Background Primary brain tumors (PBTs) pose a significant health challenge, affecting patients and their caregivers. While early integration of palliative care (PC) has shown benefits in advanced cancer, its integration for PBT patients, particularly glioblastoma (GBM) patients, remains complex. We hypothesized that our previous PC integration efforts may have failed due to knowledge-gaps and misconceptions among patients, caregivers, and providers. Objective This study aimed to identify knowledge gaps and misconceptions about PC among patients with primary brain tumors (PBTs), their caregivers, and their medical providers. Method An electronic survey was distributed to PBT patients, caregivers, and medical providers, that included questions regarding PC from the Health Information National Trends Survey (HINTS). Survey responses were analyzed; comparisons were made between the 3 groups as well as the general population. Results Of 141 respondents (59 patients, 57 caregivers, and 25 providers), each group held perspectives on PC differing from the general population. While all groups had an improved understanding of PC’s role in symptom management, uncertainty persisted among patients and caregivers regarding life-prolonging treatment and certain PC goals like caregiver support or end-of-life care. Conclusion Understanding gaps in knowledge and perceptions of PC among PBT patients and caregivers is crucial for effective intervention, with caregivers playing a vital role in advocating for PC. Future research should explore factors influencing these perceptions and development of targeted education to improve early PC referrals for patients with PBTs.

At diagnosis and throughout the disease course, patients with high-grade glioma (HGG) experience a diminished quality of life (QOL) and increased fatigue. Naltrexone, an orally semisynthetic opiate antagonist, is FDA-approved for the treatment of heroin/alcohol addiction, and low-dose naltrexone (LDN) has been observed to improve QOL and lower fatigue in other neurological illnesses, such as multiple sclerosis. LDN is believed to function as a partial agonist and can lead to shifts in neurochemicals that reduce fatigue. Based on this, we sought to study whether LDN has an impact on QOL and fatigue in patients with HGG. In a placebo-controlled, double-blind study, we randomized 110 HGG patients to receive placebo (N = 56) or LDN 4.5 mg orally at night (N = 54). Subjects received LDN or placebo at day 1 of concurrent radiation and temozolomide therapy and continued for 16 weeks. Change from baseline in patient-reported outcomes of QOL (Functional Assessment of Cancer Therapy-Brain) and fatigue (Functional Assessment of Chronic Illness Therapy-Fatigue) was assessed. Demographics were WHO grade IV (85%), male (56%), KPS 90–100 (51%), grossly resected (55%), and mean age of 56 years. QOL and fatigue changes between baseline and post concurrent chemotherapy and radiation therapy were not significantly different between patients receiving LDN or placebo. The adverse event profiles for LDN and placebo were similar and attributed to concomitant use of temozolomide. LDN has no effect on QOL and fatigue in HGG patients during concurrent chemotherapy and radiation therapy. United States National Library of Medicine Clinical Trials.gov NCT01303835, Date 2/25/2011.

Isocitrate dehydrogenase 1 (IDH1) is commonly mutated in grade II-III gliomas, and the mutant enzyme leads to the production of the oncometabolite 2-hydroxyglutarate (2-HG). 2-HG is responsible for the gliomagenesis associated with these tumors and the promotion of seizures via glutamate receptors. Ivosidenib, a small molecule oral mIDH1 inhibitor, has shown promise in clinical trials to treat IDH1 mutant gliomas, and providers can utilize this agent in IDH1 mutant glioma patients. We evaluated our IDH1 mutant glioma patients treated off-label with ivosidenib and described the radiographic response and seizure control in this cohort when ivosidenib was initiated between October 2020 to February 2021. Radiographic response was determined using RANO criteria, and seizure control was determined by comparing seizures per month before and after initiation of ivosidenib. All patients represented received single-agent ivosidenib dosed at 500 mg orally once a day. One patient required a dose reduction to 250 mg orally once a day because of drug-induced diarrhea. In our cohort of six patients, patient age range was 31 to 74 years with four female patients and two male patients. Diagnoses represented were astrocytoma, IDH1 mutant (n=3) oligodendroglioma (WHO), IDH1 mutant, 1p19q co-deleted (n=2), and anaplastic astrocytoma IDH1 mutant (n=1). Three patients experienced a reduction of seizure frequency, two patients did not have seizures before or after therapy, and one patient remained with the same level of seizures (1 seizure/month). Radiographic responses recorded included three patients with stable disease, two patients with minor responses, and one patient with a partial response. Treatment with ivosidenib is ongoing for this cohort of mIDH1 glioma patients. Updated information on prolonged disease control and seizure control in this cohort of IDH1 mutant glioma patients will be presented. Therapeutics, such as ivosidenib, can lead to improved seizure control and radiographic outcomes in IDH1 mutant glioma patients.

