Central Nervous System Cancers, Version 1.2015

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Central Nervous System (CNS) Cancers provide interdisciplinary recommendations for managing adult CNS cancers. Primary and metastatic brain tumors are a heterogeneous group of neoplasms with varied outcomes and management strategies. These NCCN Guidelines Insights summarize the NCCN CNS Cancers Panel's discussion and highlight notable changes in the 2015 update. This article outlines the data and provides insight into panel decisions regarding adjuvant radiation and chemotherapy treatment options for high-risk newly diagnosed low-grade gliomas and glioblastomas. Additionally, it describes the panel's assessment of new data and the ongoing debate regarding the use of alternating electric field therapy for high-grade gliomas.

Symptom management of brain tumor patients

OBJECTIVES

To review the symptoms frequently observed with brain tumors, focusing on the descriptions, causes, treatments, and nursing implications.

DATA SOURCES

Research and review articles and textbooks.

CONCLUSION

Patients with brain tumors commonly have symptoms caused by the tumor or treatment. Treatment approaches for these symptoms will help the patient cope with those impairments caused by the symptoms.

IMPLICATIONS FOR NURSING PRACTICE

The nurse can help move the patient toward a good quality of life by being aware of the symptoms and setting a plan to manage the symptoms with a patient and caregiver. Periodic reassessment is required to maintain continuity of care.

Relationship between fatigue and quality of life in patients with glioblastoma multiformae

PURPOSE/OBJECTIVES

To evaluate changes in fatigue at the time of diagnosis (Time 1) and two weeks after the completion of radiation therapy (Time 2) and to determine the relationship between fatigue and quality of life (QOL) at each time interval in patients with glioblastoma multiformae (GBM).

DESIGN

Descriptive study to evaluate fatigue and QOL.

SETTING

Neuro-oncology clinic for accrual. Clinic, home, or office for patients interviews.

SAMPLE

60 adult patients diagnosed with GBM who received radiation therapy.

METHODS

Participants completed a demographic data sheet, the Profile of Mood States, and the Multidimensional Quality of Life Scale-Cancer Version 2 at both time points.

MAIN RESEARCH VARIABLES

Fatigue and QOL.

FINDINGS

Fatigue significantly increased from Time 1 to Time 2 (t = -2.69, p = 0.009). Increases in fatigue were associated with significant decreases in QOL at Time 1 (r = -0.57) and Time 2 (r = -0.60).

CONCLUSIONS

Patients with GBM experience increases in fatigue after radiation therapy. Increases in fatigue are associated with decreases in almost all aspects of patients' QOL.

IMPLICATIONS FOR NURSING PRACTICE

Nurses must provide patients with information about the occurrence of fatigue during radiation therapy and recommend interventions to deal with this devastating symptom.

Quality of life of brain tumor patients

OBJECTIVES

To provide a review of the quality of life (QOL) and to delineate nursing implications to increase QOL in brain tumor patients.

DATA SOURCES

Review articles and research studies pertaining to quality of life and brain tumor patients.

CONCLUSIONS

In general, patients maintain a high physical functional level for a majority of time during their illness. The main problems include memory loss, fatigue, and loss of concentration. QOL is decreased with several debilitating symptoms relating to the tumor or recurrent disease, and increased when being actively treated or in remission.

IMPLICATIONS FOR NURSING PRACTICE

Nurses must be able to listen carefully to patients with brain tumors and take action when symptoms arise. By assisting the patients to decrease the symptoms and to access support services, QOL is increased.

Is computed tomographic scanning necessary in patients with tentorial herniation? Results of immediate surgical exploration without computed tomography in 100 patients

Computed tomographic (CT) scans are performed on virtually all patients with severe head injury at the time of admission. Because of the time involved in obtaining these studies, the evacuation of significant intracranial mass lesions is delayed. To avoid such delays, the authors performed burr-hole exploration for the diagnosis of intracranial hematomas before CT scans were obtained in 100 consecutive head-injured patients with clinical signs of tentorial herniation or upper brain stem dysfunction upon admission to the emergency room. Patients in whom a hematoma was discovered had a craniotomy for evacuation of the clot; those in whom the exploration was negative had a CT brain scan immediately after operation. Burr-hole exploration revealed extracerebral mass lesions in 56 patients. In 38 patients, the exploration was negative, and postoperative CT scanning showed no significant hematoma. Of 6 patients in whom the CT scan demonstrated extraaxial hematomas requiring surgical evacuation, 4 had subdural hematomas that were missed because the exploration was incomplete; 1 patient had an epidural hematoma and 1 had a subdural hematoma contralateral to a craniotomy on the side of a positive initial burr-hole exploration. Our results indicate that the relatively small subgroup of head-injured patients with early tentorial herniation or upper brain stem compression have a high incidence of immediate extraaxial hematomas and a low incidence of intracerebral hematomas. This is particularly true of patients over 30 years of age and those who suffer low speed trauma, such as falls and vehicle-pedestrian accidents.

Clinical pharmacology of mephenytoin and ethotoin

Effective prescribing of anticonvulsants requires foreknowledge of baseline pharmacokinetic data. Little such information is available about the hydantoins other than phenytoin, although one of them, mephenytoin, is widely used. Useful pharmacokinetic data should be derived from patients already exposed to anticonvulsants to reflect the induction of hepatic oxidative enzymes. Single-dose studies of mephenytoin (Mesantoin) and ethotoin (Peganone) were performed in adult inpatients on stable regimens of other anticonvulsants. Five patients received mephenytoin, 7 mg per kilogram of body weight. Serial blood sampling was performed rigorously. The time to peak concentration (Tmax) for mephenytoin was 1 hour, with a half-life (T 1/2) of 7 hours; the T 1/2 of its metabolite, 5-ethyl-5-phenylhydantion, was 96 hours. Ethotoin administration was 25 mg per kilogram in 5 patients. Ethotoin Tmax was 2 hours, with a T 1/2 of 5 hours. Saliva accurately represented the unbound fraction for all three agents. Mean salivary levels (as percentage of total levels) were 61% for mephenytoin, 73% for its metabolite, and 54% for ethotoin. The implications for therapy are that following mephenytoin administration, the metabolite 5-ethyl-5-phenylhydantoin will provide anticonvulsant effectiveness, with its long half-life producing stable blood levels on simple dose schedules. Ethotoin, in contrast, has a short half-life and would require divided daily doses to achieve a steady state. This, rather than pharmacological ineffectiveness, limits its usefulness.