CNS TUMORS
Diagnostic Evaluation:1. History and physical
2. CBCD, RP
3. Chest X-ray
4. CT brain:
 Relatively sensitive, but not specific
 Not good for posterior fossa
5. MRI brain (gadolinium enhanced):
 Replacing CT due to: higher sensitivity, ease of multiplanner imaging
without loss of details and better assessment of response to treatment
6. Lumbar puncture:
 Not to be done routinely, only if known tumor to disseminate to meninges
or evident meningeal spread on CT or MRI
 Contraindicated with elevated intracranial pressure
7. Angiography: For pre-operative planning of some tumors, therefore, to be ordered by
neurosurgeon
8. PET scan: helps to differentiate radiation necrosis from viable tumor
9. MR spectroscropy: Differentiate radiation necrosis from active tumor while able to
asses 3-dimensionally with simultaneous registration to normal MR
10. Biopsy:
Treatment of Specific Tumors:1. Juvenile pilocystic and subependymal and astrocytomas:
 Non-infiltrating astrocytic tumor, often curable
Recommendation:
- Surgery alone
- Radiotherapy only if residual is suspected
2. Well-differentiated and moderately differentiated astrocytoma:
 Less often curable
Recommendation:
- Complete gross resection if possible, otherwise partial resection
- Radiotherapy to tumor area and margins and not whole brain
3. Adult anaplastic astrocytoma:
 Resection followed by radiotherapy and post-irradiation combination
chemotherapy PCV or single agent BCNU.
308866591
CNS Tumor Management Guidelines
Page 1 of 6
4. Adult glioblastoma multiforme:
 Resection followed by Temozolamide 75 mg/m2 with radiotherapy. Patient
will also receive prophylaxis for PCP
Four weeks after completion of temozolamide and radiation therapy, patient will
start adjuvant temozolamide 150-200 mg/m2 for five days every four weeks for
total of 6cycles.
5. Oligodendrogliomas:
a. Well differentiated
 Complete resection (controversy about delaying until symptoms arise of
PD)
 Radiotherapy for residual disease. It can be delayed until symptoms arise
b. Anaplastic oligondendroglioma:
More sensitive to chemotherapy than other gliomas
 Resecion followed by radiotherapy
c. Recurrent disease after initial resection and radiation therapy: consider
resection if possible followed by PVC chemotherapy (CCNU 110 mg/m2 on
day #1, Procarbazine 60 mg/m2 x 14 days start on day # 8 and vincristine on
day # 8 and day # 29)
6. Ependymomas:
a. Well differentiated
 Resection alone if totally resectable
 Radiotherapy if residual disease found
b. Anaplastic ependymoma
 Resection followed by radiotherapy
7. Mixed gliomas:
Behave similar to anaplastic astrocytomas, therefore, treated similarly:
 Resection followed by radiotherapy and chemotherapy
8. Adult Medulloblastoma:



Adults —the clinical experience with medulloblastoma in adults is more
limited, and treatment should be patterned after that in children.
For adults with low-risk disease (T1-3a, M0, and no residual disease after
surgery) we suggest treatment with craniospinal RT to 36 Gy,
supplemented by a local tumor boost for a total tumor dose of 55.8 Gy.
For high risk disease (T3b-4, any M, or post operative residual disease) we
suggest after resection and craniospinal radiation, patient will be treated
with maximum of eight cycles of chemotherapy include combination of
308866591
CNS Tumor Management Guidelines
Page 2 of 6
CCNU, cisplatin and Vincritine (CCNU 75 mg/m2, cisplatin 75 mg/m2,
and vincritine)
* Pineoblastoma and PNET can be treated similarly
9. Adult Meningioma:
a. Low proliferative or Grade I meningioma
 Surgery alone (if symptomatic)
 Radiotherapy with residual disease or still symptomatic
b. Malignant maningioma
 Surgery + radiotherapy
10. Recurrent Brain Tumor:
 Re-resection or radiation, if not given before. May consider stereotactic
radiation therapy if eligible.
 Chemotherapy RR is low <30%, therefore, only to be considered with
young age (e.g. <50 years) and good PS ECOG = 0-1), high grade
gliomas, and if no prior chemotherapy was given.
