior to infusion of HD-MTX:
• 1000 mL/m2 of intravenous fluid over 4–6 h
• Sodium bicarbonate 650 mg orally night before and morning of
HD-MTX administration
• Additional sodium bicarbonate or acetate as needed to maintain urine
pH > 7.0
After infusion of HD-MTX:
• Monitor serum methotrexate level every 24 h until cleared
• Monitor urine pH every 6 h, sodium bicarbonate or acetate boluses as
needed to maintain pH > 7.0
• Leucovorin 10–15 mg/m2 every 6 h, starting 24 h after start of
HD-MTX infusion
If methotrexate level is toxic or AKI develops:
• Promptly increase leucovorin dose, transition to IV if receiving PO
• Increase IV hydration to ≥3 L/m2 per day as tolerated, monitor for fluid
overload
• Review HD-MTX dosing for future cycles of treatment
If AKI and toxicity
• Consider glucarpidase up to 50 units/kg
• Consider hemodialysis
PPI Proton pump inhibitor, HD-MTX high-dose methotrexate, NSAID non-
steroidal anti-inflammatory drug, TMP-SMX trimethoprim- sulfamethoxa-
zole, WBC white blood count, ANC absolute neutrophil count, SGPT serum
glutamic pyruvic transaminase, IV intravenous, PO by mouth
a
Selected drug interactions of interest are highlighted, not meant to be an
exhaustive list
b
Parameters as listed in the United States Food and Drug Administration
package insert for methotrexate
c
At Memorial Sloan Kettering Cancer Center, methotrexate level is consid-
ered toxic if >10,000 nmol/L at 24 h, >1000 nmol/L at 48 h, or >100 nmol/L
at 72 h
HD-MTX is generally well tolerated however, can rarely be

associated with serious and potentially fatal toxicities, especially
if appropriate monitoring and supportive therapies are not in place
(Table 6.1). Pre-treatment laboratory evaluation should be under-
taken and include adequate cell count, renal function, and hepatic
function. Due to the need for aggressive intravenous hydration
during HD-MTX treatment, transthoracic echocardiogram should
be considered for documentation of cardiac function. Methotrexate
is predominantly cleared via renal excretion with contribution
from the hepatic system. In patients with impaired renal function
or existing liver disease, methotrexate dose reduction should be
considered. Guidelines for dose reduction vary. In our practice,
we consider a reduction for patients with creatinine clearance
(CrCl) <60 mL/min and may reduce dose between 50 and 75%
depending on the clinical situation. Dose reductions are also con-
sidered for patients with aspartate aminotransferase (AST) > 180
or bilirubin >3.1, typically to 75% of originally intended dose. In
patients receiving 8 g/m2, dose reductions are typically made for
anyone with CrCl < 100 mL/min.
Methotrexate can accumulate in third-space fluids such as asci-
tes and pleural effusions. This can result in delayed clearance and
increased risk of methotrexate toxicity. Prior to initiation of HD-
MTX, patients should be assessed for presence of third-space flu-
ids by clinical examination and with a chest radiograph. If present,
elimination of third-space fluids should be undertaken prior to
treatment or a dose reduction should be considered.
upportive Medication and Monitoring

S
Methotrexate administration can result in renal toxicity. To reduce
the risk, supportive care is pre-emptively provided to all patients
in the form of hydration and urinary alkalinization. As a result,
methotrexate is almost always administered in the inpatient set-
ting with continuous hydration and frequent monitoring of urine
PH and serum methotrexate levels. Institutional guidelines for
methotrexate administration may vary but typically involve pre-
hydration with 1 L intravenous fluid over 4–6 h along with admin-
istration of sodium bicarbonate to achieve urine alkalinization to

pH above 7.0. Prior to IV fluid administration, oral acetazolamide
or oral bicacarbonate tablets can be used to more quickly alka-
linze urine.
Intravenous hydration should be maintained after methotrexate
infusion at rates between 75 and 150 mL/h as per institutional
guidelines. Intravenous fluid should include sodium bicarbonate
to maintain urine alkalinization and continuous monitoring of
urine output and pH should be maintained until methotrexate is
cleared.
Leucovorin, or folinic acid, is a rescue agent administered to
reduce the risk of tissue toxicity associated with
HD-MTX. Leucovorin provides a source of reduced folate,
bypassing the effects of methotrexate. Leucovorin can be admin-
istered orally or by injection, typically at a dose of 10–30 mg/m2
every 6 h, beginning 24–36 h after infusion of HD-MTX. The
dose is increased in the event of toxic serum methotrexate levels
and maintained until methotrexate clearance. It is important to
remember that leucovorin itself does not aid in the clearance of
methotrexate.
Serum methotrexate and creatinine levels should be monitored
daily. At our institution, methotrexate is considered cleared and a
patient safe for discharge when the serum level is 100 nmol/L or
lower.
Concomitant Medications
Methotrexate also has multiple important drug interactions that
must be considered before starting therapy. When HD-MTX is
administered with proton pump inhibitors (PPIs), serum levels
of methotrexate can be elevated and toxicity may increase.
Severe myelosuppression, aplastic anemia, and gastrointestinal
toxicity may occur when methotrexate is used with nonsteroi-
dal anti-inflammatory drugs (NSAIDs). The antibiotic trime-
thoprim- sulfamethoxazole is a folate antagonist whose
coadministration with methotrexate can potentiate toxicity and
should be avoided [7].
Methotrexate Toxicity
Despite urine alkalinization and intravenous hydration, acute kid-
ney injury (AKI) with methotrexate administration can occur
through mechanisms such as precipitation in the renal tubules,
vasoconstriction, and direct tubular toxicity. If AKI develops,
intravenous fluids should be increased to ≥3 L/m2 per day to max-
imize urine output [8]. AKI can result in delayed methotrexate
clearance and toxic levels which can lead to systemic effects such
as hepatic injury, pneumonitis, and bone marrow suppression.
Gastrointestinal toxicities including oral mucositis, ulcerative sto-
matitis, and hemorrhagic enteritis have also been reported.
Neurologic toxicities include headache, encephalopathy, leukoen-
cephalopathy, and transient focal neurologic deficits. Rarely tox-
icity can be fatal.
In the event of AKI and methotrexate toxicity, glucarpidase is
FDA approved to rapidly reduce serum methotrexate levels.
Glucarpidase is dosed at 50 units/kg though there is evidence that
lower doses may be as effective [9]. Leucovorin should not be
administered within 2 h of glucarpidase injection since leucovorin
is also a substrate for glucarpidase. If glucarpidase is not avail-
able, hemodialysis can be considered. In the event of delayed
clearance and nephrotoxicity, reduction in methotrexate dose may
be considered for future cycles. Table 6.1 provides a summary of
methotrexate treatment including precautions and supportive
measures that should be undertaken.
Common Induction Regimens
Data from multiple clinical trials support use of HD-MTX in

combination with other chemotherapy agents as part of induc-
tion therapy for PCNSL. Due to the paucity of comparative ran-
domized data, the optimal combination of chemotherapy agents
and treatment schedule remains unknown. Induction regimens
commonly used in clinical practice are summarized in Table 6.2.
These include R-MVP (rituximab, methotrexate, vincristine,
procarbazine), MT-R (methotrexate, temozolomide, rituximab),
Table 6.2 Common induction regimens

Induction regimen
R-MVP (rituximab, methotrexate, vincristine, procarbazine) [10]
Repeat every 28 days for 8 cycles
• Rituximab 500 mg/m2 Day 0 and 14
• Vincristine 1.6 mg/m2, maximum dose 2.4 mg, stop Day 1 and 15
after four total doses
• Methotrexate 3.5 g/m2 Day 1 and 15
• Procarbazine 100 mg/m2/day Day 1–7
MT-R (methotrexate, temozolomide, rituximab) [11]
• Methotrexate 8 g/m2 Day 1
• Rituximab 375 mg/m2• Stop after six total doses Day 3 and 10
• Temozolomide 150 mg/m2 PO, odd cycles Day 7–11, odd
cycles
MATRix (methotrexate, cytarabine, thiotepa, rituximab) [12]
• Rituximab 375 mg/m2 Day −5 and 0
• Methotrexate 3.5 g/m2 Day 1
• Ara-c (cytarabine) 2 g/m2 every 12 h Days 2 and 3 (4
doses)
• Thiotepa 30 g/m2 Day 4
R-MBVP (rituximab, methotrexate, carmustine [BCNU], etoposide,
prednisone) [13]
• Rituximab 375 mg/m2 on Days 0, 7, 14,
and 21
• Methotrexate 3.5 g/m2 Days 1 and 15
• Etoposide 100 mg/m2 Day 2
• BCNU 100 mg/m2 Day 3
• Prednisone 60 mg/m2/day Day 1–5
MATRix (methotrexate, cytarabine, thiotepa, rituximab), and

R-MBVP (rituximab, methotrexate, carmustine [BCNU], eto-
poside, prednisone) [3, 4, 10–13]. Combination of rituximab
and methotrexate with no additional agents is also used. Specific
considerations for each regimen are discussed here in more
detail.
R-MVP
R-MVP consists of rituximab, methotrexate (3.5 g/m2), vincris-
tine, and procarbazine. Treatment cycles are 28 days long with
methotrexate administered twice per cycle. The optimal number
of cycles is not known though we favor completion of 4 (8 doses
of methotrexate) with imaging for initial response obtained after
two.
When to incorporate vincristine is a special consideration for
the use of this regimen. Vincristine is a vinca alkaloid that inhibits
microtubule formation, causing arrest of cell division during
metaphase, leading to apoptosis. Toxicities from vincristine
include hair loss, constipation, and most significantly, peripheral
neuropathy. Vincristine is dosed at 1.6 mg/m2, capped at 2.4 mg.
The drug is only administered four times during the induction
regimen to limit toxicity. CNS penetration of vincristine is ques-
tionable, and the drug may be omitted in patients with limited
enhancing disease or pre-existing neuropathy. If neuropathy
symptoms develop while on treatment, early discontinuation of
vincristine should be considered. Vincristine is a vesicant and can
cause tissue damage in the event of extravasation, mandating
careful placement and confirmation of the intravenous line by an
experienced individual prior to treatment.
Procarbazine is an oral chemotherapy agent with unclear
mechanism of action, though likely serves as an alkylator.
Procarbazine can cause hepatotoxicity and dose reduction or dis-
continuation should be considered if this occurs. Patients should
be cautioned that ingestion of alcohol while taking procarbazine
can cause a disulfiram-like reaction. Procarbazine is a weak
monoamine oxidase inhibitor with potential for hypertensive cri-
sis upon ingestion of tyramine-rich foods or coadministration of
sympathomimetic agents.
R-MVP is often followed by use of filgrastim or pegfilgrastim,
a human recombinant form of granulocyte colony-stimulating
factor (G-CSF) which can stimulate production of neutrophils
[14]. G-CSF can be started 24 h after clearance of methotrexate.
Use of G-CSF is designed to prevent infectious complications of
severe neutropenia and allow for completion of chemotherapy

cycles without delays or dose reductions.
T-R
M
MT-R includes methotrexate, temozolomide, and rituximab.
Temozolomide is an alkylating chemotherapy agent that is typi-
cally well-tolerated. Hepatotoxicity, thrombocytopenia, and lym-
phopenia complicated by Pneumocystis jirovecii pneumonia
(PJP) can occur.
MATRix
MATRix includes methotrexate, cytarabine, thiotepa, and ritux-
imab. Cytarabine is an antimetabolite that inhibits DNA s ynthesis.
Cytarabine and thiotepa can both cause myelosuppression, hepa-
totoxicity, and pulmonary toxicity. Additional toxicities from
cytarabine such as cerebellar ataxia, corneal toxicity, and gastric
ulcers tend to occur with high-dose treatment.
R-MBVP
R-MBVP includes rituximab, methotrexate, BCNU, etoposide,
prednisone. BCNU is an alkylator, which can cause myelosup-
pression and dose-dependent pulmonary toxicity, mandating
monitoring with pulmonary function tests before and during treat-
ment. In order to minimize risk of pulmonary fibrosis, BCNU has
a lifetime dose limit of 1400 mg/m2. Etoposide is a topoisomerase
II inhibitor that prevents DNA replication. Etoposide can cause
myelosuppression, sensitivity reaction, and skin necrosis in the
event of extravasation.
Role of Rituximab
The above regimens all incorporate rituximab. Rituximab is a

monoclonal antibody directed against the B-cell surface antigen
CD20. It is well tolerated with infusion reactions the most com-
monly reported complaint. Rarely, these reactions can be fatal.
Rituximab can also be associated with hepatitis B reactivation and

patients should be screened for infection with carriers closely
monitored. Progressive multifocal leukoencephalopathy has also
been reported.
The use of rituximab has dramatically improved outcomes in
the management of systemic DLBCL however, it’s role in PCNSL
has recently been called into question. In the phase 2 International
Extranodal Lymphoma Study Group-32 (IELSG32) clinical trial,
addition of rituximab to cytarabine and HD-MTX improved over-
all response rate (ORR) and progression free survival (PFS) [12].
However, this phase II study was not designed for comparison of
treatment groups. In contrast, the randomized open-label phase III
clinical trial HOVON 105/ALLG NHL 24 demonstrated no
improvement in overall survival (OS) or PFS from addition of
rituximab to methotrexate, BCNU, etoposide, and prednisone
therapy, though long-term data is lacking [13]. Currently, our
practice is to incorporate rituximab into our treatment regimens
for B-cell lymphoma, unless there is a contra-indication or a
patient is felt to be high risk. There is no role for rituximab in
treatment of T-cell lymphoma.
Site-Specific Therapy
The role of site-specific therapy in PCNSL is unclear.In patients

with leptomeningeal disease, intrathecal (IT) therapy can be
considered. Administration via an Ommaya reservoir is gener-
ally preferred over lumbar puncture due to better CSF distribu-
tion. Commonly administered agents include methotrexate
(12 mg flat dose), rituximab (25 mg flat dose), cytarabine
(70 mg flat dose; liposomal cytarabine 50 mg flat dose), or thio-
tepa (10 mg flat dose). IT chemotherapy is contra-indicated in
patients with elevated intracranial pressure and caution is
advised in patients with bulky leptomeningeal disease as
impaired CSF flow can result in toxic drug accumulation. In
general, its use can increase treatment toxicity and no clear sur-
vival benefit has been established. Methotrexate doses 3 g/m2 or
higher is penetrate the CSF, calling utility of IT chemotherapy

into question.
Similarly, the role of intraocular therapy is not clearly estab-
lished in patients with ocular involvement from PCNSL [3, 4].
Intravitreal methotrexate, intravitreal rituximab, and ocular radia-
tion can be considered as part of the induction regimen since some
data suggest higher rates of ocular failure when site-specific ther-
apy is deferred [3, 4]. However, to date, early intraocular therapy
has not been associated with increased OS [3, 4].
Common Consolidation Regimens
Consolidation strategies for PCNSL include high-dose myeloab-

lative chemotherapy followed by autologous stem cell transplan-
tation (HDC-ASCT), high-dose non-myeloablative chemotherapy,
and whole brain radiation therapy (WBRT). Though no consensus
exists regarding the optimal consolidation strategy, chemotherapy
regimens are increasingly favored over WBRT due to chemo-
responsiveness of the tumor and potential for neurotoxicity with
RT [15].
In choosing a consolidation regimen, patient age, performance
status, medical comorbidities, and response to induction should
be considered. In general, younger patients with good perfor-
mance status, few medical comorbidities, and good response to
induction should be considered for HDC-ASCT, which has been
associated with >90% ORR and prolonged PFS. While there are
different conditioning regimens available for HDC-ASCT,
thiotepa-based regimens such as thiotepa, busulfan, and cyclo-
phosphamide (TBC) are generally favored over BCNU-based
regimens (BCNU, etoposide, cytarabine, melphalan [BEAM] or
cyclophosphamide, etoposide, BCNU [CBV]) due to improved
response rates [3, 4]. However, HDC-ASCT is associated with
serious toxicity including treatment-related mortality, requiring
thoughtful patient selection and discussion of risks and benefits.
In frail individuals, patients with multiple medical comorbidi-
ties, or in the setting of partial response to induction, consolida-
tion with high-dose non-myeloablative chemotherapy should be
considered over HDC-ASCT. The most common nonmyeloabla-

tive consolidation regimen consists of cytarabine, with or without
etoposide. Maintenance therapy with methotrexate, rituximab or
temozolomide are also considerations. Alternative maintenance
regimens with ibrutinib and other novel agents such as lenalido-
mide are currently being explored.
Finally, reduced dose WBRT (23.4–36 Gy) may provide a
reasonable consolidation strategy though confers risk of neuro-
toxicity. Longer follow up is needed to determine the level of
risk with lower doses of WBRT [10, 16]. A randomized phase 2
study of cytarabine consolidation with or without low dose
WBRT demonstrated improvement in progression free survival
(PFS) with the addition of low dose WBRT compared with
cytarabine consolidation alone (2-year PFS 78% vs 54%,
respectively), and overall survival data are maturing in both
arms [17].
Relapsed Disease
Though PCNSL is responsive to induction chemotherapy, up to

15% of patients remain refractory. Relapse can occur in up to 50%
of patients, most commonly within 2 years of diagnosis. No con-
sensus exists in management of relapsed or refractory disease.
Enrollment in clinical trials should be encouraged and considered
the first option if available.
In individuals who had an initial durable response to HD-
MTX-based induction, rechallenge with methotrexate-based ther-
apy can be considered, especially if initial response duration was
more than 12 months [18]. In patients refractory to methotrexate
or with only short duration of response, the role of further metho-
trexate is questionable and alternate strategies such as cytarabine
(with or without etoposide), temozolomide, lenalidomide, or
pemetrexed could be considered.
In recent years, the availability of ibrutinib has enhanced the
approach to recurrence. Ibrutinib inhibits Bruton tyrosine kinase
(BTK), a key enzyme in the B-cell receptor pathway. An oral
agent, it is generally well tolerated and does not require inpatient
treatment. Single-agent ibrutinib can achieve responses up to 77%

in recurrent PCNSL [19]. Ibrutinib may also be used with ritux-
imab and methotrexate and is currently being studied in other
combinations. Importantly, ibrutinib is associated with pulmo-
nary and cerebral aspergillosis as well as Pneumocystis jiroveci
pneumonia (PJP), particularly in patients who have chronic corti-
costeroid exposure. Caution is advised and PJP prophylaxis
should be considered.
Novel approaches to treating refractory or relapsed PCNSL
include immunotherapy with anti-PD-1 antibodies pembroli-
zumab and nivolumab. Anti-PD-1 checkpoint inhibitors such as
pembrolizumab may have a role in PCNSL treatment given PD-1
overexpression reported in >50% of these tumors [20, 21].
For individuals with relapse after non-myeloablative high-dose
chemotherapy, HDC-ASCT can be an option with 58.6-month OS
reported in patients successfully completing transplant in one
study [3, 22].
In individuals unable to undergo HDC-ASCT and refractory to
other treatments, WBRT can be considered.
Expectations from Treatment

1. Age and Karnofsky Performance Status (KPS) at diagnosis have been
identified as predictors of outcome in PCNSL [4]. According to the
Memorial Sloan Kettering Cancer Center (MSKCC) prognostic score, the
expected median OS for patients with age ≤50, age >50 with KPS ≥70,
age <50 with KPS <70 is 8.5 years, 3.2 years, and 1.1 years respectively
[4]. However, PCNSL is highly responsive to chemotherapy and radiation
therapy. Treatment should be attempted even in elderly patients with low
KPS, particularly if status is a result of disease. Clinical benefit and
response to methotrexate may be seen after only one or two doses.
PCNSL has a high rate of recurrence, particularly during the
first 2 years after diagnosis. National Comprehensive Care
Network guidelines recommend surveillance brain imaging every
3 months for the first 2 years after treatment, then every 6 months
for another 3 years, and annually thereafter. Periodic spine imag-
ing, CSF analysis, and ocular examination should be considered
depending on initial areas of involvement.
Patient Information
The following information is intended to be shared with patients

and family members of individuals with primary central nervous
system lymphoma to provide an overview of the condition and its
management.
What Type of Tumor Do I Have?
Primary central nervous system lymphoma (PCNSL) is a type of

cancer caused by malignant cells originating from the immune
system. Unlike systemic lymphomas, in PCNSL, the cancer cells
are confined to the brain, spine, eyes, and/or the cerebrospinal
fluid without involving other parts of the body. In most cases,
PCNSL originates from a type of immune cell called B-cells,
which are normally responsible for making antibodies to fight
infection. Rarely, a different type of immune cell called T-cells
can give rise to PCNSL.
How Do I Treat It?
Treatment of PCNSL involves two phases. During the first phase,

called induction, we administer multiple chemotherapy drugs in
combination to kill cancer cells with the goal of eliminating all
visible tumor. In the second phase, called consolidation, we
administer additional treatment such as high-dose chemotherapy
followed by stem cell transplantation or whole brain radiation
therapy to eradicate any residual microscopic disease.
hat Can I Expect to Experience During

W
Treatment?
Most induction regimens for PCNSL utilize a combination of

multiple chemotherapy agents including methotrexate.
Administration of methotrexate requires admission to the hospital

for fluids, safety, and monitoring. Your doctor may prescribe a
medication called rituximab to be administered prior to your
arrival to the hospital. Then you will receive hydration with intra-
venous fluids, followed by methotrexate infusion. Your hospital
team will monitor your urine output and labs including the level
of methotrexate in your blood. You will receive another medica-
tion called leucovorin to protect you from side effects of metho-
trexate. It can take 3–5 days, on average,to clear methotrexate.
Once this happens, you can be discharged. You may receive addi-
tional medications to take while you are at home. You will typi-
cally repeat treatments every 2 weeks until the completion of
induction. At that point, your doctor will order tests to assess the
status of your disease. You will then together choose a consolida-
tion regimen to complete the course of treatment.
How Will We Keep an Eye on This?
Your doctor will periodically order magnetic resonance imaging

(MRI) scans of your brain and/or your spine to monitor the dis-
ease. Additional tests such as positron emission tomography
(PET) scans and lumbar punctures to evaluate your cerebrospinal
fluid may be required. Once you complete consolidation, expect
to have MRI scans every few months for monitoring. You should
also report any new symptoms to your doctor.
What Is My Prognosis?
Even though PCNSL is a very serious disease requiring treatment,

it is responsive to chemotherapy and radiation therapy. While on
average people with PCNSL live 24 months, it is possible to cure
the disease with the treatments that are currently available. Up to
40% of patients are alive 5 years after the diagnosis. These statis-
tics are likely improving as novel treatments are being developed.
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Adult Medulloblastoma
7
Tresa McGranahan and Sonia Partap
Clinical Presentation
MB are rapidly growing malignant tumors and patients typically

develop neurologic signs and symptoms over the course of weeks
to months. For adults, the median age of MB diagnosis is 30 years
and diagnosis over 40 years of age is rare. The most common pre-
senting symptoms are headache, dizziness and imbalance. Other
neurologic signs and symptoms can vary depending on the extent
of disease. For example, cerebellar signs and symptoms include
changes in gait, balance, vision and coordination as well as nau-
sea, vomiting and vertigo. There may be compression of the fourth
ventricle, resulting in elevated intracranial pressure (ICP) due to
obstructive hydrocephalus. Typical symptoms of elevated ICP are
early morning headaches and double vision (due to cranial nerve
6 palsy) although elevated ICP may result in loss of conscious-
T. McGranahan
Departments of Neurology and Pediatrics, Stanford University and
Lucile Packard Children’s Hospital, Palo Alto, CA, USA
S. Partap (*)
Departments of Neurology and Neurological Surgery, University of
Washington, Seattle, WA, USA
e-mail: spartap@stanford.edu

Switzerland AG 2023
https://doi.org/10.1007/978-3-031-41413-8_7
104 T. McGranahan and S. Partap
ness. Brainstem, spinal cord, and leptomeningeal spread can

occur and result in additional symptoms. Metastasis of MB out-
side of the central nervous system have been reported but are
rarely presenting symptoms.
Physical exam should include evaluation for papilledema and
detailed cranial nerve testing as well as particular attention
towards findings such as head titubation/head bobbing, truncal
ataxia and wide based ataxic gait.
Genetic Testing
Multiple genetic syndromes have been reported in association

with MB: Li-Fraumeni syndrome, Familial adenomatous polypo-
sis (FAP), Cowden syndrome, Gorlin syndrome, Turcot’s syn-
drome, Rubinstein-Taybi syndrome. For this reason, detailed
family history is recommended for all patients. All patients with
WNT and SHH subtypes should be referred for genetic counsel-
ing and testing. Group 3 and 4 patients should be referred for
genetic counseling if family history of BRCA-associated cancers
or homologous recombination repair deficiency [1].
Radiographic Finding
By definition, MB arises in the cerebellum however, location and

enhancing pattern differ by molecular subtypes (Table 7.1). On
CT, MB are hyperdense and with limited vasogenic edema. On
MR imaging, MB typically has heterogeneous enhancement and
may contain cysts, necrosis, calcifications and hemorrhage. On
T1-weighted images these are isointense or hypointense and
T2-weighted images may be hyperintense or heterogeneous. MB
often restricts diffusion on DWI/ADC and DWI is very sensitive
for detecting non-enhancing nodules.
Given high rates of metastasis all patients require MRI full
spine pre- and post-contrast imaging. This imaging may demon-
strate nodular enhancement or with leptomeningeal spread, linear
enhancement along the pial surface. T2 imaging should also be
obtained as not all metastatic lesions are contrast enhancing.
7
Table 7.1 Medulloblastoma molecular subtypes

Rate of
Subtype Prevalence 5-year OS Histology Location MRI features metastasis
Adult Medulloblastoma
WNT 15% 80% C>>LCA Foramen of Hemorrhage Rare

Luschka
SHH 60% 70% Cerebellar Strong DWI, 5%
hemisphere more edema
TP53wt Majority C, DN
TP53 mutant Rare LCA
Non-WNT/Non-SHH
Group 3 Rare C, LCA High
Group 4 25% 45% C, LCA Midline Minimal contrast 30–40%
OS overall survival, wt wildtype, C classic, LCA large-cell/anaplastic, DN desmoplastic/nodular
105
In adults, the most common etiology of a cerebellar mass is

metastasis from a solid cancer (for example lung or breast cancer)
and not MB. The radiographic differential also includes ependy-
moma, choroid plexus papilloma, hemangioblastoma and glioma.
For children, the radiographic differential includes atypical tera-
toid rhabdoid tumor, ependymoma, and pilocytic astrocytoma.
Staging
Chang stage (Table 7.2) is used to document extent of disease and

for risk stratification [2]. Given high rates of metastasis in MB, as
well as implications for treatment, all MB require CNS staging.
An MRI brain should be obtained both preoperative as well as
within 48 h after surgery. This is essential for determining the
amount of residual disease before post-surgical inflammation
changes predominant. Patients also require MRI spine obtained
pre-operatively or 2–3 weeks after surgery. If there is no radio-
graphic evidence of leptomeningeal spread, CSF should be sam-
pled from the lumbar spine 2 weeks postoperatively to reduce the
risk of false positive results from surgical debris. Often due to
Table 7.2 Chang staging

Tumor classification
T1 <3 cm
T2 >3 cm
T3a >3 cm with spread into the aqueduct of Sylvius and/or foramen of
Luschka, cerebral subarachnoid space, third or lateral ventricles
T3b >3 cm with unequivocal spread into the brainstem; for T3b, surgical
staging may be used in the absence of involvement at imaging
T4 >3 cm with spread beyond the aqueduct of Sylvius and/or the
foramen magnum
Metastatic classification
M0 GTR and no evidence of CSF or distant spread
M1 Tumor cells found in CSF
M2 Intracranial tumor beyond primary site
M3 Gross nodular seeding in subarachnoid space
M4 Metastasis outside of neuroaxis (e.g. bone, bone marrow)
7 Adult Medulloblastoma 107
hydrocephalus, pre-operative lumbar spine sampling of CSF is

not considered safe. Due to concerns for dural enhancement
following lumbar puncture, MRI of spine should be obtained prior
to lumbar sampling of CSF. Systemic staging (PET, CT, bone
scan) is only recommended if there are concerning symptoms.
Pathologic and Molecular Findings
MB is an embryonal tumor with histology of small round blue

cells with mitosis. Histologically, MB is divided into three sub-
types (classic, large-cell/anaplastic, and desmoplastic/nodular).
Large-cell/anaplastic subtype is associated with worse prognosis
compared to other groups [3]. As of WHO 2016, MB are also
divided into four molecular subtypes (WNT, SHH, Group 3 and
Group 4) which overlap with the histological subtypes [4]
(Table 7.1). All MB subtypes are WHO grade 4 tumors.
WNT-MB subgroup represents 15% of adult MB. This sub-
group is characterized by activation of the WNT/beta-catenin
pathway and typically has classic histology, however rarely is
large-cell/anaplastic. WNT-MB has the best prognosis for both
adults and children, however the 5 year survival in adults is 80%
compared to over 95% in children. On MRI, the WNT subgroup
often arises from the cerebellar peduncle and has higher rates of
hemorrhage. Even without suspicion based on family history,
6–8% of patients with WNT-MB had germline APC mutations so
all of these patients should have genetics referral [1].
SHH-MB subgroup is the most common subtype in adults repre-
senting 60% of adult MB. This subgroup is characterized by muta-
tions in the sonic-hedgehog (SHH) pathway and subdivided into
TP53 wildtype and mutant. In adult MB, the majority of SHH-MB
are TP53 wild-type. All histologic subtypes are seen in SHH-MB,
however large-cell/anaplastic is more common in TP53 mutant
SHH-MB. The 5-year overall survival is 70% in adults. SHH-MB
are more often in the cerebellar hemispheres, although they may be
midline in adults. There is often a greater degree of edema sur-
rounding SHH-MB compared to other subtypes. Genetics referrals
should also be considered for SHH subgroups with consideration of

germline testing for TP53, PALB2 and BRCA2.
Non-WNT/Non-SHH subgroup: The 2021 WHO is comprised
of the “Group 3” and “Group 4” subtypes that were previously
defined in the 2016 WHO, as well as other molecular subtypes
that has emerged with more granular methylation and transcrip-
tome profiling.
Group 3 subgroup is extremely rare in adults with reports ranging

from 0 to 5%. This subgroup may have classic or large cell/
anaplastic. Rates of metastasis are high contributing to the
poor prognosis of this group for both children and adults [5].
Group 4 subgroup is the second most common subgroup in adults
representing 20–25% of adult MB. Histologically this may
have classic or large cell/anaplastic morphology [6]. In adults,
Group 4 MB is metastatic in 35–40% of patients contributing
to the poor prognosis with median overall survival of less than
3 years [3, 6]. Group 4 MB are more often midline and enhance
less than other subtypes.
First Line Treatment
Clinical Risk Stratification
The majority of studies have not found the risk stratification used
in children (Table 7.3) to be prognostic in adults. As a result, mul-
tiple definitions have been used to characterize high and average
Table 7.3 Childhood clinical staging of medulloblastoma

High risk Average risk
Age of child Less than 3 years Older than
3 years
Extent of resection STR or biopsy GTR/NTR
Presence of metastatic Metastatic disease M0
disease (M1–3)
Histology Large cell/Anaplastic Classic
GTR gross total resection, NTR near total resection, STR subtotal resection
risk MB in adults. The majority of studies have found metastasis

(Chang M1–4), anaplastic histology and brainstem involvement
to be associated with worse prognosis. Risk stratification based on
age or residual disease remains unclear in adult MB especially
since the identification of molecular subgroups.
Surgery
Surgery is an essential component for diagnosis and management

of MB. The goal of surgery is removal of as much visible tumor
as can be done safely without resulting in new neurologic deficits.
Residual tumor volume of less than 1.5 cm2 is considered a gross
total resection (GTR). In the setting of brain stem involvement,
leaving residual tumor volume is considered safe. In adults with
group 4 tumors there is a progression free survival benefit to GTR
[7] however maximal safe resection in all patients is recom-
mended.
In addition to diagnosis and debulking, surgery may also be
needed for management of hydrocephalus. Obstructive hydro-
cephalus is common at presentation of MB and patients may
require CSF diversion even prior to initial work up. For many
patients, debulking surgery can relieve obstruction, however some
may require shunt placement for treatment of the hydrocephalus.
Regardless of initial hydrocephalus management, development of
signs and symptoms related to elevated ICP should lead to prompt
evaluation for hydrocephalus with head imaging and funduscopic
examination.
Craniospinal Irradiation
Surgery and radiation remain the cornerstone of treatment for

adult MB while the role of chemotherapy is questioned in adults.
The standard of care is to start craniospinal irradiation (CSI)
within 4 weeks of surgery and retrospective data have found that
adult patients who started radiation after this window trend
towards worse survival [8]. Proton CSI is favored over photon CSI
due to data that found adult MB patients had less weight loss,
nausea, vomiting, hematologic toxicities and esophagitis when

treated with protons [9]. The range of dose for CSI is between
23.4 and 39.6 Gy and tumor bed is boosted to between 54 and
55.8 Gy. Despite the limitations to risk stratification noted above,
CSI to a dose of 36 Gy in 20 fractions is typically used for patients
determined to be high risk due to the presence of metastasis, ana-
plastic histology or brainstem involvement. For patients without
these high risk features, a CSI dose of 23.4 Gy in 13 fractions with
the same tumor bed boost to 54–55.8 Gy is used.
Focal radiation to sites of metastatic disease vary based on
location and tolerance of tissues. Typical doses are 50.4 Gy for
intracranial metastasis or below the conus and 45 Gy for focal
spinal metastasis above the conus. In the setting or radiographic
leptomeningeal disease, the dose of CSI is increased to 39.6 Gy.
While dose reduction is being studied in average risk WNT tumors
in patients up to 21 years of age (NCT02724579, NCT01878617),
this is not recommended for adults outside of clinical trials.
Systemic Therapy
MB is sensitive to chemotherapy, however at this time there is no

standard chemotherapy regimen for adult MB. Most chemother-
apy regimens have been adopted from pediatric studies as only
three prospective, single arm, adult MB clinical trials have
resulted and none included molecular subtypes. Most retrospec-
tive studies have not found benefit to chemotherapy, however a
recent meta-analysis did find improved survival combining a wide
variety of chemotherapy protocols (neoadjuvant, concurrent and
adjuvant). As a result, treatment guidelines from EANO-
EURACAN recommend treatment of all patients with chemother-
apy in addition to CSI regardless of risk factors or molecular
subtype [7].
The role of chemotherapy in adult MB is an area in need of
prospective clinical trials. Whenever possible patients should be
referred for participation in clinical trials. The treatment recom-
mendations differ between NCCN and EANO-EURACAN; these
authors’ recommendations are reflected [7]. Neoadjuvant chemo-
Table 7.4 First line chemotherapy following irradiation