Abstract BACKGROUND From the time of diagnosis to end of life, patients with primary brain tumors experience challenges to maintain quality of life. While traditional research focuses on clinical trials that involve directly treating cancer, we have designed a specific research committee at our institution that promotes supportive care research to improve patients’ and caregivers’ quality of life. Past research has shown that issues key to patients and caregivers often differ from what researchers and providers might appreciate as important. Incorporating input from brain tumor patients and caregivers is vital to direct the most relevant and necessary supportive care research. METHODS As part of an IRB-approved quality improvement project, we sought the opinions of our supportive care research committee about what are the essential quality of life issues for brain tumor patients and caregivers. We polled our committee before and after a session with patients and caregivers discussing factors relevant to their quality of life. After this patient/caregiver intervention, we used a group discussion and note comparison technique to distill down key elements to advance supportive care research for this population. RESULTS Engagement of the committee included members that were neuro-oncology providers, biostatisticians, and data/regulatory/clinical trial staff. Before the intervention, common themes about key issues for patients and caregivers were comfort, pain management, counteracting side effects, cognitive issues, and financial toxicity. While similar themes emerged after the patient/caregiver intervention, the committee gleaned that aspects of communicating outcomes and support of caregivers were consistently mentioned from the discussion session with patients and caregivers. CONCLUSIONS Opinions of brain tumor patients and caregivers are crucial in driving future direction and relevance of supportive care research in neuro-oncology. Our supportive care research committee will continue to engage patients and caregivers and are planning interventions to improve communication and support for caregivers.

Abstract INTRODUCTION Malignant glioma (MG) patients often experience chemotherapy-induced nausea and vomiting (CINV). Olanzapine has recently been added to national anti-emesis guidelines for patients on moderately/highly emetogenic chemotherapy. In this retrospective study, we investigated the use of olanzapine for refractory-CINV (R-CINV) in MG patients. METHODS In this chart review, we queried adult MG patients with KPS ≥ 70 who received olanzapine from January 2019-March 2020. Patients were included if they were prescribed olanzapine for CINV. Data on nausea/vomiting improvement, olanzapine dosing/schedule, number of refractory anti-emetic trials, concomitant corticosteroid use, and demographics were collected. RESULTS We identified 21 MG patients who were prescribed olanzapine, with 9 of those patients receiving olanzapine specifically for CINV. Seven patients had WHO grade IV glioma, and 2 patients had anaplastic astrocytoma (WHO grade III). Five of 9 patients (55.6%) were male, all were Caucasian and median age was 54 years. Patients tried an average of 3 anti-emetics prior to initiating olanzapine for R-CINV. Only one patient was taking concomitant corticosteroids; which is not in concordance with national anti-emesis guidelines. Four of 9 patients (44.4%) achieved control of R-CINV with olanzapine. The olanzapine dose and key biomarkers (IDH-status, MGMT promoter methylation) were similar between those experiencing R-CINV and those without symptoms. CONCLUSIONS In this study, we find that approximately half of patients with R-CINV achieved improved nausea and vomiting control with the addition of olanzapine. The lack of corticosteroid use for anti-emesis in MG continues to make this population challenging to manage. The relatively high success rate in patients that had failed, on average, 3 anti-emetics, suggests that olanzapine may be a potent addition to the anti-emetic toolkit for MG patients. These results inspire further large-scale research to validate this observation and define the optimal role for olanzapine in treating R-CINV in MG patients.

