Therapy for Diffuse Astrocytic and Oligodendroglial Tumors in Adults: ASCO-SNO Guideline

2021 ◽  
Author(s):  
Nimish A Mohile ◽  
Hans Messersmith ◽  
Na Tosha N Gatson ◽  
Andreas F Hottinger ◽  
Andrew B Lassman ◽  
...  
Keyword(s):  
Performance Status ◽  
Treatment Options ◽  
Poor Performance ◽  
Best Supportive Care ◽  
Poor Performance Status ◽  
Newly Diagnosed ◽  
Who Grade ◽  
Additional Information ◽  
Oligodendroglial Tumors ◽  
Grade 3

Abstract Purpose To provide guidance to clinicians regarding therapy for diffuse astrocytic and oligodendroglial tumors in adults. Methods ASCO and the Society for Neuro-Oncology convened an Expert Panel and conducted a systematic review of the literature. Results Fifty-nine randomized trials focusing on therapeutic management were identified. Recommendations Adults with newly diagnosed oligodendroglioma, isocitrate dehydrogenase (IDH)–mutant, 1p19q codeleted CNS WHO grade 2 and 3 should be offered radiation therapy (RT) and procarbazine, lomustine, and vincristine (PCV). Temozolomide (TMZ) is a reasonable alternative for patients who may not tolerate PCV, but no high-level evidence supports upfront TMZ in this setting. People with newly diagnosed astrocytoma, IDH-mutant, 1p19q non-codeleted CNS WHO grade 2 should be offered RT with adjuvant chemotherapy (TMZ or PCV). People with astrocytoma, IDH-mutant, 1p19q non-codeleted CNS WHO grade 3 should be offered RT and adjuvant TMZ. People with astrocytoma, IDH-mutant, CNS WHO grade 4 may follow recommendations for either astrocytoma, IDH-mutant, 1p19q non-codeleted CNS WHO grade 3 or glioblastoma, IDH-wildtype, CNS WHO grade 4. Concurrent TMZ and RT should be offered to patients with newly diagnosed glioblastoma, IDH-wildtype, CNS WHO grade 4 followed by 6 months of adjuvant TMZ. Alternating electric field therapy, approved by the US Food and Drug Administration, should be considered for these patients. Bevacizumab is not recommended. In situations in which the benefits of 6-week RT plus TMZ may not outweigh the harms, hypofractionated RT plus TMZ is reasonable. In patients age ≥ 60 to ≥ 70 years, with poor performance status or for whom toxicity or prognosis are concerns, best supportive care alone, RT alone (for MGMTpromoter unmethylated tumors), or TMZ alone (for MGMT promoter methylated tumors) are reasonable treatment options. Additional information is available at www.asco.org/neurooncology-guidelines.

scholarly journals Therapy for Diffuse Astrocytic and Oligodendroglial Tumors in Adults: ASCO-SNO Guideline

2021 ◽  
Author(s):  
Nimish A. Mohile ◽  
Hans Messersmith ◽  
Na Tosha Gatson ◽  
Andreas F. Hottinger ◽  
Andrew Lassman ◽  
...  
Keyword(s):  
Performance Status ◽  
Treatment Options ◽  
Poor Performance ◽  
Best Supportive Care ◽  
Poor Performance Status ◽  
Newly Diagnosed ◽  
Who Grade ◽  
Oligodendroglial Tumors ◽  
Mgmt Promoter ◽  
Grade 3