Packer—42 day cycle CVP—28 day cycle
D1: Lomustine 75 mg/m2 D1–4: Cisplatin 25 mg/m2
D1: Cisplatin 70 mg/m2 (consider D1–4: Etoposide IV 40 mg/
carboplatin AUC 4 as alternative) m2
D1, D8, D15: Vincristine 1.5 g/m2 (2 mg D4: Cyclophosphamide
max) 1000 mg/m2
4–8 cycles pending tolerability Goal: 4 cycles
AUC Area under the curve
therapy is not recommended. Given toxicity and unclear benefit,

chemotherapy concurrent with radiation (vincristine or carbopla-
tin) are not recommended. It is important to note that other groups
do advocate for use of concurrent chemotherapy [8]. NCCN
guidelines support adjuvant chemotherapy of either the “Packer
Protocol”, consisting of platinum agent (carboplatin or cisplatin),
lomustine and vincristine [10], or “CVP” with cyclophospha-
mide, etoposide, cisplatin [11]. In fit adult MB patients, adjuvant
chemotherapy with “Packer Protocol” should be considered
(Table 7.4). There are several older multi-drug regimens that have
been reported but are not favored as first line therapy.
Surveillance
Most adult MB recurrences are reported within 6 years of diagno-

sis, however, the high rate of late recurrences in adult MB man-
dates lifelong surveillance. The median time to tumor progression
is 24–50 months, however there is an increased risk of recurrence
in adults after 7 years and recurrences have been reported after
14 years from diagnosis [12].
During treatment, patients should have an MRI of the brain and
spine completed one month following CSI. For patients who have
metastatic disease to the spine or systemic metastasis, all surveil-
lance imaging should include known sites of disease. For patients
without metastatic disease, the role of spine surveillance is debat-
able as 50% relapses occur in posterior fossa and absence of intra-
cranial progression is predictive of absence in spine. Systemic

surveillance (bone surveillance and PET imaging) have been dis-
cussed but at this time are not recommended for adults. These
authors recommend MRI brain and spine every 3 months for the
first year. If no spine involvement, MRI brain alone can be moni-
tored every 3 months for the second year after diagnosis though
there is no standard. In children, spine MRI is obtained serially as
well until 5 years from diagnosis. During years 3–7, imaging fre-
quency can be spaced to every 6 months. Annual MRI surveil-
lance for the known sites of disease should be continued
indefinitely.
Prognosis
True prognosis and survival data are limited given rarity of dis-
ease, wide variations in treatment and limited prospective studies.
For adults, the SEER and CBTRUS databases estimate 2, 5 and
10 year survival as 85–89%, 74–78% and 67–68% [13, 14].
Molecular subtypes help with stratifying prognosis with WNT
having the best prognosis of 5 year survival of 80%, followed by
SHH with a 5 years survival of 70% and Group 4 of 5 year sur-
vival of less than 50% [3].
Recurrent Disease Treatment
At the time of recurrent disease, repeat staging should be com-

pleted with MRI spine, CSF sampling and survey of systemic
symptoms with consideration of CT chest and abdomen or PET
scan. There is very limited data to guide treatment of recurrent
MB and estimated survival after recurrence is 15 months. For this
reason, all patients should be evaluated at a comprehensive brain
tumor center for consideration of clinical trials.
Local treatment options at recurrence include, re-resection and
re-irradiation. While there are increased risks of toxicity with re-
irradiation, stereotactic radiosurgery has been reported to result in
an 89% disease control rate [15].
Table 7.5 Recurrent treatment options

First choice Enroll in a clinical trial
Other options Dosing reference
Local therapyRe-resection
Re-irradiation Brandes et al. (2015) [15]
Chemotherapy Bevacizumab and
temozolomide
Temozolomide
MOPP (methotrexate, Kunschner et al. (2001) [11]
procarbazine, vincristine,
prednisone)
Lomustine + Gill et al. (2008) [16]
platinum ± vincristine
CVP (cisplatin- See Table 7.4
cyclophosphamide-etoposide)
Tandem autologous stem cell Gill et al. (2008) [16]
transplant
Targeted Vismodegib Li et al. (2019) [17]
therapy Sonidegib Li et al. (2019) [17]
Chemotherapy is favored for multifocal relapse however there

have been no studies comparing efficacy of various treatments.
Responses have been reported with several treatments listed in
Table 7.5.
For patients with SHH- MB, SMO inhibitors vismodegib and
sonidegib are well tolerated and should be considered for recur-
rent SHH- MB [17]. There are current prospective trials studying
these agents in newly diagnosed SHH disease as well
(NCT01878617, EORTC-1634-BTG).
Survivorship
The survivorship issues for adult MB parallel those for other

malignant brain tumors with complications of neurologic injury
from site of disease as well as long term effects of radiation and
chemotherapy.
Fertility: All patients should be offered referral to fertility pres-
ervation clinics prior to start of treatment.
Cognitive: Consistent with other studies of whole brain radia-

tion in adults, survivors of adult MB have cognitive impairment.
Studies have identified the cognitive domains most impacted are
learning, memory, visuospatial skills and reasoning [18].
Differences in cognitive outcomes between proton and photon
radiation have never been proven for adults. In pediatric MB how-
ever, there is retrospective data that suggests superior global IQ,
perceptual reasoning and working memory with protons com-
pared to photons. Both groups had impaired processing speed
[19].
Endocrine: Treatment with CSI places patients at risk for pitu-
itary dysfunction as well as primary endocrine organs. The major-
ity of data for endocrinopathies following treatment for MB are
based on childhood survivors. The risk of thyroid dysfunction
(primary or second) for children treated with CSI range from 20
to 69%.
Patients who underwent CSI should have annual surveillance
for endocrine dysfunction with TSH and free T4, gonadal steroids
and AM cortisol. There should be a low threshold for shorter
intervals of endocrine screening if patients clinically decline with
unexplained weight loss, excessive fatigue, nausea or orthostatic
symptoms.
Ototoxicity: Ototoxicity develops in 48% of patients treated
for MB most often as a complication from treatment. Platinum
based chemotherapies, particularly cisplatin, cause ototoxicity
that should be monitored during treatment as well as long term.
Carboplatin can be considered in lieu of cisplatin as it has less
ototoxic effects. Cochlear dose of radiation can also impact
ototoxicity and studies in children have found that reducing the
cochlear dose of radiation reduces grade 3 and 4 ototoxicity
[8].
Neuropathy: Multiple studies in adult MB highlight the risk of
peripheral neuropathy with vincristine [8, 10]. Given the high risk
of neuropathy with vincristine, as noted above these authors do
not support including concurrent vincristine during radiation in
adults. If vincristine is used in adjuvant chemotherapy, close mon-
itoring is necessary and discontinuation if grade 2 motor or sen-
sory neuropathy develops.
Radiation related neurologic injury (radiation necrosis): Brain

and spinal radiation injury can occur in MB similar to other brain
tumors. Radiation injury in the brain stem can be particularly
toxic presenting with weakness, dysarthria or dysphagia. With
proton radiation, these changes occur 8–18 months following the
start of radiation [8].
Genetic screening: A high prevalence of genetic predisposition
were found in WNT and SHH subtypes of both childhood and
adult MB. Current recommendations are that all patients with
WNT and SHH MB should be referred for genetic counseling and
testing as standard of care [1].
Secondary Malignancy: Patients treated with radiation and
chemotherapy remain at risk for secondary malignancies. There is
no standard accepted screening however the risks include (but are
not limited to) skin cancer, secondary brain tumor (meningioma,
glioma), sarcomas, leukemia and thyroid malignancy [20].
Vascular Complications: CSI may result in a multitude of radi-
ation induced/accelerated vascular complications in the brain as
well as cardiovascular system. Cerebral microhemorrhages have
been reported to occur in 67% of patients by 4 years after treat-
ment [21]. Other vascular complications include radiation vascu-
lopathy and resulting ischemic strokes as well as cavernomas.
Additionally, spinal radiation may place cardiac structures at
increased risk, for this reason childhood cancer survivor guide-
lines recommend echocardiogram every 5 years following spine
radiation.
Future Directions
Adult MB is a rare adult malignancy and at this time there are

limited prospective clinical trials to guide treatment. All patients
with MB should be referred to a comprehensive brain tumor cen-
ter for consideration of clinical trials even inquiring at pediatric
centers for clinical trial options. Table 7.6 includes samples of
patient-facing education in lay terms to help patients understand
their condition and options.
Table 7.6 Patient education

Patient
question Patient information
Type of Adult medulloblastomas are rapidly growing brain tumors.
tumor They develop from cells in the posterior fossa, or back lower
area of the brain. They are extremely rare in adults and more
common in children
Symptoms Often adult patients with medulloblastoma present with
headache, vision changes, dizziness or imbalance
Next steps These tumors have a high risk of spreading in the fluid
surrounding the brain and spinal cord. MRI of the patient’s
spinal cord and a sample of the spinal fluid is necessary to
see if the tumor has spread
Treatment Because these are rare tumors, referral to a center that
specializes in brain tumors is recommended
Surgery is the first step of diagnosis and treatment
This is followed by radiation to the area the tumor was seen
on the MRI as well as the whole brain and spinal cord. This
radiation is typically delivered 5 days a week over 6 weeks
Chemotherapy may be given after radiation.
Side effects Tumor resection: Often after surgery patients will need to
work with a therapist to improve speech or movement
Radiation: Risks include hair loss, nausea/vomiting,
decrease in blood counts and headaches however full
discussion of side effects should occur with treating
radiation oncologist
Monitoring These tumors have a high risk of growing back. For that
reason, patients will need to be monitored with MRIs for
life. Initially these will be every 3 months but overtime the
frequency of MRIs will decrease
Genetic Multiple genetic syndromes have been reported in
testing association with medulloblastoma. All patients should be
considered for genetic counseling and patients with WNT
and SHH subtypes will need genetic testing
Prognosis Medulloblastomas are potentially curable, however may
recur even more than a decade from the time of diagnosis.
Over 70% of patients who undergo treatment live longer
than 5 years
Current clinical trials are exploring the role of molecular strat-

ification and incorporation of targeted agent. Given improved out-
comes in WNT subgroup MB, reduced doses of radiation are also
being explored in patients up to 21 years of age. The role of che-
motherapy in treatment of adult MB remains unclear but may con-
fer a benefit [22]. There have only been three prospective adult
MB clinical trials that have results [10, 12, 23]. None of these
studies used molecular stratification. There is urgent need for a
prospective randomized clinical trial in adult MB of adjuvant che-
motherapy.
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A9961. Neuro Oncol. 2013;15:97–103.
21. Roongpiboonsopit D, Kuijf HJ, Charidimou A, et al. Evolution of cere-
bral microbleeds after cranial irradiation in medulloblastoma patients.
Neurology. 2017;88:789–96.
22. Franceschi E, Bartolotti M, Paccapelo A, et al. Adjuvant chemotherapy in
adult medulloblastoma: is it an option for average-risk patients? J
Neurooncol. 2016;128:235–40.
23. Moots PL, O’Neill A, Londer H, et al. Preradiation chemotherapy for
adult high-risk medulloblastoma: a trial of the ECOG-ACRIN Cancer
Research Group (E4397). Am J Clin Oncol. 2018;41:588–94.
Treatment of Ependymoma
8
Jing Wu and Surabhi Ranjan
A 43-year old woman presented with 4 months of progressive head-

aches and neck pain. A brain MRI image with gadolinium contrast
revealed a large homogeneously enhancing mass within the fourth
ventricle extending through the foramina of Luschka and Magendie
and inferiorly to the lower aspect of C2 vertebrae. These lesions
caused mass-effect on the brainstem and upper cervical cord
(Fig. 8.1).
The patient underwent a resection of the intraventricular mass.
A postoperative MRI of the brain showed a 1 cm × 0.8 cm residual
tumor. An MRI image of the cervical, thoracic and lumbar spine
was obtained for staging, which showed no signs of tumor dis-
semination. A lumbar puncture was performed 2 weeks after the
surgery and no malignant cell was found in the cerebrospinal
fluid. The patient’s pathology report was reviewed and showed a
well delineated tumor with monomorphic cells of variable density
and round to oval nuclei with speckled chromatin. Perivascular
pseudorosettes were observed. The patient was diagnosed with a
grade 2 ependymoma. She received involved field radiation ther-
J. Wu (*) · S. Ranjan
Department of Neurology, Cleveland Clinic Florida, Weston, FL, USA
e-mail: Jing.wu3@nih.gov
Switzerland AG 2023
https://doi.org/10.1007/978-3-031-41413-8_8
120 J. Wu and S. Ranjan
a b c
Fig. 8.1 (a) Axial T1 post-contrast MRI revealing an irregular hyperintense

mass within the fourth ventricle and compressing the surrounding brainstem.
(b) Appearance of the lesion on T2 FLAIR sequence. (c) Sagittal T1 post-
contrast sequence
a b
Fig. 8.2 Sagittal T2 sequence (a) and T1 post-contrast sequence (b) of the
thoracic MRI showing sausage-shaped intradural and extramedullary masses
at the T10 and T12 levels
apy to the residual tumor and tumor bed to a total dose of 59.4 Gy
in 33 fractions. Three years later, the patient started complaining
of progressive back pain radiating to the lower anterior abdomen.
An MRI of the spine revealed intradural extramedullary masses at
T10 and T12 level (Fig. 8.2). These tumors were resected and a
pathological exam confirmed a grade 2 ependymoma. No evi-
8 Treatment of Ependymoma 121
dence of recurrence was found in the brain or cerebrospinal fluid

(CSF). Postoperatively, she received focal radiation to the T10
and T12 regions. Her low back pain was resolved after the treat-
ment and she remained symptom-free and without disease pro-
gression for 30 months following the focal radiation to the lower
thoracic spine.
Surgical Role
Surgical resection is the mainstay of the current treatment of

ependymoma. The surgical procedure is essential to establish a
pathological diagnosis and collect tissue for genomic analysis to
determine each case’s unique molecular features. If the tumor
cannot be resected safely due to its location, a biopsy of the lesion
is still required to confirm the pathological diagnosis prior to the
treatment. The extent of surgical resection has been consistently
shown as a prognostic marker in pediatric and adult studies [1–4].
Patients with gross total resection (GTR) have improved out-
comes with a lower rate of local recurrence and improved overall
prognosis. Patients who underwent subtotal resection, even with
the addition of radiation therapy, have an increased chance to have
disease progression [5]. Myxopapillary ependymoma was previ-
ously classified as a grade 1 tumor due to long survival time and
potential for cure after gross total resection, but some myxopapil-
lary ependymomas may present with late recurrence or dissemi-
nation and have been upgraded to grade 2 in the 2021 WHO
Classification of CNS Tumors. A postoperative MRI obtained
within 24–48 h of surgery is recommended to determine the extent
of the resection. GTR is defined as no residual contrast-enhanced
or non-enhanced lesion seen on postoperative MRI and a report of
no residual tumor by the operating surgeon. If there is extensive
residual disease showing on the immediate postoperative MRI
and the lesions can be resected readily, a second-look surgery can
be beneficial [6, 7].
Ependymomas are known for a high rate of CSF dissemination

as compared to other gliomas with studies reporting a rate of
7–10% [8, 9]. CSF analysis is recommended as staging in addi-
tion to imaging of the entire neuroaxis. However, a lumbar punc-
ture should be deferred by at least 2 weeks postoperatively to
avoid confusing findings in the CSF. A CSF analysis positive for
malignancy should be repeated after another week to rule out false
positive CSF dissemination as it will change the treatment para-
digm [10].
Key Pathologic and Molecular Findings
The pathognomonic features of ependymoma are perivascular

pseudorosette and true ependymal rosettes [11]. Pseudorosettes
are characterized by tumor cells arranged radially around a blood
vessel with a perivascular anuclear zone of fine fibrillary pro-
cesses. Ependymal rosettes are formed when cuboidal or colum-
nar tumor cells are arranged around a central lumen.
An overview of WHO classification will be in a separate chap-
ter. Briefly, ependymomas are classified from grades 1 to 3. Grade
1 ependymomas include subependymomas. Myxopapillary epen-
dymoma is a WHO grade 2 tumor which arises in the region of the
conus medullaris, cauda equina and filum terminale. Tumor cells
are radially arranged in papillary fashion around vascularized,
mucoid, fibrovascular cores. When resected en bloc, these tumors
have excellent prognosis. However, 34–40% of the cases will
have local recurrent and dissemination along the neuraxis [12,
13]. Grade 2 and 3 ependymomas are designated based on tumor
location: spinal, supratentorial, or posterior fossa; and further des-
ignated based on molecular findings. Supratentorial ependymo-
mas include ZFTA-fusion positive and YAP1-fusion positive. The
entity formerly known as ependymoma RELA fusion position, in
the 2016 WHO, is now included in the ZFTA-fusion positive sub-
group [14]. Posterior fossa ependymomas include group PFA and
group PFB. Spinal ependymomas include a distinct subgroup of
spinal ependymoma, MYCN-amplified. In the 2021 WHO, the
designation of “anaplastic” ependymoma has been removed,
however ependymoma may be classified by pathologists as grade

2 or grade 3 according to histopathological features [15].
Subependymomas are WHO grade I tumors, which are slow
growing, exophytic and consist of bland to mildly pleomorphic
mitotically inactive cells embedded in a fibrillary matrix. These
tumors are characterized by intraventricular location and are most
commonly found in the fourth ventricle. Subependymomas have
excellent prognosis.
The above case represents a posterior fossa ependymoma. The
pathognomonic features of ependymoma are perivascular pseudo-
rosette and true ependymal rosettes. Pseudorosettes are character-
ized by tumor cells arranged radially around a blood vessel with a
perivascular anuclear zone of fine fibrillary process. Ependymal
rosettes are formed when cuboidal or columnar tumor cells are
arranged around a central lumen.
Ependymomas have three distinct histopathological variants
without clinicopathological significance. These are papillary
ependymoma, characterized by well-formed papillary, clear-cell
ependymomas which have oligodendrocytes-like appearance and
tanycytic ependymoma, which have elongated cells with spindle-
shaped nuclei. It is important to know that geographic necrosis is
not a diagnostic feature by itself without association with high
proliferation index and vascular proliferation. Non-pallisading
necrosis can be seen in grade 2 ependymoma, while pseudopalli-
sading necrosis and microvascular proliferation are common in
grade 3 ependymomas.
Transcriptome and methylome profiling have recently identi-
fied nine molecular subgroups of ependymoma, each into three
central nervous system (CNS) compartments of supratentorial,
posterior fossa and spinal compartments [16]. These molecular
subgroups have a better clinical and prognostic association than
the histological classification and form the basis of the 2021 WHO
integrated molecular classification. Supratentorial ependymomas
are divided into ZFTA-fusion positive, which includes the RELA
fusion gene and a poor outcome, and YAP1-fusion positive, which
has a relatively good prognosis. Posterior fossa ependymomas are
categorized into PFA and PFB. PFA are found in infants, have
balanced genomes, a higher extent of CpG island methylation and
have poor prognosis [16, 17]. PFB are found in children and
adults, have genome-wide polyploidy, low CpG island methylation
and good outcomes. Posterior fossa subependymoma has a bal-
anced genome and a good outcome. Ependymomas occuring in
the spine include are spinal ependymoma, myxopapillary ependy-
moma, and subependymoma. Spinal ependymomas have frequent
NF2 gene mutation and frequently occur in neurofibromatosis
type 2 patients. These have good outcomes. Spinal myxopapillary
ependymomas have genome-wide polyploidy and good progno-
sis. Spinal subependymomas are associated with 6q deletion and
have good prognosis.
Radiation Therapy
Due to a lack of prospective studies and rarity of ependymomas,

there is a wide variation in radiation treatment recommendation
among experts. The decision for adjuvant radiation in treatment of
ependymoma depends on the tumor grade, extent of resection and
status of tumor dissemination. In general, patients with anaplastic
ependymoma, patients with subtotal resection and disseminated
tumors are treated with upfront adjuvant radiation. Cranio-spinal
irradiation (CSI) is not recommended unless the patient has evi-
dence of wide-spread dissemination. The role of radiation therapy
is unclear for WHO grade 2 ependymomas with gross total resec-
tion, and general consensus is that patients can be observed clini-
cally and radiographically after complete removal of a grade 2
ependymoma [11]. Patients with spinal cord grade 2 ependymo-
mas with subtotal resection generally undergo upfront radiation
therapy. A recent retrospective study on 1058 patients found
improved progression free survival, but no improvement in over-
all survival with the use of adjuvant radiation therapy in WHO
grade 2 spinal ependymoma [18]. Similarly, another study evalu-
ating 348 patients with spinal cord ependymoma showed an
improvement in PFS with adjuvant radiation but no improvement
in OS [19]. A total dose of 59.4 Gy to the involved field using
conventional fractionation of 1.8 Gy per day in 33 fractions can be

used [20]. Children between 12 and 18 months with a gross total
resection have been treated with a total dose of 54 Gy [20]. The
dose to the optic chiasm and spinal cord should be limited to
54 Gy or less [21].
Patients with myxopapillary ependymoma which have been
resected en bloc (without the breach of capsule) are associated
with very low risk of recurrence (0–10%) do not require any adju-
vant radiation [22, 23]. Local radiation to the spinal lesion is
administered in patients with sub-totally resected myxopapillary
ependymoma. In contrast to adults, pediatric myxopapillary epen-
dymomas do not have a benign course and a majority of patients
present with disseminated spinal disease [24]. In fact, a pediatric
myxopapillary ependymoma study found that patients who under-
went a subtotal resection followed by radiation fared better than
patients who underwent GTR alone [25].
For disseminated ependymoma, debulking of the primary
tumor should be attempted. Craniospinal irradiation may be con-
sidered in patients using a dose of 36 Gy in 1.8 Gy fractions with
a boost of 59.4 Gy to the primary tumor and metastases. A combi-
nation of chemotherapy and focal irradiation can also be used.
Subependymomas are considered WHO grade I benign tumors
and no adjuvant radiation treatment is recommended after surgi-
cal resection.
Proton therapy has been considered more in the management
of ependymomas due to its feature of sparing normal tissues. It
may be the most beneficial for young patients with tumors that
require radiotherapy near critical structures. Prospective studies
with extended follow-up are warranted to investigate the effect of
proton versus photon therapies in both pediatric and adult ependy-
momas.
Chemotherapy
The role of chemotherapy is not established in ependymoma.

Chemotherapy has been most investigated in pediatric studies.
Due to the concern for severe radiation toxicity to the developing
brain among infants, chemotherapy has been used in an attempt to

defer the radiation to the developing nervous system [26, 27].
Alternating procarbazine and, carboplatin, etoposide and cispla-
tin, cyclophosphamide and vincristine that are used postopera-
tively have been found to be active antineoplastic regimen but no
tumor has shown more than 50% reduction. The second prospec-
tive AIEOP protocol for pediatric patients investigated four
courses of vincristine, etoposide and cyclophosphamide after
radiation in patients with anaplastic ependymoma [7]. The VEC
regimen used vincristine at 1.5 mg/m2 on day 1, cyclophospha-
mide 1 g/m2 infused in one hour for 3 doses, 3 h apart on day 1
and etoposide 100 mg/m2 infused in 2 h, days 1, 2 and 3. Each
cycle was of 3–4 weeks duration, for a total of 4 cycles.
The children’s oncology group has an ongoing Phase 3 trial
COG ACNSS0831 evaluating maintenance chemotherapy versus
observation, following induction chemotherapy and radiation
therapy in treating children with newly diagnosed ependymoma.
One of its experimental arms uses a chemotherapy regimen con-
sisting of vincristine on day 1 and 8, of courses 1 and 2, carbopla-
tin on day 1 of courses 1 and 2, and cyclophosphamide on day 1–2
of course 1 only. Etoposide is administered on day 1–3 of course
2. Another experimental arm uses vincristine on day 1, 8 and 15
of course 1–3 only, etoposide on days 1–3, cisplatin on day 1,
cyclophosphamide on days 2 and 3.
The role of chemotherapy was not studied prospectively in
adults until a clinical trial by The Collaborative Ependymoma
Research Network (CERN) investigators, where they rationalized
to test a dose-dense temozolomide regimen in combination with
lapatinib in recurrent ependymoma. Some evidence of treatment
efficacy as disease control and objective response were found.
However, the survival benefit cannot be determined.
Given the positive correlation between patients with no resid-
ual tumor and prognosis, a bridge chemotherapy approach has
been used in several studies [7, 28]. This approach uses chemo-
therapy as a conduit to reduce the bulk of residual tumor, after the
first surgery so that a second-look surgery or irradiation can be
undertaken (Table 8.1).
8
Table 8.1 Upfront pediatric chemotherapy regimens for ependymoma

Patient age group
Clinical trial and number Treatment Chemo regimen PFS OS
Second 3–21 years with Group 1: Residual tumor, any VEC Grade II, Grade II,
AIEOP, 2016 intracranial grade—VEC chemo (upto vincristine at 1.5 mg/m2 D1, 5-year: 5-year:
[7] ependymoma, 4 cycles), possible second cyclophosphamide 1 g/m2 D1 and 75.3% 90.5%
N = 160 surgery, RT + boost etoposide 100 mg/m2, days 1, 2 Grade III, Grade III,
Group 2: No residual tumor, and 3 for 4 cycles of 3–4 weeks 5-year: 57% 5-year:
WHO grade II—RT Supportive treatment: granulocyte 73.3%
Group 3: No residual tumor, colony stimulating factor
Treatment of Ependymoma
WHO grade III—RT followed

by VEC × 4
UKCCSG/ Children under Surgery, followed by four Course 1, carboplatin 550 mg/ 3-year event 3-year
SIOP study, 3 years, N = 89 courses of alternating m2 + vincristine 1.5 mg/m2 free overall
2007 [27] myelosuppressive and Course 2, methotrexate 8000 mg/ survival, survival,
non-myelosuppressive drugs m2 + vincristine 1.5 mg/m2 42.7% 76.8%
repeated every 56 days for a Course 3, cyclophosphamide 5-year event 5-year
total of 7 cycles 1500 mg/m2 with mesna free overall
Course 4, cisplatin 40 mg/m2 survival, survival,
37.5% 60%
(continued)
127
128
Patient age group

Clinical trial and number Treatment Chemo regimen PFS OS
French Children under Surgery, chemo (3 courses in Course A: Carboplatin 15 mg/kg, 2-year PFS, 2-year
Society of 5 years with of 21 days each, 7 cycles) day 1 + procarbazine 4 mg/kg/day 33% OS, 79%
Pediatric intracranial Salvage radiation for disease on days 1–7 4-year PFS, 4-year
Oncology, ependymoma, progression or relapse Course B: 22% OS, 59%
2001 [26] N = 73 following chemotherapy Etoposide 5 mg/kg/day on days
22 and 23 + cisplatin 1 mg/kg/day
on days 22 and 23
Course C:
Vincristine 0.05 mg/kg on day
43 + cyclophosphamide 50 mg/kg
on day 43
German HIT Pediatric HIT 88/89: Sandwich chemo: 2 cycles of 45 months 3-year
study, 2000 anaplastic Surgery, sandwich chemo, ifosfamide, etoposide, OS:
[29] ependymoma, radiation methotrexate, cisplatin and 75.6%
N = 55 HIT 91: cytarabine
Surgery followed by Maintenance chemo: 8 cycles of
randomization to either methotrexate, cisplatin and
RT + weekly vincristine and vincristine
maintenance chemo
OR
Sandwich chemo followed by
RT
J. Wu and S. Ranjan
There is no role for upfront chemotherapy in adult patients

with ependymoma, other than in a clinical trial setting.
Other Modalities
With more identified unique molecular features and genomic

alterations are discovered, targeted therapies regimen has been
tested in the setting of clinical trials. For example, it was discov-
ered that co-expression of ERBB2 and ERBB4 is elevated in
more than 75% of ependymomas and a high expression of ERBB
receptors is associated with an aggressive tumor behavior.
Therefore, lapatinib, an inhibitor of ERBB2 receptor, has been
tested in a clinical trial of recurrent ependymoma when com-
bined with temozolomide, a commonly used alkylating agent
(NCT00826241). Another example is that VEGF inhibition was
tested as a therapeutic approach given the elevated VEGF expres-
sion in most of the ependymoma. A combination of VEGF mono-
clonal antibody and carboplatin has been tested in the recurrent
ependymoma (NCT01295944). More recently, marizomib, a
second-generation irreversible proteasome inhibitor which pen-
etrates the blood brain barrier has been tested in recurrent epen-
dymomas with a characteristic signature C11orf95-RELA fusion,
which drives tumorigenesis in 70% of supratentorial ependymo-
mas by activating the NF-KB transcription pathway
(NCT03727841).
Surveillance
Surveillance guidelines for ependymoma patients are rather arbi-

trary and extrapolated from clinical trials. Patients with intracra-
nial ependymoma should be followed with an MRI brain with and
without contrast every 3 months for the first year after treatment,
then every 3 months for the second year, and every 4–6 months
afterwards [7]. It is reasonable to add a contrast-enhanced MRI of
the entire spine every 6–12 month in the first year for staging, or
if symptoms attributed to spinal cord involvement are suspected.
For patients with disseminated ependymoma, the entire neuraxis
is imaged with contrasted MRI brain and spine every 3 months for
the first 2 years after treatment, then every 4 months for the next
2 years and every 6 months thereafter.
Most patients develop tumor recurrence at the primary site. At the

time of recurrence, staging for dissemination and CSF should be
performed. Treatment approaches for recurrent ependymoma,
again rely on surgery and radiation. Patients should undergo a
maximal safe surgical resection followed by involved field radia-
tion or reirradiation. Stereotactic radiosurgery or focal fraction-
ated reirradiation is often used. Craniospinal irradiation is
sometimes utilized but best avoided. A retrospective study on 101
pediatric patients showed that brain radiation was well-tolerated
by most patients [30]. After irradiation, the median progression
free survival was 27.3 months and the median overall survival was
75.1-months. The 10-year cumulative incidence of severe radia-
tion necrosis after reirradiation was 7.9%. Opportunities should
be investigated for clinical trial enrollment.
Prognosis and Survivorship
Rather than the tumor grade, the prognosis of ependymoma

depends on age and tumor location. A retrospective study on 123
patients with adult ependymoma found an overall survival of
221 months for all intracranial ependymomas and 67 months for
anaplastic ependymoma [31]. The overall survival for spinal
tumors was longer and could not be calculated due to the small
number of events. In this study, the median time to first recurrence
was 21 months for intracranial ependymomas, versus 25 months
for spinal tumors.
Supratentorial ependymal tumors have a worse prognosis in
adults. A meta-analysis of 183 adult patients with intracranial
ependymomas showed that supratentorial ependymoma has had a
progression-free survival of 24 months and overall survival of
61 months, as compared to a median progression free survival of

144 months in infratentorial ependymoma, whose median overall
survival could not be calculated [32].
Patients with group A posterior fossa ependymomas have a
significantly poor prognosis as compared to group B posterior
fossa ependymomas. Patients with group A posterior fossa epen-
dymomas are significantly younger (median age of 4 versus a
median age of 39 for group B posterior fossa ependymomas),
commonly male, more frequently classified as WHO grade 3
ependymoma and a higher incidence of metastasis at the time of
recurrence. For group A tumors, the progression free and overall
survival rates are 24% and 48% respectively, in contrast to 92%
and 98% for group B tumors [33].
Subependymomas are benign tumors, most commonly arising
from the floor of the fourth ventricle and lateral ventricles and
often discovered at autopsy. Symptomatic patients are managed
with maximal safe tumor resection and restoration of the normal
CSF flow. Long-term outcomes are excellent, provided there are
no postoperative complications [34].
Adult myxopapillary ependymomas have good outcomes.
Encapsulated myxopapillary ependymomas, which were treated
with a gross total resection with and intact capsule have a low
recurrence rate of 10%, whereas those with a piecemeal resection
or a subtotal resection have a higher recurrence rate of up to 19%
[23]. Overall survival with a gross total resection is 19 years and
with subtotal resection 14 years [23]. The 10-year overall survival
of patients with myxopapillary ependymoma is 92–93% and the
median time to recurrence is 26–30 months [35, 36]. While age
less than 36 years was a negative prognostic marker, the use of
adjuvant RT and a greater extent of surgical resection increased
progression free survival [36]. Pediatric myxopapillary ependy-
momas have a less favorable outcome as compared to adults. A
large retrospective study of 95 pediatric patients less than 20 years
of age, reveals a 5-year progression free survival rate at 73.7%
and a 5-year overall survival rate of 98.9% [25]. In the pediatric
population, addition of radiation therapy following resection sig-
nificantly improves progression free survival [25].
As survival for childhood central nervous system cancers have

improved, there is an increasing focus on their long-term effects
in children and adolescents. Patients may have received surgery,
focal or cranio-spinal radiation therapy and chemotherapy.
Neurological, cognitive, auditory and endocrine dysfunctions are
common in this population, especially among children who were
treated at a young age [37]. Patients who receive craniospinal
radiotherapy experience significant decline in IQ over time as
compared to patients who received focal radiation or surgery
alone. Children younger than 3 or 4 years may experience a dev-
astating longitudinal decline in IQ. Apart from radiation therapy,
hydrocephalus and posterior fossa syndrome contributes to a neu-
rocognitive decline.
Adult patients with intracranial or spinal ependymomas have a
high symptom burden. Adult patients with intracranial ependy-
moma commonly have problems with vision, language, and con-
centration whereas patients with spinal ependymoma developed
limb weakness, sexual dysfunction, radiating pain and change in
bowel pattern [38].
Better understanding of ependymoma biology and molecular fea-

tures will provide more opportunities of developing targeted and
personalized therapeutic strategies. Robust preclinical studies and
clinical trials are essential for the development of novel therapy.
Collaborations between scientists and clinicians specializing in
adult and pediatric neuro-oncology should foster rapid translation
of laboratory science into clinical trials. The rarity of ependymo-
mas makes it challenging to perform large scale or randomized
clinical trials. A collaborative effort between academic centers
should be the future direction to advance the care for ependy-
moma patients (Table 8.2).
Table 8.2 Patient information

What type of tumor do I have?
Ependymoma is a primary central nervous system tumor, which means it
begins in the brain or spinal cord. Ependymoma arises from the ependymal
cells that line the brain cavities (ventricles) and the fluid-filled space which
runs through the spinal cord. Ependymomas occur in both children and
adults. Tumors in the lower half of the brain are more common in children,
but those in the spinal cord are more common in adults. The cause of
ependymoma is not fully understood
Based on how cancer cells appear under the microscope, the World Health
Organization (WHO) grades ependymomas into grades 1, 2 and 3. A lower
grade indicates a slow-growing cancer and a higher grade means that the
cancer is more aggressive.
There are different types of ependymoma depending on the tumor
location, the mutations in the tumor, and the grade of the tumor.
• Subependymomas are WHO grade 1 tumors
• Spinal ependymomas are ependymomas are ependymomas that
occur in the spinal cord. These include
– Spinal ependymoma (WHO grade 2 or 3)
– Spinal ependymoma MYCN-amplified (WHO grade 2 or 3)
– Myxopapillary ependymoma (WHO grade 2)
• Posterior fossa ependymomas are ependymomas that occur in the
back part of the brain. These include
– Posterior fossa ependymoma (WHO grade 2 or 3)
– Posterior fossa ependymoma, group PFA (WHO grade 2 or 3)
– Posterior fossa ependymoma, group PFB (WHO grade 2 or 3)
• Supratentorial ependymomas are ependymomas that occur in the
upper part of the brain. These include
– Supratentorial ependymoma (WHO grade 2 or 3)
– Supratentorial ependymoma, ZFTA fusion-positive (WHO grade
2 or 3)
– Supratentorial ependymoma, YAP1 fusion-positive (WHO grade
2 or 3)
Your medical team will determine which type and grade of ependymoma
you have, based on pathological and molecular study on the tumor tissues
obtained from a surgery or biopsy. Ependymoma rarely grow or
metastasize outside of the central nervous system (brain and spinal cord),
but may spread to other areas of the central nervous system through the
cerebrospinal fluid
(continued)
How do I treat it?