Abstract BACKGROUND Neuro-oncology advanced practitioners (APs - nurse practitioners, physician assistants) require specialization beyond the scope of population-based generalist training and education. There are no specialty standards or certifications for neuro-oncology APs, no formal training programs, and no literature that addresses the competency requirements of neuro-oncology APs. The burden of AP turnover at an academic medical center ambulatory neuro-oncology practice was as high as 50%. This quality improvement project’s purpose was to develop a professional practice model (PPM) to support the professional development and retention of APs. METHODS Using the Focus, Analyze, Develop, Execute and Evaluate (FADE) quality improvement methodology the authors (1) reviewed literature and relevant professional organizations to identify possible professional competencies for neuro-oncology APs, (2) analyzed data to develop evidenced-based practice domains, (3) used purposive sampling to recruit a team of neuro-oncology experts, (4) conducted a Delphi study with the experts to gain consensus on practice domains and professional competencies, and finally (5) utilized the Delphi study results to create a PPM for neuro-oncology APs. RESULTS The authors recruited twenty-three participants (39% were physicians, 57% were APs, and 4% were administrators) for the Delphi study, which was executed via electronic transmission using Qualtrics. Participants reached consensus on six domains of practice (Medical Knowledge, Interprofessional Collaboration/Communication, System-based Practice, Professionalism, Practice-based learning, Patient/family-centered care) and fifty corresponding competency statements after two rounds of the Delphi. With the implementation of the PPM and the development of standardized onboarding, the AP turnover rate decreased from 50% to 12% in just two years. CONCLUSION This QI project successfully created a PPM for a neuro-oncology AP team. The PPM supports neuro-oncology APs by validating their unique skill set that combines several specialties. The PPM provided the framework to standardize orientation/training, evaluate performance, and promote job satisfaction and retention.

We previously reported to SNO, high levels of psychosocial distress in adult patients with primary brain tumors (PBTs), particularly during the first 6 months following diagnosis. The purpose of this follow-up study was to identify patterns of distress among older (≥ 65 years) patients with glioblastoma (GBM) compared to their younger (ages 18-64) counterparts. In our initial cross-sectional study, we collected the National Comprehensive Cancer Network’s Distress Thermometer (NCCN-DT) and problem list from adult patients with PBTs (WHO grades I-IV) seen at our institution between December 2013 and February 2016. We performed subsequent analyses on a subset of patients with GBM. We identified 343 patients with GBM from the original dataset, of which 23.0% (n= 78) were ≥ 65 years old. The proportion of patients ≥ 65 years old with elevated distress (i.e. DT ≥ 4) was greater than the proportion of younger patients reporting elevated distress (47.4% vs 30.6%; p= 0.0068). Elevated distress was significantly greater during the first 6 months post diagnosis for all ages (p= 0.008). In subgroup analyses, a decrease in distress beyond 6 months was seen in younger patients (45.7% vs 27.4%; p= 0.021), but not in older patients. In older patients, a greater number of problems were selected on the NCCN DT and problem list tool: emotional and physical concerns were reported more frequently compared to their younger counterparts. Older patients were more likely to report difficulty with “bathing” and “getting around” (p= 0.009, p< 0.001, respectively). There were no differences in older versus younger GBM patients with regard to housing, transportation, treatment decisions, depression, fatigue, or memory. In contrast to their younger counterparts, older patients with GBM experienced elevated levels of distress and a greater absolute number of specific psychosocial problems, mostly related to emotional and physical concerns.

