中枢神经系统肿瘤2022.v1（英文）-NCCN肿瘤临床实践指南

NCCNClinicalPracticeGuidelinesinOncologyNCCNGuidelines®)CentralNervousSystemCancersrsionJuneNCCNGuidelinesforPatients®availableat/patientsVersion1.2022,06/02/22©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon6/4/20227:37:51AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.sSystemCancers*LouisBurtNabors,MD/ChairYO'NealComprehensiveCancerCenteratUAB*JanaPortnow,MD/Vice-Chair†YCityofHopeNationalMedicalCenterJoachimBaehring,MDYOrinBloch,MDY¶UCDavisComprehensiveCancerCenterStevenBrem,MD¶nterNicholasButowskiMDY†DonaldM.Cannon,MD§SamuelChao,MD§hensiveCancerCenterChhedaMDYrkMDPhDMSCIYAndrewJ.Fabiano,MD¶lParkComprehensiveCancerCenterythMDYlowPhDilioMDYJonaHattangadi-Gluth,MD§cerCenter*MatthiasHoldhoff,MD,PhD†kins*CraigHorbinski,MD,PhD≠LarryJunck,MDY*ThomasKaley,MDYMichelleKim,MD§UniversityofMichiganRogelCancerCentermthekarMDYRobertH.LurieComprehensiveCancer*MaciejM.Mrugala,MD,PhD,MPHY†*SeemaNagpal,MD†YPhioanhL.Nghiemphu,MD†UCLAJonssonComprehensiveCancerCenternePetersMDPhDY*VinayK.Puduvalli,MDYeCancerCenterJamesCancerHospitalIanRobins,MD,PhD†YUniversityofWisconsinJasonRockhill,MD,PhD§SeattleCancerCareAlliance*ChadRusthoven,MD§UniversityofColoradoCancerCenterNicoleShonka,MD†YFredandPamelaBuffetCancerCenter*LodeJ.Swinnen,MBChB‡†YkinsAlvaWeir,MD†StephanieWeiss,MD§FoxChaseCancerCenter*PatrickYungWen,MDYeToralR.Patel,MDYenterAmericanBrainTumorAssociationesPanelDisclosures‡Hematology/Hematologyoncology¥Patientadvocacy§Radiation/Radiationoncology¶Surgery/Surgicaloncology*DiscussionSectionWritingmmitteeNervousSystemCancersPanelMembersryoftheGuidelinesUpdatesAdultGlioma:WHOGrade1(GLIO-1)AdultGlioma:Oligodendroglioma(IDHmutant,1p19qcodeleted)(GLIO-2)tGliomaNervousSystemCancersPanelMembersryoftheGuidelinesUpdatesAdultGlioma:WHOGrade1(GLIO-1)AdultGlioma:Oligodendroglioma(IDHmutant,1p19qcodeleted)(GLIO-2)tGliomaIDHmutantAstrocytomaGLIOAdultGlioma:Glioblastoma(GLIO-6)AdultIntracranialandSpinalEpendymoma(ExcludingSubependymoma)(EPEN-1)AdultMedulloblastoma(AMED-1)SInMetastasesMUEPTEPrinciplesof:•BrainandSpineTumorImaging(BRAIN-A)•BrainTumorSurgery(BRAIN-B)•RadiationTherapyforBrainandSpinalCord(BRAIN-C)•BrainandSpinalCordTumorSystemicTherapy(BRAIN-D)•BrainandSpineTumorManagement(BRAIN-E)•BrainTumorPathology(BRAIN-F)•CancerRiskAssessmentandCounseling(BRAIN-G)sSystemCancersdexlievesthatthebestmanagementforanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.FindanNCCNMemberInstitution:/home/member-institutions.ofEvidenceanddationsotherwisedNCategoriesofEvidenceandConsensus.NCCNCategoriesofPreference:Allrecommendationsareconsideredappropriate.SeeNCCNCategoriesofPreference.TheNCCNGuidelinesareastatementofevidenceandconsensusoftheauthorsregardingtheirviewsofcurrentlyacceptedapproachestotreatmentAnyclinicianseekingtoapplyorconsulttheNCCNGuidelinesisexpectedtouseindependentmedicaljudgmentinthecontextofindividualstancestodetermineanypatientscareortreatmentTheNationalComprehensiveCancerNetworkNCCNmakesnorepresentationsorwarrantiesofanykindregardingtheircontentuseorapplicationanddisclaimsanyresponsibilityfortheirapplicationoruseinanywayTheNCCNationalComprehensiveCancerNetworkAllrightsreservedTheNCCNGuidelinesandtheillustrationshereinmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.