The first goal in treating an ependymoma is to have surgery to remove as
much of the tumor as can be done safely. Sometimes, your medical team
may recommend a second surgery if there is tumor that can still be seen on
an MRI scan after your first surgery. In some patients, a complete surgical
removal of the tumor isn’t possible if the tumor is located in a critical
location of the brain or spinal cord. In these cases, a biopsy is still
recommended so that your medical team can make an accurate diagnosis
of the type of ependymoma
It is important to know that the treatment recommendation for
ependymoma may differ even among ependymoma experts. As
ependymomas are rare tumors, patients should be preferably treated at a
brain and spine tumor center, which have experience in treating this type
of tumor. Grade 2 ependymomas with a complete surgical removal may be
observed with serial MRIs and clinic visits. Grade 2 ependymomas that
are not completely removed and Grade 3 ependymomas will need to be
treated with radiation after you heal from surgery. Your team will also
perform MRIs of the brain and entire spine to find the extent of tumor
spread. A spinal tap will also be done to find out if there are microscopic
tumor cells in your brain and spinal fluid. In rare circumstances, if there is
an extensive spread of the tumor, the entire brain and spine may need to be
treated with radiation
Some centers will offer you a clinical trial for voluntary participation. It is
advised to discuss all options with your oncologist, the expectations from
treatment, and possible side effects
What can I expect to experience during treatment?
Symptoms depend on the location of the ependymoma and type of planned
treatment. Patients with ependymoma in the brain may experience
headaches, memory difficulty, speech problems, seizures and balance
issues. Patients with ependymoma of the spine may feel neck or back pain,
numbness, pain in the arms or legs, and weakness in arm or leg
During treatment with radiation, patients may experience fatigue, sleep
disturbance, memory impairment (if tumor is in the brain), pain from the
tumor location and sometimes swelling of the tumor. You may need
treatment with steroids to control the swelling
Most patients with ependymoma get treatment from a team of experts such
as a neurosurgeon, a neuro-oncologist, a radiation-oncologist, nurse
practitioner or a physician assistant and a nurse. Sometimes, you may be
referred to see a neuropsychologist for memory testing and palliative care
for pain. Your medical team will work closely with you to improve your
symptoms and quality of life
How will we keep an eye on this?

Patients have MRIs and evaluation in a doctor’s office every 3 months for
the first 2 years of treatment and then every 4–6 months thereafter. These
MRIs and clinic visits are usually conducted with a neuro-oncologist. It is
very important for ependymoma patients to continue follow-up with their
neuro-oncologist as these tumors usually recur, sometimes after many
years from initial treatment
What is my prognosis?
The prognosis of ependymoma depends on many factors such as the
patient’s age, the location of tumor, extent of surgical removal, the tumor
grade, tumor’s genetic profile and the type of treatment received. Patients
live longer and with lesser recurrence if the tumor is fully removed with
surgery. Patients with spinal cord ependymomas have better outcomes as
compared to ependymomas in the brain
References
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Part II
Supportive Care Primer
Brain Edema
and Corticosteroid Toxicity 9
Maninder Kaur and Reena Thomas
Principles of Treatment
In Neuro-oncology, steroids are generally used to relieve symp-

toms secondary to edema that affects the brain, spinal cord, and
possibly nerves and nerve roots. Cerebral edema can be due to the
tumor itself or can be a consequence of treatments such as radia-
tion therapy [1]. Cerebral edema can be classified as vasogenic
edema, cytotoxic edema or hydrocephalic edema. Characteristics
of each type of edema are described in Table 9.1.
The primary method of treatment is with corticosteroids. It is
important to treat the patient for their symptoms and not based
decisions on the MRI appearance alone. We rarely recommend the
use of steroids for asymptomatic patients. The rare exception is the
patient with extensive vasogenic edema due to tumor or related to
treatment effect, leading to midline shift or near obstruction of the
fourth ventricle. In these cases, a course of steroids to prevent the
patient from becoming symptomatic may be deemed reasonable.
Graphics: Rosyli Miramontes, MS IV.
M. Kaur
Loma Linda University Health, Loma Linda, CA, USA
R. Thomas (*)
Stanford University, Palo Alto, CA, USA
e-mail: Reenat@stanford.edu

Switzerland AG 2023
https://doi.org/10.1007/978-3-031-41413-8_9
142 M. Kaur and R. Thomas
Table 9.1 Characteristics of each type of edema

Hydrocephalic
Vasogenic Cellular edema edema
edema (Cytotoxic) (Interstitial)
Pathogenesis Increased Cellular swelling; Increased brain
capillary glial, neuronal, fluid from
permeability endothelial blockage of
CSF absorption
Location Chiefly white Gray and white Chiefly
matter matter periventricular
white matter;
hydrocephalus
Edema fluid Plasma filtrate Increased CSF
composition including intracellular water
plasma sodium
proteins
Extracellular fluid Increased Decreased Increased
volume
Capillary Increased Normal Normal
permeability to
large molecules
(insulin, albumin)
Clinical causes • Brain • Hypoxia • Obstructive
tumor hydrocephalus
• Abscess • Ischemia • Purulent
meningitis
• Infarction/ • Ischemic
hemorrhage hypo-osmolality
(water
intoxication)
• Purulent • Dysequilibrium
meningitis syndrome
(granulocytic
edema)
• Purulent
meningitis
• Reye syndrome
EEG Focal slowing Generalized Normal (often)
slowing
9 Brain Edema and Corticosteroid Toxicity 143

Hydrocephalic
Vasogenic Cellular edema edema
edema (Cytotoxic) (Interstitial)
Treatment
1. Steroids 1. Beneficial 1. Not effective 1. Uncertain
possibly in
pseudotumor
or meningitis)
2. Osmotherapy2. Reduces 2. Reduces brain 2. Rarely
volume of volume acutely useful,
normal brain improves
tissue only, compliance
acutely
3. Acetazolamide 3. May be 3. No direct 3. Minor
useful effect usefulness
4. Furosemide 4. May be 4. No direct 4. Minor
useful effect usefulness
Fig. 9.1 Glucocorticoid Pathophysiology
Corticosteroids are generally divided into glucocorticoids,

mineralocorticoids and adrenal sex hormones. Commonly used
corticosteroids and their dosing regimens are listed in Table 9.1.
Synthetic Glucocorticoids are the most widely used in cerebral
edema The proposed mechanisms of glucocorticoids include the
inhibition of release of several biochemical substances which
have been known to increase vascular permeability or induce
vasodilation (which leads to increased permeability secondary to
increased hydrostatic pressure (Fig. 9.1) [2] The key factors that
regulate the BBB are VEGF, Angiopoietin-1 (Ang-1) and angio-
poietin-2 (Ang-2) [3].The exact mechanism of action of steroids
is not well understood. One proposed mechanism is the upregula-

tion of Ang-1, which is a strong BBB stabilizing factor and
downregulation of VEGF a strong permeabilizing factor. It is also
proposed that glucocorticoids may also aid by moving the edema-
tous fluid into the ventricular system [4].
It is always the goal to use the lowest needed dose of steroids
in order to minimize side effects, which are dose dependent. It is
also important to keep in mind the anti-edema effects are also
dose dependent, thus require individualization based on the
patient’s clinical scenario.
anagement of Acute Increased Intracranial

M
Pressure
In patients with acute onset of severe symptoms and signs of

increased intracranial pressure, higher doses of steroids should be
considered. Symptoms might include severe headaches, charac-
terized by pressure-like feelings that are worse in the morning
with associated nausea and vomiting. Patients may also complain
of headache, dizziness or syncopal episode during activities that
transiently increase ICP, such as standing, sneezing, coughing or
straining during bowel movements. In these scenarios, there is a
concern for symptomatic plateau waves [4] which result from
elevated ICP and can lead to intermittent drop in cerebral perfu-
sion. In such acute presentations, we recommend an initial load-
ing dose of Dexamethasone 10–20 mg to be given intravenously.
We follow this loading dose with Dexamethasone 4–6 mg two to
four times a day. Decisions on dosing need to be made on a case
by case basis, but in general, patient rarely get additional benefit
from doses exceeding 16 mg per day.
Chronic Steroid Use and Tapering
Despite the wide use glucocorticoids, there is limited consensus

regarding the dosing, duration as well as tapering protocol. This
holds true as there is limited evidence from clinical trials provid-
ing any guidance [5]. Below are the recommendations from our
general practice. For patients requiring chronic dosing of steroids,
doses should rarely exceed 8 mg per day. Twice daily dosing is
ideal, with the second dose given in the early afternoon to prevent
insomnia.
Patients who are started on steroids but otherwise have mini-
mal or no symptoms, should be tapered off rapidly. For patients
who have been on steroids for a short period, the rapid taper
should not cause any steroid withdrawal symptoms and they can
be tapered off within a few days. The effects of a taper are typi-
cally noticeable 72 h after a dose change and tapers should involve
dose adjustments every 3 days. If they have been on steroids for
more than 2 weeks, then doses should by dropped by 2 mg every
3 days. For some patients who are symptomatic during their treat-
ment course, tapering off of steroids can be very difficult. As in
other cases, we recommend starting a taper by decreasing dexa-
methasone by 1–2 mg every 3–5 days. If patients experience neu-
rologic symptoms due to the taper, we recommend going back to
the dose they previously tolerated. The taper should then be
slower, generally 0.5–1 mg every 5–7 days. In patients that can
tolerate a taper and become steroid-dependent, alternative
approaches should be considered [5, 6].
Steroid Toxicities
The most common neurologic side effects include behavioral

changes, myopathy and insomnia. Neurologic and systemic toxici-
ties of corticosteroids are listed in Table 9.2. Euphoria and mania
are more common with exogenous steroids while depression tends
to be more common with endogenous steroids as in Cushings dis-
ease. As steroids are tapered, symptoms generally resolve.
However, in situations where a steroid taper is not feasible, mood
stabilizers such as lithium, valproic acid, olanzapine or haloperidol
can be used. It is important to note that in patients who have had
steroid induced psychosis after exposure to steroids, that it does
not necessarily predict that psychosis will occur on re-challenge.
Psychotic features can begin acutely and typically respond to with-
Table 9.2 Neurologic and systemic toxicities of corticosteroids
146
Neurologic Non-neurologic Steroid withdrawal

Neurologic (Common) (Uncommon) (Common but mild) Non-neurologic (Serious) syndrome
Behavioral changes (both Psychosis Visual blurring Osteoporosis Myalgias, Arthralgias
cyclic) Delirium Treatment Treatment (steroid pseudo
• Affective (Acute): Dementia 1. Discontinue 1. Imaging (MRI > CT, rheumatism)
Euphoria → Mania (more Seizures steroids X-ray, bone scans) Treatment
common with exogenous Dependence 2. Ophthalmologist 2. Discontinue steroids Increase dose to prior
steroids) Paraparesis consult if concern for (reversible in younger final dose and then taper
• Depression (more (epidural cataracts or glaucoma patients) off more slowly
common with endogenous lipomatosis) • Prophylaxis:
steroids like Cushing’s) Bisphosphonates,
Affective treatment Calcium (1200 mg daily)
1. Steroid taper and Vitamin D (400–
2. Mood stabilizers (Li, 800 IU daily)
valproic acid, olanzapine
or haloperidol)
• Schizophrenia-like
psychosis: begin acutely;
may require neuroleptic
treatment
• Delirium: resolves with
taper
M. Kaur and R. Thomas
9
Myopathy Increased appetite GI bleeding Headache

Treatment (weight gain) Treatment Lethargy
Physical therapy is highly Abdominal bloating Prophylaxis for high Fever
advised Moon facies doses or chronic use: H2 Nausea/vomiting
Proper protein intake and Urinary frequency blocker or PPI Anorexia
replacement of any (nocturia) Avoid sucralfate! Postural hypotension
Vitamin D deficiency Acne Papilledema
Edema (legs) Pneumocystis
Lipomatosis (spinal Pneumonia
cord compression) Adrenal insufficiency
Genital burning (IV
push)
Candidiasis
Cataracts
Insomnia Hypercalcemia
Brain Edema and Corticosteroid Toxicity
Treatment Treatment
Take second dose early in • Oral hypoglycemics
the afternoon (before • Attempt to keep
2 p.m.) glucose before 150 mg/dL
Good bedtime hygiene (no
screen time at least 2 h
prior to bed)
(continued)
147
148

Hallucinations (high Osteonecrosis (hip)
dose) Bowel perforation
Insomnia Diabetes
Tremor Opportunistic infection
Reduced taste/smell (pneumocystis)
Cerebral atrophy Glaucoma
Hiccups Kaposi sarcoma
Pancreatitis
M. Kaur and R. Thomas
drawal of steroids, and some cases, may require treatment with a

neuroleptic. Delirium can be a side effect of steroids, particularly
in older patients. Steroids should be tapered off if possible along
with standard delirium precautions on inpatients.
Myopathy, characterized by proximal lower extremity weak-
ness is worse in patients who are inactive and exercise and/or
physical therapy is recommended as a preventive measure.
Patients note difficulty getting up from a seated position, feeling
weaker while walking and older patients might feel more unsteady
when walking. Proper protein intake and replacement of any
Vitamin D deficiency can also be helpful in preventing further
muscle weakness [1].
Insomnia can be prevented by adjusting the dosing of medication.
In patients, taking twice daily regimens, taking the second dose early
in the afternoon rather than at night can be very helpful. Steroid-
induced nocturia may also contribute to insomnia and patients are
advised to avoid drinking beverages a few hours prior to sleeping.
Hypergylcemia is one of the most common toxicities associ-
ated with corticosteroids that requires active management. In
patients with persistent blood glucose above 150 mg/dL, oral
hypoglycemics are indicated [7]. However, this must be done with
care and glucose will need to be monitored when tapering ste-
roids. In rare cases, oral hypoglycemics may be insufficient and
insulin may be required in consultation with the patient’s primary
care physician.
Osteoporosis begins after a few months but may occur even
within a few weeks and can lead to fractures. In brain tumor patients,
osteonecrosis of hips, shoulder and clavicle may be confused with
spinal cord compression or peripheral neuropathy. In patients with
suspected symptoms, MRI is the most sensitive diagnostic test. In
young patients, osteoporosis generally reverses itself once steroids
are discontinued. Bisphosphonates, Calcium (1200 mg daily) and
Vitamin D (400–800 IU daily) may be given as prophylaxis.
Blurring of vision is a common complaint and can be associ-
ated with steroids. Consultation by an ophthalmologist can be
helpful to evaluate for the development of cataracts or glaucoma.
Though there is not strong evidence regarding steroids alone
leading to GI bleeding secondary to ulceration, we generally
recommend prevention with use of H2 blockers or PPI while on

high doses or chronic use of steroids. It is important to keep in
mind that both PPI and H2 blockers can cause somnolence and
confusion. H2 blockers in particular can lead to thrombocytope-
nia. We generally don’t advice use of Sucralfate as it can prevent
absorption of other medications effectively.
Preventative Measures
Gastritis is a common side effect of steroids. Gastric and duodenal

ulcers can be an eventual occurrence, especially in conjunction
with NSAIDS. Although there are no clear guidelines or evidence
on the use of Proton Pump Inhibitors (PPIs) in patients with brain
tumor, in relation to use of steroid use, gastric discomfort is a
common complaint. In our practice, we recommend the use of PPI
for all patients who are started on Dexamethasone >1 mg. If a
patient is being tapered off steroids, then we generally advise that
PPI can be stopped once the patient has come to about 1 mg of
dexamethasone (or other equivalent) per day. This is in reference
to the daily production of endogenous glucocorticoids. Bowel
Perforation is also an increased risk in patients on steroids.
Prevention by treating underlying constipation [4].
Pneumocystis pneumonia (PJP) prophylaxis with Bactrim (or
equivalent) is generally recommended for patients who are on
prednisone >20 mg (or dexamethasone ≥3 mg QD) for >4 weeks.
In our practice, it is rare for us to keep patients on such high doses
of steroids for prolonged period. We do however recommend
Bactrim prophylaxis in patients who are anticipated to have a pro-
longed taper, as the risk of infection is increased during this time
[4].
Alternative Approaches to Steroids
For refractory symptomatic edema that requires prolonged use of

corticosteroids, we recommend switching treatment to steroid
sparing agent. Anti-VEGF agents, such as bevacizumab or it’s
biosimilar Mvasi have both shown to be beneficial in these patients

who have recurrent or refractory edema, providing symptomatic
relief. We use this in our patients who we anticipate will require
prolonged use of steroids secondary to the edema or in those who
are symptomatic from radiation necrosis. Side effects to be mind-
ful of in these patients are hypertension, proteinuria, hemorrhage,
venous thrombosis, colonic perforation.
At our institution, our practice is to dose bevacizumab at dose
of 5–7.5 mg/kg. This is much lower than the recommended dose
by the manufacturer at 10 mg/kg. We have found the lower rate to
control the edema and radiation necrosis without the detrimental
side effects which generally occur at the higher dose [8].
Patient Instructions
Timing: If giving twice a day dosing, please take the first dose
early in the morning (by 8 a.m.) and second dose no later than
2 p.m. to prevent insomnia and well as nocturia which can further
lead to sleep deprivation.
Stomach protection: Continue to take medications to protect
your stomach from gastritis especially if you are on a higher dose
(>2 mg/day) of dexamethasone. We recommend famotidine or
omeprazole to be taken twice a day.
Glucose: Many patients develop elevated glucose levels, even
if they had no concerns with pre- diabetes or diabetes prior to
starting steroids. We recommend a close monitor on food intake
as increased appetite due to steroids with potential for insulin
resistance and quickly lead to elevated glucose levels that can be
detrimental.
Mood: Please be mindful that steroids can cause many differ-
ent mood disorders including depression, anxiety as well as frank
psychosis. If you feel these are affecting your daily functioning
and relationship, we advise to bring this to the attention of your
prescriber.
Myopathy: To prevent weakness, especially if you are antici-
pated to be on steroids for a long time, we strongly advice daily
exercise regimen. This can be as little as multiple small walks

around the house.
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Tumor Related Epilepsy
10
Thomas Wychowski
Epidemiology and Pathophysiology
Between 25 and 70% of patients with intracranial tumors will

experience an epileptic seizure at some point during their tumor
treatment course, depending on their tumor type [1, 2]. Seizures
occur as the presenting symptom in 30–50% of patients with a
brain tumor, while 10–30% of seizure-naïve patients will later
develop seizures [3, 4]. Based on current definitions provided by
the International League Against Epilepsy (ILAE), any patient
experiencing a seizure during the diagnosis and treatment of a
brain tumor meets criteria for a diagnosis of epilepsy [5]. Tumor-
related epilepsy (TRE) is associated with significant morbidity
and mortality related both to seizures and the medications used to
treat and prevent seizures [6, 7]. Seizures are the leading cause for
acute care utilization in patients with brain tumors [8].
The prevalence of TRE is highly dependent on tumor type and
grade. Patients with neuronal tumors (e.g., ganglioglioma) are
more likely to develop TRE than those with CNS lymphoma [9].
Within the population of diffuse glioma, patients with low-grade
astrocytoma are more likely to develop TRE than those with ana-
plastic astrocytoma or GBM [4]. It is generally accepted, based on
T. Wychowski (*)
University of Rochester, Rochester, NY, USA
e-mail: Thomas_wychowski@urmc.rochester.edu

Switzerland AG 2023
https://doi.org/10.1007/978-3-031-41413-8_10
154 T. Wychowski
electrophysiologic studies, that tumoral tissue itself is not epilep-

togenic, rather the mechanism for neuronal hyperexcitability
exists within the peri-tumoral border which can subsequently
recruit broader and more remote networks of epileptogenic poten-
tial [10, 11]. Pathophysiologic excitotoxicity mediated through
disruption of glutamate pathways has emerged as a predominant
theory in the pathophysiology of TRE. In recent years, several
genetic markers have been proposed as a mechanism for dysregu-
lation of glutamate homeostasis. These include the expression of
mutant isocitrate dehydrogenase (IDH), System xc − glutamate
transporter, and adenosine kinase [12–15]. Validation of the asso-
ciation of these markers and TRE is needed.
mergency Care and the Management of Status

E
Epilepticus
Classically, status epilepticus (SE) is considered the most extreme

form of a seizure and a life-threatening neurologic emergency that
can have short and long-term consequences, including neuronal
death, neuronal injury, and alterations of neuronal networks [16].
Based on the current understanding, a convulsive (tonic-clonic)
seizure is considered abnormally prolonged after 5 min duration,
and likely to lead to continuous seizure activity. A convulsive sei-
zure is likely to cause long term consequences (neuronal injury/
death) after 30 min. In contrast, focal SE with impaired con-
sciousness is considered abnormally prolonged if lasting greater
than 10 min and is more often associated with long-term sequelae
when persisting >60 min [16].
SE is relatively common in patients with TRE, commonly
occurring at tumor presentation or progression and as the precipi-
tant cause in 4–7% of cases of SE [17]. Presentation of SE in brain
tumor patients is associated with higher mortality and morbidity,
but remains responsive to standard interventions [1, 2, 17–19].
Nonconvulsive status epilepticus can be the presenting sign of
new brain tumors or metastatic lesions and was identified in 2% of
a cohort of brain tumor patients, with roughly 50% only experi-
encing subclinical seizures [19].
10 Tumor Related Epilepsy 155
Treatment of SE in TRE should adhere to approved institu-

tional clinical guidelines . A standard approach to SE treatment
has been promoted by the American Epilepsy Society [20], and is
as follows:
1. Stabilization phase (0–5 min)

(a) Stabilize patient (airway, breathing, circulation)
(b) Time seizure from onset, vital signs
(c) Assess oxygenation, supplement as needed
(d) ECG monitoring
(e) Check finger stick blood glucose, correct if <60 mg/dL
(f) IV access and baseline labs, ASM levels
2. Initial therapy phase (5–20 min)—if seizure continues
(a) Administration of a benzodiazepine (chose 1):
• IV lorazepam (0.1 mg/kg/dose, max: 4 mg/dose, may
repeat dose once),
• IV diazepam (0.15–0.2 mg/kg/dose, max: 10 mg/dose,
may repeat dose once)
• IM midazolam (10 mg for >40 mg, 5 mg for 13–40 kg,
single dose).
3. Second therapy phase (20–40 min), if seizure continues
(a) A recent randomized, blinded, adaptive trial demonstrated
the following interventions were equally effective and has
similar rates of adverse effects [21]:
• IV Fosphenytoin (20 mg PE/kg, max: 1500 mg PE/
dose, single dose)
• IV Levetiracetam (60 mg/kg, max: 4500 mg/dose, sin-
gle dose)
• IV valproate (40 mg/kg, max: 3000 mg/dose, single dose)
(b) If none of above available,
• IV phenobarbital (15 mg/kg, single dose)
Refractory SE occurs if seizures continue despite appropriate

treatment with benzodiazepines and second line anti-epileptic sei-
zure drug therapy. Currently there is not sufficient evidence to
support a standard approach to the treatment of refractory SE and
patients should be treated on a case-by-case basis and guided by
treatment response using continuous EEG monitoring [22].
156 T. Wychowski
Pharmacologic Management of TRE
I nitiation and Maintenance of Pharmacologic

Therapy in Patients with TRE
Patients with brain tumors who experience an epileptic seizure at

any point in their tumor treatment course are considered to have
epilepsy, as defined by the ILAE and require prophylaxis with an
anti-seizure medication (ASM) [5]. When deciding the best first
line ASM for TRE, there is currently a lack of high quality com-
parative effective data. The selection of an ASM for focal onset
epilepsy should be based on individual patient factors (e.g.,
comorbid mood disorder, liver dysfunction, history of renal cal-
culi), and with guidance from the ILAE monotherapy meta-
analysis [20]. Avoidance of enzyme-inducing ASMs in patients
with brain tumors is strongly recommended given established
interactions between these agents and chemotherapy and acceler-
ated metabolism of corticosteroids [9, 23]. Patients with brain
tumors may also be more prone to experiencing adverse effects of
older generation ASMs such as phenytoin, carbamazepine, and
phenobarbital [23].
Levetiracetam (LEV) has become a popular first line ASM in
patients with TRE. LEV has been shown to be safe, well-tolerated,
and effective at reducing seizures in patients with TRE compared
to EIASMs. However, treatment with LEV was associated with
higher prevalence and magnitude of neuropsychiatric adverse
effects compared with other ASMs [24–26]. Prophylaxis with val-
proic acid (VPA) has been promoted particularly in patients with
high grade glioma after retrospective observational studies associ-
ated VPA use with prolonged survival benefit as compared to
those not using VPA. However, pooled analysis of prospective
randomized controlled trials in newly diagnosed glioblastoma
showed no survival benefit associated with either VPA or LEV
[24].
Patients not responding to first line ASM therapy may require

initiation of an adjunctive agent and this approach should be no
different than treatment in other focal onset epilepsies, with the
caveats listed above. There are numerous non-RCT studies sup-
porting the tolerability, safety and efficacy of newer generation
ASMs (Table 10.1).
The use of ASM prophylaxis in tumor patients who have not
experienced seizures is controversial as there is lack of existing
evidence to support efficacy in preventing seizures. Despite the
high risk of developing TRE, only a handful of well designed,
class I, studies have been conducted to test the effectiveness of
ASM prophylaxis in this patient population and most of these
studies only evaluated the use of older generations ASMs. Using
this limited body of evidence, the AAN released a practice param-
eter in 2000 recommending against prophylaxis in patients with
brain tumors who have not yet experienced a seizure [23]. A
recent practice guideline update confirmed the approach [24].
Meta-analyses of these data not only failed to demonstrate effi-
cacy with ASM prophylaxis but identified a heightened risk of
ASM-associated toxicities, including interactions with anti-can-
cer agents and occasional life-threatening side effects. The use of
perioperative ASM prophylaxis to reduce the risk of postoperative
seizure is common practice at many institutions and supported by
limited data suggesting efficacy. Studies have demonstrated no
significant reduction in long-term seizure risk. It is recommended
practice at many institutions that seizure-naïve patients who had
been started on perioperative ASM therapy be tapered off of them.
With the availability of new generation ASMs, new clinical trials
may be warranted to test the effectiveness and safety of ASM pro-
phylaxis in this at-risk population.
Table 10.1 Commonly prescribed ASMs for the treatment of TRE
158
Drug Preparations Dosing Mechanism Pharmacokinetics Adverse effects Monitoring

Levetiracetam Tablets: Pediatric Synaptic t1/2 = 6–8 h Somnolence (11.7– Routine studies
(Keppra) 250 mg, Initial: 20 mg/ vesicle 2A Time to steady 45%), Loss of appetite not indicated.
500 mg, kg/day, inhibition state = 2 days (3–8%), vomiting (15%) Can consider
750 mg, divided BID Protein Abnormal behavior levels to assess
1000 mg Max: binding = 0% (7–37%), irritability for adherence
Solution: 60–80 mg/kg/ (6–12%)
100 mg/mL day Contraindications:
IV: 100 mg/ Adult allergies to LEV; dose
mL Initial: adjust for renal
250–500 mg impairment
BID, initial
maintenance
1500 mg/day
Max:
3000 mg/day
SE
60 mg/kg,
max: 4500 mg/
dose
T. Wychowski
Divalproex Depakote: Pediatric & Sodium t1/2 = 6–15 h Somnolence (7–16%), Baseline: LFTs
sodium 125 mg, Adult channel Time to steady weight gain (6–20%), Surveillance:
(Depakote, 250 mg, Initial: blockade, state = 1–2 days GI upset, alopecia CBC w/diff,
Depakote ER) 500 mg tabs; 10–15 mg/kg/ GABA Protein (5–6%). Dose-related: LFTs, VPA
125 mg day, Increase binding = 80–95% nystagmus (7%), action levels—
spinkles 5–10 mg/kg/ tremor (9–19%), ataxia therapeutic
(BID-TID) day q7 days (7%), elevated plasma range 50–100,
10 Tumor Related Epilepsy
Depakote ER: Max: 60 mg/ transaminase, and 100–120 may

250 mg, kg/day hyperammonemia. be necessary
500 mg SE Serious: pancreatitis,
extended 40 mg/kg, thrombocytopenia
release max: 3000 mg/ (27%), and hepatic
tabs—ONCE dose ×1 failure
DAILY Contraindication:
hepatic disease
(continued)
159
160

Oxcarbazepine 100 mg, Pediatric: Blocks t1/2 = 5–8 h (peds), Somnolence, headache, Serum sodium
(Trileptal) 300 mg, Initiation voltage- 7–11 h (adult) dizziness, ataxia, and shortly after
600 mg 8–10 mg/kg/ sensitive Time to steady nausea initiation or
tablets; day sodium state = 2–3 days Hyponatremia development of
300 mg/5 mL Target dosing channels, Protein (<125 mmol/L) in 3% symptoms
suspension is weight increases binding = 40% Contraindication: suggestive of
Extended- based potassium Avoid with the genetic hyponatremia
release Max: 60 mg/ conductance marker human
(Oxtellar XR): kg/day and modulation leukocyte antigen
150 mg Adult: of high-voltage (HLA) allele B*1502 as
300 mg 600 mg/day, activated there is an increased
600 mg tab increase by calcium risk for Stevens-Johnson
600 mg/day channels syndrome or toxic
weekly epidermal necrolysis
Max:
2400 mg/day
T. Wychowski
Zonisamide 25 mg, 50 mg, [<16 years Blocks sodium t1/2 = 60 h Common: somnolence, None
(Zonegran) 100 mg old]: Start channels and Time to steady anorexia, dizziness,
capsules 1–3 mg/kg/day reduces inward state = 14 days headache, nausea, and
qhs. Gradually currents Protein agitation/irritability
increase dose through T-type binding = 40% Increased risk of
to 5–9 mg/kg/ Ca2+ channels calcium or urate kidney
day stones
10 Tumor Related Epilepsy
[>16 years Contraindication:

old] Start sulfonamide allergies
100 mg qhs.
Increase by no
more than
100 mg/day q2
weeks to
400 mg daily
or divided BID
Max: 600 mg/
day
(continued)
161
162

Lacosamide Oral: 50 mg, Adults: Selective t1/2 = 13 h Common: ECG prior and
(Vimpat) 100 mg, Initially 50 mg sodium Protein Nausea, dizziness, after to
150 mg, twice daily, channel slow binding = 14% headache, diplopia initiation of
200 mg tabs; increase by inactivation; Serious: treatment in
10 mg/mL 100 mg/day collapsin Arrhythmias (AF, 1® AV patients with
solution every week to response block, prolonged PR) known cardiac
IV: daily dose of mediator Psychiatric (suicidal conduction
10 mg/1 mL 200–400 mg protein-2 thoughts), Drug reaction problems
daily (CRMP-2) with eosinophilia and
systemic symptoms
SE Status Epilepticus, LFT liver function testing, VPA valproic acid
T. Wychowski
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Treatment and Prevention
of Venous 11
Thromboembolism
Shiao-Pei Weathers and Alexander Ou
Venous thromboembolism (VTE) is among the most frequent of

medical complications experienced by patients with cancer and
represents a significant contributor to morbidity and mortality. Risk
factors for developing VTE have long been understood to include
age, obesity, immobility and vascular injury among others, and can-
cer patients are at a higher risk due to hypercoagulability [1]. For
reasons that will be discussed, patients with central nervous system
malignancies are at an even higher relative risk within the general
population of cancer patients. The overall risk of developing VTE
in patients with high-grade gliomas is comparable, and in some
descriptions surpasses, that of patients with pancreatic and gastric
cancers, historically known to carry the highest risk of VTE. The
reasons for this are not yet completely understood, but it is hypoth-
esized that a combination of high tumoral expression of procoagu-
lants, tissue factor and podoplanin—and subsequent systemic
circulation of these—play a role [2]. Podoplanin in particular has
been found to induce platelet aggregation, and its expression has
been found to be correlated with IDH-wild-type tumors and
increased risk for developing VTE [3].
S.-P. Weathers (*) · A. Ou

