Introduction and Goals
Although much less common than breast, lung, colon, or prostate cancers, tumors of the central nervous system are nonetheless an important public health problem, and one with which neurologists must have some familiarity. CNS tumors are in the differential for some of the most common chief complaints in neurology, including headache, seizure, and spells, and can result in acute, subacute, or chronically progressive focal deficits.
The goals of this elective rotation are for the PGY-3 or PGY-4 resident neurologist to develop an organized approach to the evaluation and treatment of patients with neurologic cancers with special emphasis on primary tumors. As time allows, residents may also be exposed to the treatment approach metastatic disease of the brain or spine. Residents will gain experience not only in medical oncology, but in radiation oncology, palliative care, neuroradiology, neuropathology, and interdisciplinary teamwork. Residents will also receive one-on-one didactic sessions with neuro-oncology faculty.
Objectives and Evaluation Matrix
As with all of the neurology rotations, the specific objectives are reflected in the entrustable professional activities and individual milestones listed below. These form the basis for the end-of-rotation evaluation.
| Rotation Objectives | ||
| Upon completion of the curriculum, residents will . . . | ||
| # | Description | Milestones |
| 1 | Describe the treatment approach to newly- diagnosed and recurrent gliomas based on MRI findings, extent of surgery, pathology, and tumor markers. | PC3, PC4, PC8, MK1, MK2 |
| 2 | Explain the role of tumor markers in glioma treatment and prognosis: MGMT methylation, IDH 1&2 mutations, 1p19 deletions, ATRX, TERT, & EGFR. | PC3, PC4, PL1 |
| 3 | Describe the indications for, and side effects of, radiation, tumor treating field therapy, and specific drugs: Temozolomide, PVC chemotherapy, BCNU wafers, lomustine, bevacizumab, steroids and anti-convulsants. | PC3, PC4, PL1 |
| 4 | Diagnose, and counsel patients and families regarding the following types of aphasia: Broca’s, Wernicke’s, conduction, anomic, and transcortical. | PC3, MK1, IC1 |
| 5 | Use MRI, including T1 +/- contrast, T2, FLAIR, T2*, DWI, and PWI to differentiate tumor progression, pseudo- progression, and pseudo-response and the implications for treatment. | PC8 |
| 6 | Classify primary CNS neoplasms using the old WHO scheme; demonstrate awareness of the new the WHO criteria and their implications for future practice. | MK2 |
| 7 | Describe key studies that dictate therapy: EORTC-NCIC Phase 3; RTOG 9802, RTOG 0424, RTOG 9402, RTOG 0131. | PL1 |
| 8 | Communicate bad news and empathize with patients and families and communicate effectively with the interdisciplinary treatment team, both verbally and through the electronic health record | SP3, SP4, PR1, IC3, IC4 |
| Additional Milestones | ||
| PL2, PR2 | ||
Schedule
Residents will gain valuable experience by seeing what a neuro-oncologist does for a week. Experience can include attending neuro-oncology clinics at both East Park Medical Center and University Hospital, attending and observing clinical trial meetings, participating in research and case studies, reviewing images in the radiology reading rooms and discussing materials read from the suggested references below. Residents are expected to contact Dr. Bhatia prior to the start of the week to discuss the specifics of the rotation.
Work Hours
The estimated average number of work hours per week is ~ 50. There are no call responsibilities required during this rotation.
Suggested References
CONTINUUM: Lifelong Learning in Neurology. 29(6, Neuro-oncology): December 2023.
NCCN Guidelines- Central Nervous System Cancers
Brandes AA, Franceschi E, Tosoni A, Blatt V, Pession A, Tallini G, Bertorelle R, Bartolini S, Calbucci F, Andreoli A, Frezza G, Leonardi M, Spagnolli F, Ermani M. MGMT promoter methylation status can predict the incidence and outcome of pseudoprogression after concomitant radiochemotherapy in newly diagnosed glioblastoma patients. J Clin Oncol. 2008 May 1;26(13):2192-7. doi: 10.1200/JCO.2007.14.8163. PMID: 18445844.
Wen PY, Weller M, Lee EQ, Alexander BM, Barnholtz-Sloan JS, Barthel FP, Batchelor TT, Bindra RS, Chang SM, Chiocca EA, Cloughesy TF, DeGroot JF, Galanis E, Gilbert MR, Hegi ME, Horbinski C, Huang RY, Lassman AB, Le Rhun E, Lim M, Mehta MP, Mellinghoff IK, Minniti G, Nathanson D, Platten M, Preusser M, Roth P, Sanson M, Schiff D, Short SC, Taphoorn MJB, Tonn JC, Tsang J, Verhaak RGW, von Deimling A, Wick W, Zadeh G, Reardon DA, Aldape KD, van den Bent MJ. Glioblastoma in adults: a Society for Neuro-Oncology (SNO) and European Society of Neuro-Oncology (EANO) consensus review on current management and future directions. Neuro Oncol. 2020 Aug 17;22(8):1073-1113. doi: 10.1093/neuonc/noaa106. PMID: 32328653; PMCID: PMC7594557.
Miller JJ, Gonzalez Castro LN, McBrayer S, Weller M, Cloughesy T, Portnow J, Andronesi O, Barnholtz-Sloan JS, Baumert BG, Berger MS, Bi WL, Bindra R, Cahill DP, Chang SM, Costello JF, Horbinski C, Huang RY, Jenkins RB, Ligon KL, Mellinghoff IK, Nabors LB, Platten M, Reardon DA, Shi DD, Schiff D, Wick W, Yan H, von Deimling A, van den Bent M, Kaelin WG, Wen PY. Isocitrate dehydrogenase (IDH) mutant gliomas: A Society for Neuro-Oncology (SNO) consensus review on diagnosis, management, and future directions. Neuro Oncol. 2023 Jan 5;25(1):4-25. doi: 10.1093/neuonc/noac207. PMID: 36239925; PMCID: PMC9825337.
Mellinghoff IK, van den Bent MJ, Blumenthal DT, Touat M, Peters KB, Clarke J, Mendez J, Yust-Katz S, Welsh L, Mason WP, Ducray F, Umemura Y, Nabors B, Holdhoff M, Hottinger AF, Arakawa Y, Sepulveda JM, Wick W, Soffietti R, Perry JR, Giglio P, de la Fuente M, Maher EA, Schoenfeld S, Zhao D, Pandya SS, Steelman L, Hassan I, Wen PY, Cloughesy TF; INDIGO Trial Investigators. Vorasidenib in IDH1- or IDH2-Mutant Low-Grade Glioma. N Engl J Med. 2023 Aug 17;389(7):589-601. doi: 10.1056/NEJMoa2304194. Epub 2023 Jun 4. PMID: 37272516; PMCID: PMC11445763.
Latest revision: 10/24/2024
