P21.04 Clinical pathway in glioma management; from NOSC (Neuro-Oncology Scientific Club) meetings to bedside practice

Abstract

Characterizing a working-team concept in the practice of neuro-oncology requires continued interdisciplinary efforts. The Neuro-Oncology Scientific Club (NOSC) initiative is an interdisciplinary clinical forum which has been operational in Iran since 2011 attempting towards a connect-approach in the management of CNS malignancies. NOSC comprises nation-wide group of experts and pursues its mission through interval strategic meetings, tumor-boards, case-discussions as well as publishing neuro-oncology updates and newsletters. The most recent NOSC clinical forum in Mashhad (February 2016), put together insights from international practice guidelines, emerging evidence and expert opinions to draw a locally-adapted clinical pathway for glioma management in adults. As such, the expert panel concurred that following the clinical suspicion, conventional/functional neuroimaging are taken after which stereotactic biopsy would be taken to ensure pathological diagnosis. The specimen is then assessed for molecular markers. Patients will initially undergo baseline neuropsychological assessments and further brain-mapping measures for surgical planning. Stereotactic radiosurgery or safe maximal resection will be done for which the latter includes intraoperative recording through electrocorticography or somatosensory evoked-potentials where applicable. Post-operatively, the newly-diagnosed high-grade glioma (HGG) patients would undergo Stupp's protocol of chemo-radiation and adjuvant chemotherapy with temozolomide (TMZ). Seizure control and optimized steroid use are to be considered. In recurrent HGG patients, those with the recursive partitioning analysis class V (RPA-V) would receive best supportive care, whereas patients with RPA class III/IV would either receive targeted/re-challenge therapy (anti-VEGF, TMZ re-challenge/metronomic dosing, radiosurgery, re-irradiation or TMZ+anti-VEGF) or enter the investigational setups including immunotherapy (PD-1 or IL4 receptor antagonists). In low-grade glioma (LGG) patients, watchful waiting may be recommended only in asymptomatic patients or those with minimal symptoms, while other patients require a planned treatment. Predictive and prognostic variables including 1p19q co-deletion, IDH-1 mutation and MGMT-methylation in anaplastic oligoastrocytoma or anaplastic oligodendroglioma patients would possibly help defining their preferred treatment plan including chemotherapy. On the other hand, as per the CATNON trial, TMZ can be considered for non-co-deleted anaplastic glioma patients.