Department of Neurooncology, University of Texas MD Anderson
Cancer Center, Houston, TX, USA
Neurology Department, Kelsey Seybold Clinic, Houston, TX, USA
e-mail: sweathers@mdanderson.org; Alexander.ou@kelseyseybold.com

Switzerland AG 2023
https://doi.org/10.1007/978-3-031-41413-8_11
166 S.-P. Weathers and A. Ou
Apart from focal leg weakness or immobility, other VTE risk

factors in patients with brain tumors include higher histological
grade, recent craniotomy, involvement of cerebral vasculature by
tumor, poor functional status (e.g. Karnofsky Performance Status
score of less than 70 or Eastern Cooperative Oncology Group
score of 2 or greater), active chemotherapy and exposure to anti-
angiogenic treatment [4, 5]. The rate of recurrent venous throm-
boembolic events approaches nearly 30%, and the consequent
increases in morbidity and mortality, rates of hospitalization and
length of stays, to name a few, mandate an evidence-based
approach to preventing, diagnosing and treating this all-too-
common complication [4].
ypes of Venous Thromboembolism and Clinical

T
Diagnosis
Deep venous thrombosis (DVT) should be suspected in any

patient presenting with any combination of acute or subacute
swelling and pain or warmth in one or more limbs. Patients may
or may not endorse calf or thigh tenderness on exam, but practi-
tioners should be aware that general physical exam maneuvers
such as Homan’s test (pain in the calf or popliteal fossa with pas-
sive dorsiflexion of the ankle with the patient supine) are of low
sensitivity and specificity. Similarly, our patients are at a suffi-
ciently high risk of developing VTE that serum screening tests
(e.g. d-dimer) are also of limited utility. It is advised that the rou-
tine practice should be to obtain compression ultrasonography in
the suspected leg in all patients for whom clinical concern exists
to definitively rule out DVT.
The presentation of acute pulmonary embolism (PE) is some-
what less straightforward, as the symptomatology can vary. The
classic description of sudden onset of shortness of breath with
pleuritic chest pain and cough or hemoptysis can be helpful as
these represent the most common symptoms experienced by
patients who develop PE. However, practitioners should remain
vigilant for any symptoms that may indicate acutely compromised
cardiopulmonary status. PE should be considered on the basis of
isolated tachycardia or tachypnea, new unexplained intolerance of
11 Treatment and Prevention of Venous Thromboembolism 167
physical exertion, and/or presyncopal symptoms. Physical exam

findings may be significant for tachycardia, tachypnea, dimin-
ished breath sounds, or new oxygen requirement. Bedside EKG
may be performed with relative ease, and may demonstrate sinus
tachycardia (the most common EKG finding), or in cases of sig-
nificant right heart strain an “S1Q3T3” pattern of a large S wave
in lead I, and a Q wave with T-wave inversion in lead III. Any
patient for whom an acute PE is suspected should undergo CT
pulmonary angiography of the chest with contrast in the absence
of contraindications without delay. In cases where imaging is
equivocal, a ventilation-perfusion scan of the lungs may be con-
sidered, and in cases where patients may not be hemodynamically
stable to undergo scanning, bedside echocardiography may be
expediently pursued to evaluate for right heart strain.
Perhaps the most diagnostically challenging manifestation of
VTE in patients with primary brain tumors is that of cerebral venous
or venous sinus thrombosis. This complication occurs in up to 8%
of patients with glioblastoma, and requires a high degree of suspi-
cion to diagnose [6, 7]. To this end, understanding the pathophysiol-
ogy can be helpful in recognizing its disparate manifestations.
Fundamentally, thrombosis within the cerebral venous system leads
to decreased flow through the cerebral vasculature and increased
venous pressure, while thrombosis in the sinuses leads to obstruc-
tion of blood flow away from the brain and a consequent increase in
intracranial pressure. The former mechanism leads to disruption of
the blood-brain barrier with resultant leakage of plasma and local-
ized vasogenic edema, potentially hemorrhage and decreased cere-
bral perfusion leading to infarction. The latter mechanism leads to
signs and symptoms of intracranial hypertension, such as head-
aches, nausea, vomiting, transient visual obscurations, and papill-
edema, among others. Because of the heterogeneity of the cerebral
collateral flow, ages of patients and other comorbidities, not only
the symptoms but also the time course can vary widely. The most
common complaint is headache, though patients may also experi-
ence focal deficits, seizures or altered mentation [8]. Elderly
patients in particular are more likely to present with encephalopa-
thy than headache, and this may be acute, subacute or chronic in
evolution [9]. Historical features that may suggest cerebral venous
thrombosis include recent dehydration, local infections of the head
and neck (e.g. ears, sinuses) and known involvement of cerebral

veins or sinuses by tumor.
Patients with suspected cerebral venous or sinus thrombosis
should undergo urgent neuroimaging, ideally with MRI of the
brain and contrast-enhanced MR venography (MRV) of the head
and neck. In patients with MRI contraindications or centers with
limited resources, non-contrast CT of the head may obtained to
evaluate for a dense triangle sign, or hyperdensity within the pos-
terior aspect of the superior sagittal sinus representing the venous
thrombus, as well as hemorrhagic or infarcted lesions lying out-
side the territory of known blood vessels. Contrast-enhanced CT
venography (CTV) is also considered to be equivalent to MRV for
the diagnosis of venous thrombosis and can just as reliably delin-
eate the extent of thrombosis.
Prevention of VTE
Outpatient Primary Prevention
Because patients with high-grade gliomas are among those at

highest risk for developing VTE among all patients with cancer,
a real need exists to identify which outpatients will benefit most
from pharmacologic prophylaxis. One predictive model, the
Khorana score, incorporates the site of cancer, pre-chemotherapy
platelet count (>350 k/uL), leukocyte count (>11 k/uL), hemo-
globin level (<10 mg/dL), and BMI (>35 kg/m2), but has yet to be
validated prospectively in patients with high-grade gliomas [5].
The PRODIGE trial—which was a randomized placebo-
controlled study that evaluated symptomatic DVT or pulmonary
embolism occurring within 6 months after randomization to
either low-molecular weight heparin dalteparin or placebo in 186
patients with newly-diagnosed high-grade glioma—did not find a
statistically-
significant decrease in symptomatic VTE or an
increase in major bleeding, however there was a trend toward
reduction in the former and a trend toward increase in the latter
[10]. The AVERT trial was another randomized, placebo-
controlled double-blind clinical trial evaluating the effectiveness

and safety of direct factor Xa inhibitor apixaban versus placebo
in 574 patients with a solid tumor and Khorana score of ≥2 indi-
cating intermediate to high risk of VTE. Carrier et al. found a
statistically-significant reduction in VTE, with a higher rate of
major bleeding episodes versus placebo [11]. It should be noted
that only 4.8% of those who received the study drug had a brain
tumor. Taken together, no studies have convincingly established
a role for primary medical prevention of VTE for ambulatory
outpatients with high-grade gliomas. We do not, therefore, rou-
tinely administer chemical thromboprophylaxis in this setting
and advise vigilance for potential VTE-related symptoms in
patients who are at high risk, e.g. those who are elderly
(>75 years), immobile, with poor functional status and/or receiv-
ing anti-VEGF therapy.
Inpatient Primary Prevention
In alignment with ASCO and NCCN Clinical Practice Guidelines

in Oncology (NCCN Guidelines®), the approach to primary throm-
boprophylaxis for inpatients with medical or surgical problems
requiring acute hospitalization should be pharmacologic prophy-
laxis with LMWH (in the absence of major bleeding or other con-
traindications) for all patients with active malignancy and an acute
medical illness [12, 13]. All admitted patients as part of their initial
evaluation should have baseline complete blood count with differ-
ential (CBC), activated partial thromboplastin time (aPTT), pro-
thrombin time (PT), complete metabolic panel (CMP) and hepatic
function (ALT/AST) panel. For our highest-risk patients (particu-
larly those undergoing surgery), we combine mechanical (i.e.
intermittent pneumatic compression devices or sequential com-
pression devices) and chemical prophylaxis with LMWH [14]. In
the post-operative patient, anticoagulation should be resumed as
soon as is considered safe by the neurosurgical team, which is in
general within 96–120 h post-closure. Table 11.1 provides a sum-
mary of anticoagulant agents with recommended dosages.
Table 11.1 Prophylactic and therapeutic anticoagulant dosing

Prophylactic
Prophylactic dosing—obesity
Agent dosing (≥40 mg/m2) Therapeutic dosing
Enoxaparin 40 mg SC 40 mg SC every 1 mg/kg SC every
daily 12 h 12 h
Dalteparin 5000 U SC 7500 U SC daily 200 U/kg SC daily
daily for 30 days, then
150 U/kg once daily
Fondaparinux 2.5 mg SC 5 mg SC daily 5 mg (<50 kg);
daily 7.5 mg (50–100 kg);
10 mg (>100 kg) SC
daily
Unfractionated 5000 U SC 7500 U SC every 333 U/kg SC load,
heparin—SC every 8 h 8h then 250 U/kg SC
every 12 h
Unfractionated 80 U/kg IV load,
heparin—IV then 18 U/kg/h,
target aPTT of
2–2.5× control
Rivaroxaban 15 mg PO twice
daily for 21 days,
then 20 mg daily
Apixaban 10 mg PO twice
daily for 7 days,
then 5 mg twice
daily
Agents Contraindications and warnings
LMWH • Contraindicated in patients with severe renal
dysfunction (CrCl <30 mL/min)
• Absolutely contraindicated in patients with recent
or acute (HIT)
• Relatively contraindicated in patients with past
history of HIT
Fondaparinux • Contraindicated in patients with severe renal
dysfunction (CrCl <30 mL/min)
Unfractionated • Absolutely contraindicated in patients with recent
heparin or acute (HIT)
• Relatively contraindicated in patients with past
history of HIT

Agents Contraindications and warnings
Apixaban and • Contraindicated in patients with stage IV/V
rivaroxaban chronic kidney disease
• CrCl <25 mL/min (apixaban) or <30 mL/min
(rivaroxaban)
• Contraindicated in patients with active/clinically-
significant liver disease
• ALT/AST >2× ULN; total bilirubin >1.5× ULN
(apixaban)
• ALT/AST >3× ULN (rivaroxaban)
• Concurrent use of CYP3A4 or P-glycoprotein
inducers/inhibitors
• Relatively contraindicated in patients with
genitourinary or gastrointestinal tract lesions,
pathology or instrumentation
Treatment of VTE and Special Circumstances
There are two phases in the treatment of confirmed VTE: initial

and long-term. With regard to the initial (i.e. acute) phase, all
patients with primary CNS malignancy and acute venous throm-
boembolism should be evaluated urgently, assessed for contrain-
dications to anticoagulation and started on appropriate
anticoagulation without delay. In this setting the preference for
patients who are otherwise hemodynamically stable, not planned
to undergo potential surgery and without contraindications for use
of heparin is for LWMH. For patients with absolute
contraindication(s) to anticoagulation (Table 11.2) and acute
lower extremity DVT, a retrievable inferior vena cava filter should
be considered.
Once the patient has been stabilized on their initial regimen of
anticoagulation, it is appropriate to transition to long-term antico-
agulation to minimize the risk of recurrent VTE, which tends to
peak in the first 6 months. In this setting, the most appropriate
agent is one which balances efficacy and safety with tolerability
and therefore long-term adherence. We do not recommend vita-
Table 11.2 General and specific contraindications to anticoagulation

Prophylactic or therapeutic
anticoagulation Mechanical prophylaxis
Absolute Absolute
• Recent CNS bleed, hemorrhagic • Acute DVT
CNS metastases
• Active major bleeding (more than • Severe arterial insufficiency
2 units in 24 h) (graduated compression
stockings)
Relative Relative
• Chronic, clinically significant • Large hematoma
measurable bleeding >48 h
• Thrombocytopenia (platelets • Skin ulcerations or wounds
<50 k/uL)
• Severe platelet dysfunction • Thrombocytopenia (platelets
(uremia, medications, dysplastic <20 k/uL)
hematopoiesis)
• Recent major operation at high • Mild arterial insufficiency
risk for bleeding (graduated compression
stockings)
• Underlying hemorrhagic • Peripheral neuropathy
coagulopathy (graduated compression
stockings)
• High risk for falls (head trauma)
• Neuraxial anesthesia/lumbar
puncture
• Interventional spine and pain
procedures
• Long-term antiplatelet therapy
Adapted with permission from the NCCN Clinical Practice Guidelines in
Oncology (NCCN Guidelines®) for Cancer-Associated Venous Thromboem-
bolic Disease V.2.2023. © 2023 National Comprehensive Cancer Network,
Inc. All rights reserved. The NCCN Guidelines® and illustrations herein may
not be reproduced in any form for any purpose without the express written
permission of NCCN. To view the most recent and complete version of the
NCCN Guidelines, go online to NCCN.org. The NCCN Guidelines are a
work in progress that may be refined as often as new significant data becomes
available.
min K antagonists (e.g. warfarin) for maintenance anticoagulation

as they are inferior in efficacy to low-molecular-weight heparins
[15]. For some patients, the excessive bruising, skin irritation and
frequency of dosing associated with regular subcutaneous LMWH
administration can detract from their quality of life, and in these
cases, consideration of a direct oral anticoagulant (DOAC) should
be considered. Recent trials support comparable efficacy to
LMWH with similar safety profile and improved subjective qual-
ity of life measures [16, 17].
Anticoagulation in the Patient

with Thrombocytopenia
Myelosuppression with thrombocytopenia is not an uncommon

complication experienced by patients with high-grade gliomas on
cytotoxic chemotherapy, and evidence still supports the judicious
use of anticoagulants for patients with VTE. For patients whose
platelets are above 50 k/uL, no dose adjustment is necessary, how-
ever platelet transfusions to maintain platelets above 50 k/uL are
recommended. For patients whose platelets are between 25 and
50 k/uL with low-risk thrombi (i.e. those related to central venous
catheter placement, incidental subsegmental pulmonary embo-
lism), anticoagulation can be halved. For patients with high-risk
thrombi, however (proximal DVT, symptomatic DVT), no dose
reduction is recommended; rather these patients should receive
platelet transfusions to maintain their platelets above 40 k/uL
[16]. Anticoagulation should be held for patients whose platelets
are less than 20 k/uL.
Medical Risks of Treatment
Despite the benefit of anticoagulation in preventing recurrent VTE,

the risks of major bleeding—defined as a decrease in serum hemo-
globin of 2 g/dL within 24 h or any bleeding into a vital organ—
and non-major clinically-relevant bleeding—that which requires
interfacing with healthcare provider—are 3% and 10%, respec-
tively. Within our patient population, the foremost disease-specific
risk of anticoagulation is intracranial bleeding. Observational data

describes a one-year incidence of all intracranial bleeding of 28%
in patients with primary brain tumors on therapeutic LMWH ver-
sus 14% in patients not on anticoagulation, with similar reported
rates for patients on DOACs [18–20]. The increased subsequent
morbidity and mortality can be significant.
Vigilant monitoring for changes in renal and hepatic function
as well as potential drug-drug interactions, then, is crucial in pre-
venting these events, however not all unfortunately are prevent-
able. In the setting of bleeding while on anticoagulation, the first
steps include immediately stopping the anticoagulant, hemody-
namic stabilization and prompt administration of appropriate
reversal agent particularly if emergency surgery is anticipated.
For specific reversal strategies please refer to the 2.2023 version
of the NCCN Guidelines® for Cancer-Associated Venous
Thromboembolic Disease. Obtaining neurosurgical and benign
hematologic consultation is also recommended. The discussion
regarding the safety of resuming anticoagulation is best individu-
alized to each unique patient circumstance.
Patient Instructions
Patients with brain tumors are at a higher risk for developing

blood clots in the veins of the legs, lungs and brain. Symptoms
concerning for the development of a blood clot can include leg
swelling, leg pain, leg redness, shortness of breath, chest pain that
is worse with breathing, or a headache that will not go away.
When a blood clot is discovered, the recommended treatment will
likely be blood thinning medication to prevent these blood clots
from causing more symptoms and complications from a blockage
of blood flow. Starting a blood thinning medication will increase
the risk for bleeding, which can range from easy bruising and
prolonged bleeding of minor cuts to major bleeding which might
require urgent medical care. While on blood thinning medica-
tions, it is also important to monitor for any new severe headache,
sudden lightheadedness, difficulty breathing, or new neurologic
symptoms which might indicate significant bleeding for which you
will need to seek medical attention immediately.
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Management
of Neurocognitive 12
Symptoms
Christina Weyer-Jamora
and Jennie W. Taylor
Patients with CNS involvement of their malignancy—such as

gliomas, meningiomas, and primary CNS lymphoma and meta-
static disease—frequently experience cognitive impairment.
Additionally, cognitive sequelae from treatments such as radio-
therapy and chemotherapy also lead to measurable deficits on
neuropsychological assessments and negatively impact the health
related quality of life (HRQOL) of these patients. Though these
impairments are often localizable, network disruptions from
tumor invasion, edema, and injury from treatment often lead to
more broad deficits than expected.
This chapter provides an overview of cognitive symptoms
commonly seen across adults with primary brain tumors of varied
histologies, locations, or specific treatments. In this chapter, we
discuss differential diagnoses and work-up, comorbidities and
other factors in the care of this population. We also review non-
C. Weyer-Jamora
Department of Neurological Surgery, University of California, San
Francisco, San Francisco, CA, USA
Department of Psychiatry, Zuckerberg San Francisco General Hospital,
San Francisco, CA, USA
J. W. Taylor (*)
Department of Neurology, University of California, San Francisco,
San Francisco, CA, USA
e-mail: Jennie.taylor@ucsf.edu

Switzerland AG 2023
https://doi.org/10.1007/978-3-031-41413-8_12
178 C. Weyer-Jamora and J. W. Taylor
pharmacologic and pharmacologic treatment strategies to consider

and conclude with discussion of cognitive and behavioral changes
near the end of life.
Causes and Differential Diagnosis
The prevalence of cognitive impairments in patients with brain

tumors varies widely and changes over the illness trajectory. At
diagnosis, tumor characteristics, including location, size, extent
of edema, and grade, have all correlated with cognitive function.
Though many patients experience improvement in cognition in
the 3–6 months following resection, many remain impaired or
have further decline from subsequent treatments such as radio-
therapy and chemotherapy and/or tumor progression.
Radiotherapy has the off-target effect of acutely injuring neuro-
nal generation, causing inflammation, and disrupting the micro-
environment that leads to degenerative changes and chronic
damage to cognition. The hippocampus is particularly sensitive
to radiotherapy-induced injury, resulting in common memory
deficits. Chemotherapy demonstrates neurotoxic effects and,
while the mechanism may be better understood for CNS pene-
trating drugs such as methotrexate and platinum based treat-
ments, the mechanisms of injury for many other cytotoxic and
targeted agents are less well understood. The neurotoxic effects
of radiation and/or chemotherapy may be evident on MRI as dif-
fuse leukoencephalopathy or atrophy. Additional factors such as
metabolic changes, steroids, pain medication, seizures, and anti-
epileptic use may also exacerbate cognitive inefficiencies.
Tumor progression should also be considered in patients with
acute or subacute cognitive changes.
Workup for acute or subacute cognitive changes

• Metabolic abnormalities—B12, TSH, urine analysis
• Medications—offending AEDs or steroids
• Uncontrolled seizures
• Fatigue/sleep disturbance
• Under-treated psychiatric diagnosis
• Tumor progression
• Post-radiation changes—radiation necrosis or leukoencephalopathy
12 Management of Neurocognitive Symptoms 179
Clinical Presentation of Cognitive Symptoms
Brain tumor related cognitive symptoms are varied and often

related to tumor site. The most commonly affected cognitive
domains are those reliant on distributed functional networks and
white matter tracts, rather than highly localized cognitive skills
(for example thinking speed rather than facial recognition).
Specifically, impairments in processing speed, executive func-
tions, attention and concentration, learning efficiency and mem-
ory retrieval, and language are common. Fatigue and stamina,
sleep, medication toxicities and co-morbid illnesses, can also con-
tribute. Below is an overview of common areas of cognitive
impairment and associated symptoms.
Slowed Processing Speed
Processing speed (i.e. thinking speed) usually refers to the speed

at which cognitive operations can be performed and is an interac-
tion between specific cognitive skills, brain network recruitment,
and speed of reaction and stimulus transmission. Slowed process-
ing is among the most common cognitive impairment found in
brain tumor patients, regardless of tumor type or location. Slowed
cognitive processing makes task completion more challenging.
Patients experience slowed processing as difficulty keeping up
with the pace of conversations, finding words, and needing more
time to complete tasks. Fatigue, disruption in sleep, medication
effects, comorbid illness, and impacts of active treatment may
also contribute.
Slowed processing speed is prevalent in individuals with dam-
age to white matter and subcortical systems. Radiotherapy, some
antiepileptic medications, and/or certain psychiatric conditions
are all associated with slowed processing speed.
Localization: subcortical white matter changes.
Executive Dysfunction and Behavioral Changes
Executive function is generalized localized to the frontal lobes

and is the higher order processing responsible for engagement in
self-directed, self-serving, and independent behaviors. It allows
prioritization of what to pay attention to and how to respond, and
whether or not one attempts a behavior at all. Executive functions
are very vulnerable to injury from brain tumors and related treat-
ments leading to difficulty formulating a desired goal; and the
planning, sequencing, and execution required to achieve it.
Problem solving, self-monitoring, and ability to perform tasks are
often compromised. Executive dysfunction is often linked to neg-
ative impacts on gainful employment, transportation use, and
reduced quality of life.
Changes to behavioral and emotional control associated with
executive dysfunction particularly impacts social and interper-
sonal functioning. Patients may express emotional flattening or
lability, irritability or excitability, impulsivity, carelessness, and
inflexibility. Insight and judgment may also be impaired and con-
tribute to poor understanding of their cognitive or behavioral
changes.
Lesions in the dorsolateral prefrontal cortex may result in per-
severative or inflexible behavior, lack of awareness, and easy dis-
tractibility. These individuals also have a tendency to exhibit
reduced memory and learning, particularly freely recalling infor-
mation despite having intact recognition of the newly learned
material. Orbitofrontal disruption may result in impulsiveness,
inappropriate social behavior, and mood lability. Anterior cingu-
late gyrus lesions can lead to abulia, reduced engagement, and
poor motivation and social interaction. More diffuse frontal defi-
cits are more likely to cause disinhibition.
Localization: frontal lobe (dorsolateral prefrontal area, orbi-
tofrontal, anterior cingulate gyrus), intraventricular, posterior
fossa.
Attention and Concentration Impairment
Majority of everyday functions rely on intact attention and con-

centration for successful completion. Being able to effectively
divide or shift attention depends on availability of resources to
manage competing task demands. Selective attention, or the abil-
ity to focus on chosen stimuli while ignoring distractions, often
susceptible to effects of brain disorders including tumors. Other
aspects of attention, such as sustaining a state of mental concen-
tration over a period of time, dividing attention between compet-
ing stimuli, or alternating attention between two tasks are also
impacted by brain disease or injury. Radiotherapy, changes in
mood, and fatigue in brain tumor patients impact the arousal and
vigilance needed for attentional focus. Patients often describe
themselves as being highly distractible and have difficulty com-
pleting tasks.
Localization: frontal lobe, language dominant hemisphere.
Memory and Learning Impairment
Memory is not a single operation, but rather the integration of sev-

eral systems to function, including some areas more vulnerable to
injury, such as attention (as described above). Memory is frequently
impacted by brain tumors and related treatments, especially tumors
located in the frontal and temporal lobes and thalamus. Problems
with memory may also be more salient to patients if tumors are
located in the third ventricle region. Patients with brain tumors in
the left hemisphere tend to have more trouble learning and remem-
bering verbal information, though visual memory may remain
intact. Memory based impairments are often reported by patients as
forgetfulness and difficulty learning new tasks.
Localization: frontal and temporal lobes (dominant hemi-
sphere), thalamus, diencephalon, corpus callosum.
Language Impairment
Patients with tumors located in the language dominant hemisphere

may exhibit deficits in expressive and receptive language, and ver-
bal learning/memory. However, slowed and incoherent speech are
seen in tumors of the non-dominant hemisphere. Patients with lan-
guage impairments report difficulties naming objects, understand-
ing conversations, and/or following verbal instructions.
Localization: language dominant hemisphere.
Clinical Management and Recommendations
Cognitive screening can inform early detection of cognitive

changes and be helpful in determining additional assessment
needs. Management of cognitive sequelae of brain tumor and
related treatment begins with assessment. By providers asking
patients and caregivers early and often about cognitive changes,
patients can receive timely intervention to improve quality of life.
It is crucial early in the disease course to identify the neuropsychi-
atric changes, investigate co-morbid causes, and identify, when
possible, functional impairment experienced by the patient.
Standardized cognitive screening instruments are one method
used in medical settings for brief assessment of cognitive func-
tioning—e.g. the Montreal Cognitive Assessment (MoCA), Mini-
Mental State Examination (MMSE) and the Neurobehavioral
Cognitive State Examination (NCSE). It should be noted, how-
ever, that these tools vary regarding their sensitivity and specific-
ity for detecting cognitive impairments in the brain tumor
population. A focused interview of symptoms may be more effec-
tive to identify cognitive concerns and appropriate referrals/inter-
ventions (Tables 12.1 and 12.2). This interview should also
include questions about mood, sleep, and fatigue given their cog-
nitive impact. Ideally, patients who report cognitive symptoms or
are observed to have cognitive challenges should be referred to a
Table 12.1 Examples of patient and provider discussion of cognitive symp-

toms and associated referral considerations
Examples of “I forget what I am saying during a conversation”
reported cognitive “I’m always late! I can’t multitask anymore”
concerns “I’m trying to take my medication every day, but I
keep forgetting”
“I have a hard time finding the right words. I know
what I want to say, but I can’t get it out”
Provider follow-up Do you have more trouble learning and remembering
questions new things?
Do you have more trouble making decisions?
Do you have more trouble finding the words you want
to use?
Does it take you longer to do things? Do you feel
easily rushed?
Clinical and/or • Easily distracted by stimuli in the environment
collateral (e.g. sounds, movements)
observations • Pauses during conversation, loses train of thought
mid- sentence. Asks others to reorient them to
what they were talking about
• Late and missed appointments
• Forgetful
Patient education • Minimize environmental distractions, such as
having conversations in quiet areas
• Ask others to repeat information
• Pre-plan to do one task at a time and avoid
multitasking
• Consider using an alarm for when to take
medications
• Organizational strategies such as using calendars,
to-do lists, and structured daily routines
• Encourage others to slow down rate of speech and
use alternative words to describe what you mean
Referral Neuropsychology; speech therapy
considerations
neuropsychologist for comprehensive cognitive and emotional

assessments and, if available, consideration for cognitive rehabili-
tation.
Table 12.2 Examples of patient and provider discussion of mood/behavior

symptoms and associated referral considerations
Examples of reported “I have been feeling down lately and not really
mood/behavior concerns interested in much”
“I get so irritable and impatient”
“The littlest things seem to worry me. I can’t
turn my brain off”
Provider follow-up Is this a change compared to before your
questions diagnosis?
How bothersome is this symptom to you?
Do these symptoms get in the way of things
that are important to you?
How ready are you to do something different
about these symptoms?
Clinical and/or collateral • Tearful
observations • Blunted expression
• Tense, irritable, restless
• Negativistic
Patient education • Encourage scheduling daily pleasant
activities (such as socialization, hobbies,
and other interests)
• Encourage self-care (such as meditation,
self-affirmations, exercise, journaling, and
relaxation strategies)
• Sleep hygiene and fatigue management with
self-pacing emphasis
• Anxiety, depression, and anger-management
education
• Managing over-stimulation education
Referral considerations Psychiatry; psychology
Common reasons to refer for neuropsychological evaluation

for brain tumor patients
• Patient and/or caregiver report cognitive complaints interfering with
their HRQOL
• Provider observes cognitive changes as compared to baseline
• Evaluate cognitive status and level of care needs
• Determine cognitive and emotional status to inform treatment planning
and rehabilitation needs
• Document support for disability and/or accommodations
• Evaluate decisional capacity (financial, testamentary, medical
decisions, etc.)
Non-pharmacological Interventions
Non-pharmacological interventions are effective methods of man-

aging cognitive symptoms including patients with cancer.
Cognitive training and rehabilitation, exercise, and meditation/
mindfulness-based stress reduction have demonstrated efficacy.
Other non-pharmacologic approaches to treat sleep, fatigue, and
mood can also be helpful in improving cognition and are dis-
cussed below.
Cognitive Training and Rehabilitation
Cognitive rehabilitation is the standard of care to address cogni-

tive impairments in other neurologic diseases such as traumatic
brain injury, multiple sclerosis, and stroke. Mechanistically, cog-
nitive rehabilitation gains are second to neuroplasticity through
the brain’s ability to relearn and establish alternative cognitive
pathways. Studies in brain tumor populations, though limited,
demonstrate overall positive effects, particularly in areas of atten-
tion and memory. By using cognitive retraining and teaching
compensatory strategies to improve skills and decrease environ-
mental demands, patients are better able to optimize their cogni-
tion and learn new ways to achieve their goals. Careful
neuropsychological evaluation of cognitive strengths and weak-
nesses is a substantial prerequisite to inform treatment planning
for appropriate cognitive rehabilitation strategies and other inter-
ventions to improve cognition. Cognitive rehabilitation is likely
most beneficial in medically stable patients who feel their cogni-
tive vulnerabilities are influencing their daily life.
Exercise
Exercise shows promise as a supportive care intervention to coun-

teract the adverse cognitive impact of brain tumors and related
treatment. Regular physical activity, specifically cardiorespiratory
fitness, can offset hippocampal damage. Aerobic exercise is asso-
ciated with improvements in cognition through increasing neuro-
genesis, enhanced angiogenesis, and upregulation of

neurotrophins, such as BDNF. Exercise may also aid in reduction
of endogenous corticosteroids and pro-inflammatory cytokines,
decrease oxidative stress, preserve brain volume, improve vascu-
larization and blood flow, and increase hormones beneficial to
neural structure and function. Regular exercise can improve
depression and overall distress in patients with brain tumors.
Exercise related improvements in mood, reduced stress, cancer-
related fatigue, and sleep disruption may indirectly benefit cogni-
tive functioning particularly attention and memory consolidation.
When considering exercise for patients with brain tumors, it is
important to address safety concerns, especially for those who are
acutely ill or actively undergoing treatment. The American College
of Sports Medicine (ACSM) states, “exercise testing and prescrip-
tion are best done by exercise professionals and physical therapists
in consultation with the cancer care team.” The American Cancer
Society (ACS) recommends cancer survivors take part in regular
physical activity (with consultation of cancer team and exercise
professional), avoid inactivity and return to normal daily activities
as soon as possible, aiming to exercise at least 150 min per week,
and include strength training at least 2 days per week (cancer.org.).
Meditation/Mindfulness Based Stress Reduction
Though mindfulness based stress reduction is not extensively

studied in the brain tumor population, it shows great benefit in
reducing negative psychological stress effects on neurogenic
inflammation. Mindfulness practice improves attentional capacity
and executive functioning through activation of the cingulate cor-
tex. Studies demonstrated both short-term and sustained cognitive
improvement.
Mood and Behavior Management
Depression and anxiety are commonly seen in the brain tumor

population and negatively influence cognition. Problematic psy-
chiatric symptoms may be difficult to distinguish from cognitive

impairment with normative grieving, expected physiological
effects of the tumor and related treatments such as fatigue, loss of
appetite, or sleep disruption. The subtly progressive (rather than
dramatic) nature of these mood changes may further delay symp-
tom detection. Psychologists and other mental health providers
can help patients learn more effective coping strategies, and how
their thoughts, feelings, and behaviors act together to contribute
to their distress. Further evaluation of possible psychotropic med-
ication may also be beneficial.
For patients with more severe and difficult to manage behav-
ioral issues, such as disinhibition and agitation, it is important to
consider psychotropic medications and/or psychiatry consulta-
tion. Further, referrals to rehabilitation professionals for special-
ized caregiver training and support regarding de-escalation and
behavior modification may be useful. In milder cases, cognitive
rehabilitation can re-teach problem-solving, and increase aware-
ness and self- monitoring. In more severely impaired individuals,
environmental restructuring is indicated (e.g. creating a daily rou-
tine with alarms and written cues, linking behaviors together that
occur naturally such as medication and meals, reducing environ-
mental stimulation such as lowering light and sound, etc.). For
non-verbal individuals, it is important to track issues regarding
untreated pain and other irritants.
De-escalation strategy: the four D’s
• Delay: “I want some time to consider what you are saying, let’s talk
about it later”
• Distract: go for a walk or suggest another activity
• De-personalize: realize the attacks are more than likely part of the
disorder, not personal
• Detach: get support to avoid taking things personally and getting upset
Sleep and Fatigue Management
Sleep disruption and fatigue often exacerbate cognitive difficul-

ties, especially attention, concentration, learning, and memory.
Optimizing sleep hygiene, managing emotional stressors, increas-
ing exercise, and considering pharmacologic sleep aids should be

considered. Exercise has particularly been associated with
improved sleep and reducing cancer related fatigue. Utilizing
fatigue management strategies, such as pacing, avoiding sensory
overstimulation, can help to improve energy and stamina. Patients
who have concurrent mood and sleep issues may particularly ben-
efit from behavioral treatment such as cognitive behavioral ther-
apy for insomnia (CBTi). In some cases, evaluation for obstructive
sleep apnea and circadian rhythm issues may additionally yield
therapeutic effects.
Anticipatory guidance for managing mood and sleep
• Establish a bedtime routine with winding-down activities
• Refrain from stimulating activities before bed (e.g. screen exposure,
emotionally triggering material, etc.)
• Limit caffeine later in the day
• Avoid lying in bed awake for extended periods of time
• Encourage daily pleasurable and meaningful activities
• Increase social connection (e.g. talk to friends, support group, engage
in counseling)
• Maintain consistent physical activity
• Encourage relaxation and meditation
Pharmacologic Interventions
Several medications used in management of attention disorders or

dementia, have been investigated for safety and efficacy in cogni-
tive management of brain tumor patients and are discussed below
(Table 12.3).
Methylphenidate
Methylphenidate is a dopaminergic and noradrenergic agonist

approved for treatment of attention deficit hyperactivity disorder.
It is a CNS stimulant that has demonstrated improvement in atten-
tion and processing; with particular efficacy in long-term survi-
vors of childhood cancers treated with either radiotherapy or
Table 12.3 Pharmacologic management of cognition in brain tumor patients

