| Setting | Treatment |
|---|---|
| Symptomatic oedema / seizure any diagnosis | Dexamethasone for rapid relief
⚠ hold pre-biopsy if PCNSL is possible Seizure → antiepileptic
no routine seizure prophylaxis without a seizure history |
| BRAIN METASTASES | SRS (1–4 lesions) / WBRT (many) / surgery (solitary, accessible, symptomatic) + treat the primary
stereotactic radiosurgery · whole-brain RT ⚠ Poor performance status → best supportive care instead (QUARTZ)
WBRT adds little over steroids + supportive care in poor-PS patients CNS-penetrant systemic options by driver
vital when unfit for RT / surgery — EGFR-mutant lung → osimertinib · ALK → alectinib / lorlatinib · HER2+ breast → tucatinib combination or T-DXd · BRAF melanoma → dabrafenib + trametinib ± IO ⚠ HR+ breast
tamoxifen and AIs do cross the BBB usefully; abemaciclib has the best CNS penetration (phase II activity in HR+ brain mets) but is not a substitute for local therapy in bulky / symptomatic disease |
| GLIOBLASTOMA — fit IDH-wildtype | Stupp protocol — maximal safe resection → RT (~60 Gy) + concurrent temozolomide → 6 cycles adjuvant temozolomide
± tumour-treating fields MGMT-methylation predicts temozolomide benefit Bevacizumab at recurrence
symptom / oedema control only |
| GLIOBLASTOMA — elderly / frail | Short-course (hypofractionated) RT ± temozolomide MGMT-methylated → temozolomide alone is reasonable Poor PS → best supportive care |
| PILOCYTIC ASTROCYTOMA WHO grade 1 · children / young adults · cerebellum, optic pathway, brainstem | CIRCUMSCRIBED, not a diffuse glioma — gross-total resection is usually CURATIVE
the best-prognosis brain tumour in the section; do not counsel it like a glioma Residual / unresectable / progressing → BRAF-directed therapy, and the LESION TYPE picks the drug
KIAA1549-BRAF FUSION (the commonest) → MEK inhibitor alone (selumetinib / trametinib) — ⚠ a BRAF inhibitor can PARADOXICALLY ACTIVATE a fusion · BRAF V600E → dabrafenib + trametinib Alternatives where targeted therapy is unavailable: carboplatin-based chemo (esp. optic-pathway, young) · radiotherapy AVOIDED in the young if possible
decades of survivorship ahead — late RT effects matter more here than anywhere Dabrafenib + trametinib watch → PYREXIA (hold BOTH for fever) · LFTs · LVEF (echo) · eyes · skin |
| ASTROCYTOMA — IDH-mutant grades 2–4 · younger adults, seizures common | Maximal safe resection FIRST — every grade
extent of resection is prognostic; then the grade + risk decide what follows Grade 2, LOW-risk (<40 + gross-total resection) → observe, MRI surveillance
the one glioma you may watch after surgery Grade 2, HIGH-risk (≥40, or residual disease) → RT + adjuvant chemo (PCV or temozolomide) (RTOG 9802)
adding PCV to RT roughly doubled overall survival in high-risk low-grade glioma Grade 2, residual/recurrent, wanting to defer chemo/RT → VORASIDENIB (INDIGO)
an IDH1/2 inhibitor — PFS HR 0.39; the first targeted therapy here; delays chemo/RT · ⚠ hepatotoxicity — monitor LFTs Grade 3 → RT + adjuvant temozolomide (CATNON)
adjuvant TMZ after RT improves survival in non-co-deleted grade 3 Grade 4 IDH-mutant (or CDKN2A/B homozygous deletion → auto-grade 4) → treat along the GBM pathway
RT + temozolomide — the mutation still carries a better prognosis than true GBM |
| OLIGODENDROGLIOMA IDH-mutant + 1p/19q co-deleted | Resection → high-risk → RT + PCV
the best-prognosis diffuse glioma and the most chemo-sensitive — long-term survival with RT + PCV; the 1p/19q co-deletion is both the diagnosis and the chemo-sensitivity marker |
| MENINGIOMA | Observe if small / asymptomatic Surgery ± RT if symptomatic / growing |
| PRIMARY CNS LYMPHOMA (PCNSL) | High-dose methotrexate-based chemo ± rituximab — NOT primarily surgery Recognising it
periventricular; homogeneous enhancement, DWI-restricted, low perfusion; immunosuppressed / elderly Check HIV, slit-lamp eye exam, CSF |
| Frail / elderly / poor PS (ECOG 3–4) | Best supportive / palliative care
dexamethasone + comfort — fitness, not just the tumour, drives the plan |
| RADIOTHERAPY — dose & technique modality detail across the settings above | SRS — single-fraction, size-dependent dose, 1–4 metastases WBRT — fractionated for multiple lesions
hippocampal-avoidance reduces neurocognitive decline GBM (Stupp) — ~60 Gy/30 fx concurrent with temozolomide |