The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Central Nervous System Cancers, published in this issue (page 1114), include the latest updates. To assist readers interested in noting how the guidelines were updated, highlights of major changes pertaining to the abbreviated version published in this issue are printed below. To view the complete list of updates and full versions of these guidelines, visit the NCCN Web site at NCCN.org
Central Nervous System Cancer
Updates in Version 2.2013 of the NCCN Guidelines for Central Nervous System Cancers from version 2.2012 include:
After “Maximal safe resection,” the adjuvant treatment options for low-risk and high-risk patients were combined. Previously, low-risk patients were only “Observed” after maximal safe resection.
Footnote “h” was revised as follows: “High-risk features: 3 or more of: Astrocytoma, age >40 y, KPS <70, tumor dimension >6 cm, tumor crossing midline, preoperative neurological deficit of more than minor degree. One or no deletions on 1p and 19q, IDH1 or 2 not mutated, increased perfusion on imaging are also adverse factors that may be considered.”
No prior fractionated external-beam pathway: the term “progression” was removed.
Under “Pathology,” “Anaplastic gliomas” was changed to “Anaplastic oligodendroglioma, Anaplastic oligoastrocytoma, Anaplastic astrocytoma, Anaplastic gliomas.”
This page was reorganized into treatment recommendations according to 1p19q co-deletion status and recommendations for patients with poor performance status.
Glioblastoma ± carmustine (BCNU) wafer; Good performance status; Adjuvant treatment
The recommendation “Fractionated external-beam RT ± concurrent and adjuvant temozolomide for age >70 y” changed to “...+ concurrent and adjuvant temozolomide for age >70 y.”
The recommendation “Fractionated external-beam RT (hypofractionated or standard)” changed to “Fractionated external-beam RT (hypofractionated) (category 1) for age >70 y.”
Chemotherapy (temozolomide if methylguanine methyl-transferase [MGMT] promotor methylation positive)” was added as an adjuvant treatment option for age >70 y.”
“Combined treatment” was removed as an adjuvant treatment option.
For “Diffuse or multiple” and “Local” recurrences, “Consider alternating electric field therapy (for glioblastoma) (category 2B)” was added as a treatment option.
Adult Medulloblastoma Supratentorial PNET
Standard risk for recurrence
The recommendations “Localized brain tumor (<1.5 cm2 residual tumor); no spine metastases and negative CSF; no disseminated disease” changed to:
▪ No evidence of metastasis (brain, spine, CSF, extraneural)
▪ Small volume residual disease (contrast volume <1.5 cm2)
▪ Classic or desmoplastic histology
High risk for recurrence; Adjuvant treatment
The recommendation changed to “Craniospinal radiation and post-radiation chemotherapy (consider collecting stem cells before craniospinal radiation).”
Follow-up: The imaging recommendations changed to “Brain MRI every 3 mos and spine MRI every 6 mos for 2 y; then brain MRI every 6 months and spine MRI every year for 3 y; then brain MRI yearly. For patients with previous spine disease, concurrent spine imaging as clinically indicated.”
Limited (1-3) Metastatic Lesions
Recurrent disease; local site; Previous WBRT or Prior SRS
For the recommendation “Single dose or fractionated stereotactic RT,” single dose changed from category 2A to a category 2B recommendation.
Multiple (>3) Metastatic Lesions
Primary treatment; After “Stereotactic or open biopsy/resection”
“Stereotactic radiosurgery” was added as an option with corresponding footnote “f” that states, “SRS can be considered for patients with good performance and low overall tumor volume.”
The following footnote was removed: “SRS should only be considered in selected cases (eg, limited number of lesions).”
Principles of Brain Tumor Radiation Therapy
The recommendation was revised as follows: “Doses to vertebral body metastases will depend on patient’s performance status, spine stability, location in relationship to spinal cord, and primary histology. Generally doses of 20-37.515-40 Gy are delivered in 5-151-15 fractions over 1-3 weeks1 day-3 weeks. In general, the surface of the spinal cord should be kept to ≤12 Gy. In selected cases, or recurrences after previous radiation, stereotactic radiotherapy is appropriate. At the retreatment site, it is critical to consider tolerance of the spine and/or spinal nerve roots. Generally recommended that 6 months or more of time between treatments is required and that at retreatment the surface of the cord should not receive more than 10 Gy.”
Principles of Brain Tumor Systemic Therapy
For clarity, “CCNU” changed to “lomustine” and “BCNU” changed to carmustine.