Starting
dose and
Treatment Indication goal dose Toxicities
Methylphenidate Slowed processing 5 mg to Insomnia
speed, executive titrate up to Palpitations
dysfunction, fatigue ~40 mg Appetite
daily in suppression
divided
doses
Modafenil Slowed processing 100 mg Appetite
speed, executive daily to suppression
dysfunction, fatigue titrate up to
200 mg
daily
Donepezil Preservation of verbal 5 mg daily GI toxicity
memory and to increase
concentration with to 10 mg
radiation daily
Memantine Preservation of verbal 20 mg daily GI toxicity
memory, executive
function and
processing speed with
radiation
chemotherapy. In an adult clinical trial, patients with primary

brain tumors who were treated with radiotherapy ± chemotherapy
and received methylphenidate at 10 mg or 18 mg twice daily for
4 weeks demonstrated improvement in processing speed and
executive function. It should be noted that findings were in
patients who were actively on therapy; therefore, improvements
may be secondary to treatment response rather than
methylphenidate.
Methylphenidate starts at a lower dose and is titrated slowly—
starting at 5 mg daily with titration up to 40 mg daily in divided
doses for efficacy. Common toxicity includes insomnia, palpita-
tions, decreased appetite, and dependency. Recommend close
monitoring for patients with active seizures as it may lower sei-
zure threshold.
Modafenil
Modafenil decreases GABA in hypothalamus responsible for

sleep-wake cycle regulation (approved for treatment of narco-
lepsy). In a study randomizing patients on active treatment to
modafinil 200 mg daily versus methylphenidate, there was sig-
nificant improvement in processing speed, executive function, and
fatigue. However, as discussed above with methylphenidate, this
study did not include a placebo to account for possible improve-
ments secondary to treatment response.
Modafenil is often well-tolerated and is started at 100 mg daily
with titration up to 200 mg daily and can be considered in patients
with contraindications for methylphenidate. The most common
toxicity is decreased appetite and weight loss.
Donepezil
Donepezil is an acetylcholinesterase inhibitor approved in

Alzheimer’s disease and used in primary brain tumor patients
undergoing radiotherapy to preserve concentration and memory.
Patients treated with donepezil 10 mg improved in verbal memory
and concentration after 24 weeks. The long-term use of donepezil
is unknown as most trials stopped treatment after 24 months. The
timing of use is unknown with either concurrent radiation or fol-
lowing radiation.
The recommended starting dose of donepezilt 5 mg daily,
which can be increase to 10 mg daily. Donepezil is generally well
tolerated with GI toxicity as the most common side effect.
Memantine
Memanatine is a NMDA antagonist neuroprotectant and approved

for Alzheimer’s disease, Lewy body dementia, and other types of
dementia. Memantine was studied in a placebo-controlled trial in
brain metastases patients receiving radiation. At 20 mg daily for
24 weeks, there was less decline in verbal memory, executive
function, and processing speed compared to placebo, though the
dropout rate was high in this clinical trial. Additional studies sup-
port preserving cognition by combining memantine with whole
brain radiation with hippocampal avoidance.
Individuals with brain tumors who meet criteria for clinical
depression and/or anxiety may consider antidepressants such as
selective serotonin reuptake inhibitors (SSRIs). Though SSRIs
may not directly improve cognition, effective mood management
can lead to improvement in cognitive symptoms, as discussed
above. Similarly, antipsychotics may improve HROL in patients
with significant behavioral problems.
onsideration for Cognitive and Behavioral

C
Changes at End of Life
As patients near the end of their life, issues such as acute confu-
sion, reduced communication, and diminished memory can be
quite distressing for both patients and caregivers. In general,
reducing environmental stimulation (e.g. low light and noise, lim-
ited visitation), planning activities when the patient is most alert,
and providing calm reassurance (as needed) are helpful strategies.
Rapid changes can magnify confusion, and consistency in care
providers, talking through tasks with simple instructions (such as
helping with ADLs), and maintaining a consistent daily routine
help to minimize confusion. Other strategies include ensuring
sensory adaptation for hearing and vision, keeping instructions
simple with frequent repeating, and using diversional activities
(e.g. folding items, looking at pictures, etc.). Antipsychotics such
as olanzapine, haloperidol, or quetiapine may be helpful toward
the end of life for effective behavior management for treatment of
agitation and disorientation.
In conclusion, patients with CNS involvement of their malig-
nancy commonly experience cognitive impairment from direct
injury from tumor or radiotherapy/chemotherapy, and may be
exacerbated by seizures, medications, mood and sleep distur-
bances. These symptoms can significantly impair their quality
of life and are important to identify and treat with a combina-
tion of both non-pharmacologic and pharmacologic interven-
tions.
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Chemotherapy-Related
Toxicities and Management 13
Haroon Ahmad and David Schiff
Chemotherapies used in the treatment of brain tumors vary widely,

ranging from oral outpatient regimens for gliomas to intensive
inpatient courses for less common brain tumors. To cover all
chemotherapy-induced toxicities in neuro-oncology would be an
arduous task. Here, we concentrate on toxicities of the most com-
mon chemotherapies for brain tumors.
Generally, these more common chemotherapies are well-
tolerated and have reasonable logistics of administration. The tra-
ditionally challenging regimen of procarbazine, lomustine
(CCNU), and vincristine (PCV) is being less preferentially used,
in favor of temozolomide (TMZ). Another set of tumor drugs with
complex toxicity profiles, the checkpoint inhibitors (CPIs), have
yet to become a major component in brain tumor management.
We will review the most common regimens with their frequent
and infrequent adverse effects. Unique traits and clinical pearls
are included for each therapy. Common side effect management is
H. Ahmad (*)
Department of Neurology, University of Virginia, Charlottesville,
VA, USA
e-mail: hahmad@som.umaryland.edu
D. Schiff
Department of Neurology, University of Maryland, School of Medicine,
Baltimore, MD, USA
e-mail: s4jd@hscmail.mcc.virginia.edu

Switzerland AG 2023
https://doi.org/10.1007/978-3-031-41413-8_13
196 D. Schiff and H. Ahmad
discussed afterwards. The management of TMZ is discussed most

extensively as a neuro-oncologist should be adept in navigating a
patient through this bread-and-butter regimen. This chapter is not
a comprehensive reference on toxicities, rather a clinically ori-
ented tip sheet.
Temozolomide
TMZ is the most commonly used chemotherapy in the manage-

ment of brain tumors. Overall, it is a well-tolerated oral agent that
is conveniently taken at home. For both low- and high-grade glio-
mas, it is standard of care. TMZ is less commonly used in other
refractory brain tumors.
Dosing can vary from 75 mg/m2/day during the induction
phase of glioma treatment to 200 mg/m2 for 5 days every 28 days
in adjuvant cycles. Dose reductions are usually made by 25–50 mg/
m2 in the setting of leukopenia or thrombocytopenia, or with sig-
nificant clinical side effects.
The most commonly experienced side effects are nausea
(53%), vomiting (42%), headache (41%), fatigue (34%), and con-
stipation (33%) [1]. Nausea can be tempered by administering
ondansetron 30–60 min prior to taking the TMZ, which is stan-
dard of care. Symptoms can be further mitigated by taking the
TMZ 30–60 min before bedtime. Other anti-nausea medications
such as promethazine and dexamethasone can be used and will be
discussed further. Patients should be advised that mild intermit-
tent nausea is expected, but any vomiting or persistent nausea
should be discussed with the neuro-oncology team. Patients ben-
efit from proactive bowel regimens. This should be emphasized in
those with prior history of motility issues. Over-the-counter regi-
mens using typical stool softeners and motility agents (docusate
and senna) are effective. As-needed (PRN) polyethylene glycol
can be added for refractory constipation, and occasionally a sup-
pository may be needed. Hydration should be encouraged
throughout.
Anorexia is common, occurring in 9% of patients [1]. Tapered
weight should be recorded at each visit and tracked over time.
13 Chemotherapy-Related Toxicities and Management 197
Corticosteroids can stimulate appetite, but are not specifically

used for this indication. Management of weight loss is discussed
further in the next section.
Fatigue varies widely. Some patients are able to continue
working throughout adjuvant cycles, while others require dose
reductions due to impact on quality of life. Approximately 4% of
patients experience grade 3–4 fatigue [1]. Other factors causing
fatigue must also be taken into consideration such as patients’
recent radiation therapy, mood disorders, or adjustment disorders.
Concurrent medications such as anti-epileptic drugs (AEDs) may
also contribute. A few interventions can be used to alleviate
fatigue including supplementation with dexamethasone, struc-
tured physical activity, regulated sleep patterns. Stimulant medi-
cations are uncommonly used.
During the concurrent phase of radiation and chemotherapy:
these constitutional symptoms tend to peak around week 4–5 of
therapy. Similarly, during the adjuvant cycles, patients often
remark that their most difficult days are on days 4–5 of the cycle.
However, each patient reacts differently, and some report their
worst week after they have completed the TMZ dose.
Completed blood count (CBC) with cell differential and com-
prehensive metabolic panel (CMP) work should be checked
weekly during the induction phase. During the adjuvant phase,
labs should be checked monthly around the nadir, recommended
as “within 48 h of day 22” [1]. Lymphopenia, Neutropenia, and
thrombocytopenia can occur with TMZ with incidences of 55%,
14%, and 19% for grade 3–4, respectively [1]. The nadir for these
values typically occur about 3–4 weeks after administration, and
this is the ideal time to check labs. Absolute neutrophil count
(ANC) should be monitored and therapy paused for values less
than 1000. Granulocyte colony-stimulating factors (GCSF) are
typically not used, unless neutropenia is severe or neutropenic
fever develops. Lymphocytes should also be closely monitored,
with pneumocystis pneumonia (PJP) prophylaxis initiation with
absolute lymphocyte count (ALC) consistently below 600. It
should be noted that the FDA package insert recommends PJP
prophylaxis for the entire induction phase of TMZ, but not all
neuro-oncologists find this necessary as the prophylactics them-
selves have potential side effects. PJP prophylaxis choices are dis-
cussed in the following section. Thrombocytopenia with platelet
values less than 100,000 should delay the next cycle of therapy.
Exceptions can be made based on which way a platelet value is
trending. TMZ dose should be titrated down by 25–50 mg/m2 for
grade 3–4 neutropenia or thrombocytopenia. Specific manage-
ment of neutropenia, thrombocytopenia, and lymphopenia is also
discussed in the next section.
TMZ has no specific drug-drug interactions, though adverse
effects can be additive with other medications, such as thrombo-
cytopenia induced by certain AEDs.
TMZ is a teratogen; both men and women of child-bearing age
should be strongly advised to use birth control during the therapy.
TMZ can cause long term azoospermia and infertility. Patients
should consider spermatocyte banking or oocyte retrieval prior to
the initiation of treatment. It is critical that these topics be dis-
cussed with appropriate patients at the time of consent.
CV: Procarbazine, Lomustine (CCNU),

P
Vincristine
These medications will be discussed together as the traditional

glioma regimen uses them in tandem. The PCV regimen is still
considered standard of care for patients with oligodendroglioma
and is used in recurrent gliomas. PCV therapy is recommended
for about 6–7 cycles, but patients sometimes do not complete
therapy due to toxicity. It should also be noted that the three-drug
regimen is also logistically complicated.
Procarbazine is administered for 14 consecutive days dur-
ing days 8–21 of each cycle. It is generally well-tolerated but
can cause mild nausea, fatigue, and anorexia in some.
Procarbazine has the potential for interacting with several
medications and foods, as a monoamine oxidase (MAO) inhib-
itor. Tyramine-containing foods should be avoided, such as red
wines, yogurt, and cheese. It can also cause a disulfiram-like
reaction with alcohol. There is also a rare systemic allergic
syndrome which can lead to dangerous angioedema. An early,

and more common, sign of this is urticaria and the drug should
be discontinued. Finally, the MAO inhibition could cause dan-
gerous surges in serum catecholamine levels if taken with sym-
pathomimetic drugs. Notably, selective serotonin reuptake
inhibitors should be avoided to reduce the risk of serotonin
syndrome [2].
Lomustine (CCNU) is given on day one of the PCV cycle. In
addition to nausea and vomiting, lomustine causes more severe
leukopenia and thrombocytopenia with nadir of 5–6 weeks. In the
PCV regimen, this occurs around the same time as the procarba-
zine nadir and the effect can be additive. Lomustine is a nitro-
sourea, with potential for pulmonary fibrosis. This will be
discussed in the carmustine section.
Vincristine is an intravenous medication infused on days 8 and
29 of the PCV cycle. Vincristine is well-known for the risk of
producing peripheral neuropathy. This adverse effect is dose
dependent and can range from mild peripheral dysesthesias, to
severe sensorimotor neuropathy causing gait ataxia and disability.
It is critical to assess neuropathic symptoms at each visit, and to
conduct a focused neurological exam. Areflexia can be an early
sign and cessation of vincristine should be considered. Vincristine
is a vesicant and must be administered by vesicant certified pro-
viders; irreversible skin necrosis can occur if administered incor-
rectly [3].
Each of PCV’s three components are teratogens and can cause
decreased fertility. As with TMZ, birth control and sperm/oocyte
banking discussions are prudent with all appropriate patients at
the time of consent.
PCV is a relatively toxic and complicated regimen. The com-
bined risk of grade 3–4 anemia, neutropenia, and thrombocytope-
nia are 7%, 10%, and 28%, respectively [4]. The hematologic
effects, diet restrictions, dosing logistics, and risk of neuropathy
have caused it to be slowly supplanted by TMZ. Finally, it should
be mentioned that many centers now just use “PC” regimen for
gliomas, meaning that vincristine is left out due to side effect pro-
file and lesser perceived efficacy in gliomas.
Carmustine (BCNU)
BCNU is another nitrosourea chemotherapy used for the treat-

ment of gliomas. It is typically administered intravenously but is
also FDA approved as a biodegradable implant placed during
tumor surgery. When used intravenously, it has a side effect pro-
file similar to lomustine.
Nitrosourea-induced interstitial pulmonary fibrosis (PF) is a
rare but serious complication. Most cases onset within 3 years but
it can manifest years later. In a study of 17 pediatric brain tumor
patients treated with carmustine: 6 (35%) died within 3 years due
to PF and another four (23.5%) died within the next 13 years [5].
Another 6 (35%) of the surviving patients had clinically evident
PF at 25 year follow up [5]. The risk of PF is dose-dependent and
most cases reported cumulative doses of 1110 mg/m2 and
1400 mg/m2 for lomustine and carmustine, respectively [6, 7].
Patients should have baseline pulmonary function tests (PFTs)
including diffusing capacity of carbon monoxide (DLCO). The
PFTs should be repeated as the cumulative dose approaches
1000 mg/m2 or if any pulmonary symptoms develop. Some guide-
lines recommend checking more regularly, especially in patients
with pre-existing pulmonary disease. Worsening of >10% in PFTs
or DLCO should necessitate further workup and cessation of the
drug.
Nitrosoureas uncommonly cause renal or hepatic injury. A
comprehensive metabolic panel is usually done with lab tests
prior to each dose and liver function tests (LFTs) should be
tracked.
Bevacizumab
Bevacizumab is a monoclonal antibody and is used to treat recur-

rent gliomas and radiation necrosis. Standard dosing for glioblas-
toma is 10 mg/kg every 2 weeks, though alternative doses ranging
from 7.5 to 15 mg/kg every 2–3 weeks have been used. For the
most part it is well tolerated, with patients noting mild fatigue.
Hypertension (HTN) is a common side effect of bevacizumab,

occurring most frequently in patients with preexisting
HTN. Generally, this can be managed with titrations in patients’
anti-HTN medication dosage. It is helpful to have a primary care
provider involved in these decisions. Blood pressure readings
must be below 150/90 for each administration.
Proteinuria and eventual nephrotic syndrome are complica-
tions of bevacizumab. It is important to assess a baseline creati-
nine clearance prior to starting treatment and a screening urine
dipstick test prior to each administration. Dipstick readings of 2+
or greater should lead to a 24-h urine collection. If >2 g of protein
is collected over 24 h, bevacizumab should be suspended, and it
may be helpful to involve nephrology [8].
Hemorrhage and coagulopathy are both risks of bevacizumab.
History of ischemic stroke, DVTs, MI/angina, or petechial intra-
tumoral hemorrhage are not contraindications for use, but patients
with recent ischemic events should be approached with caution.
In a study of patients treated with bevacizumab: grade 3–4 arterial
thrombotic events occurred in 2.6% of patients, compared to 0.8%
in control arms [8]. Posterior reversible leukoencephalopathy
(PRES) is another reported risk, but clinical studies reported an
incidence of <0.1% [8].
For patients undergoing surgical procedures, bevacizumab
should be held for 3–4 weeks. For dental procedures above the
gumline, it is generally okay to proceed. Finally, bevacizumab is
teratogenic. However, there is no human data on the long-term
effects of male or female fertility.
Irinotecan
Though irinotecan is not yet well-proven in its efficacy in recur-

rent gliomas, it is occasionally used. It is administered as an infu-
sion every 2 weeks, often combined with bevacizumab. The most
common unique side effect is diarrhea. It has been shown to occur
in up to 88% of patients, with 31% reporting grade 3–4 severity
[9]. Diarrhea can occur within 24 h of administration, often as a
cholinergic-like toxidrome: with rhinorrhea, increased salivation,
sweating, and flushing. More commonly, diarrhea occurs days to

weeks after the infusion, without the cholinergic symptoms. It
should be treated with scheduled antimotility agents (if infectious
etiology is not considered,) such as loperamide or atropine.
Hydration and electrolytes should be monitored if diarrhea is per-
sistent. Cytopenia, fatigue, and nausea are also possible side
effects, but generally less commonly. Labs should be checked
prior to each infusion.
Irinotecan is metabolized by cytochrome P450 and inducers
and inhibitors should be avoided. It is teratogenic but has not been
shown to affect long term fertility.
Checkpoint Inhibitors
CPIs, including PD-1, PD-L1, and CTLA-4 inhibitors are a newer

class of immunotherapeutics which are now widely used in oncol-
ogy. Neuro-oncologists will most commonly encounter them
when treating patients with brain metastases. Their benefit is not
yet established in gliomas.
By definition, CPIs release the immune system to cause an
inflammatory response within the body. This mechanism leads to
end-organ toxicity: meningitis, dermatitis, hepatitis, hypophysitis
etc. The toxicity is often reversible if identified early enough.
Drug cessation and treatment with corticosteroids usually is suf-
ficient. In refractory cases intravenous immunoglobulin and plas-
mapheresis can be used.
anagement of Specific Chemo-Induced Side

M
Effects
Nausea/Vomiting
Pre-administering ondansetron 30–60 min prior to most che-

motherapies is helpful in dampening most nausea. Other PRN
abortives can be used including prochlorperazine or metoclo-
pramide to good effect. If nausea is affecting quality of life, or

vomiting is frequent, chemotherapy dose adjustments should
be considered. Other useful medications included in guide-
lines are often overlooked, including dexamethasone, olan-
zapine, benzodiazepines, aprepitant, and cannabinoids. Many
of these agents can treat more than one of the patient’s symp-
toms.
Weight Loss
Weight loss can be due to true anorexia from chemotherapy or

from sensation of nausea. Patient weight should be tracked at each
visit and early intervention from nutrition/dietary consultants
should be considered if a patient has lost 5–10% of their baseline
weight. Dexamethasone can be used to stimulate appetite by
improving gut motility. Patients occasionally complain of a metal-
lic taste, though this is often due to the radiation therapy and
hopefully will dissipate with time. Dieticians can often recom-
mend interventions to deal with this metallic sensation such as
using plastic utensils or coffee-flavored foods. Constipation
should also be assessed and managed.
Fatigue
Fatigue and malaise may be the biggest contributor to a patient’s

inability to return to work. As with the other side effects dis-
cussed, fatigue can be multifactorial. A combination of chemo-
therapy, radiation therapy, mood disorders, and sleep patterns can
contribute. Adrenal insufficiency should be assessed in patients
with recent corticosteroid use. Hydrocortisone supplementation is
needed for morning cortisol levels less than 10, with possible
endocrinology involvement. Pituitary insufficiency should also be
assessed in patients who have received radiation therapy that
involves that region of the brain.
Peripheral Neuropathies
Neuropathies from vinca alkaloids (vincristine) and platinum-

based chemotherapies are common and are dose dependent. They
can manifest as loss of sensation, dysesthesias, sensory ataxias, or
less commonly autonomic neuropathies. Burning, painful neu-
ropathies are more treatable than loss of sensation. Gabapentin
and pregabalin are widely used, though can cause lethargy.
Duloxetine has been shown to improve pain and quality of life in
chemotherapy-induced painful neuropathy [10].
Cytopenia and Bone Marrow Suppression
CBC with differential should be monitored frequently during any

chemotherapy regimen and an attempt should be made to draw
labs around the nadir for each drug. An ANC of <1500 cells/mm3
is considered mild and a dose/cycle modification should be con-
sidered. Moderate neutropenia with ANC of <1000 may necessi-
tate pausing therapy and a dose adjustment. For ANC values
<500, neutropenic precautions should immediately be instituted.
GCSF like filgrastim and pegfilgrastim are not typically used as
glioma therapy is considered palliative but can be considered for
severe neutropenia.
Lymphocytes are often depleted early in glioma therapy.
Patients with ALCs consistently below 700 cells/mm3 should be
started on PJP prophylaxis. Trimethoprim/sulfamethoxazole is
commonly used on a Monday-Wednesday-Friday schedule. Daily
atovaquone or monthly pentamidine inhalations can be consid-
ered for patients with sulfa drug allergies.
Platelet counts are also checked routinely and are depleted by
the more toxic regimens. Thrombocytopenia of <100,000 can be
a warning to consider delaying the next cycle and/or modify the
dose. Levels <50,000 should halt treatment, and <10,000 neces-
sitates platelet transfusions.
Bone marrow suppression is a long-term risk for procarbazine,

nitrosoureas, and even TMZ. Delayed or unrecovered CBC counts
should prompt consideration for hematologic evaluation and pos-
sible bone marrow biopsy.
There is a risk of developing secondary malignancies with
these chemotherapies. Unfortunately, the typical glioma
patient does not have a life expectancy lending towards a sig-
nificant absolute risk. One study cited 2.9–13 cases of second-
ary hematologic malignancies per 1000 patient years, in
patients treated for glioma with various combinations of alkyl-
ating agents [11]. The secondary malignancy risk of chemo-
therapy should not be a major factor in most neuro-oncology
patient management.
Teratogenic Effects and Decreased Fertility
All the chemotherapies discussed are teratogenic and both male

and female patients must be on a consistent form of birth control.
The potential risk of post-treatment infertility must also be dis-
cussed at the time of consent. This is a difficult decision for many
patients as sperm and egg banking programs are not usually cov-
ered by insurance.
Conclusion
Glioma chemotherapy toxicity is tolerable for most patients,

which is a critical consideration given the palliative nature of
these treatments. A neuro-oncologist must be adept in navigat-
ing the dosage and timing of these drugs in order to preserve
quality of life, especially in patients with glioblastoma
(Table 13.1).
Table 13.1 Common neuro-oncology chemotherapies and toxicities
206
Common toxicity Less common Dosing and Pregnancy and

(>10%) toxicity Lab nadir reduction fertility Interactions References
Temozolomide Fatigue, nausea, Neutropenia, 3–4 weeks 75 mg/m2 in Pregnancy None [1]
vomiting, lymphopenia, induction category D. Can significant
headaches, thrombocytopenia phase. decrease male
constipation 150– fertility
200 mg/m2
in adjuvant
cycles.
Decrease by
25–50 mg/
m2 for
toxicity
Procarbazine Nausea, vomiting, Myelosuppression, 3–6 weeks 100 mg/m2/ Pregnancy Avoid MAO [2]
leukopenia, serotonin reaction, day. Dose category inhibitors
anemia hypertensive crisis, reductions in D. Azoospermia (e.g., SSRIs)
secondary 50 mg and infertility Avoid
malignancies (rare) increments reported with tyramine-
due to procarbazine in containing
standard human trials foods and
tablet dose (though alcohol
combined with
other therapies)
D. Schiff and H. Ahmad
13
Vincristine Peripheral Constipation, ileus, None 1.4 mg/m2 Pregnancy Metabolized [3]
neuropathy skin necrosis significant IV, dose cap category D by and
(vesicant) of 2 mg weakly
induces
CYP3A4
enzyme
Lomustine Neutropenia, Pulmonary WBC 80–110 mg/ Pregnancy None [7]
lymphopenia, toxicity, renal 5–6 weeks, m2 each category significant
nausea, vomiting toxicity Platelets cycle. D. Affected male
4 weeks Reduce to fertility in
70% for preclinical
hematologic studies
toxicity
Carmustine Nausea, vomiting, Pulmonary WBC 200 mg/m2 Pregnancy None [6]
(intravenous) facial flushing, toxicity, hepatic 5–6 weeks, IV each category significant
neutropenia, toxicity Platelets cycle D. Affected male
lymphopenia, 4 weeks fertility in
thrombocytopenia preclinical
studies
Chemotherapy-Related Toxicities and Management
(continued)
207
208

Bevacizumab Fatigue, Nephrotic None 10 mg/kg Pregnancy None [8]
hypertension, syndrome, venous significant every category C. May significant
proteinuria, or arterial clots, 2 weeks for impair fertility
impaired wound PRES, bowel gliomas but may be
healing perforation 7.5 mg/kg reversible per
every preclinical data
3 weeks for
4 doses, for
radiation
necrosis
Irinotecan Diarrhea, nausea, Leukopenia, WBC, 125 mg/m2 Pregnancy Metabolized [9]
vomiting, nausea, vomiting, about every category D by CYP3A4
weakness anemia 2 weeks 2 weeks
This table is not meant to be comprehensive
MAO Monoamine oxidase, SSRI Selective Serotonin Reuptake Inhibitor, CYP3A4 Cytochrome P450 3A4 enzyme, CP450 Cyto-
chrome P450 enzyme
D. Schiff and H. Ahmad
References
1. Merck IWS, NJ, USA. Temodar (Temozolomide) [Package Insert]. US
Food and Drug Administration. Revised 2015.
2. Sigma-Tau Pharmaceuticals IG, MD. Matulane (Procarbazine) [Package
Insert]. US Food and Drug Administration. Revised 2008.
3. Hospira ILF, IL. Vincristine sulfate [Package Insert]. US Food and Drug
Administration. Revised 2013.
4. Jutras G, Belanger K, Letarte N, et al. Procarbazine, lomustine and vin-
cristine toxicity in low-grade gliomas. Curr Oncol. 2018;25(1):e33–9.
5. O’Driscoll BR, Hasleton PS, Taylor PM, Poulter LW, Gattameneni HR,
Woodcock AA. Active lung fibrosis up to 17 years after chemotherapy
with carmustine (BCNU) in childhood. N Engl J Med. 1990;323(6):378–
82.
6. Bristol-Myers Squibb Company P, NJ. BiCNU (Carmustine) [Package
7. NextSource Biotechnology M, FL. Gleostine (Lomustine) [Package
8. Genentech ISSF, CA. Avastin (Bevacizumab) [Package Insert]. US Food
and Drug Administration. Revised 2009.
9. Pfizer Injectables. NY N. Camptosar (Irinotecan) [Package Insert]. US
Food and Drug Administration. Revised 2014.
10. Smith EM, Pang H, Cirrincione C, et al. Effect of duloxetine on pain,
function, and quality of life among patients with chemotherapy-induced
painful peripheral neuropathy: a randomized clinical trial. JAMA.
2013;309(13):1359–67.
11. Momota H, Narita Y, Miyakita Y, Shibui S. Secondary hematological
malignancies associated with temozolomide in patients with glioma.
Neuro Oncol. 2013;15(10):1445–50.
Radiation Related Toxicities
and Management 14
Sara J. Hardy and Michael T. Milano
Introduction to Cranial Radiotherapy
Radiotherapy plays an important role in management of many

types of brain tumors. Cranial radiotherapy is typically adminis-
tered form a source outside the patient (external beam radiother-
apy or EBRT), delivered via ionizing radiation produced through
either radioactive decay (for example, using cobalt-60 in Gamma
Knife-based radiosurgery) or acceleration of electrons into a tar-
get to produce photons or x-rays (linear accelerators). Proton
therapy is a form of particle therapy that can also be used for
EBRT [1, 2]. Conventionally fractionated radiation is given in
1.8–2 Gy per fraction. Standard treatment with whole brain radia-
tion therapy (WBRT) (with or without hippocampal sparing) is
typically 30 Gy in 10 fractions. Stereotactic radiosurgery delivers
high doses of radiation in 1–5 fractions using highly precise deliv-
ery systems [2].
In radiotherapy planning, the radiation fields and treatment
schedule are optimized to allow appropriate radiation dose to the
target while sparing normal tissues. While simple beam arrange-
S. J. Hardy (*) · M. T. Milano

Department of Radiation Oncology, University of Rochester,
Rochester, NY, USA
e-mail: Sara_hardy@urmc.rochester.edu; Michael_milano@urmc.
rochester.edu

Switzerland AG 2023
https://doi.org/10.1007/978-3-031-41413-8_14
212 S. J. Hardy and M. T. Milano
ment are often still used in palliative radiation (including WBRT

without hippocampal sparing), 3D-conformal radiotherapy and
intensity modulated radiotherapy (IMRT) are often used to
match the high dose radiation region to the target volume as
defined on imaging. Normal tissue structures are also delineated
on imaging in order to minimize radiotherapy dose and radio-
therapy toxicities [2]. Different normal tissues have different
sensitivities to radiation, and radiotherapy tolerance guidelines
for some normal tissues are summarized in the Quantitative
Analysis of Normal Tissue Effects in the Clinic (QUANTEC)
reviews [3].
Radiotherapy-Related Toxicity in the Central

Nervous System (CNS)
Acute Cranial Radiation Side Effects
Acute side effects occur days to weeks after irradiation [4]. Aside
from fatigue, the majority of acute side effects from cranial radio-
therapy can be predicted from the dose distribution. Worsening
intracranial edema can occur in the high dose region; this can
cause headaches, nausea/vomiting, altered mental status, or wors-
ening of focal neurologic symptoms. Less frequent symptoms
include vertigo or seizures. Symptoms are typically transient and
managed with corticosteroids [5]. If the acoustic structures are in
the radiation field, patients can experience serous otitis media due
to eustachian tube dysfunction, occasionally requiring over-the-
counter decongestants. This will usually resolve several weeks
after completion of radiotherapy, but if persistent, can be treated
using myringotomy [6]. Alopecia can occur over the whole scalp
with WBRT or in patches with partial brain radiotherapy.
Permanent hair loss is more common with higher radiation doses
[7]. If the parotid gland is irradiated, patients can experience
parotid swelling, dry mouth, and tenderness consistent with par-
otitis [8].
Skin may be exposed to radiation incidentally during radio-
therapy of intracranial lesions, particularly superficial tumors,
14 Radiation Related Toxicities and Management 213
potentially causing radiotherapy-related dermatitis [4]. Risk of

dermatitis is significantly impacted by systemic therapy. For
example, concurrent phenytoin and cranial radiation can cause
Erythema Multiforme associated with Phenytoin and Radiation
Therapy (EMPACT) [9]. Concurrent BRAF inhibitors can also
lead to grade 3 skin toxicity with cranial radiation [10].
Treatment of cerebellopontine angle tumors such as vestibular
schwannomas can rarely cause facial numbness and weakness
(92–98% trigeminal nerve preservation and 93–97% facial nerve
preservation in a modern series) [11]. Even more rarely, hemifa-
cial spasm, spontaneous, intermittent, and repetitive contraction
of the unilateral facial muscle, can occur. Steroids are given to
reduce swelling and compression on the facial nerve. Of note, in
the general population, hemifacial spasm is most commonly
caused by vascular compression of the facial nerve rather than
tumor [12]. Hydrocephalus is an uncommon side effect that is
seen mainly with SRS for larger cerebellopontine angle tumors.
In one series of larger volume vestibular schwannomas between 3
and 4 cm, 5% of patients developed symptomatic hydrocephalus
after single-fraction radiosurgery requiring ventricular-peritoneal
shunt placement [13].
In adults, the major functional bone marrow sites are the pelvis
and the vertebrae [14]. For that reason, craniospinal radiation
which treats the meninges, whole brain, spinal cord, and thecal
sac, can cause decreased blood counts. Decrease in lymphocytes
and neutrophils will be seen initially, then decrease in platelets
and erythrocytes [15].
Unrelated to the radiotherapy dose distribution, fatigue and
anorexia often occur by the second week of radiotherapy and typ-
ically improve by 2 weeks after completion. This is thought to be
due to acute inflammation and cytokine production during radio-
therapy [4].
Shorter radiotherapy courses like radiosurgery typically cause
less fatigue. In a study of acute side effects experienced by patients
during radiosurgery or 2 weeks after, one-third of patients had
mild to moderate side effects including nausea, dizziness/vertigo,
seizures, and new persistent headaches, which were generally
self-limited [16].
Late Cranial Radiation Side Effects
Late side effects from radiation occur ≥6 months after radiother-

apy. There are multiple etiologies including vascular injury, dam-
age from inflammation, impaired neurogenesis, and production of
reactive oxygen species. Multiple factors impact the risk of long-
term complications including treated brain volume, radiation dose
and fractionation, systemic therapy, surgery, and host factors such
as age or history of autoimmune disease [4].
adiation-Induced Necrosis (Also Called

