LWBK1006-28 LWW-Govindan-Review December 9, 2011 16:52
Chapter 28•Neoplasms of the Central Nervous System 391Answer 28.16. The answer is A.
Surgical resection is the mainstay for the treatment of meningioma, and it
is classified into Simpson grades based on the extent of surgery. Grade 1
is GTR of the tumor, with removal of the dural attachments and hyperos-
totic bone. The relapse rate after this procedure is 9%. Grade 2 does not
include removal of hyperostotic bone (relapse rate 19%). Grade 3 is GTR
of the tumor alone (relapse rate 29%). Grade 4 is partial resection (relapse
rate 44%). Grade 5 refers to biopsy alone without resection. Adjuvant
radiotherapy is not recommended for patients with low-grade menin-
gioma who undergo Simpson grade 1 to 2, and sometimes grade 3, resec-
tion. The patient in this case has undergone grade 2 resection for a low-
grade meningioma and therefore does not require further radiotherapy.
For patients with resected anaplastic and malignant meningioma, adju-
vant radiotherapy is recommended. Radiosurgery can be used in patients
with unresectable disease, but there is no evidence to support the use
of chemotherapy in patients with meningioma. Tamoxifen, mifepristone,
and hydroxyurea have not been shown to be effective in this disease.Answer 28.17. The answer is A.
High-dose methotrexate is the treatment of choice for immunocompetent
patients with primary CNS lymphoma. The 5-year survival with high-
dose methotrexate treatment is approximately 20%. Whereas whole brain
radiation therapy is effective but is associated with serious neurotoxicity
and 5-year survival is only 5%. Whole brain radiation is used upfront
in patients who are not candidates for methotrexate, due to poor renal
function and poor PS. In a phase III, noninferiority trial comparing high-
dose methotrexate with or without whole brain radiation therapy showed
no significant overall survival benefit to combining whole brain radiation
with high-dose methotrexate. R-CHOP is not an appropriate choice for
frontline therapy, though it is used to treat many types of non-Hodgkin’s
lymphoma.Answer 28.18. The answer is D.
Long-term follow-up data from the phase III EORTC-NCIC trial showed
improved survival in all patients treated with combined temozolomide
and radiation, followed by adjuvant radiation compared to patients
treated with radiation alone.Answer 28.19. The answer is D.
Some degree of sexual dysfunction occurs in approximately 90% of
all adult patients presenting with craniopharyngioma. Visual dysfunc-
tion occurs in 40% to 70% of these patients. Hypothyroidism occurs
in 40% of patients, and diabetes insipidus occurs in 10% to 20% of
patients. However, the incidence of diabetes insipidus after surgical resec-
tion increases substantially; in one study, it increased from 16.1% in the
preoperative setting to 59.4% after surgery.