PURPOSE To provide guidance to clinicians regarding therapy for diffuse astrocytic and oligodendroglial tumors in adults. METHODS ASCO and the Society for Neuro-Oncology convened an Expert Panel and conducted a systematic review of the literature. RESULTS Fifty-nine randomized trials focusing on therapeutic management were identified. RECOMMENDATIONS Adults with newly diagnosed oligodendroglioma, isocitrate dehydrogenase (IDH)–mutant, 1p19q codeleted CNS WHO grade 2 and 3 should be offered radiation therapy (RT) and procarbazine, lomustine, and vincristine (PCV). Temozolomide (TMZ) is a reasonable alternative for patients who may not tolerate PCV, but no high-level evidence supports upfront TMZ in this setting. People with newly diagnosed astrocytoma, IDH-mutant, 1p19q non-codeleted CNS WHO grade 2 should be offered RT with adjuvant chemotherapy (TMZ or PCV). People with astrocytoma, IDH-mutant, 1p19q non-codeleted CNS WHO grade 3 should be offered RT and adjuvant TMZ. People with astrocytoma, IDH-mutant, CNS WHO grade 4 may follow recommendations for either astrocytoma, IDH-mutant, 1p19q non-codeleted CNS WHO grade 3 or glioblastoma, IDH-wildtype, CNS WHO grade 4. Concurrent TMZ and RT should be offered to patients with newly diagnosed glioblastoma, IDH-wildtype, CNS WHO grade 4 followed by 6 months of adjuvant TMZ. Alternating electric field therapy, approved by the US Food and Drug Administration, should be considered for these patients. Bevacizumab is not recommended. In situations in which the benefits of 6-week RT plus TMZ may not outweigh the harms, hypofractionated RT plus TMZ is reasonable. In patients age ≥ 60 to ≥ 70 years, with poor performance status or for whom toxicity or prognosis are concerns, best supportive care alone, RT alone (for MGMT promoter unmethylated tumors), or TMZ alone (for MGMT promoter methylated tumors) are reasonable treatment options. Additional information is available at www.asco.org/neurooncology-guidelines .

Determinants and Outcomes of the Use of Positron Emission Tomography (PET)-Staging in Newly Diagnosed Follicular Lymphoma (FL)

Blood ◽  
2014 ◽  
Vol 124 (21) ◽  
pp. 2600-2600
Author(s):  
Ashish Rai ◽  
Loretta J. Nastoupil ◽  
Jessica N. Williams ◽  
Joseph Lipscomb ◽  
Kevin Ward ◽  
...  
Keyword(s):  
Propensity Score ◽  
Regression Models ◽  
Performance Status ◽  
Poor Performance ◽  
Survival Advantage ◽  
Research Network ◽  
Poor Performance Status ◽  
Newly Diagnosed ◽  
Apparent Survival ◽  
Grade 3