R
Radionecrosis)
Description: Radionecrosis typically occurs 1–2 years after radia-

tion is completed. Per the QUANTEC review, the risk of radione-
crosis with conventionally fractionated radiotherapy is 5% at
5 years for a dose of 72 Gy [4]. This complication is more com-
mon with SRS due to the higher dose per fraction and dose hetero-
geneity within the target. The major factors that predict the risk of
radionecrosis from SRS are total dose, fractionation, tumor size,
volume of brain receiving 10–12 Gy, and concurrent systemic
therapy including HER2 antibodies, EGFR and VEGF tyrosine
kinase inhibitors, and immune checkpoint inhibitors [17–19].
Symptoms from radionecrosis are dependent on location in the
brain and include seizures, focal neurologic symptoms, headache,
nausea, and vomiting, and result from reactive brain edema at the
site of necrosis.
Work-up and diagnosis: It can be difficult to differentiate
between radionecrosis and tumor progression on structural MRI
scans. Perfusion MRI generally shows increased cerebral blood
volume in the setting of recurrent tumor compared to radionecro-
sis; there may be decreased accuracy in the setting of hemorrhage.
On diffusion-weighted imaging, recurrent tumor often has lower
ADC values than necrosis. With MR spectroscopy, the choline-
creatine ratio and choline-N-acetyl aspartate ratio are significantly
higher in recurrent tumor than in radionecrosis. FDG-PET has a
sensitivity and specificity for the diagnosis of recurrent tumor of

86% and 22%, but may have false positives in the setting of sub-
clinical seizures [20].
Treatment: The clinical course of radionecrosis is variable. It
may be asymptomatic or resolve after a short course of corticoste-
roids. In patients with radionecrosis who are refractory to cortico-
steroids or for whom corticosteroids are not a good option,
bevacizumab may be considered for treatment (Fig. 14.1). A small
randomized clinical trial showed that patients with radionecrosis
treated with bevacizumab 7.5 mg/kg every 3 weeks for a total of
four doses had improvement either in neurologic symptoms or on
imaging [21]. There was also a larger trial that compared bevaci-
zumab 5 mg/kg every 2 weeks for four doses with glucocorticoids
in 112 patients with temporal lobe necrosis. Patients with history
a b
c d
Fig. 14.1 MRI brain for patient with radiation necrosis after radiotherapy (a,
b) before and (c, d) after treatment with bevacizumab
of bleeding related to radiation or tumor, active CNS hemorrhage,

inadequately controlled hypertension, and recent intra-abdominal
fistula, perforation or abscess were excluded. The trial showed
that patients on bevacizumab had higher radiographic response
(66% vs 32%) and more clinical improvement (62% vs 43%) at
60 days with similar recurrence rates at 6 months (29% vs 27%)
when compared to corticosteroids. 20% of both groups experi-
enced hypertension. In the bevacizumab arm, one patient had an
ischemic stroke and four patients had hemorrhage, while one
patient on the glucocorticoid arm had an infection [22]. There is
also data for laser interstitial thermal therapy in the treatment of
radionecrosis [23]. For severe radionecrosis, surgical resection
may be required.
Pseudoprogression
Description: Pseudoprogression refers to a phenomenon seen in

20–30% of patients treated with radiotherapy for high-grade gli-
oma, for whom their first post-radiation MRI (within the first
3 months) shows increased contrast enhancement that eventually
subsides without any change in therapy. The mechanism is thought
to be transiently increased permeability of the tumor vasculature
from irradiation, which may be enhanced by temozolomide. This
occurs more frequently in patients with a methylated MGMT gene
promoter [24] Of note, high grade glioma patients on combination
lomustine and temozolomide were noted to have prolonged and
increased late pseudoprogression in a randomized phase 3 clinical
trial [25].
Work-up and diagnosis: Typically, the contrast enhancement
that characterizes this finding will resolve on subsequent MRIs.
Treatment: No treatment is typically required, though cortico-
steroids may be used for management of neurological symptoms.
In cases, where patients become corticosteroid-dependent or have
significant toxicities from corticosteroids, bevacizumab can be
considered.
Eyes and Optic Pathways
Radiation can impact multiple structures within the eyes and optic
pathways including the optic nerves.
Optic Neuropathy
Description: Optic neuropathy from radiation can be due to two

clinical syndromes that present with different symptoms. Anterior
ischemic optic neuropathy results from vascular injury to the dis-
tal portion of the optic nerve. Patients experience gradual painless
visual loss 2–4 years after completing radiotherapy. Retrobulbar
optic neuropathy is caused by damage to the proximal segments
of the optic nerve. Visual field deficits and rapidly progressive
vision loss, which are sometimes associated with ocular, perior-
bital, or retrobulbar pain. These are frequently due to disk abnor-
malities. Both types of injury are correlated with increasing
patient age, total radiotherapy dose >59 Gy, and daily fraction
size >2 Gy [4]. Systemic therapy may impact the risk of optic
neuropathy from radiation, and there have been reports of late
onset optic neuropathy in patients on bevacizumab [26].
Work-up and diagnosis: Work-up should include a clinical eye
exam including fundoscopic exam to confirm optic neuropathy.
MRI brain is also helpful. Lumbar puncture can be considered if
inflammatory or neoplastic cause is suspected [27].
Treatment: Hyperbaric oxygen, corticosteroids, and anticoagu-
lation have been tried with limited efficacy.
Ocular Neuromyotonia
Description: Ocular neuromyotonia is characterized by tonic

spasms of extraocular muscles innervated by a specific extraoc-
ular nerve that occurs during sustained eccentric gaze (hyperac-
tion of the muscle). It can occur after radiation to the pituitary or
skull base (involving the ocular motor nerves), nerve compres-
sion due to tumor/vasculature, or in the setting of myasthenia

gravis and thyroid eye disease. The etiology may be nerve
demyelination and ephaptic transmission vs calcium channel
dysfunction [28].
Work-up and diagnosis: Ocular neuromyotonia should be con-
sidered in differential for transient recurrent diplopia. Ask the
patient to look in a specific direction for several seconds and see
if this elicits a transient abnormality in eye movements. Patients
with suspected ocular neuromyotonia should get an MRI brain if
there is not a clear cause. The differential for diplopia also includes
stroke, intracerebral aneurysms, brain tumors, and giant cell arte-
ritis [27].
Treatment: Episodes can be treated with carbamazepine or
lacosamide.
Other Eye Disorders
Description: Radiation can damage different parts of the eye and

orbit. Cataracts are the most common effect to the lens. Radiation
typically causes posterior subcapsular cataracts. Radiation reti-
nopathy occurs at ≥40 Gy and develops 6 months to 3 years post-
treatment. Corneal ulceration can occur with doses ≥40 Gy. The
ocular surface is covered by a tear film, made up of aqueous,
mucinous, and lipid layers produced by the lacrimal and meibo-
mian glands. Radiation that disrupts the structures that produce
these elements will cause dry eyes or xerophthalmia. Atrophy of
the meibomian glands occurs at doses <30 Gray while damage to
the lacrimal gland occurs at 50–60 Gy.
Work-up and diagnosis: All of these are identified with a com-
prehensive eye exam.
Treatment: Xerophthalmia is typically managed artificial tears
or anti-inflammatory drops that treat the inflammatory component
of dry eyes. Radiation-induced cataracts are treated using lens
replacement.
Sensorineural hearing loss: Radiation can cause hearing loss
months to years after completion of treatment. Risk factors
include age, radiation dose to the cochlea, and ototoxic systemic
therapy such as cisplatin. Higher frequencies are more sensitive to

radiation dose. SRS for vestibular schwannoma typically results
in gradual sensorineural hearing loss over years, possibly related
to cranial nerve injury (from tumor and/or radiotherapy) or
radiotherapy-mediated cochlear injury.
Work-up and diagnosis: Sensorineural hearing loss can be
evaluated using standard audiometry.
Treatment: Symptoms can be managed with hearing aids as
needed for quality of life.
Central Hypopituitarism
Description: Radiation-induced hypopituitarism can occur when

the hypothalamic-pituitary axis receives significant radiation
dose. Factors that affect risk in fractionated radiotherapy include
total dose, fraction size, age at time of radiation, and length of
time after radiotherapy. Specific hormone deficiencies are sum-
marized in Table 14.1. The growth hormone (GH) axis is particu-
larly sensitive and is frequently the only site affected with lower
dose fractionated radiotherapy (≥18 Gy). GH deficiency may be
asymptomatic in adults but can cause decreased muscle mass and
increased adipose tissue. At higher doses, gonadotropins, TSH,
ACTH, and prolactin can be affected. LH/FSH and TSH defi-
ciency can occur with doses >40 Gy. LH/FSH deficiency can
cause amenorrhea or oligomenorrhea in women and low testoster-
one in men. Infertility, sexual dysfunction, and decreased libido
can occur. TSH deficiency may be subclinical, but can manifest
with fatigue, constipation, cold-intolerance, and weight gain.
Clinically relevant ACTH deficiency increases with hypothalamic-
pituitary axis dose >50 Gy with symptoms of fatigue, weakness,
nausea, vomiting, anorexia, and abdominal cramping.
Additionally, ACTH deficiency can lead to life threatening com-
plications in the setting of severe illness including hypoglycemia
and hypotensive shock. Hyperprolactinemia can occur with doses
>50 Gy due to damage to the hypothalamus and loss of hypotha-
lamic inhibition of prolactin release, leading to amenorrhea, infer-
tility and/or decreased libido. Some studies suggest that GH
Table 14.1 Syndromes seen in radiation-induced hypopituitarism, radio-

therapy doses, symptoms, screening, and management [29]
RT Common Hormone
Syndrome dose symptoms Screening replacement
Central adrenal >50 GyFatigue, Serum Hydrocortisone
insufficiency weakness, cortisol levels
nausea, at 8–9 a.m.,
vomiting, corticotropin
anorexia, stimulation
abdominal test
cramping,
complications in
the setting of
illness such as
hypotension
Central >40 Gy Fatigue, cold Serum free Levothyroxine
hypothyroidism intolerance, T4 and TSH
constipation,
weight gain
GH deficiency ≥18 Gy Decrease in GH GH
muscle mass stimulation
and increased testing (singe
adipose tissue, GH
fasting measurements
hypoglycemia are not
helpful)
Central >40 Gy Infertility, Serum Testosterone
hypogonadism sexual testosterone,
in males dysfunction, FSH, and LH
decreased (perform in
libido, the absence of
decreased bone illness and
density, before 10
decreased a.m. after
energy, overnight
decreased fast)
muscle mass
Central >40 Gy Oligomenorrhea Serum Estrogen
hypogonadism or amenorrhea, estradiol,
in females infertility, FSH, and LH
sexual
dysfunction,
decreased libido
deficiency is the first to emerge after injury to HPA, followed by

deficiencies of gonadotropin, ACTH, and TSH [29].
Work-up and diagnosis: The diagnosis is established through
bloodwork (Table 14.1). Radiation dosimetry should also be
reviewed to establish dose to the hypothalamic pituitary axis [29].
Treatment: Hypopituitarism can be managed through endo-
crine replacement therapy and is quite treatable (Table 14.1) [29].
Vascular Malformations and Microbleeds
Description: Vascular malformations such as cavernomas (clus-

ters of abnormal dilated blood vessels with blood-filled cavities,
see Fig. 14.2) and telangiectasias (dilated capillaries with a thin
endothelial lining can form as late radiation sequelae years after
radiotherapy. Cerebral microbleeds occur in both adults and chil-
dren who have received radiotherapy, typically years after. They
form primarily in regions that received at least 30 Gy, but also in
lower dose regions [30]. Children are more susceptible to devel-
oping these late sequelae compared to adults who receive cranial
radiation [31].
a b
Fig. 14.2 Patient with frontal cavernomas on imaging 11 years after treat-
ment with radiotherapy for a glioma shown on the (a) T1 + gadolinium
sequence (b) susceptibility weighted imaging sequence
Work-up and diagnosis: Cavernomas and telangiectasias can

be visualized on MRI scans, particularly on susceptibility-
weighted sequences, CT angiography, or cerebral angiography.
Cerebral microbleeds are best seen on susceptibility-weighted
sequences such as gradient echo sequences.
Treatment: Asymptomatic cavernomas can be managed con-
servatively. Resection is indicated for symptomatic lesions (pro-
gressive neurologic deficit, intractable epilepsy, and recurrent
hemorrhage). For surgically inaccessible lesions, SRS may be
considered. Telangiectasias are managed conservatively.
Atherosclerosis and Ischemic Stroke
Description: Similar to other vascular radiation side effects, chil-

dren are more susceptible to accelerated atherosclerosis and isch-
emic stroke. Risk factors include receipt of chemotherapy, young
age, radiation dose, and diagnosis of neurofibromatosis type 1.
After cranial radiation, individuals can develop either focal steno-
sis or Moya Moya, a syndrome with progressive occlusion of the
arteries of the circle of Willis leading to development of collateral
vessels [31]. While it may be an overestimate now, given the
advances in radiation techniques that lead to more sparing of nor-
mal tissue, one study reported a 16% rate of large vessel arteri-
opathy at 10 years for patients who received radiation for
childhood brain tumors [32]. Ischemic stroke also occurs after
cranial radiation and is well-studied in the pediatric population. A
Childhood Cancer Survivor Study analyzed leukemia and brain
tumor survivors, finding 0.8% rate of stroke in leukemia survi-
vors, 3.4% rate of stroke in brain tumor survivors, and higher rates
(6.5%) in survivors who received both cranial radiotherapy and
alkylating agents [33]. Significant radiation dose to the circle of
Willis increases risk of stroke events [34].
Treatment: Management of stroke in cancer survivors who
have received cranial radiation is extrapolated from management
of other stroke patients. However, there is some evidence that in
the setting of stenting for high grade carotid stenosis, there is
higher rate of in-stent restenosis [31]. One population-based study
showed a significant reduction in stroke in patients post radio-

therapy to the thorax, head, and neck who were on statins, so there
is some data for statin use in this population [35]. Other strategies
to decrease risk of vasculopathy include delaying radiotherapy if
the patient is very young, using lower radiotherapy doses, and
using more conformal radiotherapy. For long-term follow-up,
Children’s Oncology Group guidelines recommend annual neuro-
logic exam for survivors who received ≥18 Gy cranial radiother-
apy and MRI if clinically indicated [31].
SMART Syndrome
Description: SMART (stroke-like migraine attacks after radiation

therapy) syndrome is an extremely rare syndrome seen 1–5 years
after radiotherapy characterized by recurrent episodes of compli-
cated migraine symptoms along with focal neurologic deficits.
The majority of patients will have received a dose of >50 Gy and
received radiation to the posterior fossa. It is potentially a revers-
ible radiation vasculopathy, but the pathology is not well under-
stood [36].
Work-up and Diagnosis: Differential diagnosis should include
transient ischemic attack, stroke, and seizures. MRI and vascular
imaging can be performed to rule out acute stroke or recurrent
tumor. It may also show characteristic MRI features for SMART
syndrome including focal gyral thickening and gyriform contrast
enhancement most commonly in the parieto-occipital region [37].
Electroencephalography (EEG) can be done to rule out seizure.
Other considerations for differential diagnosis include mitochon-
drial encephalomyopathy, lactic acidosis, and stroke-like epi-
sodes, posterior reversible encephalopathy syndrome, and cerebral
autosomal dominant arteriopathy with subcortical infarcts and
leukoencephalopathy [37].
Treatment: There is some evidence that corticosteroids can
decrease neurologic deficits, though this is controversial. Per a
recent review, the majority of patients received antiepileptic med-
ications including valproate, levetiracetam, phenobarbital, phe-
nytoin, lamotrigine, carbamazepine, topiramate, and
oxcarbazepine. Aspirin, propranolol, verapamil, and various anti-

convulsants were used most frequently over long-term, but only
aspirin and verapamil reduced frequency and severity of episodes
[36].
Radiation-Related Cognitive Decline
Description: In recent decades, there has been significant interest

in the effect of radiotherapy on cognition. Contributing factors
include the brain tumor(s) themselves, medications such as corti-
costeroids and antiepileptics, age and other host factors, systemic
therapy, surgery, and factors specific to the radiotherapy including
total radiation dose, fraction size (larger doses causing greater
normal tissue damage), and radiation field [38]. In 1989, Deangelis
et al. published an 11% risk of radiation-related dementia in 47
patients undergoing WBRT for brain metastases . Notably, three
patients received large daily fractions (5–6 Gy), one received con-
current adriamycin, and one received concurrent lonidamine (a
radiosensitizer) [39]. However, modern studies with standard
WBRT treatment regimens have shown more subtle declines in
verbal learning and memory and executive function in brain
metastases patients receiving WBRT at 4 months [40]. Recently,
hippocampal sparing WBRT has shown improvement in neuro-
cognitive decline compared to standard WBRT [41]. However, it
remains unclear whether SRS for multiple metastases has better
cognitive outcomes than hippocampal sparing WBRT. There are
randomized clinical trials studying this [23], as well as others
evaluating SRS for up to 20 brain metastases.
Work-up and diagnosis: Neurocognitive change in patients
who have received radiotherapy is often multi-factorial. Initial
assessment should include history to identify other factors such as

medications, mood disorders, sleep disturbances, as well as screen
for endocrine abnormalities which are both common and could
result from cranial. Screening for other causes of neurocognitive
decline, such as vitamin deficiencies (B12), metabolic abnormali-
ties, hydrocephalus, tumor recurrence, or stroke may be war-
ranted.
Treatment: Based on recent trials, many treatments begin at
time of initial radiotherapy using new radiation techniques to
reduce complications. A trial in young patients showed improved
IQ and decreased neuroendocrine complications with conformal
radiotherapy in conventional fractionation using stereotactic
technique compared to conventional radiotherapy [42].
Additionally, there are retrospective studies that proton therapy
may cause less cognitive decline compared to non-proton-based
radiotherapy, and a randomized trial (NRG BN005;
NCT03180502 is underway [43]. As noted above, hippocampal
sparing WBRT has now become standard of care and work is
being done to compare this to SRS for multiple metastases.
There is evidence for some medications as well. There is evi-
dence that memantine started at the time of WBRT increases
time to neurocognitive decline [44]. A phase 3 trial of donepezil
showed no significant difference in the primary outcome (a com-
posite score of cognitive performance, subjective confusion, and
fatigue) between patients who received donepezil compared
with those who received placebo, but did show improvement in
some domains such as memory and may be an option in some
patients [45]. There are mixed data for methylphenidate and
modafinil, but they can be considered for patients with signifi-
cant fatigue or attentional deficits [38] (Table 14.2).
Table 14.2 Late side effects from radiotherapy, work-up, and management
226
Complication Patient population Work-up Imaging findings Timing Management

Treatment effects
Radiation necrosis Patients treated with Imaging, typically Favor tumor: Most Steroids,
radiosurgery or MRI with perfusion or increased cerebral commonly bevacizumab, laser
receiving >60 Gy in MRS, PET/CT blood volume, 1–2 years interstitial thermal
conventional lower ADC values therapy, resection if
fractionation than necrosis, on needed
MR spectroscopy
choline-creatine
ratio and choline-N-
acetyl aspartate
ratio higher,
FDG-PET avidity
Pseudoprogression Patients with glioma; Serial imaging Increased contrast- Within Typically no
more common in enhancement on T1 3 months of change in
MGMT methylated post-gad radiation treatment; if
tumors on symptomatic,
temodar ± lomustine steroids and/or
bevacizumab can
be administered
Vision changes
S. J. Hardy and M. T. Milano
14

Optic neuropathy Increased risk with A clinical exam Optic nerve atrophy 2–4 years Hyperbaric oxygen,
increasing patient age, including fundoscopy on imaging after corticosteroids, and
total radiotherapy to confirm optic radiotherapy anticoagulation
dose >59 Gy, and neuropathy. MRI brain have been tried
daily fraction size is also helpful. Lumbar with limited
>2 Gy puncture can be efficacy
considered if
inflammatory or
neoplastic cause is
suspected
Ocular Radiation to the Eye movement exam n/a Years after Carbamazepine or
neuromyotonia pituitary or skull base after sustained radiotherapy lacosamide
(involving the ocular eccentric gaze, MRI
motor nerves) brain
Cataracts Radiation dose >7 Gy Eye exam n/a 2–3 years Lens replacement
Radiation Related Toxicities and Management
to lens post
radiotherapy
Dry eyes 30 Gy to meibomian Eye exam n/a Years after Artificial tears,
gland, 50–60 Gy to radiotherapy anti-inflammatory
lacrimal gland eye drops
(continued)
227
228

Serorineural hearing Cranial radiotherapy Audiogram n/a Months to Hearing aids as
loss with mean dose to years after needed
cochlea >45 Gy, radiotherapy
exposure to ototoxic
chemotherapy
Vascular
complications
Cavernomas Children and adults MRI with T1, T2, T1- and Years after Observe
after radiotherapy susceptibility weighted T2-weighted radiotherapy asymptomatic
imaging images include a lesions, Resection
“popcorn” pattern Indications for
of variable image symptomatic
intensities lesions (progressive
consistent with neurologic deficit,
evolving blood intractable epilepsy,
products and recurrent
hemorrhage),
consider SRS if
surgically
inaccessible
S. J. Hardy and M. T. Milano
14
Telangiectasias Children and adults MRI with T1, T2, Hypo- to isointense Years after Conservative
after radiotherapy susceptibility weighted on T1, iso- to radiotherapy management
imaging slightly
hyperintense on T2,
faint enhancement
on T1 postcontrast,
dark on SWI
Stroke-like Received a dose of MRI brain with Focal gyral 1–5 years Aspirin,
migraine attacks >50 Gy and received contrast thickening and after propranolol,
after radiation radiation to the gyriform contrast radiotherapy verapamil,
therapy (SMART) posterior fossa enhancement most anticonvulsants
syndrome commonly in the
parieto-occipital
region
Accelerated Child and adults, MRA, CTA, cerebral Focal stenosis, >5 years Statins, aspirin,
atherosclerosis particularly if angiography vessel antiplatelets
radiation dose to circle collateralization
Radiation Related Toxicities and Management
of Willis
Cognitive change Children and adults Metabolic work-up, n/a 4 months to Memantine,
who receive partial or vitamin B12, MRI brain, years after investigational
whole brain radiation neuropsychological radiotherapy strategies
therapy testing, depression/
anxiety screen
229
Patient Advice
Whole brain radiation: This is typically given over
10 days (2 weeks). During the initial planning session, the
patient will be fitted for a mask to give the radiation treat-
ment safely. Patients will typically feel fine for the first
week, but will start to have some tiredness starting the sec-
ond week. This should resolve about 2 weeks after complet-
ing treatment. Less common symptoms include headache,
poor appetite, nausea, vomiting, and worsening of neuro-
logic symptoms. Most patients will have hair loss, but it will
typically grow back. Some patients will have hearing
changes due to an issue with the middle ear, which should
improve on its own. Studies show that many patients have
changes in memory months to years after completing radia-
tion treatment. Patients may receive a medication called
memantine and/or treated using a technique called hippo-
campal sparing to decrease these side effects.
Radiosurgery: Patients will receive radiation treatment
over 1–5 days. During the initial planning session, the
patient will be fitted for a tight mask to give radiotherapy
safely. Some patients will have mild tiredness the week
after completing this treatment. About one-third of patients
have immediate mild to moderate side effects after radiosur-
gery. They typically resolve on their own, but may be treated
with a short course of corticosteroids.
Partial brain radiotherapy for glioma: Most patients
are treated with 27–30 radiation treatments given over
5–6 weeks. It is possible that the radiation oncologist will
recommend a shorter treatment based on the specific case.
During the initial planning treatment, the patient will be fit-
ted for a mask to give the radiotherapy safely. The radiation
oncologist will coordinate with a neuro-oncologist (or med-
ical oncologist) so that chemotherapy will be started appro-
priately. Most patients will experience tiredness starting in
the second week of radiotherapy. This will gradually worsen
during treatment. There is usually patchy hair loss. Hair
may not grow back even after treatment ends. Patients may
experience headaches, nausea, vomiting, seizures, or
changes in neurologic symptoms. Patients will start to feel
more normal about 2 weeks after radiotherapy ends and
should be mostly recovered by 4–6 weeks after the end of
treatment.
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Neurosurgical
Complications in Brain 15
Tumor Patients
Tyler Schmidt
The surgical management of brain tumor patients has dramatically

evolved over the last 20 years. Neurosurgical adjuncts, such as the
operating microscope, neuronavigation, intraoperative neuromoni-
toring, tumor-fluorescence (5-ALA), tractography, and cortical
mapping have been successfully incorporated into the neurosurgi-
cal theater. These modalities have enhanced the safety profile of
neurosurgical intervention. These technologies have allowed for
improved preservation of neurologic function as well as mitigation
of potential morbidities. Despite the continued advancement of
radiation, chemotherapy, and immunotherapy, surgery remains the
initial treatment modality in the majority of patients with brain
tumors. The main objective of neuro-oncological surgery is to pro-
vide maximal cytoreduction, decrease the mass effect and associ-
ated complications, and establish the pathologic diagnosis. Studies
have repeatedly shown the benefit of gross total resection of brain
lesions, including most common high and low grade gliomas, soli-
tary brain metastasis and meningiomas. This chapter will review
the complications related to neurosurgical treatment of brain
tumors and provide guidance on the management of those patients
from pre- to post-operative care.
T. Schmidt (*)
University of Rochester, Rochester, NY, USA
e-mail: Tyler_Schmidt@URMC.Rochester.edu

Switzerland AG 2023
https://doi.org/10.1007/978-3-031-41413-8_15
236 T. Schmidt
There are generally two groups of complications related to

brain tumor surgery—surgical and systemic [1]. Surgical compli-
cations arise as a direct result of the surgery and are usually
specific to the neurosurgical site and procedure. They include
neurologic complications, such as postoperative seizures and neu-
rologic deficits, as well as postoperative cerebral edema, cerebral
hemorrhage, infarction, hydrocephalus, and regional complica-
tions, such as CSF leak, wound infection or dehiscence. Systemic
complications are not directly related to the neurosurgical site and
procedure and include the following: pulmonary complications
(e.g. pulmonary embolism, pneumonia, atelectasis), cardiac com-
plications (e.g. myocardial infarction, arrhythmias, hypo/hyper-
tension), renal complications (e.g. urinary tract infections, acute
kidney injury) and others. The risk of both surgical and systemic
complications can be reduced with preoperative planning, meticu-
lous surgical technique and use of intra-operative adjuncts as well
as proper post-operative management.
Preoperative Management
Every preoperative assessment should begin with obtaining thor-

ough medical history and performing careful physical examination
in order to identify any comorbidities that might affect the outcome
of the tumor resection procedure. Common medical comorbidities
to screen for include hypertension, diabetes, atrial fibrillation as
well as other cardiac conditions which require anticoagulation and
antiplatelet therapy. Therefore, all current medications need to be
reviewed and adjusted according to the patient’s status.
Perioperative Antiepileptic Therapy
There is little to no evidence on the efficacy of antiepileptic drugs

(AED) in prevention of postoperative seizures in patients with brain
tumors and no history of seizures [2, 3]. Thus, they should not be
routinely prescribed unless a documented seizure has occurred. The
patients who present with single or multiple seizures are at higher risk
for recurrence in the presence of intracranial pathology. In these
15 Neurosurgical Complications in Brain Tumor Patients 237
patients, AED therapy should be continued or initiated before sur-

gery. Potential interactions between AED and other medications
(especially chemotherapy) need to be considered before choosing a
specific AED. Levetiracetam at the loading dose of 20 mg/kg intrave-
nously followed by 500–1000 mg twice a day is commonly pre-
scribed for seizure prophylaxis due to its low side effect profile.
Steroids
Steroids in patients with both primary and metastatic brain tumors

significantly alleviate the symptoms occurring due to vasogenic
edema and increased intracranial pressure both pre- and post-
operatively. Dexamethasone is a corticosteroid of choice in neuro-
oncological patients and has been shown to improve outcomes
postoperatively in those patients. The initial IV bolus of 10 mg is
followed by administration of 16 mg/day in 2–4 divided doses.
The initiation of therapy should occur at least 3 days before sur-
gery for maximal effect. Dexamethasone may be tapered off grad-
ually in 2–3 weeks after surgery or quickly—3 days after surgery,
depending on the individual benefit and the duration of pre-
operative steroid therapy. In general, lowest possible doses and
early taper are recommended to avoid unnecessary side-effects
and comorbidities due to steroid use. Prevention of steroid-
induced ulcers requires gastrointestinal prophylaxis, such as pro-
ton pump inhibitors. Monitoring of blood glucose levels is also
recommended while on steroid therapy. Prophylaxis against
Pneumocystis jirovecii should be considered for patients requir-
ing prolonged used of steroids.
Antiplatelet and Anticoagulation Medications
The risk of hemorrhage for intracranial surgery is high. Antiplatelet

and anticoagulation therapy, including chemical DVT prophy-
laxis, should be withheld before surgery unless there are specific
circumstances that are discussed with the surgical team. In general
antiplatelet/anticoagulant medications should be stopped 5–7 days
before elective surgery. Patients with drug-eluting stents
238 T. Schmidt
(DES) need to be administered dual antiplatelet therapy for up to

12 months after DES surgery. Even brief cessation of the therapy
drastically increases the chances of life-threatening stent throm-
bosis. Therefore, the decision concerning the continuation of ther-
apy through brain tumor surgery should be based on consultation
between the patient’s neurosurgeon and cardiologist and the con-
sensus should be balanced between risks and benefits.
Anticoagulation drugs are stopped preoperatively (unfractionated
heparin: stop full IV anticoagulation 4–6 hours before surgery,
subcutanoueous dosig, stop 12 hours before surgery; low molecu-
lar weight heparin (LMW heparin): stop prophylactic dose
12 hours before surgery, stop full anticoagulation 24 hours before
surgery; fondaparinux: stop 2 to 4 days prior to surgery; rivaroxa-
ban: stop 24 hours before; apixaban: stop 8 hours before surgery).
Patients who require constant anticoagulation therapy with vita-
min K antagonists (VKA) (e.g. mechanical heart valves) need to
be bridged with LMW heparin. VKA (warfarin, acenocoumarol)
are stopped 5 days before surgery and LMW heparin is started,
with the last dose administered subcutaneously no later than 12 h
before surgery.
Hyperglycemia
Perioperative hyperglycemia is significantly associated with

adverse effects in patients undergoing brain tumor resection [4].
Glucose levels should be maintained at <180 mg/dL and hypogly-
cemia should be avoided in all patients. Close surveillance for
hyperglycemia is especially warranted in patients that receive corti-
costeroids. The target level of glycosylated hemoglobin (HbA1C)
should be <7.0% before surgery in patients with diabetes.
Antidiabetic drugs are withheld preoperatively (metformin and
short-acting sulfonylureas: 24 hours before surgery; thiazolidine-
diones: 24 to 36 hours before surgery; long-acting sulfonylureas: 48
to 72 hours before surgery) and substituted with intravenous insulin
infusion or sliding scale insulin. Postoperatively, IV or subcutane-
ous insulin is administered as appropriate with careful attention as
corticosteroids are weaned and pre-procedure diabetic medications
are restarted to prevent hypoglycemia.
Optimizing Other Medical Conditions
Decision to withhold or administer antihypertensives and other

cardiac medications perioperatively needs to be determined after
consultation with a cardiologist and/or anesthesiologist. Fluid sta-
tus should be addressed and optimized accordingly to prevent
post induction hypotension and acute kidney injury. Patients with
a history of pulmonary disease are at greater risk for perioperative
respiratory complications, therefore optimization of lung function
should be completed preoperatively.
Preoperative Imaging
There are several neurosurgical adjuncts that aid the neurosur-

geon with preoperative planning and intraoperative approaches
that optimize the extent of resection and safety profile.
Moreover, additional imaging technologies are used for tumors
located in eloquent areas to mitigate potential neurologic defi-
cits related to resection. Neuronavigation utilizes thin-sliced
MRI and CT scans to form a 3D reconstruction of the lesion
and its relationship with adjacent anatomy. It can be further
supplemented with functional data, such as functional MRI
(fMRI) or diffusion tensor imaging (DTI). fMRI data is particu-
larly useful for preoperative planning of surgical approach and
surgical corridor as well as intraoperative navigation for intra-
axial lesions located in eloquent areas. DTI tractography allows
for a visualization of white matter fibers, such as the visual
pathway, arcuate fasciculus, corticospinal tract and others.
Despite the usefulness of intraoperative MRI (iMRI), fMRI,
and DTI tractography in identification of crucial anatomical
structures and their relationship to the lesion, current research
shows low quality evidence on their efficacy in maximizing the
extent of resection, postoperative neurological status,
progression-free survival and overall survival in patients with
gliomas, when compared to traditional neuronavigation [5–7].
However further research is ongoing as these new techniques
are integrated into the neurosurgical workflow.
240 T. Schmidt
Intraoperative Management
Patient Positioning
Proper patient positioning is essential in providing surgical corri-

dor visualization while minimizing iatrogenic pressure or traction
injury due to the lengthy nature of some neurosurgical procedures.
Prevention of pressure ulcers relies both on crafted positioning
and ample use of gel and foam padding. The patient should be
placed in a physiological position to prevent brachial plexus and
other peripheral nerve injuries. The position of the patient can
also affect the risk of developing venous air embolism (VAE).
Venous Air Embolism
The incidence of VAE during intracranial procedures has been

reported in up to 76% of cases [8], the majority of which are
asymptomatic. The risk of VAE increases when the surgery is
done in close proximity to dural sinuses. Elevation of the patients
head above the heart (e.g. sitting position for posterior fossa
tumors) creates an additional gravitational gradient. Other risk
factors include blood loss and dehydration. In patients with pre-
operatively detected patent foramen ovale, decision to avoid sit-
ting or semi-sitting position should be considered.
Any unexplained hypotension, decreases in end-tidal carbon
dioxide, arterial oxygen saturation, hypercapnia, and/or increase
in end-tidal nitrogen should immediately suggest the possibility
of VAE during surgery. Precordial Doppler and transesophageal
echocardiography can be used to screen for air emboli. Surgeons
should immediately soak the surgical field with saline to prevent
further emboli by blocking venous channels. The patient is then
placed in partial left lateral decubitus position (Durant maneuver),
nitrogen dioxide is discontinued (if being utilized) and the patient
should receive 100% oxygen. Catheter aspiration can be consid-
ered in severe cases. Hemodynamic instability should be treated
immediately and if not effective, the surgery should be aborted.
Skin Incision and Tissue Handling
Planning of the scalp incision parallel to the major scalp vessels

allows for better perfused skin flaps than U-shaped incisions. The
base of the flap should be wider than the height to maintain ade-
quate blood supply. The initial skin incision should be well opti-
mized for possible salvage opportunities in case of postoperative
infection, treatment induced dehiscence, or possible reoperation
for disease recurrence. Meticulous dissection and gentle tissue
handling prevent maceration of tissues that can lead to infection
or delayed wound healing.
nsuring Gross Total Resection and Preventing

