Neuro-Oncology Practice: Time Flies When You Are Having Fun!

The inaugural year of Neuro-Oncology Practice draws to a close with this fourth issue. Each issue of Neuro-Oncology Practice has enjoyed the same overwhelming positive response as was enjoyed by the Neuro-Oncology “Supplement on Applied Neuro-Oncology” piloted in 2012. In the past year Neuro-Oncology Practice has received a steady stream of high-caliber manuscripts for consideration and publication. Reflecting back on the last three issues it is encouraging to see that the original intention for Neuro-Oncology Practice – to review and discuss the application of new trial results, to translate scientific advances into the framework of applied treatment decision making, and to enhance awareness of symptom management, neuropsychological, caregiving, survivorship, palliative care and end-of-life issues to improve standards of patient care through publications from multi-disciplinary and international experts – has been achieved. The current issue continues to reflect this commitment to offering science-based practice recommendations that are aimed at improving the lives of the patients and families for whom we offer care. The explosion of “omics” data in neuro-oncology is reshaping the classification of tumors, selection of therapies, and prognostication of outcomes. Vanan and Eisenstat provide an excellent review in which they cogently remind practitioners that high-grade gliomas not only occur far less frequently in the pediatric population than in adults, but that they have distinct genomic alterations and respond differently to adult therapeutic regimens. While the scientific infrastructure necessary to develop personalized approaches based on molecular diagnostics and clinical phenotypes share many similarities between pediatric and adult neuro-oncology, it is clear that in many cases drug development may need to proceed down different pathways with different targets that will hopefully lead to improved outcomes across the lifespan. Second injury syndrome and the more general concern of returning to play after an injury to the brain has been a prominent issue in sports-related brain injury research and practice. Despite active monitoring involving pre and post injury testing in both amateur and professional athletics, controversy abounds and gold standard practice criteria have yet to be universally accepted. Perreault and colleagues exhaustively reviewed the published literature and surveyed 111 clinicians who care for pediatric patients with central nervous system tumors to determine the incidence of cardinal signs and symptoms during the course of participating in sports, complications associated with returning to play in this population with an undeniable brain injury, and common practice recommendations. Notably, few sport-related complications were identified, and, not surprisingly, no consist practice recommendation was identified across providers to guide return to play decisions in this population. As brain tumor survivorship improves and interest in physical activity for both recreational and therapeutic benefits increases, the neuro-oncology community will be called upon more frequently to wrestle with this challenging situation. Patients are often diagnosed with glioblastoma after persistence or severe worsening of an existing sign or symptom (e.g., headache, altered mental status) or due to rapid onset of a new sign or symptom (e.g., seizure). In many instances patients obtain their care in the institution at which they initially arrive without time to consider, or information to weigh about, the experience the providers there have with that particular tumor and clinical situation. Brandes and colleagues offer provocative exploratory findings from prospectively gathered data on 267 glioblastoma patients participating in the Project of Emilia-Romagna on Neuro-Oncology (PERNO) primary brain tumor registry suggesting that patients treated at high volume centers may have longer survival times than patients treated at low volume centers. If these observational findings are validated, and the “driver” variables are identified that account for these differences, this may lead to opportunities for identification and dissemination of best practices and/or reconsideration of regional healthcare organization and specialty-service lines for diseases such as glioblastoma. Patients with malignant glioma will progress and require consideration of salvage therapy, which often is associated with poor outcomes. Clark and colleagues report results from a small single institution cohort of 21 progressed malignant glioma patients, some with larger recurrent tumor target volumes, treated with concurrent hypofractionated stereotactic radiosurgery and bevacizumab. They report similar survival outcomes and no new safety signals when compared to prior reports that limited their sample to patients with smaller target volumes. Reirradiation with bevacizumab may provide improved outcomes to patients with recurrent malignant glioma. However, many patient selection and treatment factors remain to be evaluated in larger randomized studies. Wirsching and colleagues contribute a case study report of an elderly glioblastoma patient that despite an MMSE of 30/30 inadvertently self-administered an eventually lethal dose of lomustine over 4 days. This case tragically highlights the risks inherent in the practice of medicine. Given the particularly compelling survival results from trials in patients with 1p/19q co-deleted OA/AOA and high-risk low grade glioma, the authors provide a timely and clear set of recommendations to try to prevent (e.g., supply the dose for one cycle at a time) and manage the complication of lomustine overdose, which will serve as an important resource for clinicians who care for patients treated with lomustine and for pharmacies that supply this medication. Posterior reversible encephalopathy syndrome is a recognized neurologic syndrome that can occur in cancer patients. Few cases of PRES have been reported in primary brain tumor patients and diagnosing this condition is complicated by the presence of an intracranial tumor, symptoms that can mimic disease progression, and adverse treatment effect. Kamiya-Matsuoka and colleagues summarize the eight cases reported in the literature and 4 additional cases observed at M.D. Anderson Cancer Center between 2012–2014. They discuss the challenges of radiographically diagnosing this syndrome and offer potential radiographic and clinical patterns that may increase the clinician's index of suspicion for PRES, which may lead to earlier identification of the syndrome and avoidance of permanent deficits. Every clinician who cares for brain tumor patients is aware that caregivers will assume an increasingly heavy burden during the disease trajectory. Assessing caregiver quality of life and assisting the caregiver to optimize their quality of life is an important aspect of holistically caring for the brain tumor patient. Minaya and colleagues examined profiles of caregiver quality of life in caregivers of patients with brain tumor compared to caregivers of patients with other forms of cancer. There was no dimension of caregiver quality of life assessed on which caregivers of patients with brain tumor reported statistically significantly better quality of life than caregivers of patients with other forms of cancer. Further, caregivers of patients with brain tumor reported significantly greater burden (greater time devoted to caring for the patient's needs) and less leisure time (inability to relax and care for one's self) than other caregivers of cancer patients. Identifying caregiving challenges that are more unique to caregivers of brain tumor patients improves the clinician's ability to target these issues, as general cancer support programs may be less effective in recognizing and assisting in managing these issues.