©2022.Version1.2022,06/02/22©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.UPDATESVersion1.2022,06/02/22©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon6/4/20227:37:51AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.sSystemCancersdexersionoftheNCCNGuidelinesforCentralNervousSystemCancersfromVersioninclude•ChemotherapychangedtoSystemictherapythroughoutGLIO-1•Pagetitlechanged:AdultGlioma:Low-GradeWHOGrade1or2•Pathologycolumnmodified:pWHOGrade1isanewheaderforthebulletsPilocyticastrocytoma(PA)◊Pleomorphicxanthoastrocytoma(PXA)◊Subependymalgiantcellastrocytoma(SEGA)◊GangliogliomapLinksforgrade2astrocytoma/oligodendrogliomaandanaplasticWHOgrade3astrocytomaremovedandreplacedwithlinkstooligodendrogliomagrade2isocitratedehydrogenase(IDH)mutant,1p19qcodeleted(GLIO-2)andIDH-mutantastrocytoma,grade2(GLIO-3)•"f",deleted:Ifradiographicallythetumorappearstobeahigh-gradeglioma,seeGLIO-1•"h":SeePrinciplesofCancerRiskAssessmentandCounseling(BRAIN-G)correspondingto,ConsidertreatmentwithanmTORinhibitor(eg,everolimus)GLIO-2•AdultLow-Grade(WHOGrade1or2)Glioma(formerlyLGG-2)andAnaplasticGliomas(formerlyGLIO-2):thesepageshavebeenreorganizedintotwonewpageswithextensiverevisions:AdultGlioma:Oligodendroglioma(IDHmutant,1p19qcodeleted)andAdultGlioma:IDH-mutantAstrocytoma(GLIO-3).•Poorperformancestatus(KPS<60):+/-concurrentoradjuvantTMZaddedtoadjuvantRT(AlsoforGLIO-3)•Follow-uppBrainMRIevery3–6mofor5ythenatleastevery6–12moorasclinicallyindicatedforWHOgrade2(goodperformancestatus,KPS≥60)GLIO-3•"s":WHO6Aepoves}Aoo八}omeseAoenowoIessiJoe}ionin}uoZ0ZpWHOOIessiJoe}iono}TumoAs.TuososuouIpqo}Aoe}op}uosemoesWHO6Aepoc•"t":TAoe}mon}o}6Aepovpisoesoisox}AedoIe}op}AomOATNON.」ineIAosuI}so}OATNONeAono}八o}eveiIeqIo.GLIO-4Columnmodifiedtoinclude:GLIO-5•Pathologycolumnmodified:pAnaplasticOligodendrogliomaAepocIaHmuenenppdp6b-oopoIo}oppAnaplasticAstrocytoma,IDH-mutant,grade3orgrade4•"z":ThispathwayincludestheoIessiJoe}iono}6Aepoces}Aoo八}ome‘IaH-mu}en}‘6AepocoIi6oponpAo6Iiome‘IaH-mu}en}enppdp6b-oopoIo}op‘enpo}uoAAeAo6Aepoc6Iiomes.anaplasticastrocytoma(AA),anaplasticoligodendroglioma(AO),andotherrareanaplasticgliomas.PrintedbyMinTangon6/4/20227:37:51AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.sSystemCancersdexersionoftheNCCNGuidelinesforCentralNervousSystemCancersfromVersioninclude•Pagetitlechanged:AdultGlioma:Glioblastoma(AlsoforGLIO-7)GLIO-8•Modified:Recurrentdiseasefor:pAnaplasticOligodendroglioma,grade3,IDH-mutantand1p19q-codeleted,KPS≥60pAnaplasticAstrocytoma,IDH-mutant,WHOgrade3orgrade4,KPS≥60pAnaplasticgliomasAMED2ColumnmodifiedLargecell/anaplasticmedulloblastoma•"q",deleted:Recommendaplatinum-basedchemotherapyregimensuchaseitherofthetreatmentarmsusedintheChildren’sOncologyGroupstudyreferencedinfootnote"k."AMED3TreatmentforRecurrence•Additionalradiationsuchasstereotacticradiosurgery(SRS),afterresectionFootnotes•"f":SeePrinciplesofCancerRiskAssessmentandCounseling(BRAIN-G),correspondingtoconsiderscreeningforvonHippel-Lindausyndrome.MENI-1AdjuvantTreatment•Bullet3,modified:Grade2withincompleteresection:RTorobservationinselectcases(eg,lowPS)Treatment•HA-WBRT+memantine(ifeligible)andWBRTwithoutHA+/-memantinewereaddedastreatmentoptionsforpatientswithlimitedandextensivenewlydiagnosedandrecurrentorrelapsedbrainmetastases(alsoforLTD-3,LTD-4,MU-1,andMU-2).