Abstract BACKGROUND Primary brain tumor patients experience high levels of distress due to their diagnosis and treatment leading to changes in their health-related quality of life (HRQoL). Even with the standard treatment of 6 weeks of radiation with concurrent temozolomide for malignant gliomas, the prognosis remains poor. We sought to provide a new intervention and coping skill for our patients during chemoradiation to alleviate some of their stress and anxiety. Mindfulness meditation is a mind-body therapy used in many other cancer groups which can alleviate stress and improve fatigue, cognition, and sleep. METHODS 15 newly diagnosed malignant glioma subjects started 1-hour weekly phone mindfulness sessions during the 6 weeks of chemoradiation. They completed an in-person mindfulness session and interview upon return to the clinic with a final follow up survey 2 months later. Patient reported outcomes questionnaires were collected at each time point. RESULTS 0/15 subjects completed their post-chemo/in-person visit, and 9 completed their final follow-up surveys 2 months later. Scores for perceived cognition, fatigue, sleep, anxiety, spiritual-well being and mindfulness improved over these time points. Completed HRQoL patient-reported outcome questionnaires with positive trends noted from the mean (SD) post-chemo/in-person visit change from baseline and the follow-up change from baseline were: FACT-Cog perceived Cognitive Impairments subscale 4.11(13.55), 9.14(16.77); FACT-G total -5.48(16.02), 7.02(13.44); FACT-Br total -3.15(24.76), 13.17(23.37); FACIT-F -5(7.68), 0(7.92); and the FACIT-Sp12 -1.38(7.6), 2.17(4.88). Trail making Part A completion times from baseline to follow up decreased over time in 8/9 subjects and 7/9 subjects in Part B. Per the final follow up survey, 7/9 subjects continued their meditation practices after the training sessions and subjectively noted benefits with their stress and anxiety. Conclusion: Despite this small sample size, this mindfulness meditation intervention did positively impact patient-report outcomes of HRQoL in this patient population, thereby larger randomized studies are warranted.

Low grade gliomas (LGGs) develop in young adults and represent 10-15% of all glial tumors. While LGG patients can have longer survival than higher grade tumors, progression, transformation, and ultimately mortality occurs. Mutations in Isocitrate dehydrogenase 1/2 (IDH1/IDH2) are prevalent in LGG and are responsible for gliomagenesis. The classic IDH1 mutation is located at 132 codon and represented as p.Arg132His, but there are non-canonical IDH1 and IDH2 mutations. We sought to compare clinical characteristics of LGG patients with classic IDH1 p.Arg132His mutation to LGG patients with non-canonical IDH1 and IDH2 mutations. We queried an IRB-approved registry retrospectively from 12/2004- 9/2019. We included IDH1/IDH2 mutant LGG (WHO grade II) and known IDH1 and IDH2 targeted mutation analysis using standard PCR followed by DNA sequencing to detect point mutations in IDH1/IDH2 genes. We obtained available clinical and histopathological data. We estimated progression-free survival (PFS), time to transformation (TT), and overall survival (OS) using Kaplan-Meier methods. We identified 267 LGG patients with median follow-up of 9.1 yrs (95%CI 8.4-9.9 yrs). Classic IDH1 p.Arg132His mutation occurred in 223 (83.9%) patients. IDH2 mutations occurred in 14 (5.2%) patients. Non-canonical IDH1 mutations were in 30 (11.2%) patients and included the following mutations: p.Arg132Cys (13), p.Arg132Gly (10), p.Arg132Ser (4), p.Arg132Leu (1), p.Arg119Gln (1), and p.Arg172Met (1). Initial presentation, OS, and TT did not differ between IDH1/IDH2 groups. PFS differed significantly between groups with improved median PFS in IDH2 mutant LGG (5.4 yrs; 95%CI 3.5-25.2) versus classic IDH1 mutant LGG (4.1 yrs; 95%CI 3.7-4.9 yrs) and non-canonical IDH1 mutant LGG (2.6 yrs; 95%CI 2.1-4.8) (log-rank p=0.019). Notably, non-canonical mutations were more common in astrocytoma (22/30; 73.3%) than other LGG histologies (p=0.018). In this cohort, LGG patients with non-canonical mutations have a shorter time to progression than patients with classic p.Arg132His mutation and IDH2 mutations.

