This issue of CONTINUUM was created for all of us “non–neuro-oncologist” neurologists.
This issue of CONTINUUM was created for all of us “non–neuro-oncologist” neurologists. Like neuro-oncologists, we diagnose patients with primary and secondary brain, leptomeningeal, and other nervous system neoplasms and manage their neurologic and medical complications. Like neuro-oncologists, we diagnose and manage the complications of chemotherapy and radiation therapy for neurologic and systemic cancers. And like neuro-oncologists, we diagnose and manage paraneoplastic neurologic disorders. Unlike neuro-oncologists, however, most of us are unlikely to be directly involved in chemotherapeutic or radiotherapeutic decisions, but we need to be thoroughly informed about the most up-to-date treatment recommendations and the science and evidence on which they are based.
With these needs in mind, I was so pleased when Dr Patrick Y. Wen, director of the Center for Neuro-Oncology at Dana-Farber Cancer Institute, director of the Division of Neuro-oncology of the Department of Neurology at Brigham and Women’s Hospital, and professor of neurology at Harvard Medical School, graciously accepted my invitation to be guest editor of this volume. He has assembled a prominent group of neuro-oncology experts to review the current state of the art in the diagnosis and management of patients with primary and secondary malignancies of the nervous system as well as the neurologic disorders that can occur in association with, or as a result of the treatment of, systemic cancers.
The issue begins with Dr Nicholas A. Butowski’s overview of the epidemiology and diagnosis of brain tumors, which serves as a very practical and informative underpinning for the articles on primary brain tumors that follow. Dr Amy A. Pruitt then thoroughly covers the current recommendations regarding management of the many medical and neurologic complications that can arise in patients with brain tumors and for which neurologists are frequently consulted to diagnose and treat. Next, Dr John F. de Groot provides a state-of-the-art review of the diagnosis and management of high-grade gliomas, including a very accessible discussion of how molecular genetic markers have impacted the current treatment algorithms. Similarly, Dr David Schiff discusses the current management recommendations for low-grade gliomas, including a clear explanation of how genetic markers are beginning to inform contemporary risk stratification. Drs Lakshmi Nayak, Elena Pentsova, and Tracy T. Batchelor then provide a comprehensive update on the diagnosis and treatment of primary CNS lymphoma and also review the neurologic complications that can occur in patients with systemic lymphomas and leukemias. Drs Elizabeth M. Wells and Roger J. Packer next provide an encyclopedic and clear discussion of the diagnosis and management of the varieties of primary brain tumors that occur in pediatric patients, where the evolving nomenclature and management algorithms, the efforts to reduce neurologic sequelae of treatment, and the promise for near-future improvements in molecular-based classification and risk stratification should be recognized by adult as well as child neurologists. Next, Drs Mariza Daras and Thomas J. Kaley review the diagnosis and management of the typically histologically benign brain tumors—the sporadic meningiomas and schwannomas—as well as the many kinds of tumors that can arise in the context of the neurocutaneous syndromes.
Dr Eudocia Q. Lee next provides an in-depth overview of the diagnosis and management of nervous system metastases that can occur in the setting of systemic cancer, highlighting that early recognition and management can minimize neurologic decline and help improve quality of life. In their comprehensive review of the diagnosis and management of the neurologic complications that can be seen as a consequence of chemotherapy and radiation therapy, Drs Craig P. Nolan and Lisa M. DeAngelis highlight the important diagnostic role played by neurologists in providing appropriate and early attribution of neurologic toxicity from such treatment while also being careful to avoid false attribution to a complication of therapy when an alternative cause of symptoms exists. Dr Eric Lancaster provides the final review article of this issue, with a very thorough and up-to-date discussion of the many neurologic paraneoplastic disorders, including their clinical presentation, pathologic basis, and diagnosis using autoantibody and other testing, as well as current recommendations for their management.
In this issue’s Ethical Perspectives piece, Dr Kaarkuzhali B. Krishnamurthy discusses the ethical considerations that arise when religious beliefs prohibit a surgical patient’s acceptance of blood transfusion, an issue that can occur in the diagnosis and care of patients with brain tumors as well as many other situations in which our patients’ care is likely to involve surgical management. In this issue’s Practice piece, Dr Michael D. Perloff provides a very practical and concise review of the considerations involved in opioid use for patients with brain neoplasms. Finally, Dr Bruce H. Cohen provides five brief clinical scenarios to help clearly illustrate the considerations involved in coding for patients with neuro-oncologic disorders.
As with every CONTINUUM issue, a number of opportunities exist for CME. As I noted in the preface to the most recent (February 2015) CONTINUUM issue, the American Board of Psychiatry and Neurology (ABPN) no longer requires the completion of a pretest in order be eligible for Self-Assessment (SA) (part 2) credit for Maintenance of Certification, so the CONTINUUM Self-Assessment Pretest has been eliminated. By taking the Postreading Self-Assessment and CME Test, expertly crafted by Drs Eduardo E. Benarroch and Adam G. Kelly, after reading the issue, you may earn up to 12 AMA PRA Category 1 CreditsTM toward self-assessment and CME. The Patient Management Problem, carefully and expertly written by Drs Jordi Bruna and Patrick Y. Wen, follows the case of a 62-year-old man beginning with his presentation to the emergency department with symptoms and signs of a brain neoplasm and progressing through the course of his disorder. By following this case and answering multiple-choice questions corresponding to diagnostic and management decision points along his illness, you will have the opportunity to earn up to 2 AMA PRA Category 1 CME Credits.
I would like to give my sincere thank-you to Dr. Wen for his tireless dedication to this volume since its inception. I would also like to give additional gratitude to his entire group of distinguished neuro-oncology experts, whose contributions to this issue have succeeded in providing such up-to-date and clinically relevant information of benefit to all of us as we encounter patients with neuro-oncologic disorders in our daily practices.
—Steven L. Lewis, MD, FAAN