Abstract Background: PET-assisted initial staging (PET-staging) may be useful for the accurate identification of stage I and limited stage II FL patients (pts) as candidates for potentially curative radiotherapy, for guidance of biopsy, and in determining the field of radiation. However, most guidelines recommend its judicious use in FL because its impact on treatment decisions and outcomes remains unclear. We sought to identify the factors associated with the use of PET-staging in FL and its impact on survival. Methods: We used the linked Surveillance, Epidemiology, and End Results-Medicare database to identify FL patients (pts) ≥ 65 years diagnosed between 2001 and 2009. We defined PET-staging as any whole body PET scan received 3 months prior through 6 months after diagnosis, and before the receipt of any treatment. We used multivariable logistic regression models to evaluate the relationships between pt and treatment setting characteristics, and the use of PET-staging. We examined the effects of PET-staging on overall and lymphoma-related survival (OS and LRS) using standard and propensity score (PS) matched Cox proportional hazards (CPH) regression models adjusted for pt and treatment setting characteristics. We evaluated the effect of unmeasured confounders on survival advantage from PET-staging by performing an instrumental variable (IV) CPH analysis using regional patterns of PET-staging as an instrument associated with PET use but not associated with survival (Wright, J.D. et al. Cancer 2014; Hadley, J. et al. JNCI 2010). Results: Of the 4,409 eligible pts, 58% were female, 93% were white, 80% lived in metropolitan areas, 23% lived in areas where ≥ 25% of the population had not completed high school, 46% had stage III/IV FL, 18% had grade 3 FL, 6% had B-symptoms, 16% had extra-nodal involvement, 13% had ≥ 2 comorbidities, 13% had poor performance status, and 56% most frequently visited hospitals affiliated with a research network. The increasing use of PET-staging for FL by year is displayed in the figure. Pts were more likely to undergo PET-staging if they lived in metropolitan areas (ref. less urban/rural pts; odds ratio [OR] 1.30; 95% CI 1.04-1.63); in areas with higher education levels (ref. lower levels; OR 1.25; 95% CI 1.01-1.54); had grade 3 FL (ref. grade 1 or 2 FL; OR 1.56; 95% CI 1.29-1.90); and if they most frequently visited a hospital affiliated with a research network (ref. no affiliation; OR 1.29; 95% CI 1.11-1.49). PET-staging was less commonly associated with age ≥ 81 years (ref. age 66-70; OR 0.55; 95% CI 0.45-0.67), residence in the Midwest region (ref. Southern region; OR 0.49; 95% CI 0.38-0.63), African American race (ref. White race; OR 0.59; 95% CI 0.39-0.89), presence of B-symptoms (OR 0.70; 95% CI 0.53-0.91), and poor performance status (OR 0.63; 95% CI 0.51-0.77). Results from the CPH regressions are shown in the table. Even after controlling for pt demographics, comorbidities, performance status, disease characteristics, treatment, year of diagnosis, and characteristics of the most frequently visited hospital, PET-staging was associated with improved OS (hazard ratio [HR] 0.77; 95% CI 0.69-0.86) and LRS (HR 0.69; 95% CI 0.57-0.83). This survival advantage persisted after either PS or IV-based adjustments. Conclusion: PET-staging has been widely used in newly diagnosed FL patients as a baseline investigation before initiation of therapy without well-established evidence of benefits and increased substantially over the study period. Regional, institutional, and socio-demographic variability exists in the use of PET-staging. PET-staging has been more commonly used in higher grade patients, and less commonly used in the oldest patients, patients with poorer performance status, and in patients with B-symptoms, indicating that clinicians may selectively utilize PET-staging for certain subgroups. However, the apparent survival advantage associated with PET-staging may not be entirely due to selection based on observed or unobserved confounders. Further investigation is warranted into the mechanisms of the apparent survival advantage associated with the use of PET-staging in FL. Figure 1 Figure 1. Table. OS LRS Estimation method HR (95% CI) HR (95% CI) CPH 0.77 (0.69 - 0.86) 0.69 (0.57 - 0.83) Propensity score matched CPH (caliper width 0.005) 0.82 (0.70 - 0.95) 0.63 (0.50 - 0.79) Propensity score matched CPH (caliper width 0.01) 0.81 (0.69 - 0.94) 0.74 (0.59 - 0.92) IV 0.44 (0.26 - 0.78) 0.20 ( 0.09 - 0.46) Disclosures No relevant conflicts of interest to declare.

scholarly journals P14.35 The modern management of brain metastases

2019 ◽  
Vol 21 (Supplement_3) ◽  
pp. iii74-iii75
Author(s):  
N D Wallace ◽  
P J Kelly
Keyword(s):  
Decision Making ◽  
Brain Metastases ◽  
Performance Status ◽  
Treatment Options ◽  
Poor Performance ◽  
Best Supportive Care ◽  
Poor Performance Status ◽  
Trade Off ◽  
Cns Penetration ◽  
The Impact

Abstract BACKGROUND Technological and clinical advances have improved outcomes for patients with brain metastases. They have also added significantly to the complexity of decision-making in such cases. We set out to review the roles of different treatment options to guide management for patients with newly-diagnosed brain metastases. MATERIAL AND METHODS We undertook a comprehensive literature review to examine all treatment options for brain metastases. We particularly focused on recent advances and where these can be applied to clinical practice.We examined the impact of the improvement of SRS technology from older frame-based setups to modern linear accelerator based treatment with the capacity for fractionated stereotactic radiotherapy (SRT). We identified clinical situations where either SRS or WBRT, or a combination of the two, should be most strongly considered. Several novel targeted systemic therapies cross the blood-brain-barrier so we have explored their outcomes for patients with brain metastases from BRAF-mutated melanoma and EGFR or ALK/ROS1 mutated NSCLC. By examining these techniques in detail, we have formulated an algorithm-based approach which can inform management. RESULTS Surgery is most beneficial in patients with a reasonable prognosis and where other treatment options are unlikely to provide equivalent control. SRS to the surgical cavity can frequently be used alone for post-operative consolidation. SRS and fractionated SRT are valuable treatment options for increasingly large lesions and for increasing numbers of lesions. The choice between SRS and WBRT is, in many cases, a trade-off between the improved intracranial control of WBRT and the more favourable side effect profile of SRS. Upfront therapy with some systemic agents with CNS penetration is an acceptable approach in carefully-selected patients whose outcome is felt to be more related to their extracranial disease. Best supportive care is preferable for many patients with poor performance status and/or short prognosis, although more aggressive measures have a role in the case of symptomatic lesions. CONCLUSION A multidisciplinary approach involving Neurosurgeons, and both Radiation and Medical Oncologists is needed to fully evaluate the options for individual patients. As many of the treatment decisions are a trade-off between quality of life and outcome metrics, shared decision-making with patients is also critical to ensure that patients receive the best treatment for them.