The metalloporphyrin, BMX-001 (MnTnBuOE-2-PyP5+), uniquely protects normal tissues from radiation damage and sensitizes tumor cells to radiation damage. We demonstrated this dual action in preclinical models where it protected white matter from radiation damage but augmented radiation-induced cell kill in human glioblastoma (GBM) xenografts. Therefore, we performed a phase 1 study to evaluate safety of BMX-001 in newly diagnosed patients with HGG receiving concurrent radiation therapy (RT) and temozolomide (TMZ). This clinical trial was an IRB-approved, phase 1, single-center, dose-escalation study of BMX-001 in combination with concurrent RT (daily fractions of 1.8-2 Gy to a total of 59.4-60 Gy) and TMZ (75 mg/m2 daily X 42 days). We delivered BMX-001 via subcutaneous injection at a loading dose before the start of RT/TMZ and then 2 times/week for 8 weeks. The primary endpoint was the maximum tolerated dose (MTD). Key secondary endpoints included progression-free survival, overall survival, and neurocognition. We defined progression-free survival and overall survival as survival from time of first BMX-001 injection until progression and death, respectively, and calculated both based on Kaplan-Meier analyses. There were 15 evaluable subjects in the phase 1 study that received all planned BMX-001 doses. All 15 subjects had GBM (WHO grade IV) with age range of 19 to 80 years. BMX-001 at 28 mg loading dose and 14 mg subsequent dose was the MTD. Sinus tachycardia (grade 3) was the dose-limiting toxicity at 42 mg loading dose (n=1). The only other related grade ≥ 3 event was hypotension (grade 3, n=1). The most common related toxicity was grade 1 injection site reaction (n=7). Median follow-up time was 20.5 months (95% CI: 8.9, -). Progression-free survival was 7.1 months (95% CI: 3.9, 11.4). Overall survival was 23.4 months (95% CI: 11.2, 25.9) with seven GBM patients still alive at the time of this analysis. At time of this analysis, long-term results of neurocognition are pending. BMX-001 was safe to administer during concurrent chemoradiation in newly diagnosed HGG. Early results of survival analyses are promising, and long-term neurocognitive protection remains to be determined. Thus, we launched a multi-institutional Phase 2 study with BMX-001 in combination with concurrent chemoradiation in newly diagnosed HGG with key endpoints including overall survival and neurocognition and exploratory endpoints examining white matter integrity and health-related quality of life. Clinical trials are underway also for utilization of BMX-001 with radiation therapy for patients with head and neck cancer and brain metastases.

There is no validated model for delivering palliative care (PC) in the glioblastoma (GBM) population. The primary objectives were to assess the feasibility and determine the acceptability of a time-based model of integrated specialty PC to patients and providers. Secondary objectives were to estimate the impact on healthcare utilization and quality of life (QoL) compared to historical controls. We consented and referred patients to PC at their initial Neuro-Oncology consultation between 4/2018 and 5/2019. We conducted QoL assessments (NCCN Distress Tool; Functional Assessment of Cancer Therapy-Brain (FACT-BR); Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F); Epworth Sleepiness Scale (ESS)) at (1) baseline (2) immediately after chemoradiation, and (3) 6 months following chemoradiation. Ongoing PC follow-up was at the discretion of the PC provider. We administered the Edmonton Symptom Assessment System (ESAS) before and after PC visits. We measured patient and referring provider satisfaction using FAMCARE-16 and a PC departmental survey, respectively. We did not meet our goal enrollment of 50 patients. 32 were offered participation, 12 consented and 8 attended at least one PC visit. The mean number of PC visits was 1.6. Mean age was 62 (42–79). 75% had a KPS ≥80. Of those that did not complete the study, 2 died and 5 either withdrew consent or declined further visits. At baseline, 91.7 % had a NCCN distress score ≥4. Patients were overall satisfied with the intervention. Introduction of specialty PC at the time of GBM diagnosis is challenging. Participants reported their experience as overall positive. Results from referring providers are pending. Due to low-enrollment we did not pursue further statistical comparisons regarding healthcare utilization compared to historical controls.

