08/23/2017

NCCN has published updates to the NCCN Guidelines, NCCN Compendium, and NCCN Imaging AUC™ for Central Nervous System Cancers

NCCN has published updates to the NCCN Guidelines, NCCN Compendium, and NCCN Imaging Appropriate Use Criteria (NCCN Imaging AUC™)  for Central Nervous System Cancers. These NCCN Guidelines are currently available as Version 1.2017.   

• Imaging frequency, target and modality were clarified throughout the guideline
• Adult Low-Grade Infiltrative Supratentorial Astrocytoma/Oligodendroglioma (Excluding Pilocytic Astrocytoma)
  • Postoperative Adjuvant Treatment (ASTR-1)
    • For low-risk pathway, “Fractionated external beam RT” category designation changed from 2A to 2B
  • Recurrent or Progressive Low-grade Disease (ASTR-2) 
    • New recommendation added for unresectable disease: “Consider biopsy” 
    • Treatment options clarified for patients with no prior RT: “RT + chemotherapy” replaced with the following options:
      • “RT + adjuvant PV”
      • "RT + adjuvant TMZ”
      • “RT + concurrent and adjuvant TMZ”
• Anaplastic Gliomas/Glioblastoma
  • Anaplastic Gliomas Pathology and Postoperative Adjuvant Treatment (GLIO-2)
    • Top pathway: 
      • Includes only “Anaplastic oligodendroglioma (1p19 codeleted)”; “Anaplastic oligoastrocytoma” was removed
      • A treatment option was clarified: “Fractionated external beam RT with concurrent and adjuvant temozolomide chemotherapy”
    • Middle pathway:
      • Now includes “Anaplastic astrocytoma” and “Anaplastic oligoastrocytoma”; “Anaplastic oligodendroglioma” and the label “1p19q uni- or non-deleted” were removed
      • Treatment options changed: 
        • Amended: “Fractionated external beam RT with concurrent and adjuvant temozolomide chemotherapy” 
        • Added: “Fractionated external beam RT with neoadjuvant or adjuvant PCV”
        • Removed: “PCV or temozolomide chemotherapy”
        • “Fractionated external beam RT” changed from category 1 to category 2A
• Adult Medulloblastoma
  • Postoperative adjuvant treatment (AMED-2)
    • For patients with standard risk of recurrence, a treatment option was modified: “Standard-dose craniospinal radiation ± chemoptherapy”
    • For patients with high risk of recurrence, the recommended treatment was modified: “Craniospinal radiation with chemotherapy followed by and post-radiation chemotherapy”
• Primary CNS Lymphoma
  • Induction Therapy (PCNS-2)
    • For patients on high-dose methotrexate-based regimen:
      • “If CSF positive or spinal MRI positive, and not responding to systemic chemotherapy, consider intra-CSF chemotherapy (category 2B)”
      • “If eye exam positive shows vitreous involvement and patient is not responding to systemic chemotherapy, consider RT to globe or intraocular chemotherapy (category 2B)”
    • “WBRT if patient is not a candidate for systemic chemotherapy”:
      • “If eye exam positive shows vitreous involvement, RT to globe”
  • Consolidation Therapy (PCNS-2)
  • For patients with complete response to induction therapy, “Continue monthly high-dose methotrexate-based regimen for up to 1 year” is a new treatment option
  • Treatment of Relapsed or Refractory Primary CNS Lymphoma (PCNS-3)
    • “Consider focal irradiation” is a new treatment option for patients with prior WBRT
• Meningiomas: MENI-1 was extensively revised 
• Limited (1-3) Brain Metastases
  • For patients with newly diagnosed or stable systemic disease or reasonable systemic treatment options (LTD-2)
    • For resectable: 
      • Treatment options removed: “SRS alone or SRS + WBRT”
      • To the remaining treatment option, “surgical resection” followed by “SRS (preferred) or WBRT”, a new footnote “i” was added: "SRS is preferred when safe, especially for low tumor volume. WBRT is generally not recommended but may be appropriate in some rare clinical circumstances (eg, ventricle is violated, cerebellar lesions, risk of meningeal disease, need for complete CNS control before going on protocol, not good SRS candidate for technical reasons, poor PS, advanced age).” 
    • For unresectable or opted not to resect:
      • Treatment options changed: “SRS (preferred) or WBRT” replaced “WBRT and/or SRS”
      • A new footnote “j” was added: "SRS + WBRT is generally not recommended but may be appropriate in some rare clinical circumstances. Brown 2016 showed that for tumors <3 cm, SRS + WBRT improved local control compared with SRS alone, but did not significantly improve survival, and was associated with greater cognitive decline and poorer quality of life. (Brown PD et al. JAMA 2016;316:401-409)”
• Leptomeningeal Metastases
  • For “Poor risk”, the radiation recommendation was revised: 
    • "Consider involved field RT fractionated external beam RT to symptomatic painful sites for palliation (including spine and intracranial disease)" (LEPT-2)
    • Footnote deleted: “Usually WBRT and/or partial spine field is recommended.”
  • For “Good risk”, treatment options were revised: "WBRT and/or involved field RT to bulky disease and symptomatic sites (including spine and intracranial disease)" (LEPT-2)
  • For CSF cytology negative (after “Primary Treatment”), recommendation revised: "Continue on current regimen and re-evaluate CSF cytology on a monthly basis induction intra CSF chemotherapy for 1 mo", and removed footnote: “Induction intra-CSF chemotherapy can start with radiation (concomitant) or high-dose methotrexate for lymphoma or CSI” (LEPT-4)
• Principles of Brian and Spinal Cord Tumor Radiation Therapy (BRAIN-C): Revisions made to the following sections: High-Grade Gliomas (Grades III/IV), Ependymoma, Primary CNS lymphoma, Brain Metastases, Metastatic Spine Tumors
• Principles of Brain and Spinal Cord Tumor Systemic Therapy
  • The following systemic therapies were added for the treatment of brain metastases (BRAIN-D 2 of 6):
    • Ipilimumab + nivolumab (melanoma)
    • Pembrolizumab (melanoma or non-small cell lung cancer)
    • Erlotinib, afatinib, gefitinib (EGFR sensitizing mutation-positive non-small cell lung cancer)
    • Osimertinib (EGFR T790M mutation-positive non-small cell lung cancer)
    • Crizotinib (ALK rearrangement-positive or ROS1 rearrangement-positive non-small cell lung cancer)
    • Ceritinib, alectinib (ALK rearrangement-positive non-small cell lung cancer)