Predicting survival in resected pancreatic cancer: A Canadian provincial experience.

2012 ◽  
Vol 30 (4_suppl) ◽  
pp. 361-361
Author(s):  
Gillian Gresham ◽  
Sylvia Ng ◽  
Anderson Chang ◽  
Shannon Valdez ◽  
Sharlene Gill
Keyword(s):  
Pancreatic Cancer ◽  
Histological Grade ◽  
Performance Status ◽  
Poor Performance ◽  
Poor Performance Status ◽  
Significant Difference ◽  
Cancer Agency ◽  
Trial Outcomes ◽  
Grade 3 ◽  
Poor Outcomes

361 Background: Surgical resection offers the only hope for long-term disease control in patients (pts) with pancreatic adenocarcinoma. Randomized trials (ESPAC 1, ESPAC3) further support a role for adjuvant chemotherapy (AC) in the management of pancreatic cancer (PC). Trial outcomes may not reflect clinical reality due to pt selection bias, and it is often difficult to predict which pts are most likely to benefit from adjuvant intervention. Methods: Consecutive pts between 2003 and 2008 referred to the BC Cancer Agency (BCCA) with operative intent at diagnosis (dx) were retrospectively reviewed. Results: 145 pts were identified; median age 65 years (y) (range 38-84), male/female (45.5%, 54.5%). EUS/PET staging was performed in 21% of pts. Median CA19-9 value at dx was 210 ku/L. Pancreaticoduodenectomy was performed in 65% of pts. Complete resection (RO) of tumours occurred in 87 pts (60%) overall. 66% of pts were node positive. 43% of pts were subsequently treated with adjuvant therapy (AT) where 5% of these pts received chemoradiotherapy and 95% received AC (65% gemcitabine). There was no statistically significant difference in either OS (p=0.39) or DFS (p=0.28) amongst resected pts who were treated by sx alone versus pts who received AC. In subgroup analysis, AC was associated with significantly improved OS in pts (n=58) with positive margins (R1) (median 17.3 mos vs 8.9 mos, p=0.0045) but benefit was not seen in R0 pts (n=87) (22.9 mos vs 22.4 mos, p=0.20). In multivariate analysis, poor performance status (ECOG 3-4), weight loss of more than 10% of initial body weight, baseline CA19-9 value greater than 210 ku/L, positive nodes, R1 status and histological grade 3-4 were significant adverse prognostic factors. Conclusions: PC continues to have poor outcomes with a 5yOS of 5% in pts treated with sx alone. Among pts with resectable PC treated at the BCCA, AC tended towards increased DFS and OS. Although R1 status was associated with inferior OS, the benefit of AT was greater in this subgroup. [Table: see text]

Weekly chemotherapy instead of best supportive care alone must be considered for patients of small cell lung cancer with poor performance status.