•"k",modified:Forbrainmetastasesnotmanagedwithresection,SRS+WBRTisgenerallynotrecommended,astheadditionofWBRTtoSRSdoesnotimprovesurvivalandcanbeassociatedwithgreatercognitivedeclineandpoorerqualityoflife(BrownPD,etal.JAMA2016;316:401-409).However,thecombinationofSRSandWBRTmaybeappropriateincarefullyselectedclinicalcircumstances(eg,WBRTisalreadybeingofferedforextensivebrainmetastasesandanSRSboostisconsideredforalargelesionorradioresistanthistologyforthegoalofimprovinglocalcontrol)(AndrewsDW,etal.Lancet2004;363.9422:1665-1672).butmaybeappropriateinsomerareclinicalcircumstances.Brown2016showedthatfortumors<3cm,SRS+WBRTimprovedlocalcontrolcomparedwithSRSalone,butdidnotsignificantlyimprovesurvival,andwasassociatedwithgreatercognitivedeclineandpoorerqualityoflife.(BrownPD,etal.JAMA2016;316:401-409.)•"l",modified:Hippocampalavoidance(HA)preferred.SeeBRAIN-C.InpatientswithoutBrainmetastasesnotwithin5mmofthehippocampi;KPS≥70;lifeexpectancyofatleast4months.Inpatientswithoutbrainmetastaseswithin5mmofthehippocampi,HA-WBRT+memantinewassuperiortoWBRT+memantineintermsofcognitivepreservationandpatient-reportedqualityoflife(BrownPD,etal.JClinOncol2020:38:1019-1029andBrownPD,etal.NeuroOncol2013:15:1429-1437).(AlsoforLTD-3,LTD-4,MU-1,MU-2).fmodified2ndsentencetoinclude:SeeLEPT-3forresponseassessment.UPDATESVersion1.2022,06/02/22©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon6/4/20227:37:51AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.sSystemCancersdexersionoftheNCCNGuidelinesforCentralNervousSystemCancersfromVersionincludePrinciplesofBrainTumorSurgery•Options,1stsub-bullet,modified:LITTmaybeconsideredforpatientswhoarenotpoorsurgicalcandidates(craniotomyorresection).Potentialindicationsincluderelapsedbrainmetastases,radiationnecrosisandrecurrentglioblastoma.pCorrespondingreferences:◊Mohammad,AM,SharmaM,BeaumontTL,etal.UpfrontMagneticResonanceImaging-GuidedStereotacticLaser-AblationinNewlyDiagnosedGlioblastoma:AMulticenterReviewofSurvivalOutcomesComparedtoaMatchedCohortofBiopsy-OnlyPatients.Neurosurgery2019;85:762-772.◊KamathAA,FriedmanDD,AkbariSHA,etal.Glioblastomatreatedwithmagneticresonanceimaging-guidedlaserinterstitialthermaltherapy:safety,efficacy,andoutcomes.Neurosurgery2019;84:836-843.BRAIN-C1of9PrinciplesofRadiationTherapyforBrainandSpinalCord•Subtitle,modified:AdultLow-GradeGlioma:WHOGrade1,WHOGrade2Oligodendroglioma(IDH-mutant,1p19qcodeleted),WHOGrade2IDH-mutantAstrocytoma•1stbullet,2ndsentence,modified:...forIDHwild-typeorCDKN2A/B-deleted,IDH-mutated,low-gradegliomas•2ndbullet,1stsentence,modified:NewMRIforradiationtreatmentplanningisrecommendedastherecanbechangesinmasseffect,tumorbedandcytotoxicedema.p2ndsentence,modified:Distinguishingnon-enhancingtumorfromvasogenicedemaonT2FLAIRcanbechallenging...