(2014). Adherence to antiemetic guidelines in patients with malignant glioma: A quality improvement project to translate evidence into practice. The impact of a palliative care program in a rural Appalachian community hospital: A quality improvement process. Intraoperative implementation of a tissue sealant on all lung surgery patients: A quality improvement project. (2011). Use of a Clinical Decision Support Tool to improve guideline adherence for the treatment of methicillin‐resistant Staphylococcus aureus skin and soft tissue infections.

Abstract With a bleak prognosis for malignant glioma, maintaining quality of life (QoL) and decreasing distress of the patient are important in the clinical care of the patient. Mindfulness meditation is a mind-body therapy that has been recently investigated in the oncology field as a non-pharmacological strategy to ameliorate cancer symptoms and to improve QoL. This practice has not been studied in the primary brain tumor population. We initiated a pilot study among newly diagnosed brain tumor patients with the hypothesis that mindfulness meditation practice may benefit the patient by decreasing stress and anxiety and provide a means to cope with their new diagnosis. The specific aim of this pilot study is to determine the feasibility of a mindfulness meditation program to this population during standard of care chemoradiation and to determine whether it merits additional research in a subsequent trial. The intervention consists of six weekly one hour telephone-based mindfulness sessions followed by one in- person mindfulness session consisting of: mindfulness and healing, understanding stress, abiding in kindness, working with difficult emotions, finding peace, going forward and living fully. Subjects are provided with downloadable guided meditations. We plan to enroll fifteen newly diagnosed WHO grade III or IV malignant glioma subjects prior to their 6 week chemoradiation course. We will determine the percentage of subjects approached vs enrolled, number of sessions that each subject attends, completion of study questionnaires and satisfaction of the subjects. QoL surveys include: Functional Assessment of Cancer Therapy- Brain, Functional Assessment of Cancer Therapy- Cognitive Function, Pittsburgh Sleep Quality Index, Functional Assessment of Chronic Illness Therapy-Fatigue and the Five Facet Mindfulness Questionnaire – short form. 13 subjects have been approached and 8 signed consent over a two-month period. We will provide final study results at time of presentation.

BMX-001 (MnTnBuOE-2-PyP5+) is a metalloporphyrin with differential action in response to oxidative stress caused by radiation therapy (RT)and chemotherapy, both critical components in the treatment of high-grade gliomas (HGG). In preclinical studies, BMX-001 functions as a radioprotectant of normal tissue, for example protection of central nervous system white matter and radiosensitizer of human glioblastoma (GBM) xenografts. Therefore, we underwent a phase 1 study to evaluate safety of BMX-001 in newly diagnosed patients with HGG receiving concurrent RT and temozolomide (TMZ). We performed a phase 1, single-center, dose-escalation study of BMX-001 in combination with concurrent RT (daily fractions of 1.8–2 Gy given 5 days/week for 6 weeks for a total of 59.4–60 Gy) and TMZ (75 mg/m2 daily X 42 days). We administered BMX-001 as a subcutaneous injection at a loading dose before start of RT and TMZ and then subsequently 2 times/week for 8 weeks. Primary endpoint was determination of the maximum tolerated dose (MTD). We assessed safety using National Cancer Institute Common Terminology Criteria for Adverse Events 4.03. We enrolled 15 subjects with GBM (WHO grade IV) with age range of 19 to 80 years. BMX-001 at 42 mg loading dose and 20 mg subsequent dose was the maximum administered dose and 28 mg loading dose and 14 mg subsequent dose was the MTD. Sinus tachycardia (grade 3) was the dose-limiting toxicity at 42 mg loading dose (n=1). Only other related grade ≥ 3 event seen was hypotension (grade 3) (n=1). Most common related toxicity was grade 1 injection site reaction (n=7). BMX-001 with RT plus TMZ and post-RT TMZ for patients with newly diagnosed HGG was safe and well-tolerated. Phase II study with BMX-001 in combination with concurrent RT and TMZ in subjects with newly diagnosed HGG is planned.