2020 ◽  
Vol 38 (15_suppl) ◽  
pp. e21102-e21102
Author(s):  
Gunjan Shrivastav ◽  
Alok Gupta ◽  
Neha Sonthwal ◽  
Suhas Kirti Singla ◽  
Tarun Mohindra ◽  
...  
Keyword(s):  
Chemotherapy Regimen ◽  
Performance Status ◽  
Objective Response ◽  
Poor Performance ◽  
Median Number ◽  
Best Supportive Care ◽  
Poor Performance Status ◽  
Weekly Chemotherapy ◽  
Group A ◽  
Group B

e21102 Background: Many patients of Small Cell Lung Cancer (SCLC) present with advanced age & comorbidities. Although chemotherapy may benefit these patients, therapy is denied due to treatment toxicities. We studied tolerability and efficacy of weekly Etoposide with carboplatin in patients unfit for 3-weekly regimen to analyze the hypothesis if small dose weekly chemotherapy can replace the current standard of care of best supportive care (BSC) alone in patients with poor performance status (PS). Methods: We retrospectively studied consecutive patients of SCLC treated between January 2015- December 2017. Based on team’s assessment, patients received either Etoposide100 mg/m2 (Day 1,2,3) + Cisplatin25 mg/m2 (Day 1,2,3) (or Carboplatin AUC5 Day 1) q 21 days OR Etoposide100 mg/m2 + Carboplatin(AUC2)q weekly OR BSC. Responses at 6-9 weeks of therapy and toxicities were studied according to RECIST 1.1 and CTCAEv4 criteria respectively. Results: 66 patients were diagnosed with SCLC. 24 patients received 3-weekly chemotherapy regimen (Group A). Of the 42 unfit patients, 21(50 %) received weekly chemotherapy regimen (Group B). Median age was higher in Group B ( 66 vs 61 yrs ) and Co-morbidities (≥ 2)were also more in Group B, 53 vs 33 %. Furthermore, Group B had more brain metastases (38 vs 21 %) but there was equal distribution of liver metastases and SVCO (4 patients each group). Altogether Group B had worse prognostic patients. In Group A the median number of chemotherapy cycles received were 4.5 (1-8) over a median duration of 3.37 months (0.75 - 6) while in group B the median number of chemotherapy cycles were 2 (1-5) over 1.5 months (0.5 - 3.75). G-CSF was required in 22(92%) in Group A and 15(71%) in Group B. Grade 3-4 toxicity and Febrile neutropenia were seen in 11(46%) and 7(29%) patients in Group A respectively and 8(38.1%) and 7(33%) patients in Group B respectively. Progressive disease was seen in 3(13%) and 6(29%) patients in group A and B respectively. Objective response was seen in 14(59%) and 9(43%) in Group A and B respectively. Clinical benefit rate (CBR) (Objective response + Stable disease) was 75% in Group A and 57% in Group B. Among patients with brain metastasis, CBR was 60% in Group A and 50% in Group B. This was better than most patients that are not offered treatment. Conclusions: Although 3 weekly doublet remains a better regimen, weekly etoposide and platinum is a valid option for patients unfit for standard regimen with no excess toxicity. Clinical benefit is seen irrespective of poor prognostic features.

Use of gemcitabine-platinum (Gem-P) in patients with advanced gall bladder (GB) cancer: A more aggressive disease compared to the West—Tata Memorial Centre (TMC) experience.

2014 ◽  
Vol 32 (3_suppl) ◽  
pp. 349-349
Author(s):  
Bhawna Sirohi ◽  
Vipul Sheth ◽  
Ashish Singh ◽  
Alok Gupta ◽  
Mahesh Goel ◽  
...  
Keyword(s):  
Clinical Benefit ◽  
Performance Status ◽  
Poor Performance ◽  
Standard Of Care ◽  
Median Number ◽  
Best Supportive Care ◽  
Poor Performance Status ◽  
The West ◽  
Clinical Benefit Rate ◽  
Northern India

