95.3 🩺 內科專科考前版

95.3.0.1 📌 䞀頁重點

  • 22E:
    • Vorasidenib (Voranigo, FDA 2024) IDH1/2 inhibitor for IDH-mut grade 2 glioma — first targeted for low-grade glioma
    • WHO 2021 CNS tumor classification (molecular-based)
    • Tucatinib + trastuzumab + cape (HER2CLIMB) for HER2+ brain mets
    • Osimertinib penetrates CNS well (AURA, FLAURA)
    • Lorlatinib best CNS penetration ALK+
    • Dabrafenib + trametinib BRAF V600E brain mets (gliomas + melanoma)
    • TTF (Optune) modest GBM benefit (EF-14)
    • Bevacizumab for radiation necrosis differential
  • Taiwan: 健保 surgery + RT + temozolomide; 健保 bevacizumab (recurrent GBM 條件); 健保 TTF (Optune) 自費 倚; 健保 vorasidenib 自費 (新, 限制); 健保 high-dose methotrexate for PCNSL; 健保 rituximab; 健保 SRS / Gamma Knife / CyberKnife (條件)

95.3.0.2 🌟 Pearls (10)

  1. Extent of resection (EOR) for GBM: > 95% gross total resection vs subtotal — significant survival difference
  2. Pseudoprogression vs true progression: 20-30% post-RT show transient enhancement; perfusion MRI + repeat in 4-8 wk
  3. Radiation necrosis vs recurrence: difficult; bevacizumab can treat necrosis
  4. CNS lymphoma + HIV: EBV-driven; treat HIV + chemo
  5. Vorasidenib trial (INDIGO 2024 NEJM): significant PFS in IDH-mut grade 2 glioma
  6. HER2CLIMB: tucatinib superior CNS penetration for breast brain mets
  7. Meningioma molecular: NF2 (most common); surgery for symptomatic; RT for atypical / recurrent
  8. Pediatric brain tumors: distinct biology (medulloblastoma subgroups, DIPG)
  9. DIPG (diffuse intrinsic pontine glioma): H3 K27M-mutant; very poor prognosis (peds); ONC201 trial
  10. Leptomeningeal disease: poor prognosis; intrathecal chemo (methotrexate, cytarabine), proton craniospinal RT

95.3.0.3 📍 Taiwan + 健保

  • 健保 brain MRI 條件
  • 健保 craniotomy + biopsy + EVD
  • 健保 temozolomide (oral)
  • 健保 RT (60 Gy + boost)
  • 健保 bevacizumab for recurrent GBM 條件
  • 健保 SRS / Gamma Knife / CyberKnife 條件 (selected)
  • 健保 high-dose methotrexate for PCNSL
  • 健保 rituximab
  • 健保 dexamethasone, mannitol, antiseizure
  • TTF (Optune) 自費 倚 (新, 限制)
  • Vorasidenib (Voranigo) 自費 倚 (新, 限制䞭心)

95.3.0.4 🎓 內專必懂 (10)

  1. WHO 2021 CNS molecular classification (IDH, 1p/19q, MGMT, EGFR)
  2. GBM Stupp protocol + survival prognostication
  3. Vorasidenib for IDH-mut grade 2 glioma (22E)
  4. Brain mets management by primary
  5. HER2CLIMB + osimertinib + alectinib + dabrafenib for brain mets
  6. PCNSL treatment + autoSCT consolidation
  7. Meningioma management
  8. Pediatric tumors (medulloblastoma subgroups)
  9. Increased ICP management
  10. Pseudoprogression + radiation necrosis vs recurrence

⚠ AI 草皿。