•2ndsub-titlemodified:AnaplasticGliomas/GlioblastomaHigh-GradeGlioma:Glioblastoma,WHOGrade3Oligodendroglioma(IDH-mutant,1p19qcodeleted),WHOGrade3and4IDH-mutantAstrocytomaandAstrocytomaIDH-WildType(WHOGrade2)BRAIN-C2of9AsectiononReirradiationforGliomashasbeenadded.BRAIN-C4of9PrimaryCNSLymphoma•Bullet1,modified:WBRTmaybe"istypically"withheldintheprimarysettinginpatientstreatedwithsystemictherapy.PrimarySpinalCordTumors•5thsub-sub-bullet:InsomeinstancesfocalSRS/SBRTtospinaltumorslikehemangioblastomamaybeappropriate,withcaretorespectnormaltissueconstraintsofspinalcordandsurroundingstructures.pDalyME,ChoiCYH,GibbsIC,etal.Toleranceofthespinalcordtostereotacticradiosurgery:insightsfromhemangioblastomasIntJRadiatOncolBiolPhys2011;80:213-220.•6thsub-sub-bullet:Protontherapymayalsobehelpfulinthesettingofprimaryspinalcordtumorstobettersparesurroundingnormaltissues,uninvolvedcord,andnerveroots.PrintedbyMinTangon6/4/20227:37:51AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.sSystemCancersdexersionoftheNCCNGuidelinesforCentralNervousSystemCancersfromVersionincludeINCofMeningiomas•Bullet3,sub-sub-bullet1,modified:1-2cm0.5-2cm•Sub-sub-bullet3,new:CTVsshouldbeeditedandconstrainedanatomicallytoencompasspathofextensionintomeningealandduralsurfaces•Bullet3,sub-sub-bullet2:SelectWHOgrade2cases:recurrencepostpriorradiationandsmallersizeamendabletoSRS)mayalsobetreatedwithSRSdosesof16-20Gyinasinglefractionwhenappropriate,orconsiderhypofractionatedSRT(27.5–30Gyin5fractions)ifnearcriticalstructures.Optimaldosinghasnotbeendetermined.pCorrespondingreferences:◊KowalchukRO,ShepardMJ,SheehanK,SheehanD,FaramandA,NiranjanA,KanoH,GurewitzJ,BernsteinK,LiscakR,GuseynovaK,GrillsIS,ParzenJS,CifarelliCP,RehmanAA,AtikA,BakhsheshianJ,ZadaG,ChangE,GiannottaS,SpeckterH,WuHM,KondziolkaD,MathieuD,LeeCC,WarnickRE,LunsfordLD,TrifilettiDM,SheehanJP.TreatmentofWHOGrade2MeningiomasWithStereotacticRadiosurgery:IdentificationofanOptimalGroupforSRSUsingRPA.IntJRadiatOncolBiolPhys2021;110(3):804-814.◊MominAA,ShaoJ,SoniP,AlmeidaJP,SuhJH,MurphyES,ChaoST,AngelovL,MohammadiAM,BarnettGH,RecinosPF,KshettryVR.OutcomesofsalvageradiationforrecurrentworldhealthorganizationgradeIImeningiomas:aretrospectivecohortstudy.JNeurooncol.2021;152(2):373-382.BRAIN-C6of9esINDofBulletndsentenceWBRTcanbedonewithINDofPrinciplesofBrainandSpinalCordTumorSystemicTherapyAdultGlioma:WHOGrade1,RecurrentorProgressiveDisease•Deleted:Platinum-basedregimens,from"Otherrecommendedregimens"(AlsoforBRAIN-D2)pAddedthefollowing:◊Cisplatin/etoposide◊Carboplatin◊Carboplatin+vincristine(category2B)◊Thioguanine+PCV(category2B)•"a":Therearemultiplereasonableoptions,butthereisnouniformlyrecommendedoptionatthistimeforrecurrentdisease.standardofcareatthistimeforrecurrentdisease.(AlsoforBRAIN-D2andBRAIN-D3)•"d":IfnopriorRT;orifpriorRT,considerwithhighlyfocusedRTinselectcases,ifnewlesionoutsidetargetofpriorRTortherecurrenceissmallandgeometricallyfavorable,correspondingtoRT+systemictherapyforrecurrentorprogressivelow-gradedisease(AlsoforBRAIN-D2and3)•"e"deleted:Platinum-basedregimensincludecisplatinorcarboplatin.