In this issue of Continuum: Lifelong Learning in Neurology, under the very capable leadership of Guest Editor David Schiff, we revisit the important subject of neuro-oncology for the first time in 6 years. The issue focuses on diagnosis and management not only of primary brain tumors but also on the more commonly encountered neurologic complications of systemic cancer.
Patients with brain tumors face many potential medical problems in addition to the presence of the mass lesion itself. Dr Jan Drappatz kicks off this issue with a discussion of the medical care of patients with brain tumors. Later in the issue, Dr Amy Pruitt addresses another very specific medical complication of cancer, CNS infections. Many of these are the consequences of the treatment of cancer, particularly when it involves suppression of the immune system.
Metastatic capability is a characteristic property of systemic cancer, and remote spread from a primary malignancy to a part of the nervous system is the most frequent neuro-oncologic circumstance that brings a patient to the attention of a neurologist. The next several articles address various types of neurologic metastasis. First, Drs Christine Lu-Emerson and April Eichler discuss the management of patients with metastatic brain tumors, by far the most common type of neoplasm encountered in the CNS. Spinal cord compression is among the most devastating complications of systemic cancer and one that requires urgent action. Yet, prompt recognition and modern treatment can produce gratifying results that restore neurologic function and greatly impact quality of life. Dr Julie Hammack, a long-time contributor to CONTINUUM as a writer of multiple-choice questions, updates us on this subject. Completing the trilogy of articles on metastatic complications, Dr Jennifer Clarke tackles the subject of leptomeningeal metastasis. Spread of systemic carcinoma or lymphoma to the leptomeninges is less common than metastasis to the brain or spine, and its diagnosis is often elusive. Knowledge of the diagnosis and the management of leptomeningeal metastasis, albeit often palliative, is important for the practicing neurologist.
In recent years, considerable and continuing advances have occurred in the treatment of patients with cancer. A variety of techniques in radiotherapy and chemotherapy are available, many of which were discussed in the aforementioned articles on metastatic disease. However, the aggressive management of cancer often leads to the development of potentially serious and debilitating neurologic complications. Dr Lisa Rogers addresses the possible unwanted neurologic consequences of radiation. Then, Drs Eudocia Quant Lee, Isabel Arrillaga-Romany, and Patrick Wen elucidate the myriad neurologic effects of the burgeoning number of chemotherapeutic agents.
For many years, paraneoplastic disorders were regarded as an extremely rare, albeit fascinating, consequence of systemic cancer. Recently, however, the spectrum of these unusual neurologic disorders has expanded, and their occurrence, particularly of those in which the culpable antibodies are directed against extracellular epitopes, has been increasingly recognized in people without cancer. Drs Myrna Rosenfeld and Josep Dalmau bring us up to date on this intriguing subject.
Primary brain tumors, specifically malignant gliomas and primary CNS lymphoma, represent the minority of brain tumors. Their management remains extremely challenging, although modest therapeutic progress is unquestionably occurring. Increasing understanding of the biology of these tumors will undoubtedly lead to further advances in treatment. Drs Rosenfeld and Pruitt, doing double-duty, collaborated to educate us on advances in this area.
The review article on malignant gliomas segues neatly into the Ethical Perspectives article by Dr Edward Dropcho entitled, “Should the Cost of Care for Patients With Glioblastoma Influence Treatment Decisions?” While the exorbitant cost of pharmacologic treatment is by no means unique to brain tumors, Dr Dropcho’s discussion particularly highlights the painful decisions that must sometime be made in situations where such treatment will prolong life minimally. In the Practice Issues article, Dr Morris Groves Jr and Ava Plummer extend discussion of this subject as they address the question of the duration of temozolomide chemotherapy for glioblastoma.
Coding is a necessary part of life for practicing neurologists, and it is particularly critical for us to understand the details and nuances of evaluation and management coding. In this issue, Dr Bruce H. Cohen addresses this subject. While he focuses on the use of Evaluation and Management (E/M) coding in neuro-oncology, much of the information can be generalized to other neurologic conditions.
Be sure to challenge yourself with the patient management problem, involving a patient with glioma, devised by Dr Marc Chamberlain. Complete your experience by working through the multiple-choice questions, crafted for this issue of CONTINUUM by Drs Ronnie Bergen and Joseph Safdieh.
Finally, we are pleased to let you know that beginning with this issue, CONTINUUM is now available on the iPad. Download the app for free in the App Store. This issue is also available as a free download, so be sure to tell your colleagues who don’t yet subscribe to take advantage of this special one-time offer. Downloads of subsequent issues will be free only to CONTINUUM subscribers. Be sure to complete the survey at the end of the iPad issue and let us know what you think.
Without question, cancer continues to strike fear in all those affected by the illness. But, with the tutelage of Dr Schiff and the very able authors he recruited, the challenge of caring for neurologic patients should now be more comfortable for you.
—Aaron E. Miller, MD