NCCN Guidelines® Updates

NCCN Guidelines® Updates

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

Central Nervous System Cancer

Updates in Version 2.2013 of the NCCN Guidelines for Central Nervous System Cancers from version 2.2012 include:

Adult Low-Grade Infiltrative Supratentorial Astrocytoma/Oligodendroglioma (Excluding Pilocytic Astrocytoma)


  • 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.

Anaplastic Gliomas/Glioblastoma


  • 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.”

  • Glioblastoma ± carmustine (BCNU) wafer; Poor performance status; Adjuvant treatment

    • “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


  • Metastatic Spine

    • 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 20-37.5 15-40 Gy are delivered in 5-15 1-15 fractions over 1-3 weeks 1 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.

  • Anaplastic Gliomas

    • Adjuvant treatment: “Concurrent (with RT) temozolomide 75 mg/m2 daily” was added.

    • Recurrence/Salvage therapy

      • ▪ Cyclophosphamide changed from category 2A to a category 2B recommendation.

  • “Anaplastic Oligoastrocytoma/Anaplastic Oligodendroglioma” was added as a sub-type with the following options:

    • Adjuvant Treatment: RT and PCV for 1p19q co-deleted (category 1)

  • Glioblastoma

    • Adjuvant treatment: “Temozolomide 150-200 mg/m2 5/28 schedule” was added.

    • Recurrence/Salvage therapy: Cyclophosphamide changed from category 2A to a category 2B recommendation.

  • Primary CNS Lymphoma

    • Primary treatment

      • ▪ The following recommendation was added, “Consider urgent glucarpidase (carboxypeptidase G2) for prolonged methotrexate clearance due to methotrexate induced renal toxicity.”

    • Recurrence or Progressive Disease

      • ▪ “Dexamethasone, high-dose cytarabine, cisplatin” was added as an option.

  • Meningiomas

    • The following agents changed from category 2A to a category 2B recommendation: Hydroxyurea, Interferon alfa.

  • Leptomeningeal Metastases

    • Under Intra-CSF chemotherapy

      • ▪ “Interferon alfa” changed from category 2A to a category 2B recommendation.

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