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. (Please see the section End-of-Rotation Evaluations above for the list of milestone abbreviations).
| 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 |
| Milestones | ||
| Please grade the resident on any of the following milestones you were able to evaluate during this rotation: | ||
| PL2, PR2 | ||
Schedule
| AM | Monday | Tuesday | Wednesday | Thursday | Friday |
| Neuropathology | Inter-Disciplinary Neuro-Oncology Clinic | Neuro-Oncology Follow-up Clinic | Neuroradiology | Didactic Teaching and Feedback | |
| Grand Rounds | |||||
| PM | 1:45pm Brain Cutting | 1:45pm Brain Cutting | Self-Study | ||
| 4pm Tumor Board | Neuroradiology |
Work Hours
The estimated average number of work hours per week is ~ 50. There are no call responsibilities required during this rotation.
Suggested References
Nabors LB, Portnow J, Ammirati M, et al. NCCN Guidelines Insights: Central Nervous System Cancers, Version 1.2017. J Natl Compr Canc Netw. 2017;15(11):1331-1345.
Kruser TJ, Mehta MP, Robins HI. Pseudoprogression after glioma therapy: a comprehensive review. Expert Rev Neurother. 2013;13(4):389-403.
Tipping M, Eickhoff J, Ian Robins H. Clinical outcomes in recurrent glioblastoma with bevacizumab therapy: An analysis of the literature. J Clin Neurosci. 2017;44:101-106.
Stupp R, Hegi ME, Mason WP, et al. Effects of radiotherapy with concomitant and adjuvant temozolomide versus radiotherapy alone on survival in glioblastoma in a randomised phase III study: 5-year analysis of the EORTC-NCIC trial. Lancet Oncol. 2009;10(5):459-466.
CONTINUUM: Lifelong Learning in Neurology. 26(6, Neuro-oncology):December 2020.
Latest revision: 5-14-2021
