Palliative care in brain tumors

The diagnosis of a brain tumor is a life-changing event for patients and families. High-grade gliomas (especially glioblastomas) are incurable, and long-term survival is limited. Metastatic brain lesions comprise the majority of intracranial neoplasms and are a significant source of morbidity and mortality in patients with systemic cancer. Response to treatment, prognosis, and survival depends not only on the underlying pathology, but more importantly on recently defined molecular features. Other crucial predictors of survival include age and performance status. Among patients with primary brain tumors, neurologic decline and psychological distress contribute to a high symptom burden and impaired quality of life (QoL) throughout the disease trajectory. While many symptoms in central nervous system (CNS) and non-CNS cancers overlap, others predominate in the brain tumor population, including seizures, headaches, depression, fatigue, and treatment-induced toxicity, all of which can be addressed with palliative interventions. Patients, families, and caregivers also report disproportionately high supportive care needs, which frequently differ from those of other systemic cancers. In addition, progressive neurologic decline often results in impaired communication and decision-making capacity at the end of life. Early palliative care (PC) integration has become more common in systemic cancers, but remains limited in neuro-oncology. These factors combined contribute to a uniquely challenging disease course that may benefit from a multidisciplinary approach with early involvement of specialized (PC) to address tumor-related symptoms and improve QoL. We review how to approach patients with brain tumors and address prognosis, symptom management, and advance care planning with the goal of improving QoL for patients, families, and caregivers.

Ivosidenib for the treatment of IDH1-mutant glioma, grades 2-4: Tolerability, predictors of response, and outcomes

Background

Mutant isocitrate dehydrogenase (IDHm) inhibitors represent a novel targeted approach for treating IDHm glioma patients, yet their optimal use in clinical practice outside of clinical trials remains undefined. This study describes the real-world utilization of the mutant IDH1 inhibitor (IDHi), ivosidenib, in patients with IDHm glioma.

Methods

We retrospectively reviewed clinical and radiographic data from patients with IDHm glioma treated with ivosidenib monotherapy from 2020 to 2024 at the Dana-Farber Cancer Institute and Massachusetts General Hospital.

Results

This cohort included 74 patients with a median age of 39. There were 35 astrocytomas and 39 oligodendrogliomas, with 49, 23, and 2, grade 2, 3, and 4 tumors, respectively. Nineteen patients (26%) experienced an adverse event, although only 1 patient discontinued ivosidenib for adverse events. Median progression-free survival was 31 months and median overall survival was not reached. Seven patients (9%) had partial response, 3 (4%) had minor response, 47 (64%) had stable disease, and 17 (23%) had progressive disease. The presence of enhancing disease at ivosidenib initiation was associated with lower disease control rates (DCR) whereas DCR differences were not detected based on grade (grade 2 vs. 3), tumor histology, or age. Subsequent-line ivosidenib use had lower DCR although this may have been explained by enrichment of patients with enhancing disease.

Conclusions

In this large cohort of IDHm glioma patients, ivosidenib was well tolerated. Our results support the use of IDHi therapy in patients with grade 2 or 3 astrocytoma or oligodendroglioma and highlight limited effectiveness in patients with enhancing disease.

Targeted treatment for craniopharyngioma

INTRODUCTION

Craniopharyngioma is a rare solid-cystic tumor of the hypothalamopituitary region. Two distinct craniopharyngioma types (formerly subtypes), adamantinomatous and papillary, have been described. These tumors often manifest with neuroendocrine dysfunction, vision problems, hydrocephalus, and cognitive changes. Despite efforts to spare vital brain structures, conventional treatments such as surgery and radiation can exacerbate preceding deficits and contribute to permanent neurologic impairment. Recent studies have identified BRAF-V600E mutations in nearly all papillary craniopharyngiomas (PCP), and CTNNB1/Wnt pathway alterations in adamantinomatous craniopharyngiomas (ACP). These discoveries have advanced our understanding of craniopharyngioma pathogenesis and have opened opportunities for targeted biological treatments.

PURPOSE

The primary objective of this article is to review the current landscape of targeted treatments in papillary and adamantinomatous craniopharyngioma.

RESULTS

Treatment of PCP with BRAF/MEK inhibition has demonstrated durable tumor response in the adjuvant and neoadjuvant settings in multiple case studies and one phase II clinical trial. Although treatment advances are more limited for ACP, CTNNB1/Wnt pathway inhibitors showed promising results in pre-clinical studies and are under continued investigation.

CONCLUSION

The efficacy of BRAF/MEK inhibition in PCP supports the use of targeted therapy in patients with newly diagnosed PCP. The optimal targeted treatment combinations and their timing, duration, long-term effects, and sequencing with traditional therapeutic modalities have not been established and warrant further study. Targeted therapies represent a significant advancement in the field of oncology, and craniopharyngiomas are viable candidates for these approaches pending further research.