E
New Neurologic Deficits
Ensuring gross total resection (GTR) relies on meticulous surgical

technique and visualization of the tumor. Intraoperative micro-
scope and intraoperative imaging modalities, such as traditional
neuronavigation, DTI tractography, fMRI and iMRI allow for
preservation of crucial adjacent anatomical structures and deep
white matter tracts, and as such, prevention of new neurological
deficits (see Sect. 2.3). Moreover, fluorescence guided surgery
with 5-aminolevulinic acid (5-ALA) or sodium fluorescein can
additionally aid in visualization of the tumor margins and in max-
imizing GTR. Studies on the 5-ALA guided resections with and
without addition of iMRI showed significantly higher rates of
GTR and progression-free survival than those using white light
alone [9, 10]. Utilization of 5-ALA requires low light conditions
for 48 hours postoperatively to prevent photosensitivity reactions.
Other techniques and modalities, such as neuro-endoscopy or
BrainPath allow for minimally-invasive transsulcal approaches to
subcortical lesions sparing transcortical injury. Preservation of
en-passage vessels to adjacent functional cortex is of utmost
importance during tumor dissection.
242 T. Schmidt
Intraoperative Neurophysiological Monitoring
Somatosensory evoked potentials (SSEP), motor evoked potentials

(MEP) and intraoperative electromyography (EMG) can be used to
evaluate the functioning of sensory and motor pathways. Cortical
and subcortical mapping allows for navigation around those regions
and tracts during resection of lesions in eloquent brain. Cortical
mapping is particularly useful to maximize safe resection in motor,
language, and cognition related lesions. Sleep mapping (during
anesthesia) is usually performed for lesions that do not directly infil-
trate eloquent regions, while awake mapping is preferred for more
infiltrating lesions as they allow for real time feedback. All tech-
niques have been shown to mitigate the risk of postoperative neuro-
logic deficit and are utilized extensively in modern neurosurgical
oncology.
Closure
Ensuring proper watertight dural and galeal closure decreases the

risk of cerebrospinal fluid (CSF) leak, CSF fistula, pseudomeningo-
cele, delayed wound healing, and infection. Skin approximation
can be completed with surgical staples, absorbable, or non-
absorbable suture with alignment of the dermal edges being critical
for proper wound healing. The use of subgaleal closed drainage
systems can minimize hematoma formation and improve healing.
Postoperative Complications and Management
Hemorrhage
Postoperative intracranial hemorrhage is one of the most feared

complications of brain tumor surgery with high morbidity and
mortality. However, small hematomas in the tumor cavity are
found on postoperative imaging in up to 30% of patients [11].
Major hemorrhage requiring reoperation accounts for 2% of
brain tumor cases [12]. Risk factors include subtotal resection,
tumor type (hemangioblastoma, infratentorial tumors), older

age, pre-existing conditions, such as hypertension or coagu-
lopathy. Ensuring intraoperative hemostasis and perioperative
normotension are essential in preventing postoperative hemor-
rhage.
Seizures
Seizures occur in up to 10% of patients after brain tumor surgery

[13]. Seizures can result from the cortical irritation after tumor
resection, idiopathic causes, brain manipulation, or prolonged
retraction. In some cases, intracranial hemorrhage or cerebral
edema can result in postoperative seizures. Therefore, early post-
operative seizures warrant reimaging usually with a noncontrast
CT head. In general, patients are managed with antiepileptic
drugs (see Sect. 2.1).
Neurologic Deficit
There are a number of factors contributing to the risk of new neu-

rologic deficit after brain tumor resection. Many of them might be
anticipated secondary to location of the lesion and surgical corri-
dor. Deep location of tumors, location in or near eloquent areas,
and tumors encasing major vessels are risk factors for postopera-
tive deficits. Arterial or venous infarcts due to vessel sacrifice or
injury can lead to symptomatic deficits. Neurologic deficits are
often transient and resolve over the ensuing days/weeks/months.
Intraoperative imaging, neuronavigation, and neurophysiological
monitoring can reduce the risk of iatrogenic injury and new neu-
rologic deficits (see Sect. 3.4).
Patients with new neurologic deficits should be evaluated by a
comprehensive therapy/rehab team consisting of physical, occu-
pational, and speech therapy as clinically warranted. Modern
rehabilitation techniques/devices improve the quality of life of
patients with persistent deficits.
244 T. Schmidt
Postoperative delirium can occur. Environmental techniques

that can improve or prevent postoperative delirium include orient-
ing the patient towards time and surroundings (lights on during
daytime, family members present), proper uninterrupted sleep
protocol, proper nutrition, and early mobilization.
Hydrocephalus
The rates of postoperative hydrocephalus reach 6–8% [14] for the

lesions located at the skull base in close proximity to the fourth
ventricle. Other risk factors include metastatic disease, intraven-
tricular lesions, and transventricular approaches. The etiology of
postoperative hydrocephalus is multifactorial and case dependent,
including obstructive hydrocephalus from obstruction of CSF
flow pathways or nonobstructive hydrocephalus from protein or
blood product buildup in the CSF inhibiting normal CSF reab-
sorption. In the cases of persistent hydrocephalus, permanent CSF
diversion via shunt is necessary.
Infection
Infections after brain tumor resection occur in 2–4% of patients

[15, 16]. Known risk factors include duration of surgery, male
sex, postoperative CSF leak and length of preoperative stay of
more than one day [15]. Presentation ranges from superficial
skin infection to meningitis, subdural empyema, or abscess.
Additional risk factors for meningitis include elderly age group,
presence of lumbar drain, and enteral nutrition. Standard antibi-
otic therapy based on sensitivity patterns should be started if
infection is suspected. Subdural empyema and abscess may
require additional reoperation for source control. Preventive
methods include administration of perioperative antibiotics
before induction (cefazolin), meticulous technique, strict steril-
ity practices, and proper dural, galeal, and skin closure.
Wound Healing Complications
Dehiscence and wound healing problems can be related to older

age, frailty syndrome, diabetes, previous surgery, previous chemo
and radiotherapy, angiogenesis inhibitor utilization (bevaci-
zumab), and carmustine (Gliadel©) wafer use. In order to improve
wound healing the management should include correcting hyper-
glycemia, optimizing nutrition, utilizing proper closure tech-
niques, and decreasing the pressure on the incision.
Venous Thromboembolism
Patients who undergo surgery due to brain tumor are at increased

risk for developing venous thromboembolism (VTE). Additional
risk factors for VTE include presence of malignancy, leg weak-
ness, duration of surgery, and absence of thromboprophylaxis.
Previous studies have shown the efficacy of intra- and postopera-
tive intermittent pneumatic compression (IPC) [17] and LMW
heparin [18] in reducing the risk of VTE. The timing of the start
of anticoagulation therapy seems to affect the risk of postopera-
tive hemorrhage, with higher rates of bleeding detected if the
therapy is started during or early after the craniotomy. Current
ESA guidelines [19] recommend the initiation of IPC thrombo-
prophylaxis before surgery in all patients undergoing intracranial
procedures. Moreover, the addition of subcutaneous LMW
heparin is advised no earlier than one day post-surgery in patients
with evidence of postoperative intracranial hemorrhage [19].
Other Systemic Complications
Cardiac complications occur in 1.1% and 0.7% of patients under-

going surgery for benign tumors and gliomas, respectively [20].
The incidence of acute renal failure after tumor resection is
between 1.3 and 1.5% [20]. The treatment of those patients
246 T. Schmidt
requires a multidisciplinary approach and management.

Malnutrition results in poor wound healing and worse outcomes.
Nutrition consultation is advised in those patients.
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Management of Older
Patients with Brain Tumors 16
Andrea Wasilewski
The incidence of malignant glioma, specifically glioblastoma

(GBM), IDH-wild type, is increasing among older patients [1].
Increased age has been associated with decreased overall survival,
with older patients often surviving less than 6 months [2]. The
definition of an older adult is variable, although most often is
defined as those age 65 or older. Currently, no consensus exists on
how to treat older patients with GBM, who have traditionally been
underrepresented in clinical trials and often have additional
comorbidities and impaired performance status that limit their
ability to tolerate standard therapy [3]. Treatment strategies for
older patients with glioblastoma are largely physician and institu-
tion dependent with large disparities in care. Patients over the age
of 70 comprise greater than 25% of the GBM population yet
remain significantly under-treated, often receiving no treatment or
significantly less than standard care [3]. These patients have
unique risks and needs that require careful and often multidisci-
plinary consideration and care.
The diagnosis, evaluation and determination of appropriate
treatment present particular challenges in older adults. Older
patients are more likely to experience delays in diagnosis due to
non-specific symptoms such as headache, personality or cognitive
A. Wasilewski (*)
Givens Brain Tumor Center, Allina Health, Minneapolis, MN, USA
e-mail: andrea.wasilewski@allina.com

Switzerland AG 2023
https://doi.org/10.1007/978-3-031-41413-8_16
250 A. Wasilewski
changes. They may be offered less aggressive diagnostic proce-

dures (e.g. offered a diagnostic biopsy rather than resection) and
abbreviated courses of treatment or no treatment at all.
Additionally, older patients frequently have medical comorbidi-
ties which may affect the safety, tolerability and effectiveness of
treatment. Though this chapter focuses on evidence-based treat-
ment strategies for older patients with glioblastoma, it is impor-
tant to do a thorough functional and geriatric assessment prior to
embarking on tumor-directed treatment. Older patients with poor
performance status, patients who are frail, or patients with a lim-
ited life expectancy may be best served with palliative care and
early integration of hospice. This chapter highlights the limited
existing evidence for treatment of glioblastoma in older adults,
approaches for the evaluation and risk stratification of older
patients with brain tumors and discusses critical supportive care
interventions for this population.
reatment Options for Older Patients

T
with Malignant Gliomas
The balance between the benefit and risks of glioma treatment in

older adults is difficult in the setting of minimal evidence specific
to this population. The current standard of care for treatment of
glioblastoma (GBM) includes maximally safe surgical resection
followed by radiation and alkylating chemotherapy with temo-
zolomide (TMZ), with a median survival of 14.6 months in
patients under the age of 70 with good performance status [4].
Subsequently, a randomized trial studying the addition of tumor-
treating fields (TTF) to this regimen demonstrated an improve-
ment of median survival to 19.6 months. Patients up to the age of
83 were included in this study, although the median age was much
younger at 57 [5]. Older patients have traditionally been under-
represented on glioma clinical trials, thus making it difficult to
apply such results to this population. In the past two decades sev-
eral prospective clinical trials focused specifically on older
patients have been conducted, the results of which are summa-
rized in Table 16.1. The majority of these trials included patients
Table 16.1 Prospective randomized clinical trials in older adults with malignant gliomas
Radiation: Dose/ Median
No. of fraction/Duration overall
Clinical trial Age patients (weeks) Chemotherapy survival Significance
Keime-Guibert 70– 42 GBM 50 Gy/1.8 Gy/6 16.9 weeks RT prolongs survival compared
et al. [6] 85 39 GBM 29.1 weeks to best supportive care
Supportive care
vs. Standard RT
Roa et al. [7] 60+ 47 GBM 60 Gy/2Gy/6 5.1 months Hypofractionated RT is
Standard RT vs. 48 GBM 40 Gy/2.6 Gy7/3 5.6 months non-inferior to standard RT
HfRT
IAEA Trial [8] 50+ 50 GBM 40 Gy/2.67 Gy/3 6.4 months 1-week HfRT can be considered
HfRT vs. 48 GBM 25 Gy/5 Gy/1 7.9 months in the very elderly and/or frail
1 week HfRT
NOA-8 [9] 66– 178 60 Gy/2 Gy/6 TMZ 100 mg/m2, 8.6 months TMZ alone is non-inferior to RT
TMZ alone vs. 84 GBM 7 days on, 7 days off 9.6 months alone (most benefit if MGMT
Standard RT 17 AA methylated)
153
16 Management of Older Patients with Brain Tumors
GBM
23 AA
(continued)
251
252
Radiation: Dose/ Median

No. of fraction/Duration overall
Clinical trial Age patients (weeks) Chemotherapy survival Significance
Perry et al. 65– 281 40 Gy/2.67 Gy/3 Concurrent TMZ 7.6 months HfRT+TMZ should be
[10] 90 GBM 75 mg/m2 for 21 days 9.3 months considered in all older patients
HfRT vs. 281 during RT with reasonable performance
HfRT + TMZ GBM Adjuvant TMZ status, particularly if MGMT
150–200 mg/m2 for methylated
5 days per 28-day
cycles (up to 12 cycles)
Nordic Trial 60– 93 GBM 34 Gy/3.4 Gy/2 TMZ 200 mg/m2 for 8.3 months Older patients have better
[11] 88 98 GBM 60 Gy/2 Gy/6 5 days per 18-day 7.5 months outcomes with HfRT than
TMZ vs. HfRT 100 cycles (up to 6 cycles) 6 months standard RT
vs. Standard RT GBM TMZ monotherapy can be
considered in MGMT
methylated patients
GBM Glioblastoma, AA anaplastic astrocytoma, RT Radiotherapy, HfRT hypofractionated radiotherapy, TMZ temozolomide
A. Wasilewski
16 Management of Older Patients with Brain Tumors 253
who were functionally able to perform self-care with a Karnofsky

Performance Status (KPS) of 70 or above. Data is limited for frail
older patients who have additional functional impairments.
Surgical Treatment
Many factors should be considered prior to neurosurgical inter-

vention in older patients. Older patients are more likely to have
additional medical comorbidities that may increase their risk of
surgical complications, prolonged hospitalization or requirement
of rehabilitation post-operatively. Biopsy alone has been shown to
have an inferior survival to subtotal or gross total tumor resection,
although may be appropriate in those with significantly impaired
functional status, significant comorbidities or multifocal tumors
[12]. Maximally safe resection should be considered in patients
for diagnosis, symptom control and survival benefit whenever
possible. Surgical decisions should be guided by the use of a geri-
atric assessment or screening tool, medical risk evaluation and
input from a multidisciplinary tumor board.
Radiotherapy
Radiotherapy should be considered in older glioma patients with

several available regimens that can be administered with or
without temozolomide. Radiation schedule and dose need to be
considered and weighed against risk of adverse effects of treat-
ment such as fatigue, cognitive toxicities and effects on quality
of life. A hypofractionated course of radiotherapy (40 Gy in 15
fractions) has been shown to be at least as effective as standard
radiotherapy (60 Gy delivered in 30 fractions) and is a preferred
regimen for older or frail patients given improved tolerability
and convenience. A standard radiotherapy regimen carries an
increased risk of fatigue and cognitive dysfunction, which may
be persistent and impairing for older patients but may be consid-
ered in those patients with excellent functional status.
Abbreviated radiotherapy schedules (such as 25 Gy in 5 frac-
254 A. Wasilewski
tions) can be used for patients with significant frailty or barriers

to daily radiotherapy. Whenever possible, hippocampal sparing
should be employed to limit both acute and long-term effects on
memory and cognition.
Adjuvant Therapy
Apart from TMZ, no other systemic antineoplastic agents have

demonstrated a survival benefit for older patients with malignant
gliomas [13]. For patients who are functionally independent and
without major medical comorbidities, concurrent radiation and
TMZ followed by adjuvant treatment with TMZ is recommended
and results in prolonged survival over radiation or TMZ alone.
Treatment with TMZ is often withheld in patients with impaired
performance status or an unmethylated O6-methylguanine-DNA
methyltransferase (MGMT) promoter. Monotherapy with TMZ
can be used for patients with MGMT-methylated tumors. While
combined chemoradiotherapy confers the largest survival benefit,
treatment with TMZ alone can be considered in MGMT-
methylated patients with lower performance status (KPS 50–70),
significant cognitive issues or barriers to radiotherapy. The use of
adjuvant TTF is considered standard of care but requires several
considerations in older patients. TTF should be used in patients
with adequate support systems to manage skin care as well as the
strength and mobility to carry a weighted battery pack.
Older patients are at increased risk of toxicities from treatment
with TMZ particularly fatigue, constipation and hematologic
adverse effects. TMZ causes thrombocytopenia and lymphopenia
which may be dose or treatment limiting. It is reasonable to stop
treatment with TMZ in older patients with unmethylated MGMT
promoters if they experience significant hematologic toxicities,
fatigue or impaired quality of life. Patients with MGMT methyl-
ated promoters should be considered for dose reductions or delays
in treatment if adverse effects are manageable. Adequate support-
ive care interventions, such as effective management of constipa-
tion, are necessary to improve tolerability of TMZ.
Disease Recurrence
At time of disease recurrence patients often experience func-

tional decline which limits the safety and tolerability of further
treatment. Re-resection, re-irradiation and second line chemo-
therapeutic agents such as lomustine are rarely used in older
patients given high risk of morbidity and systemic toxicities.
Clinical trials are increasingly becoming more inclusive of older
patients and should strongly be considered in the appropriate
setting. Bevacizumab, a monoclonal antibody against vascular
endothelial growth factor, is commonly used for recurrent dis-
ease in older patients. There are serious toxicities of bevaci-
zumab including nephrotic syndrome, gastrointestinal
perforation, hypertension and thromboembolic events—which
may occur more frequently in older patients. In patients with
significant cerebral edema or those with steroid dependence,
bevacizumab can be used for symptomatic control and to
improve neurologic function [14, 15]. As there are no therapies
which improve survival in recurrent disease, continual reassess-
ment of the safety, tolerability and goals of treatment is recom-
mended. TTF monotherapy, which has demonstrated
non-inferiority to physician’s choice of chemotherapy, can also
be used for disease recurrence with significantly lower risks of
systemic adverse effects [16].
valuation and Risk Stratification of Older

E
Patients with Malignant Gliomas
In current practice, a patient’s functional status is defined using

a performance scale such as the Karnofsky Performance Status
(KPS) or Eastern Cooperative Oncology Group (ECOG) perfor-
mance status. These scales are neither sensitive or specific and
are largely based on a physician assessment of a patient’s abili-
ties at a specific time point. Additionally, these scales have limi-
tations when used in patients with malignant gliomas, may not
accurately reflect the true functional abilities of patients with
256 A. Wasilewski
neurologic symptoms and are unable to capture small changes in

function [17]. Baseline evaluations such as the comprehensive
geriatric assessment and screening tools such as the Geriatric-8
survey can be a powerful tool for identifying frailty and predict-
ing treatment risk. The geriatric assessment uses multiple vali-
dated tools to assess the geriatric domains of comorbidities,
functional and psychological status, cognition, physical perfor-
mance, nutrition, medication reconciliation and social support
[18]. GA has been shown to detect unsuspected condition that
may affect cancer treatment in over 50% of older patients [19].
According to the National Comprehensive Cancer Network
(NCCN) guidelines for Senior Adult Oncology and the
International Society of Geriatric Oncology recommendations,
the GA should be a key part of the treatment approach for all
older patients with cancer [20]. While the GA has not yet been
incorporated into the evaluation of patients of older patients
with primary brain tumors it has been shown to assist in select-
ing those most appropriate for treatment [21]. GA has also been
useful in identifying underlying medical, functional and psycho-
social issues that may interfere or disrupt treatment and high-
lighting domains of vulnerability and allow for interventions
that may improve outcomes in older cancer patients, such as
reducing treatment toxicity [22] (Table 16.2).
When a comprehensive geriatric assessment cannot be com-
pleted, a brief screening tool such as the Geriatric-8 (G8) can
be considered. The G8 is comprised of 8 questions regarding
age, nutritional status, medications, cognition, presence of
depression, mobility, and self-rated health metrics. Total scores
range from 0 to 17 with a score of 14 or higher defined as nor-
mal. Poor scores on the G8 in elderly patients with glioblas-
toma has been shown to be an independent prognostic factor
[23].
Table 16.2 Suggested components of the comprehensive geriatric assess-

ment for older brain tumor patients
Score signifying
Domain Tool impairment
Physical function • Activities of daily living • Any impairment
(ADL) in ADL or IADL
• Independent activities of • Any history of
daily living (IADL) falls
• Fall history
Objective physical • Short physical performance • < or =9
performance battery (4 m walk, chair stands,
balance test)
Comorbidity • Average number of • >5 comorbidities
comorbid conditions
Nutrition • Body mass index • BMI < 21
• Mini nutritional assessment
Social support • OARS medical social • Any deficit
support
Polypharmacy • Number of total • > or =5
medications medications
• Medications on Beer’s • Any medications
criteria list on Beer’s criteria list
Psychological • Geriatric depression scale • > or =5
Cognition • Montreal cognitive • <26
assessment
upportive Care for Older Adults with Malignant

S
Gliomas
While all brain tumor patients are at risk of treatment- and tumor-
related complications, these issues are of particular importance
for older patients. This population is at increased risk of polyphar-
macy, adverse effects from supportive care medications, falls,
mood issues and sleep dysregulation which impact quality of life
and survival. Supportive care interventions should begin early in
the course of treatment and should be continually addressed and
reassessed.
258 A. Wasilewski
Corticosteroids
While the use of corticosteroids is often necessary to decrease

cerebral edema and manage neurologic symptoms, older patients
may be particularly sensitive to their side effects. Corticosteroids
should be used at the lowest tolerated dose that manages neuro-
logic symptoms in order to mitigate toxicities such as weight gain,
diabetes, emotional lability, insomnia, proximal myopathy and
osteopenia. Older patients are at high risk of developing a proxi-
mal myopathy and osteopenia, which increases their risk of falls
and subsequent fractures. Skin fragility also occurs with pro-
longed corticosteroid use and predisposes to skin tears and
impaired wound healing- an important consideration, especially
in patients also receiving bevacizumab. Emotional lability is a
common occurrence with corticosteroids and can manifest as irri-
tability, abnormally elevated mood or hypoactive delirium in
older adults. Additionally, corticosteroids increase appetite and
result in weight gain which can be problematic and lead to
impaired mobility.
Tumor-Associated Epilepsy
Approximately 50% of glioma patients will experience a seizure

during their disease course and require treatment with anti-seizure
medication (ASM) [24]. Newer generation ASMs are preferred
given their lower risk of sedation, bone marrow suppression and
hepatotoxicity which may interfere or limit treatment with temo-
zolomide. As fatigue, falls and cognitive dysfunction may be
more common in older glioma patients, close attention to drug
choice and dosage are required. The lowest possible ASM dose
that effectively controls seizures should be used. If possible, older
generation drugs such as phenytoin, valproic acid and phenobar-
bital should be avoided given increased risk of toxicities and
drug-drug interactions. Levetiracetam is one of the most com-
monly used ASMs and is an attractive choice given its renal clear-
ance, minimal drug interactions and relative tolerability. Older
patients are at increased risk of irritability or personality changes

with levetiracetam, which can be compounded by toxicities from
corticosteroids. Commonly used second line agents include val-
proic acid and lacosamide. Older patients are also at increased
risk of cardiac arrhythmias, therefore an electrocardiogram should
be done prior to initiation of lacosamide, as it can cause PR inter-
val prolongation and first-degree atrioventricular block [25].
Fall Prevention
Most older patients with malignant gliomas, particularly those

with corticospinal tract dysfunction, ataxia, visual field deficits or
pre-existing mobility issues are at risk for falls. A thorough fall
history should be obtained at each visit with an older patient.
Physical therapy, occupational therapy and home safety evalua-
tions should be considered in any glioma patient with falls, or
neurologic impairment putting that at risk for falls. The use of
assistive devices or orthotics should also be considered when
appropriate.
Cognition Dysfunction
Older patients are more likely than their younger counterparts to

experience cognitive effects from the tumor itself, as a conse-
quence of radiotherapy or from supportive care medications such
as AEDs. Cognitive ability should be considered in all older
patients to determine whether a patient has the decisional capacity
to consent to treatment, adhere to medication instructions and
understand the indications to seek medical attention [26]. Patients
with cognitive impairments often require the involvement of care-
givers to maintain their safety. Cholinesterase inhibitors such as
donepezil and NMDA receptor antagonists such as memantine
which are commonly used for the treatment of Alzheimer’s
dementia have not been effectively studied in glioma patients.
Given the poor prognosis and risks of side effects including nau-
sea, dizziness and increased risk of seizures, use of these medica-
260 A. Wasilewski
tions for cognition enhancement is generally not recommended

for older glioma patients. Social work support and occupational
therapy should also be considered all older glioma patients with
cognitive dysfunction. Comprehensive review of a patient’s medi-
cations, metabolic status, mood and fatigue should be done to
determine whether these factors may be affecting cognition.
Mood
Mood disorders, particularly major depressive disorder, are com-

mon in older brain tumor patients and often under-reported [27].
Older patients are more likely to present with anhedonia, signifi-
cant fatigue or pseudodementia and their symptoms are often
incorrectly ascribed to aging or effects of their tumors and treat-
ments. All older brain tumor patients should be screened for
depression at every visit and provided treatment when appropri-
ate. Tricyclic antidepressants should generally be avoided in older
patients given the risk of anticholinergic effects which increase
the risk of urinary retention, orthostatic hypotension and falls.
Bupropion lowers the seizure threshold and should also be
avoided. Serotonin reuptake inhibitors (SSRIs) and serotonin-
norepinephrine reuptake inhibitors (SNRIs) are generally well
tolerated in older patients and should be considered first line for
treating depression in older glioma patients. Conventional and
atypical antipsychotics should be avoided in older patients given
the increased risk of stroke and death in older patients (especially
those with a history of dementia). If absolutely necessary for
patient safety concerns, a low dose of an atypical antipsychotic
can be used.
Fatigue and Sleep Disturbances
Fatigue is reported by 40–70% of brain tumor patients and may be

functionally limiting for older adults [28]. The etiology of a
patient’s fatigue is often multifactorial encompassing the effects
of chemotherapy, cranial irradiation, antiepileptic and analgesics,
metabolic derangements, mood disorders and sleep disturbances.

It is critical to assess fatigue at every encounter and to complete a
thorough assessment of possible contributing factors including all
cancer directed treatments, medications, laboratory values, nutri-
tional status, neuropsychiatric symptoms and sleep patterns.
Laboratory evaluations of thyroid function, serum sodium, glu-
cose, vitamin B12, urea, ammonia and hematocrit should be con-
sidered. Older patients are at significant risk of polypharmacy and
dose adjustment or elimination of any sedating medications, in
particular opiate and benzodiazepines should be considered.
Aerobic exercise should be recommended to all older patients
if their functional status allows, as this has been shown to reduce
cancer-associated fatigue [29]. While some patients may experi-
ence increased energy from corticosteroids, their use for treatment
of fatigue is not recommended given the serious side effects asso-
ciated with chronic use in older adults. In cases where fatigue is
functionally limiting and refractory to medical and lifestyle man-
agement, neuro-stimulants such as modafinil and methylpheni-
date can be used. These drugs should be used with extreme caution
in older patients given their increased sensitivity to central ner-
vous stimulation and tachycardia.
Sleep dysregulation is common amongst all brain tumor
patients and can be an important cause of fatigue in cancer patients
[30]. Sleep disturbances in older patients tend to present as hyper-
somnia and can be difficult to differentiate from fatigue or depres-
sion. All patients should be educated on proper sleep hygiene and
in older patients this frequently means limiting or shortening day-
time naps. Work-up of excessive sleepiness is similar to the evalu-
ation of fatigue described earlier and in older patients there should
be a particular focus on polypharmacy and medication effects.
Insomnia is often reported by brain tumor patients, particularly
in patients taking corticosteroids. To manage corticosteroid-
induced insomnia, patients should be treated with the lowest pos-
sible dose of corticosteroids and evening doses should be avoided.
Melatonin is generally safe and is the recommended sleep aid for
older brain tumor patients. Antihistamines, benzodiazepines and
non-benzodiazepine hypnotics (zolpidem, eszopiclone, zaleplon)
appear on Beers Criteria Medication List and should be avoided in
262 A. Wasilewski
older patients given the increased risk of delirium, ataxia, cogni-

tive dysfunction and falls [31].
Polypharmacy
In patients with a cancer diagnosis, additional comorbidities and

polypharmacy are associated with a poorer overall survival [32].
Older patients are at increased risk of drug-drug interactions and
toxicities from many medications due to increased sensitivity and
decreased metabolism. A thorough medication review should be
completed after which medications appearing on the Beers
Criteria Medication List should be adjusted or eliminated.
Table 16.3 shows a list of medications commonly prescribed med-
ications that should be avoided in older adults. Older brain tumor
patients are more sensitive to the compounding effects of cen-
trally acting medications, which may manifest as fatigue or con-
fusion, often occurring at much lower doses than in younger
patients. For older patients, discussions regarding limiting or
stopping non-essential medications prescribed for other comor-
bidities may be valuable.
Advance Care Planning
Advance care planning in older brain tumor patients should begin

as soon as possible. Given the poor prognosis and increased risk
of cognitive and functional decline, treatment goals and advance
directives should be discussed and documented prior to starting
treatment. Older brain tumor patients often require increased sup-
port as their disease progresses. Active and early involvement of
caretakers is crucial, as many may be elderly themselves and have
limitations to the care they can provide. A multidisciplinary sup-
port team including nursing, social work, home care and/or hos-
pice should be considered early in an older patient’s disease
course to better anticipate changing needs and home support.
Table 16.3 Commonly used medications to avoid in older brain tumor

patients
Therapeutic Commonly prescribed
medication class medications Risks in older patients
Antihistamines • Diphenhydramine • Anticholinergic effects
• Hydroxyzine • Sedation
• Falls
Antipsychotics • Haloperidola • Increased risk of stroke
• Perphenazinea and mortality in older
• Chlorpromazinea adults with dementia
• Aripiprazoleb
• Olanzapineb
• Quetiapineb
• Risperidoneb
• Ziprasidoneb
Barbiturates • Butalbital • Sedation
• Phenobarbital • Physical dependence
• Risk of overdose at low
doses
Tricyclic • Amitriptyline • Anticholinergic effects
antidepressants • Clomipramine • Orthostatic hypotension
• Doxepin • Falls
• Imipramine • Sedation
• Nortriptyline
• Maprotiline
Benzodiazepinesc • Alprazolam • Cognitive impairment
• Lorazepam • Delirium
• Temazepam • Sedation
• Chlorazepate • Falls
• Clonazepam • Fractures
• Diazepam • Paradoxical agitation
• Flurazepam
Non- • Eszopiclone • Delirium
benzodiazepine • Zolpidem • Falls
hypnotics • Zaleplon • Fractures
• Confusion
• Minimal effect on sleep
latency or duration
Skeletal muscle • Cyclobenzaprine • Anticholinergic effects
relaxants • Tizanidine • Sedation
• Falls
a
First generation antipsychotics
b
Atypical antipsychotics
c
Benzodiazepines may be appropriate for procedural sedation, seizure abor-
tion or end-of-life care
264 A. Wasilewski
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Palliative Care
in Neuro-oncology 17
Young-Bin Song and Lynne P. Taylor
Introduction
Palliative care is the active, total care of patients and families who
are dealing with serious, life-threatening, illness which is not
expected to be responsive to curative treatment. Palliate, derived
from the Latin root palliare, or “to cloak,” means to protect and
comfort with the goal of preserving the best possible quality of
life. Because the hospice movement began in the United States in
1985 with the establishment of the Medicare hospice benefit, and
the National Hospice Organization renamed as the National
Hospice and Palliative Care Organization (NHPCO) in 2000, the
average American has always assumed that palliative care and
hospice services are one and the same. It is our hope that palliative
care becomes a normative part of the early care of our patients
with primary brain tumors to allow adequate exploration of goals
of care, and to improve communication and maximize treatment
of all symptoms. The goal is to acknowledge dying as a natural
process and to provide compassionate care by relieving physical,
social, psychological, and spiritual suffering.
Y.-B. Song · L. P. Taylor (*)

Departments of Neurology, Neurologic Surgery and Medicine | UW
Medicine, Fred Hutchinson Cancer Center, Alvord Brain Tumor Center,
Seattle, WA, USA
e-mail: ltaylor@uw.edu

Switzerland AG 2023
https://doi.org/10.1007/978-3-031-41413-8_17
268 Y.-B. Song and L. P. Taylor
I ntroduction of Palliative Care Throughout

the Disease Course
hat Should the Neuro-oncologist Be Addressing

W
Themselves?
Studies of palliative care in cancer patients have recognized that

early introduction of palliative care results in improved symptom
management and quality of life and reduction in the use of aggres-
sive therapies near death. The value of palliative care is increas-
ingly recognized in nonmalignant neurologic diseases, such as
amyotrophic lateral sclerosis (ALS), Parkinson disease, multiple
sclerosis, and Huntington disease, with a focus on expert treat-
ment of physical symptoms, interdisciplinary communication and
assisting with the formulation of advanced care plans.
The American Academy of Neurology (AAN) published a
position paper in 2022 updating the appropriate palliative care for
patients with disorders of consciousness. In addition, it tried to
distinguish between palliative care provided by neurologists to all
patients with neurologic diseases versus the sub-specialty
Palliative care that is also often required to appropriately and
aggressively manage troublesome symptoms [1]. Palliative care
in neuro-oncology sits at the nexus between the two worlds of
oncology and neurology. One study of symptom burden in patients
with malignant glioma found a high incidence of mood issues,
confusion, communication deficits, headaches, seizures, and
decreased mobility from hemiparesis [2]. Because of these chal-
lenges our patients necessarily rely heavily on family members
and caregivers to communicate their needs, which brings unique
challenges to their care team.
Communication Skills
Communication within a neuro-oncology practice presents
numerous challenges brought about by our patient’s symptoms
and varying degrees of caregiver support. Many of our patients
suffer from slowed cognitive processing, aphasia, and difficulties
with insight and judgment, and might not be fully able to partici-
pate in discussions about prognostication, goals of care, or
17 Palliative Care in Neuro-oncology 269
advance care planning. Family members are often forced to be

proxy decision-makers, a role for which they feel unprepared.
Therefore, excellent communication requires an understanding of
patient and family emotions when explaining complex medical facts
and formulating treatment plans compatible with patients’ wishes
and goals [3]. This is a fluid situation that requires frequent re-evalu-
ation throughout the disease course, and it is a challenge to determine
when to introduce the concept of palliative care. The timing of
advanced care planning [advanced directives and portable medical
orders or physician orders for life-sustaining treatment (POLST)] and
end-of-life/hospice care discussions in a studied neuro-oncology
population was highly variable [4]. Determining whether to involve a
specialist palliative care team for facilitating these conversations is
both patient and disease specific. Patients may intuitively understand
the benefits of palliative care consultation but still decline the option
due to logistical and travel challenges.
Excellent communication can be practiced and there are strate-
gies and guidelines [5] to help us navigate through often difficult
conversations. Unfortunately, given the nature of our specialty, we
are often giving information which will be interpreted as “bad
news,” even if it is just “uncertain news.” We firmly believe that it is
important that neuro-oncologists embrace the empathic communi-
cation of complex news as part of their sub-specialty expertise.
elivering Bad News