(AlsoforBRAIN-D2of16)BRAIN-D2of16SystemictherapyforAnaplasticGliomashasbeensplitintotwopages:pAdultGlioma:Oligodendroglioma(IDH-Mutant,1p19qcodeleted)andAdultGlioma:IDH-MutantAstrocytoma(BRAIN-D3).RecommendationsarenoworganizedbyWHOgrade.•Adjuvanttreatment,KPS˂60anaplasticgliomaspRT+concurrentoradjuvantTMZ,Category2A,Otherrecommendedregimen(AlsoforBRAIN-D3)•RecurrentDiseaseWHOgrade3,KPS≥60(AlsoforBRAIN-D,3)pUsefulincertaincircumstances:platinum-basedregimensdeleted,withthefollowingregimensadded:◊Carboplatin(category3)◊Cisplatin(category3)UPDATESVersion1.2022,06/02/22©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.UPDATESVersion1.2022,06/02/22©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon6/4/20227:37:51AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.sSystemCancersdexUpdatesinVersion1.2022oftheNCCNGuidelinesforCentralNervousSystemCancersfromVersion2.2021include:BRAIN-D2of16(continued)Footnotes(AlsoforBRAIN-D,3and4)•"j":HypofractionatedRTpreferred,isanewfootnotecorrespondingto,RT+concurrentoradjuvantTMZBRAIN-D4of16AdultGlioma:Glioblastoma•Adjuvanttreatment,KPS≥60pUsefulincertaincircumstances,revisionsmadeforconsistencywithalgorithm◊RTwithconcurrentandoradjuvantTMZ(forpatientsage70oryoungerandKPS<60)◊TMZ(forpatientswithMGMTpromoter-methylatedtumorsandKPS<60orage>70yearsandKPS≥60)◊RT+withconcurrentandadjuvantlomustineandTMZ(forpatientswithMGMTpromoter-methylatedtumorsKPS≥60,andage≤70years)(category2B)BRAIN-D5of16AdultMedulloblastoma•High-dosecyclophosphamide±etoposide,referenceadded:pGururanganS,KrauserJ,WatralMA,etal.Efficacyofhigh-dosechemotherapyorstandardsalvagetherapyinpatientswithrecurrentmedulloblastoma.NeuroOncol2008;10:745-751.BRAIN-D6of16PrimaryCNSLymphomaInductionTherapy•Otherrecommendedregimensp"High-dose"methotrexate/cytarabine/thiotepa/rituximabpRegimenremoved:Methotrexate/carmustine/teniposide/prednisone±rituximabConsolidationTherapy•PreferredregimenspCarmustine+thioteparevisedasCytarabine+thiotepafollowedbycarmustine+thiotepa(category2A)RelapsedorRefractoryDisease•Usefulincertaincircumstances,considerhigh-dosesystemictherapywithautologousstemcellreinfusionineligiblepatients,regimensadded:pHigh-doseMTXfollowedbycytarabine+thiotepafollowedbycarmustine+thiotepa(category2A)pHigh-dosecytarabine+etoposide,followedbythiotepa+busulfan+cyclophosphamide(category2A)pHigh-dosecytarabine+rituximab+thiotepafollowedbythiotepa+rituximab+carmustine(category2A)BRAIN-D8of16•Tableheadingrevised:MiscellaneousCNSTumorsHemangioblastomaPrintedbyMinTangon6/4/20227:37:51AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.sSystemCancersdexersionoftheNCCNGuidelinesforCentralNervousSystemCancersfromVersionincludeesreastCancerpHER2positive◊Newregimen:Fam-trastuzumabderuxtecan-nxki(category2A)–Correspondingreferences:▪JerusalemG,ParkYH,YamashitaT,etal.Trastuzumabderuxtecan(T-DXd)inpatientswithHER2+metastaticbreastcancerwithbrainmetastases:asubgroupanalysisoftheDESTINY-Breast01trial.ASCO2021▪CortésJ,KimS-B,ChungW-P,etal.Trastuzumabderuxtecan(T-DXd)vstrastuzumabemtansine(T-DM1)inpatientswithHER2+metastaticbreastcancer:resultsoftherandomized,phase3studyDESTINY-Breast03.ESMO2021.