308866591
CNS Tumor Management Guidelines
Page 3 of 6
Modified Chang System for Staging of Medulloblastoma
Extent of tumor
T1
Tumor less than 3 cm in diameter
T2
Tumor greater than 3 cm in diameter
T3a
Tumor greater than 3 cm in diameter with extension into the aqueduct of
Sylvius and/or the foramen of Luschka
T3b
Tumor greater than 3 cm in diameter with unequivocal extension into the
brain stem
T4
Tumor greater than 3 cm in diameter with extension up past the aqueduct of
Sylvius and/or down past the foramen magnum
No consideration is given to the number of structures invaded or the presence of
hydrocephalus.
T3b can be defined by intraoperative demonstration of tumor extension into the
brain stem in the absence of radiographic evidence.
Degree of metastasis
M0
No evidence of gross subarachnoid or hematogenous metastasis
M1
Microscopic tumor cells found in the cerebrospinal fluid
M2
Gross nodular seeding demonstrated in the cerebellar/cerebral subarachnoid
space or in the third or lateral ventricles
M3
Gross nodular seeding in the spinal subarachnoid space
M4
Metastasis outside the cerebrospinal axis
From Chang, CH, Housepain, EM, Herbert, C, Radiology 1969; 93:1351, and Cohen,
ME, Duffner, PK (Eds). Brain Tumors in Children, 2d ed, McGraw-Hill, New York,
1994, p. 187.
308866591
CNS Tumor Management Guidelines
Page 4 of 6
Reference:
1. Lusdford LD Martinez J, Latchaw TW: Stereostatic Surgery with MR and CT. J
Neurosurg 1986; 64: 872-878.
2. Chang CH, Horton J, Schoenfeld D, et al: Comparison of postoperative radiotherapy
and combined postoperative radiotherapy and chemotherapy in the multidisciplinary
management ECOG study. Cancer 1983; 52 (6) 997-1007.
3. Layin VA, Silver P, Hannigas J, et al: Superiority of post-radiotherapy adjuvant
chemotherapy with CCNU, procabazine and UCR (PCU) and BCNU for anaplastic
glioma: NCOG 6G-61, Final Report. International J of Radiation Oncology, Biology
and Physics 1990; 18(2): 321-324.
4. Kyritsis AP, Yung WK, Bruner J, et al: Treatment of anaplastic oligodendrogliomas
and mixed gliomas. Neurosurgery 1993; 32(3): 365-371.
5. Brados MD< Berger MS, Wilson CB: Primary CNS tumors: Advances in knowledge
and treatment. Cancer J Clin 348: 331-360.
6. Packer RJ, Sutton LN, Goldwin JW et al: Improved survival with the use of adjuvant
chemotherapy in the treatment of medulloblastoma. J Neurosurg 1991; 74: 433.
7. Louis DN, Cavenee WK: Neoplasms of the CNS, Cancer: Principle and Practice of
Oncology, 5th Edition. 2013-2082; 1997.
8. Adult Brain Tumors. NCI PDQ. Treatment – Health professionals. Reviewed in
08/98.
9. Phase II Study of First-Line Chemotherapy With Temozolomide in Recurrent
Oligodendroglial Tumors: The European Organization for Research and Treatment of
Cancer Brain Tumor Group Study 26971. Journal of Clinical Oncology, Vol 21, Issue
13 (July), 2003: 2525-2528.
10. Procarbazine, Lomustine, and Vincristine (PCV) Chemotherapy for Anaplastic
Astrocytoma: A Retrospective Review of Radiation Therapy Oncology Group
Protocols Comparing Survival With Carmustine or PCV Adjuvant
Chemotherapy.Michael D. Prados, Charles Scott, Walter J. Curran, Jr, Diana F.
Nelson, Steve Leibel, Simon Kramer . JCO Vol 17, 1999
11. Chemotherapy in adult high-grade glioma: a systematic review and meta-analysis of
individual
patient
data
from
12
randomized
trials.
StewartLA. Lancet 2002 Mar 23;359(9311):1011-8.
308866591
CNS Tumor Management Guidelines
Page 5 of 6
12. Stupp R, Mason WP, van den Bent MJ, et al.: Radiotherapy plus concomitant and
adjuvant temozolomide for glioblastoma. N Engl J Med 352 (10): 987-96, 2005.
13. Phase III study of craniospinal radiation therapy followed by adjuvant chemotherapy
for newly diagnosed average risk medulloblastoma:Packer RJ; Gajjar A; Vezina G;
Rorke-Adams L; Burger PC; Robertson PL; Bayer L; LaFond D; Donahue BR;
Marymont MH; Muraszko K; Langston J; Sposto R J Clin Oncol. 2006 Sep
1;24(25):4202-8.
308866591
CNS Tumor Management Guidelines
Page 6 of 6