Glioblastoma (GBM) occurs commonly in 6th to 7th decades of life. GBM in young adults (age 18–39 yrs) is rare and the implications of this diagnosis during young adulthood has different considerations than in their older counterparts. We planned to identify young adults with GBM and to evaluate the clinical and histopathological factors in this rare group. We queried retrospectively an IRB-approved database registry from 12/2004- 10/2016. We included GBM patients by these factors: 1. Age at diagnosis as 18–39 yrs, 2. Confirmed GBM pathology at initial diagnosis, and 3. Usable information on time to first progression. We excluded patients with an initial diagnosis of WHO grades II-III glioma. We obtained available clinical and histopathological information. We estimated progression-free survival (PFS) and overall survival (OS) using Kaplan-Meier methods. We found 184 young adult patients that met our criteria for inclusion in this evaluation. Median age was 33 yrs with a majority being males (n=109, 59.2%). The majority (89.1%) had surgical resection at time of diagnosis (GTR, n=106 and STR, n=58). Median OS was 41.6 mos (95% CI: 31.2, 51.6), with a 5-year OS of 38.9% (95% CI: 31.2%, 46.5%). Median PFS was 17.2 mos (95% CI: 14.1, 21). Recurrence occurred in 148 patients (80%) and 25% (n=37) were enrolled in clinical trials after 1st recurrence. While most had pathology described as GBM, there were 50 variants (27.2%) including giant cell (n=20), small cell (n=15), oligodendroglial (n=10), PNET (n=4), and rhabdoid (n=1). Known IDH1 status was 29 mutant (15.8%) and 51 wild type (27.7%) CONCLUSIONS: Diagnosis of GBM in young adults associated with a longer OS. Surgical resection at diagnosis and participation in clinical trials are common. Histopathology for this group can be heterogeneous. Providers should tailor treatment and survivorship planning uniquely to the young adult GBM population.

Meningiomas, the most common CNS neoplasm, are often deemed less threatening than their glial counterparts. Unfortunately, these tumors recur and necessitate surgery, radiation, and/or systemic treatment. We explored the psychosocial distress of patients with recurrent meningioma using The National Comprehensive Cancer Network Distress Thermometer (NCCN-DT) and Problem List. This was a retrospective analysis of patients with recurrent meningioma seen at the Preston Robert Tisch Brain Tumor Center between 12/31/2004–10/10/2018 who completed a NCCN-DT and Problem List. The first or only NCCN-DT assessment after initial recurrence was used for analysis with a score of 4 indicating moderate to severe distress. 45 patients were identified, 56% female, median age was 61 years and 58% had unifocal disease. 60% were Grade 1, 33% Grade II, 4% Grade III, and 2% indeterminate recurrent meningioma. The median NCCN-DT score was 3, and 49% had a NCCN-DT score 4 indicating moderate to severe distress. 64% of females vs 30% of males reported distress scores 4 (p=0.04). 65% of patients with unifocal disease reported 4 scores compared to 26% with multifocal disease (p=0.02). Fatigue (N=24), Worry (N=23), Nervousness (N=22), Depression (N=19) and Memory/Concentration (N=19) were the most commonly reported problems. A higher incidence of worry among females (64%) than males (35%) was the only problem showing a trend towards significance (p=0.08). Between initial recurrence and NCCN assessment, the type and number of treatments patients received included: surgery (median=1, range 0–5), radiation (median=2, range 0–5), systemic treatment (median=2, range 0–12). There was no association between distress and the number of surgeries (p=0.99), radiation treatments (p=0.49) or systemic therapies (p=0.87). CONCLUSIONS: In our study population, nearly half of recurrent meningioma patients reported moderate to severe distress. Therefore, even in this benign tumor population, the NCCN-DT and problem list should be administered at every clinic visit.

effects (weight gain, fatigue, pain, vision changes) contributing to dissatisfaction throughout the disease trajectory.Specific changes in appearance (hair loss, indentation on head, skin dryness) were also problematic factors affecting adjustment and coping.An ascribed negative outlook (9%) (self-conscious, feeling ashamed or vulnerable) magnified awareness of longterm permanent changes, but some (8%) described the implementation of a positive outlook (using exercise and hope) allowing for acceptance of these changes.CONCLUSION: These findings offer insight from the patients perspective on identified physical, mental and treatment-related factors regarding body image concerns and the scope of issues faced by PBT patients.Understanding patient concerns allows for a multidimensional approach in management of key areas with the goal of improving overall quality of life.