D
The SPIKES protocol (Table 17.1) is designed for delivering
unwelcome news to cancer patients. Its aim is to gather informa-
tion from the patient, give medical information, provide support
Table 17.1 The SPIKES S: SETTING UP the interview

protocol for delivering bad
P: Assessing the patient’s
news
PERCEPTION
I: Obtaining the patient’s INVITATION
K: Giving KNOWLEDGE and
information to the patient
E: Addressing the patient’s EMOTIONS
with empathic responses
S: STRATEGY AND SUMMARY
Baile et al. (2000) [6]
Table 17.2 The NURSE acronym

Naming Name the emotion
Understanding Acknowledge and explain their perspective
Respecting Respect the patient by offering praise or reassurance
Supporting Support the patient by offering your presence and
expertise
Exploring Explore the emotions further by using “Tell me more”
statements
Back et al. (2009) [7]
to patients, and develop a treatment plan together consistent with

the patient’s goals.
Responding to Emotions
The NURSE acronym is a tool that can be used to help us identify
emotions and respond in ways to help us understand the patient
perspective more completely. See Table 17.2.
Prognostication
Discussion of prognosis should begin by first asking permission
from the patient and family if they are ready to have the conversa-
tion while adjusting it in the moment to their emotional responses
[8]. When symptom progression leads to re-addressing treatment
plans or goals of care, prognostic discussions are vital. To help
decision making, if asked about the likelihood of overall survival,
instead of using a specific period, it is recommended to use terms
like “months to years,” “days to weeks,” or “hours to days” [8].
hen Do We Need to Involve a Palliative Care

W
Expert?
We are inconsistent in how often our patients are referred to pal-

liative care. Studies by Walbert [9, 10] have demonstrated that
there is variability in utilization of specialty palliative care consul-
tation from neuro-oncologists. Neuro-oncologists differ in their
comfort level in dealing with end-of-life issues. One group of
neuro-oncologists adopted a “solo practice model” in which they

used both their skills at providing tumor-directed therapies and
palliative care as needed, whereas other neuro-oncologists
referred their patients to the specialty palliative care service [9].
We know that having a perspective free from treatment decisions
can prevent “folie à deux (folly of the two),” a condition where
both the patient and the treating physician unconsciously tell each
other that things are going better than they are, as a coping mech-
anism.
In addition, patients are referred to palliative care at different
time points from close to diagnosis to near death. Referral to a
specialist palliative care service typically occurs late in the trajec-
tory of the disease and bridges to hospice care, which has been
termed the “Traditional Approach” [9]. While studies have shown
the benefit of the “Integrated Approach” for oncology patients,
where early referral is made to palliative care, we still lack unam-
biguous evidence from randomized studies of the efficacy and
benefit of this approach for brain tumor patients but, nonetheless,
believe it is likely to be the best model based on data from patients
with metastatic lung cancer [11].
Common Symptoms in Patients with Brain Tumors
Cognitive Dysfunction
Cognitive dysfunction is common among brain tumor patients,
including deficits in memory, attention, and executive function-
ing, and can be caused by the tumor, seizures, and side effects of
treatment [8] as well as energy levels, sleep quality, and medica-
tion side effects.
Managing cognitive dysfunction can be difficult. Setting short
and long-term goals can be helpful for those who exhibit disorga-
nization; cognitive rehabilitation can improve visual attention and
verbal memory. Patients with attentional deficits might benefit
from pharmacologic interventions such as methylphenidate
(Ritalin) or modafinil (Provigil) though proof of efficacy in large
studies does not exist. See Table 17.3.
Table 17.3 Pharmacologic management for fatigue

Condition Medications Dosing
Attention and Methylphenidate 10 mg twice daily
fatigue IR (Ritalin) 18 mg q day
Methylphenidate
SR (Concerta)
Dextro/ 5–10 mg in 1–2 divided doses
amphetamine
Modafinila 200 mg q a.m.
Insomnia Melatonin 2–3 mg 30 min before bedtime
Trazodone 50 mg 1 h before bedtime
Range: 50–100 mg daily
Nighttime Quetiapine Starting dose: 25 mg at bedtime
agitation and Range: 25–75 mg daily
delirium Risperidone Starting dose: 0.5–1 mg at bedtime
Range: 0.5–2 mg daily
Olanzapine Starting dose: 2.5 mg at bedtime
Range: 2.5–5 mg daily
Lorazepam Starting dose: 0.5 mg at bedtime
Range: 2–3 mg per day divided 2–3
times a day
Diazepam Starting dose: 2–5 mg daily
Range: 2–10 mg every 3–4 h a day
Haloperidol 0.5 mg every 1–4 h, as needed per
day
Walbert (2017) [12], Gehring et al. (2012) [13], Thomas and Carver (2015)
[14]
a
Porter et al. (2020) [15] study demonstrated no improvement in fatigue in
high grade glioma population using armodafinil (Nuvigil)
Fatigue
Fatigue occurs commonly in our brain tumor patients and is mul-
tifactorial in etiology. It affects more than 80% of patients who are
undergoing radiation therapy [12]. Fatigue can also result from
chemotherapy, both directly as a drug side effect, and indirectly
by anemia and metabolic deficiencies. Other contributing factors
include anxiety and depression, seizure medications, steroid use,
and decreased mobility.
Management strategies for fatigue should be specific and tar-
geted. Fatigue due to medications should lead to a discussion of
risks verses benefits, and feasible alternative medications. For

cancer-related fatigue, a nonpharmacologic intervention can be
encouragement to increase physical exercise [16].
Psychostimulants are generally well tolerated and may be ben-
eficial for improving cognitive functioning and mood in selected
brain tumor patients. See Table 17.3.
Insomnia
Insomnia is a common symptom among primary glioma patients.
In one study by Robertson et al. (2016) [17], 46.8% of 340 recur-
rent glioma patients had insomnia and 20% required the use of
sleep medications. Causes of insomnia are multifactorial, includ-
ing mood issues, disruption to circadian rhythm, and steroid use.
The same study [17] found that use of corticosteroids was associ-
ated with insomnia. Treatments for insomnia include sleep
hygiene education, evaluation for sleep apnea, and sleep aid med-
ications. Pharmacologic sleep aids include melatonin, trazodone,
and for those experiencing nighttime agitation or delirium, con-
sider atypical psychotics, such as quetiapine or risperidone
(Table 17.3).
Mood Issues
Mood issues are common in neuro-oncology patients and are
caused by many varied factors, including past psychiatric illness
and medication side effects (dexamethasone and antiepileptic
drugs (AEDs). Among patients with primary brain tumors, the
rates of depression can vary from 13 to 47% and rates of anxiety
from 35 to 48% [18]. These negatively affect our patient’s quality
of life through decreased emotional well-being, which should be
screened and addressed during clinic visits.
A meta-analysis [19] confirmed that physician-based assess-
ment tools are reliable and consistent for diagnosing depression in
a clinical setting. Different treatment options (see Table 17.4) for
depression include medication, counseling, and therapy. SSRIs
and SNRIs are generally well tolerated with minimal drug-to-
drug interactions. Gabapentin, lamotrigine and valproic acid can
all be used as mood stabilizers. Pseudobulbar affect (PBA) can be
a very difficult problem in patients with either deep bihemispheric
Table 17.4 Depression and anxiety medications

Class Medications Dose range
Selective serotonin Citalopram 20–40 mg daily
reuptake inhibitors (SSRI) Escitalopram 10–20 mg daily
Fluoxetine 20–80 mg daily
Sertraline 50–200 mg daily
Serotonin-norepinephrine Duloxetine 20–30 mg twice a day
reuptake inhibitors Venlafaxine 37.5–75 mg twice a day
(SNRI)
AEDs (off-label or Lamotrigine Slow upward titration 25 mg
adjunct) daily to 200 mg daily in
weekly increments
Valproic acid 250–500 mg three times
daily
Gabapentin 300–900 mg three times
(anxiety) daily
tumors or those in the brainstem. Dextromethorphan/quinidine

(Neudexta) which comes in a 20 mg/10 mg capsule and is used in
doses of 1 cap bid can lessen emotional incontinence and lead to
improvement in quality of life.
Headache
Headaches in brain tumor patients often present in a similar fash-
ion to migraines and will respond if treated as such, if not due to
increased intra-cranial pressure [20]. Otherwise, of course, ste-
roid therapy is the mainstay of treatment.
Steroid Use
Steroids are used to treat vasogenic edema and can rapidly allevi-
ate focal neurologic symptoms. Dexamethasone is the steroid of
choice, due to its long half-life and lack of mineralocorticoid
activity. It has many side effects, however, including insomnia,
irritability, psychosis, delirium, and anxiety, in addition to hyper-
glycemia and proximal muscle weakness. While dexamethasone
is given 3–4 times a day in the hospital, it should be given only
once or twice daily in the outpatient setting as it has an exception-
Table 17.5 Steroid tapering guideline

• Goal: “As little as possible, but much as you need”
• Most can safely taper down every 3–7 days to dexamethasone 2 mg
daily. Once at 2 mg daily, long-term steroid users >3 weeks may
require slow taper every 14 days
• If dexamethasone dosing is BID, second dosing should be no later than
2 p.m.
• For slow taper schedule, consider obtaining morning fasting cortisol
level
– Level < 10 μg/dL, further tapering likely necessary, consider
switching to hydrocortisone or prednisone
– Level > 10 μg/dL, dexamethasone can be discontinued
• Consider PJP (Pneumocystis Jirovecii Pneumonia) prophylaxis with
trimethoprim/sulfamethoxazole at dexamethasone ≥3 mg daily for
>1 month duration or lymphopenia (ALC < 500 or CD4 < 200)
Steroid Conversion Chart
Steroid Equivalent Duration
dose (mg) of action
Dexamethasone 0.75 36–72 h
Hydrocortisone 20 8–12 h
Prednisone 5 8–12 h
Shimmer and Funder (2017) [21]
ally long serum half-life of 36–72 h, with the second dose early in
the afternoon to mitigate against insomnia. Look for opportunities
for dose tapering and give a clear schedule to patients and caregiv-
ers. See Table 17.5 for guidelines. Dexamethasone can usually be
tapered quickly down to 2 mg daily, followed by a slower tapering
plan.
Seizures: See Table 17.7. Most of our patients will have a well-
defined anti-convulsant regimen by the time they are near the end
of their lives. In an urgent situation, it is helpful to know that both
midazolam and diazepam can be given intra-nasally. Both now
have a pre-packaged device for administration but a small syringe,
fitted with a mucosal atomization device (MAD) is much less
expensive. One to two drops can also be dripped into the nasal
cavity with seizure cessation at 4 min [23].
Approach to Advanced Care Planning
Discussions about a patient’s goals and wishes should occur at the

time of diagnosis and be re-evaluated throughout the disease
course. These conversations will shape the discussion of potential
future treatment planning. One helpful tool, called the “Ask, Tell,
Ask” method is used to assess a patient’s understanding regarding
any issue they might face (Table 17.6).
Part of the goals of care discussions involve advance care plan-
ning (Table 17.7), which aims to encourage shared decision mak-
ing with caregivers or family members regarding patients’ wishes
and preferences. This includes completing POLST forms, regard-
ing the use of cardiopulmonary resuscitation and other medical
interventions, and advance directives [22].
Five Wishes: This is an excellent resource to help people navi-
gate their wishes regarding DPOA and other aspects of palliative
care during a serious illness. It is legal in most states when signed
by two individuals and can be accessed and stored online at:
https://fivewishes.org/individuals-and-families.
Table 17.6 Ask, Tell, Ask Method

Ask: the patient to describe his/her current understanding of the issue
Tell: the patient in straightforward language what you need to
communicate in small chunks
Ask: the patient if he/she understood what you just said
Back et al. (2005) [24]
Table 17.7 Advanced care planning

Legal documents Medical orders
• Advance directives • Portable medical order; POLST
• Living wills, healthcare power of and others
attorney • Do-not-resuscitate orders
• Surrogate appointment and • Medical orders based on shared
statement of preferences decision-making
POLST legislative Guide (2014) [22]
Family/Caregivers
Family members are important because they are also caregivers

and bear significant physical and emotional loads of their own.
Our patients rely on their caregivers to keep them safe around
the house, transport them to clinic visits and therapies, and help
them remain compliant with their medications. Family members
often express distress at the fact that they feel unprepared to
manage unexpected symptoms such as seizures and abrupt neu-
rologic decline. It is important to identify and address any barri-
ers for access to resources for social, emotional, and
psychological needs, including counseling services and support
groups.
Hospice and End of Life Care
During the end-of-life phase, the symptom burden is always high

and can produce significant distress in patients, family members
and caregivers. With progressive tumor growth, patients experi-
ence worsening neurologic and cognitive deficits and fatigue,
often caused by increased vasogenic edema. Dexamethasone can
be restarted or increased in dose for short-term symptom relief,
though doses of 2–4 mg daily should be considered the maximum
without further upward dose titration as that increases delirium
and agitation (Table 17.8).
Seizures are common during this period, occurring in 45% of
patients [25]. Seizure management can be further complicated by
dysphagia, which has been observed in 70% of patients in their
last month of life who have difficulty with nutritional, fluid, and
medication intake. Alternative AED options are available; see
Table 17.9. There is no medical justification for the use of fluids
and nutrition via feeding tube for our patients. When there are no
longer any treatments that will lead to the slowing of growth of a
brain tumor, the use of fluids often worsens cerebral edema and
delirium without providing any benefit.
Table 17.8 Symptoms during end-of-life phase

Symptoms % of patients (N = 55)
Drowsiness/progressive loss of 48
consciousness
Dysphagia 39
Progressive focal neurological deficits 28
Seizures 25
Incontinence 22
Progressive cognitive deficits 18
Headache 18
Confusion 16
Bodily pain 14
Fatigue 14
Nausea/vomiting 11
Dyspnea 9
Constipation 5
Anxiety/depressive symptoms 5
Adopted from Sizoo et al. (2010) [25]
Table 17.9 Pharmacologic therapies during the end-of-life

Condition Medications Route and dosing
Cerebral edema Dexamethasone 2–4 mg daily with no further upward
adjustments
Seizures Phenobarbital PO: 50–100 mg 2 or 3 times daily
IM: 1–3 mg/kg/day
SC: 1200 mg/day
Diazepam Rectal: 0.3 mg/kg, then 20 mg PR
Intranasal: 5/7.5/10 mg per 0.1 mL
Lorazepam IM/SC: 0.1 mg/kg
Midazolam Intranasal: 0.2 mg/kg
Clonazepam IM/SC: 1 mg
Agitation and Haloperidol PO: 0.5–2 mg 2–3 times daily
delirium IM: 2–5 mg every 4–8 h or up to
hourly; max: 20 mg/day
Quetiapine 25–100 mg daily, in divided doses
Olanzapine 2.5–5 mg daily
Adapted from Krouwer et al. (2000) [26]
Delirium can be multi-factorial, produced by medications,

organ failure and infection, and metabolic imbalance.
Antipsychotics, such as quetiapine and olanzapine can be helpful
for agitated delirium, and when a patient is unable to swallow,
haloperidol can be administered via intramuscular route.
Unlike other patients with solid tumors, the end of life for
brain tumor patients generally does not include much physical
pain. Death is most often caused by brain herniation [25], although
a more recent glioblastoma autopsy study demonstrated extensive
brainstem infiltration showing that recent extensions of survival
rates may be leading to a different root cause of death than his-
torically described [27]. During the days to weeks before dying,
symptoms of drowsiness and dysphagia increase significantly to
87% and 71% respectively [25]. Patients have more difficulty
clearing their pharyngeal secretions and they develop a loud respi-
ratory noise, known as the “death rattle.” These symptoms can be
alleviated with atropine drops, glycopyrrolate, or scopolamine
patch [14]. Eventually, patients become less conscious and
descend through drowsiness to somnolence, and then coma in the
days before death, generally succumbing to dehydration over
10–14 days.
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Index
A
Absolute neutrophil count (ANC), 197
Advance care planning, 262
5-Aminolevulinic acid (5-ALA), 6
Anaplastic oligodendrogliomas, 41
Antibiotic trimethoprim-sulfamethoxazole, 90
Anticoagulation medications, 237, 238
Anti-edema effects, 144
Anti-epileptic therapy, 12
Antiplatelet medications, 237, 238
Ask, Tell, Ask Method, 276
Aspartate aminotransferase (AST), 89
Asymptomatic meningiomas, 75
Atherosclerosis, and ischemic stroke, 222, 223
AVERT trial, 168
B
B-cells, 99
Bevacizumab, 200, 201
Bone marrow suppression, 204, 205
BRAFi/MEKi therapy, 55
BRAF-mutated glioma
clinical scenario, 51
clinical trials, 64
high-grade glioma, 55, 56
low grade glioma, 54, 55
mutations, 52, 53
prognosis/survivorship, 63
surveillance, 57, 60
targeted therapy and dosing, 56, 57
toxicities management, 60, 63
© The Editor(s) (if applicable) and The Author(s), under exclusive 283
license to Springer Nature Switzerland AG 2023
https://doi.org/10.1007/978-3-031-41413-8
284 Index
Brain edema
alternative approaches to steroids, 150, 151
chronic steroid use, 144, 145
intracranial pressure management, 144
patient instructions, 151
preventative measures, 150
steroid toxicities, 145, 150
tapering, 144, 145
treatment, principles of, 141, 144
Brain tumor patients
antiplatelet and anticoagulation medications, 237, 238
closure, 242
gross total resection (GTR), 241
hydrocephalus, 244
hyperglycemia, 238
infections, 244
intraoperative neurophysiological monitoring, 242
neurologic deficit, 243, 244
optimizing other medical conditions, 239
other systemic complications, 245, 246
patient positioning, 240
perioperative antiepileptic therapy, 236, 237
postoperative intracranial hemorrhage, 242, 243
preoperative imaging, 239
seizures, 243
skin incision and tissue handling, 241
steroids, 237
venous air embolism, 240
venous thromboembolism (VTE), 245
wound healing complications, 245
Bruton tyrosine kinase (BTK), 97
C
Carmustine (BCNU), 200
Central hypopituitarism, 219, 221
Checkpoint inhibitors, 202
Chemo-induced side effects
cytopenia and bone marrow suppression, 204, 205
fatigue and malaise, 203
nausea/vomiting, 202, 203
peripheral neuropathies, 204
teratogenic effects and decreased fertility, 205
weight loss, 203
Index 285
Cognition dysfunction, 259, 260, 271

Cognitive symptoms
attention and concentration impairment, 181
behavioral changes, 191
causes and differential diagnosis, 178
clinical management and recommendations, 182, 183
de-escalation strategy, 187
executive dysfunction and behavioral changes, 180
language impairment, 182
memory and learning impairment, 181
non-pharmacological interventions, 185, 188
pharmacological interventions, 188, 191
processing speed, 179
Corticosteroids, 143, 258
Cranial radiotherapy
acute side effects, 212, 213
atherosclerosis and ischemic stroke, 222, 223
central hypopituitarism, 219, 221
eyes and optic pathways, 217, 218
late side effects, 214
microbleeds, 221, 222
pseudoprogression, 216
radiation-induced necrosis, 214, 216
radiation-related cognitive decline, 224, 226–229
sensorineural hearing loss, 218, 219
SMART syndrome, 223, 224
vascular malformations, 221, 222
Craniospinal irradiation (CSI), 109, 110
Creatinine levels, 90
CSF dissemination, 122
Cushings disease, 145
Cytopenia, 204, 205
D
Deep venous thrombosis (DVT), 166
Dexamethasone, 144
Diffuse astrocytoma (DA)
awake vs open craniotomy, 23
clinical features, 22
clinical vignette, 21, 22
fertility preservation (FP), 28
pathology, 24
patient information, 31, 35
286 Index
Diffuse astrocytoma (DA) (cont.)

patient selection for treatment, 24, 25
PCV, 27, 28
post-operative treatment, 25, 27
preoperative planning, 23
prognosis, 29, 31
recurrence treatment, 29
resection vs biopsy, 23, 24
risk stratification, 24, 25
surveillance, 29
survivorship, 29, 31
TMZ, 27
watchful waiting/surgery, 23
Diffuse large B-cell lymphoma (DLBCL), 84
Dihydrofolic acid reductase, 87
Direct oral anticoagulant (DOAC), 173
Donepezil, 190
Drug-eluting stents (DES), 238
E
Ependymoma treatment
chemotherapy, 125, 127–129
clinical scenario, 119, 120
other modalities, 129
pathologic and molecular, 122, 124
patient information, 133–135
prognosis, 130, 132
proton therapy, 125
radiation therapy, 124, 125
recurrence, 130
RELA fusion position, 122
surgical resection, 121, 122
surveillance guidelines, 129, 130
External beam radiotherapy (EBRT), 211
F
Fall prevention, 259
Fatigue
palliative care, 272, 273
and sleep disturbances, 260, 262
Fertility preservation (FP), 28
Fluorescence in situ hybridization (FISH), 41
Folinic acid, 90
Index 287
G
Gastritis, 150
Gene sequencing, 41
Glutamate pathways, 154
Granulocyte colony-stimulating factor (GCSF), 93, 197
Gross total resection (GTR), 75, 121, 241
H
Headache, palliative care, 274
High-dose myeloablative chemotherapy followed by autologous stem cell
transplantation (HDC-ASCT), 96
High-grade glioma (HGG), 55, 56
Hospice and end of life care, 277, 278
Hydrocephalus, 244
Hyperglycemia, 149, 238
Hypertension (HTN), 201
Hypofractionated radiotherapy, 8
I
IDH-wildtype, 24
Immunohistochemistry staining, 41
Insomnia, 149, 261
Integrated histopathologic-molecular diagnosis, 41, 42
Irinotecan, 201, 202
Ischemic stroke, 222, 223
Isocitrate dehydrogenase (IDH), 154
IDH1, 22
mutation, 7
L
Leucovorin, 90, 99
Levetiracetam (LEV), 156
LMWH, 173
Lomustine (CCNU), 198, 199
Low grade glioma (LGG), 54, 55
M
Malignant glioma
adjuvant therapy, 254
advance care planning, 262
anti-epileptic therapy, 12
288 Index
Malignant glioma (cont.)

chemotherapy, 8, 9
clinical trial older adults, 251–252
cognition dysfunction, 259, 260
corticosteroids, 258
diagnosis, 4, 7
disease recurrence, 255
evaluation and risk stratification of, 255, 256
fall prevention, 259
fatigue and sleep disturbances, 260, 262
geriatric assessment for, 257
mood disorders, 260
older patients treatment options, 250, 252
patient information, 15
polypharmacy, 262, 263
prognosis, 14, 16
radiation therapy, 7
radiotherapy, 253, 254
recurrence treatment, 14
supportive care for older adults, 257
surgical treatment, 253
surveillance, 13
treatment flowchart, 5, 10–11
tumor-associated epilepsy, 258, 259
tumor treating fields (TTF) therapy, 9, 12–13
vasogenic edema management, 13
MATRix (methotrexate, cytarabine, thiotepa, rituximab), 94
Medulloblastomas (MB)
Chang staging, 106
childhood clinical staging of, 108
clinical presentation, 103, 104
clinical risk stratification, 108, 109
craniospinal irradiation, 109, 110
first line chemotherapy, 111
genetic testing, 104
group 4 subgroup, 108
molecular subtypes, 105
prognosis, 112
radiographic, 104, 106
recurrent disease treatment, 112, 113
recurrent treatment options, 113
SHH-MB subgroup, 107, 108
Index 289
staging, 106, 107

surgery, 109
systemic therapy, 110, 111
WNT-MB subgroup, 107
Memanatine, 190, 191
Meningioma treatment
histologic features of, 74
histologic subtypes of, 74
imaging, 70, 71
mutations and fusions, 68–69
pathology, 71, 73
radiation therapy, 76, 78
radiation tolerability, 78
radiation treatment, 77
radiographic mimics of, 72–73
Simpson grade of, 76
surgery, 75, 76
systemic therapies, 79, 80
Methotrexate, 90
therapy, 87, 89
toxicity, 90, 91
Methylome profiling, 123
Methylphenidate, 188, 189
MGMT (unmethylated O6-methylguanine-DNA methyltransferase
promoter), 7
Microbleeds, 221, 222
Modafenil, 190
Mood disorders, 260
Mood issues, palliative care, 273, 274
MT-R (methotrexate, temozolomide, rituximab), 93
Myopathy, 149
Myxopapillary ependymoma, 121
N
Next generation sequencing (NGS), 73
Non-pharmacological interventions, cognitive symptoms
exercise, 185, 186
meditation/mindfulness stress reduction, 186
mood and behavior management, 186, 187
sleep and fatigue management, 187, 188
training and rehabilitation, 185
290 Index
O
Ocular neuromyotonia, 217, 218
Oligodendroglioma
chemotherapy, 43, 46–47
integrated histopathologic-molecular diagnosis, 41, 42
patient information, 47
prognosis, 44, 45
radiation therapy, 42
surgery, role of, 40, 41
treatment, 44
treatment flowchart, 46
Optic neuropathy, 217
Osteoporosis, 149
P
Palliative care, 268, 270
advanced care planning, 276, 277
cognitive dysfunction, 271
fatigue, 272, 273
headaches, 274
hospice and end of life care, 277, 278
insomnia, 272, 273
mood issues, 273, 274
need, 270, 271
steroids, 274, 275
Partial brain radiotherapy, 230
PCV (procarbazine, lomustine, and vincristine), 27, 28
Perioperative antiepileptic therapy, 236, 237
Pharmacologic interventions, cognitive symptoms
donepezil, 190
memanatine, 190, 191
methylphenidate, 188, 189
modafenil, 190
Polypharmacy, 262, 263
Positron emission tomography (PET) imaging, 86
Primary CNS lymphoma (PCNSL)
common consolidation regimens, 96, 97
common induction regimens, 92
concomitant medications, 90
diagnosis of, 85
epidemiology, 84
high-dose methotrexate treatment, 87–88
Index 291
MATRix, 94
methotrexate therapy, 87, 89
methotrexate toxicity, 90, 91
MT-R, 93
patient information, 86, 98
relapsed disease, 97, 98
rituximab, 94, 95
R-MBVP, 94
R-MVP, 92, 93
site-specific therapy, 95
staging of, 86
supportive medication and monitoring, 89, 90
treatment expectations, 98
Procarbazine, 93, 198, 199
Proton Pump Inhibitors (PPIs), 150
Pseudoprogression, 216
Pulmonary embolism (PE), 166
R
Radiation-related cognitive decline, 224, 226–229
Radiation therapy (RT)
chemoradiotherapy, 26, 27
chemotherapy, 26, 27
doses, 26
timing of, 25, 26
toxicities, 26
Radionecrosis, 214, 216
Radiosurgery, 230
Relapsed disease, 97, 98
Rituximab, 94, 95
R-MBVP (rituximab, methotrexate, carmustine [BCNU], etoposide,
prednisone), 94
R-MVP (rituximab, methotrexate, vincristine, procarbazine), 92, 93
S
Sensorineural hearing loss, 218, 219
Serum methotrexate, 90
Signaling aberrations, 16
Simpson grade of resection, 76
Single nucleotide variants (SNVs), 52
Site-specific therapy, 95
Sleep dysregulation, 261
SMART syndrome, 223, 224
Sonic-hedgehog (SHH) pathway, 107
292 Index
SPIKES protocol, 269

Spinal subependymomas, 124
Status epilepticus (SE), 154, 155
Stereotactic radiosurgery (SRS), 77
Steroids, 237
Subependymomas, 125, 131
Synthetic glucocorticoids, 143
T
Tapering protocol, 144
T-cells, 99
Temozolomide (TMZ), 8, 27, 196, 198
monotherapy, 8
Transcriptome profiling, 123
Tumor-associated epilepsy, 258, 259
Tumor-related epilepsy (TRE)
epidemiology, 153, 154
pathophysiology, 153, 154
pharmacologic management of, 156–157
status epilepticus (SE), 154, 155
Tumor treating fields (TTF) therapy, 9, 12–13
V
Valproic acid (VPA), 156
Vascular malformations, 221, 222
Vasogenic edema management, 13
Venous air embolism (VAE), 240
Venous thromboembolism (VTE), 245
anticoagulation, 173
and clinical diagnosis, 166, 168
contraindications to anticoagulation, 172
inpatient primary prevention, 169
medical risks, 172, 173
outpatient primary prevention, 168, 169
patient instructions, 174
prophylactic and therapeutic anticoagulant dosing, 170–171
treatment, 171, 173
Vincristine, 198, 199
Vision, blurring of, 149
W
Whole brain radiation therapy (WBRT), 211, 230

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Brain

ISBN 978-3-031-41412-1 ISBN 978-3-031-41413-8 (eBook)

Paper in this product is recyclable.

This Springer imprint is published by the registered company Springer Nature

Part I Brain Tumor Primer

Part II Supportive Care Primer

WHO CNS Classification:

A 58 year old right handed man came to medical attention due to

© The Author(s), under exclusive license to Springer Nature 3

He developed distant disease recurrence 7 months after com-

Making the Diagnosis

eases, infections, and radiation necrosis. Tissue diagnosis is

Fig. 1.1 Glioblastoma Treatment Flowchart

nent. The controversy lies in the extent of resection of the T2

Beyond cytoreduction, the role of surgery is to provide tissue

Glioblastoma is characterized by microscopic invasive disease

are several approaches to radiation therapy volume planning

Temozolomide (TMZ), a pro-drug alkylating agent which methyl-

study, 12 months of adjuvant therapy were given to individuals

Tumor Treating Fields

Tumor treating field (TTF) therapy is offered for frontline treat-

Table 1.1 Glioblastoma treatment

efit difference of nearly 5 months (20.9 months vs 16 months)

Anti-epileptic therapy. Patients may present with seizures as

Vasogenic edema management. Vasogenic edema results

After the initial concurrent chemoradiotherapy, it is standard prac-

After the determination of progressive disease and assessment of

The prognosis of patients with GBM is dependent upon age and

Table 1.2 Glioblastoma patient information

Patients with MGMT promoter methylation had a median OS of

There is limited data on survivor care for patients with GBM

Trends and Future Directions

Glioblastoma is characterized by marked heterogeneity which

of ICI therapy in recurrent GBM although it remains to be seen

18. Tremont-Lukats IW, Ratilal BO, Armstrong T, Gilbert MR. Antiepileptic

32. Ito H, Nakashima H, Chiocca EA. Molecular responses to immune

WHO CNS Classification: Astrocytoma, IDH-mutant, CNS

A healthy ambidextrous 37 year-old male sustained a head

© The Author(s), under exclusive license to Springer Nature 21

He started levetiracetam 750 mg twice daily and consulted with

The causes of most DAs are unknown. Genetic cancer predis-

Watchful Waiting or Surgery: Once a lesion suspicious for low

Fig. 2.1 Management flowchart for Diffuse Astrocytoma, WHO grade 2,

there is no clear evidence to definitively guide decision-making or

According to WHO 2021 guidelines, DAs are graded as 2, 3, or

be performed to evaluate for noncanonical mutations, especially

 isk Stratification and Selection of Patients

The optimal management remains controversial with respect to:

RT-Related Toxicities: Acute side effects present during and

Chemotherapy Dosing and Symptom Management

Table 2.1 Chemotherapies, toxicities, monitoring, and dose modifications

Regimen Considerations Side effects Monitoring toxicity Dose modificationsa, b

Regimen Considerations Side effects Monitoring toxicity Dose modificationsa, b

(a) Nausea: Ondansetron (or other 5-HT3 serotonin receptor

Fertility Preservation (FP)

Alkylating agents, such as TMZ, CCNU, and procarbazine can

An MRI brain with and without contrast should be obtained

Options for treatment at recurrence include: surgery, RT, chemo-

Prognosis and Survivorship

Part I Brain Tumor Primer

Part II Supportive Care Primer

Making the Diagnosis

Tumor Treating Fields

Trends and Future Directions

isk Stratification and Selection of Patients

Chemotherapy Dosing and Symptom Management

Fertility Preservation (FP)

Prognosis and Survivorship

5. Tesileanu CMS, et al. Survival of diffuse astrocytic glioma, IDH1/2-

The Clinical Scenario

Making the Diagnosis

The Role of Surgery

Integrated Histopathologic-Molecular Diagnosis

Treatment at Recurrence (Regimens with Dosing)

The historical survival for patients with histologically diag-

Trends and Future Directions

The Clinical Scenario

Making the Diagnosis

BRAF-Mutation Frequency by Tumor Type

Low Grade Glioma

Standard first-line therapy for adults with BRAF-mutated high-

Targeted Therapy Regimens and Dosing

Surveillance While on Treatment

Management of Common Toxicities

o ffending BRAFi or MEKi should be held until the adverse event

rends and Future Directions: When Do

The role of clinical trials in the treatment of patients with BRAF-