NCCN CNS Tumor Guidelines Update for 2024

Abstract

The National Comprehensive Cancer Network® (NCCN®) is a not-for-profit alliance of 33 National Cancer Institute-designated Comprehensive Cancer Centers. The NCCN efforts are focused on patient care, research, and education. It is best known for the establishment of tumor-specific clinical practice guidelines. The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for central nervous system (CNS) cancers1 are formed by the efforts of a 36-member committee comprised of 13 neurologists, 7 medical oncologists, 6 radiation oncologists, 5 neurosurgeons, 1 neuropathologist, 1 neuroradiologist, and 1 patient advocate. The Guidelines are reviewed and updated annually. Member institutions, industry representatives, or individuals can submit comments, which are discussed at the annual committee meeting held at the NCCN Headquarters in Plymouth Meeting, PA. The data supporting these comments are reviewed by the committee with a determination to alter the guideline algorithms using the NCCN Categories of Evidence (1, 2A, 2B, 3) and Preference as shown in Table 1. The committee votes on assigning category recommendations based on the quality of the data (randomized controlled trials [RCTs], non-RCTS, meta-analyses, systematic review of the literature, or expert opinion from clinical experience), the amount of evidence (extensive, less extensive, little, or anecdotal clinical experience), and reproducibility of the evidence (highly consistent, single trial, or variable). The impact has been far-reaching: in 2023 the CNS Guidelines were downloaded 222 983 times, including 114 906 from sites outside the United States. NCCN Categories Recommendations are based on the level of clinical evidence available and the degree of consensus Category 1: Based upon high-level evidence, there is uniform NCCN consensus that the intervention is appropriate Category 2A: Based upon lower-level evidence, there is uniform NCCN consensus that the intervention is appropriate Category 2B: Based upon lower-level evidence, there is NCCN consensus that the intervention is appropriate Category 3: Based upon any level of evidence, there is major NCCN disagreement that the intervention is appropriate All recommendations are category 2A unless otherwise indicated (B) Categories of Preference Preferred intervention: Interventions that are based on superior efficacy, safety, and evidence; and, when appropriate, affordability Other recommended intervention: Other interventions that may be somewhat less efficacious, more toxic, based on less mature data; or significantly less affordable for similar outcomes Useful in certain circumstances: Other interventions that may be used for selected populations (defined with recommendation) General: The NCCN Guidelines® for Central Nervous System Cancers has had 3 updated versions for 2024 in response to new evidence and requests. These have been made available electronically in real-time over the year and include Version 1.2024, Version 2.2024, and Version 3.2024 (1). BRAIN METS-A, GLIO-A: The updated results for the TRIDENT-1 trial of repotrectinib for NTRK gene fusion-positive cancers were incorporated to provide this option.2 GLIO GLIO-2 and 4: There were significant updates to these pages so that they now focus separately on oligodendroglioma and astrocytoma, World Health Organization grade 2. GLIO-2A, GLIO-4A, GLIO-A, pages 2, 3, 4, 5 of 9: The guidelines now incorporate the results of the phase 3 trial of vorasidenib versus placebo into appropriate locations for IDH mutated glioma.3 BRAIN METS-A The following were added for systemic therapy considerations of brain metastases. A preferred regimen of pembrolizumab was included for MSI-H/dMMR or TMB-H (>10 mut/Mb) isolated brain metastases, regardless of the primary site of origin, although the committee vote was to designate this recommendation a category 2B. The targeted therapies adagrasib and sotorasib were added for brain metastases from KRAS G12C mutated Non-small cell lung cancer (NSCLC). LEPT For the treatment of leptomeningeal metastases, the incorporation of craniospinal irradiation (CSI) for CNS and CSF (cerebrospinal fluid) disease control was made to the algorithm, using advanced modalities to minimize toxicity like proton radiotherapy or conformal photon-based radiation techniques.4 BRAIN-C Principles of Radiation Therapy for Brain and Spinal Cord Tumors This section was edited to reflect more modern radiation planning techniques, including smaller margins for clinical target volumes in the treatment of glioma, image guidance, and new imaging for treatment planning. Recommended prescription radiation doses were refined to reflect modern data on local control and safety across tumor types and indications. Management of leptomeningeal metastases with CSI is addressed. BRAIN-D Principles of Brain and Spine Tumor Management There were continued efforts to provide clarification about recommended multidisciplinary care, medical management, and psychiatric care for CNS cancer patients. Links to existing resources both within the NCCN Guidelines and outside were updated or provided. BRAIN-E Principles of Brain Tumor Pathology This section is maturing with updates related to appropriate molecular markers and specific CNS tumor types addressed each year. The updates for 2024 focused on the delineation of next-generation sequencing (NGS) as the preferred approach for pathological workup of CNS tumors given the ability to screen for multiple diagnostic and prognostic alterations in one test. An additional bullet was included to ensure readers are aware that NGS results do not screen for the existence of heritable cancer predisposition syndromes, so additional steps must be taken if such syndromes are suspected. The 2024 NCCN Clinical Practice Guidelines for Central Nervous System Cancers continue to predicate its recommendations on the best data available. The glioma algorithms continue to be reorganized based on recently revised molecular-based diagnostic classifications. The results from subtype-specific clinical trials have been used to include new recommendations. The text is the sole product of the author and no third party had input or gave support for its writing. None declared.

Topics & Concepts