Cerebral Tumor Management

Diagnostic Approach

The diagnosis of cerebral tumors requires gadolinium-enhanced MRI as the standard imaging modality, followed by tissue diagnosis through biopsy or surgical resection to establish both histopathological and molecular characteristics 1, 2, 3
MRI with gadolinium contrast is mandatory for initial evaluation, using T1-weighted (with and without contrast), T2-weighted, and FLAIR sequences 4
Advanced imaging (perfusion MRI, MR spectroscopy, amino acid PET) should be considered when distinguishing tumor progression from treatment-related changes 3, 5

For newly diagnosed glioblastoma, maximal safe surgical resection followed by concurrent temozolomide with radiotherapy, then adjuvant temozolomide is the standard of care 7, 8
Attempt maximal tumor resection without compromising neurological function 7, 6
Use 5-aminolevulinic acid (5-ALA) fluorescence guidance during surgery to improve complete resection rates and progression-free survival 6

For anaplastic astrocytomas and oligodendrogliomas, surgical resection followed by radiotherapy is standard, with chemotherapy added based on molecular features 7, 8
For anaplastic oligodendrogliomas with 1p/19q co-deletion, radiotherapy plus PCV chemotherapy significantly improves survival compared to radiotherapy alone 7, 8

For resectable brain metastases with good systemic disease control, surgical resection followed by stereotactic radiosurgery (SRS) is preferred over whole-brain radiotherapy (WBRT) to preserve neurocognitive function 1, 2, 3
Single resectable metastasis: Surgical resection followed by WBRT or SRS + WBRT or SRS alone 10, 9

For patients with more than 3 brain metastases, treatment depends on systemic disease status and prognosis 1, 2, 3
Favorable prognosis: SRS/stereotactic radiotherapy (SRT) or systemic pharmacotherapy 1, 2, 3

For recurrent glioblastoma, repeat cytoreductive surgery should be considered in selected patients with symptomatic circumscribed relapses diagnosed at least 6 months after initial surgery, good performance status, and possibility of gross total resection 11
Lomustine is the standard chemotherapy option with confirmed single-agent efficacy 11
Bevacizumab provides high response rates with steroid-sparing effect, though overall survival benefit is uncertain 11

Treatment options for recurrent brain metastases are determined by performance status, neurological function, type of CNS progression, and prior treatment 1, 2, 3
Surgery followed by SRS/SRT, SRS/SRT alone, systemic pharmacotherapy, or WBRT if not previously administered 1, 2

Use the lowest effective dose for the shortest duration to control raised intracranial pressure 5, 6
Minimum dose: Dexamethasone 4 mg every 6 hours, though doses may vary for spinal cord compression 10, 9

Brain MRI every 2-3 months or at any instance of suspected neurological progression 1, 2, 3, 5
Neurological examination every 2-3 months using standardized procedures 1, 2, 3
Use RANO criteria for response assessment in clinical practice 1, 2, 3