Malignant gliomas represent the majority of primary brain tumors, and the prognosis of the patients afflicted with these tumors has been historically dismal, with almost uniform progressive neurologic impairment and rapid death. Even with multimodal treatment using surgery, focal radiation, and chemotherapy, no major strides were made until recently. The development of interstitial BCNU wafers (carmustine wafers, Gliadel((R))) has led to promising results in the treatment of a selected patients with malignant gliomas, as well as with other intracranial malignancies.BCNU is one of the first systemic chemotherapies which had obtained United States Food and Drug Administration (FDA) approval for the treatment of brain tumors. However, systemic use has been hampered by the modest prolongation of survival and by the prolonged myelosuppression and potentially fatal pulmonary toxicity. The development of interstitial therapies with BCNU represented a great step forward, allowing direct delivery to the tumor bed, with virtually no systemic toxicities. Clinical studies of BCNU wafers have showed good efficacy in both newly diagnosed and recurrent gliomas, as well as a possible therapeutic role in other primary or secondary intracranial malignancies. New studies are currently underway trying to improve the efficacy of the BCNU wafers (Gliadel((R))) by combining them with different systemic chemotherapies. An overview of the current knowledge ranging from the preclinical developments, to the efficacy and safety seen in the clinical trials and in clinical practice following the drug approval to the future avenues of research is therefore timely.

19527 Background: Glioma patients are at risk for osteoporosis and associated morbidity as a result of neurological deficits, anticonvulsants and glucocorticoid therapy. The prevalence of osteoporosis in glioma patients has not been reported. We hypothesized that the prevalence of the osteopenia (defined by bone mineral density (BMD) T-score < -1) or osteoporosis (defined by T- score < -2: spine; T-score < - 2.5: femur) in glioma patients supports consideration of bisphosphonate treatment to prevent or reduce the severity of osteoporosis and skeletal complications. Methods: BMD was conducted on 19 eligible patients. Eligibility criteria included: (1) histologically confirmed diagnosis of a primary glioma, (2) age ≥ 18 years, (3) KPS ≥ 60%, (4) treated with valproate or an EIAC and/or on more than physiologic replacement steroid therapy, (5) creatinine < 2.0 mg/dl and calculated creatinine clearance of >60 ml/min, (6) bilirubin < 1.5 x nl, LFTs < 2.5 x nl, (7) recovery from surgery, (8) life expectancy >12 wks, and (9) written informed consent. Exclusion criteria: Previously diagnosed with osteoporosis requiring oral bisphosphonates. Results: 89% were diagnosed with a glioblastoma. Mean age, 54.6 (±SD 9.4; range 35–70). 68% (13/19) were male and all were white race. 53% (10/19) had a KPS of ≥90: 42% (5/19) KPS ≥80: 5% (1/19) KPS ≥70%. AC use: 64% phenytoin; 11% valproate; 5% phenobarbital; 5% oxcarbazepine; 10% levetiracetam; and 5% none. 37% were on dexamethasone, 16% other steroids, and 47% off steroids. Mean N-telopeptide (a marker of bone turn over) was 12.6 (±SD 5.5; range 5.6–22.2). 22% of patients (4/19) had osteopenia and 16% (3/19) had osteoporosis. Conclusions: Overall 38% percent of glioma patients had evidence of osteopenia and 16% had osteoporosis. Thus, bisphosphonates should be considered to prevent skeletal complications. Subsequently, we have initiated an open-labeled Phase II trial to further determine the prevalence of osteoporosis in glioma patients and the effect of every three month prophylactic zoledronic acid on bone density. An update of the prevalence of osteoporosis in patients enrolled on this trial will be presented. No significant financial relationships to disclose.