◊Newregimen:Pertuzumabandhigh-dosetrastuzumab(category2A)–Correspondingreferences:▪LinN,PegramM,SahebjamS,etal.PertuzumabPlusHigh-DoseTrastuzumabinPatientsWithProgressiveBrainMetastasesandHER2-PositiveMetastaticBreastCancer:PrimaryAnalysisofaPhaseIIStudy.JClinOncol2021Aug20;39(24):2667-2675.•Non-SmallCellLungCancerpRETfusionpositive◊Selpercatinib(category2A)–Correspondingreference:▪SubbiahV,GainorJF,OxnardGR,etal.Intracranialefficacyofselpercatinibinretfusion-positivenon-smallcelllungcancersonthelibretto-001trial.ClinCancerRes2021;27:4160-4167.•"aa":Ifanactiveagentexists(eg,cytotoxic,targeted,immunemodulating),trialofsystemictherapywithgoodCNSpenetrationmaybeconsideredinselectpatients(eg,forpatientswithsmallasymptomaticbrainmetastasesitisreasonabletoholdontreatingwithradiationtoseeifsystemictherapycancontrolthebrainmetastases.ConsultationwitharadiationoncologistandcloseMRIsurveillanceisstronglyrecommended.Therearenodatafromprospectiveclinicaltrialscomparingthetwostrategiestoassesswhattheimpactofdelayedradiationwouldbeintermsofsurvivalorindelayofneurologicdeficitdevelopment.BRAIN-E2of5PrinciplesofBrainandSpineTumorManagement•MassEffect,BrainEdema,RadiationNecrosis,bulletadded:pLITTisaminimallyinvasivetechniqueusingphotothermaltechnologyandcanbeconsideredonacase-by-casebasisfortreatmentofradiationnecrosisinpatientswithahistoryofradiationtherapyforprimarybraintumorormetastaticdisease.ConsultationwithadeptneurosurgeonstrainedinLITTshouldbedonewhentheprocedureisconsidered.◊Correspondingreferences–AhluwaliaM,BarnettGH,DengD,TatterSB,LaxtonAW,MohammadiAM,LeuthardtE,ChamounR,JudyK,AsherA,EssigM,DietrichJ,ChiangVL.Laserablationafterstereotacticradiosurgery:amulticenterprospectivestudyinpatientswithmetastaticbraintumorsandradiationnecrosis.JNeurosurg.2018May4;130(3):804-811.–KimAH,TatterS,RaoG,PrabhuS,ChenC,FecciP,ChiangV,SmithK,WilliamsBJ,MohammadiAM,JudyK,SloanA,Tovar-SpinozaZ,BaumgartnerJ,HadjipanayisC,LeuthardtEC.LaserAblationofAbnormalNeurologicalTissueUsingRoboticNeuroBlateSystem(LAANTERN):12-MonthOutcomesandQualityofLifeAfterBrainTumorAblation.Neurosurgery.2020Sep1;87(3):E338-E346.Version1.2022,06/02/22©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.UPDATESUPDATESVersion1.2022,06/02/22©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon6/4/20227:37:51AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.sSystemCancersdexersionoftheNCCNGuidelinesforCentralNervousSystemCancersfromVersionincludeBRAIN-E3of5PrinciplesofBrainandSpineTumorManagement•PsychiatricDisorderspPhysicians,Alloncologyprovidersandotherteammembersoftheirhealthcareteams,shouldbesensitivetothesesymptomsandinquireabouttheminfollow-upvisitsinordertodetermineifthepatientmaybeacandidateforpsychologicalorpsychiatrictreatment.•ThissectionextensivelyupdatedbasedontheWHOClassificationofCNSTumors(5thedition).BRAIN-G•Newpage:PrinciplesofCancerRiskAssessmentandCounseling.RinhibitoregmusgPrintedbyMinTangon6/4/20227:37:51AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.RinhibitoregmusgAdultGlioma:WHOGrade1dexHYPERLINK\l"_bookmark