349 Background: GB cancer is a common cancer in northern India. Gem-P is currently the standard of care for pts with advanced biliary tract cancers based on the ABC02 study which had 61 pts with GB cancer with a clinical benefit rate (CR+PR+SD) of 85%. Indian patients have a higher risk disease and present at a more advanced stage than in the West and data on treatment is lacking. Methods: This is retrospective analysis of the prospectively maintained database of 131 pts with advanced GB cancer treated at TMC between Jan 2012-May 2013. Aim of the study is to assess the clinical benefit rate in this group of pts with the Gem-P. Pts received cisplatin 25 mg/m2 and gemcitabine 1000 mg/m2 on D1 and D8 of a 21day cycle, for gem-oxaliplatin, pts received gemcitabine 1000mg/m2 on D1 and oxaliplatin 100mg/m2 on D2 every 14 days. Response was assessed after 3-4 cycles. Results: Of the 131 patients, 110 pts were treated with Gem-P (95 oxaliplatin, 15 cisplatin; 1 received cetuximab-Gem-P) and 21 (16%) pts received best supportive care alone in view of poor performance status and deranged organ function. Median age was 53 years (range, 27-76), 82F/49 M; median CA19.9 206 (<2-2251660); median CEA 6.9 (0.8-3541); site of metastases was liver in 66 (50%), nodal in 74(56%), peritoneal in 29(22%) and bilateral ovarian in 5(3.8%) patients. Of the 110 pts treated with GEM-P, PS was 0-1 in 91% of patients; median number of cycles received was 4 (1-12); grade 3 &4 toxicities were- thrombocytpenia-12 (11%), neutropenia -2 (2%), hepatitis -2 (2%) patients, neuropathy-4 (4%) and diarrhea-8 (7.2%). 86/110 (78%) were evaluable for response out of which 4 (5%) had CR, 31(36%) had PR, 13(15%) had SD, and 38 (44%) had progressive disease. 32/110 (29%) pts received 2nd-line chemotherapy (majority capecitabine -irinotecan based). Conclusions: This is the single largest study to show tolerance and efficacy of Gem-P in Indian pts with advanced GB cancer. Compared to the ABC 02 study, the clinical benefit rate is low at 56% suggesting that the biology of advanced GB cancers in Indian pts is likely to be aggressive and needs to be studied in prospectively designed studies.

Treatment of hepatocellular carcinoma (HCC) after sorafenib (S) over the last 10 years.

2019 ◽  
Vol 37 (4_suppl) ◽  
pp. 438-438
Author(s):  
Andrea S. Fung ◽  
Richard M. Lee-Ying ◽  
Daniel E. Meyers ◽  
Hao-Wen Sim ◽  
Jennifer J. Knox ◽  
...  
Keyword(s):  
Radiation Treatment ◽  
Performance Status ◽  
Treatment Options ◽  
Poor Performance ◽  
Outcome Data ◽  
Subsequent Treatment ◽  
Poor Performance Status ◽  
Kaplan Meier ◽  
Impact On Survival ◽  
Prognostic Group

438 Background: Until recently there were no standard treatments for HCC patients after S. This study characterizes subsequent treatments (STx) received by HCC patients over the past 10 years and assesses their impact on survival. Methods: HCC patients treated with S between 01/2008 – 06/2017 in British Columbia, Alberta, and two cancer centers in Toronto, Ontario, Canada (Princess Margaret and Sunnybrook Cancer Centre) were included. Clinical, pathologic, laboratory, treatment, and outcome data were collected. The Kaplan-Meier method was used to assess overall survival (OS) based on STx, and stratified according to a better prognostic group (BPG), defined as ECOG 0-1 and CP-A, and worse prognostic group (WPG), defined as ECOG≥2 or CP-B/C. Results: A total of 730 patients were identified. 177 (24.2%) received STx (table). Patients who received STx had longer median OS (mOS) than those who had no further treatment (12.1 vs. 3.3 months; p < 0.001). For patients treated with localized, systemic, or palliative radiation treatment, mOS was 16.8, 10.5 and 8.6 months, respectively (p < 0.001). After S, there were 206 (30.7%) patients in the BPG and 464 (69.3%) in the WPG. BPG patients were more likely to receive STx compared to WPG patients (60.5% vs. 39.5%, p < 0.001). BPG patients who received STx had better mOS than those who did not (15.9 vs. 7.0 months; p < 0.001). WPG patients also had better mOS if they received STx compared to those who did not (6.0 vs. 2.6 months; p < 0.001). Conclusions: Only a small proportion of HCC patients received subsequent treatment after sorafenib. This is likely due to poor performance status, liver dysfunction, or lack of treatment options. Patients who received subsequent treatment had improved mOS, regardless of whether they were in the better or worse prognostic group. [Table: see text]

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