Imaging features of leptomeningeal metastases

AIMS

To assess the range of appearances, and accuracy of various methods of diagnosing leptomeningeal metastases.

MATERIALS AND METHODS

In a retrospective study, the notes and imaging of all patients with a radiological and/or CSF cytological diagnosis of leptomeningeal metastasis (LM) were identified, and assessed for the following: age and sex, primary tumour type, presenting symptoms, initial radiological and cytological diagnosis, radiological appearances and length of survival following diagnosis. Discordance between the CSF cytology and radiological diagnosis of LM was also noted.

RESULTS

41 positive cases (36 female) of LM were identified over a 2.7 year period (diagnosis based on: imaging only--19 cases, cytology only--6, both--16 cases). The average age was 48 years, and the most frequent primary tumour was breast carcinoma (27/41). Two thirds of patients presented with at least one cranial or spinal nerve palsy. Where performed, contrast-enhanced CT was normal in 40% (10/25), with LM mistaken for parenchymal disease in a further 24% (6/25). CSF cytology was positive in 85% (22/26). Gadolinium-enhanced MRI was positive in all cases where it was performed (25/25). Pial enhancement and nodularity was the commonest finding (67%), but other manifestations included nodular disease, neural enhancement and white matter changes. Prognosis was uniformly poor.

CONCLUSION

Leptomeningeal metastatic disease has a poor prognosis, and treatment regimen may differ from those of parenchymal CNS metastases. CT is normal or misleading in two thirds of patients, and CSF cytology may also be negative. Gadolinium-enhanced T1-weighted MRI complements CSF cytology, and is the investigation of choice in patients with a non-haematological primary tumour and suspected LM.

Modern brachytherapy: current state and future prospects

This article reviews the current trends and future developments in brachytherapy. Established techniques including interstitial and high-dose rate brachytherapy are discussed with particular reference to lung, oesophageal, cervical and endometrial cancer. Intra-operative high-dose rate brachytherapy and other new techniques are also mentioned.

High-dose chemotherapy supported by peripheral blood progenitor cells in poor prognosis metastatic breast cancer--phase I/II study. Edinburgh Breast Group

Current treatments for metastatic breast cancer are not associated with significant survival benefits despite response rates of over 50%. High-dose therapy with autologous bone marrow transplantation (ABMT) has been investigated, particularly in North America, and prolonged survival in up to 25% of women has been reported, but with a significant treatment-related mortality. However, in patients with haematological malignancies undergoing autologous transplantation, haematopoietic reconstruction is significantly quicker and mortality lower than with ABMT, when peripheral blood progenitor cells (PBPCs) are used. In 32 women with metastatic breast cancer, we investigated the feasibility of PBPC mobilisation with high-dose cyclophosphamide and granulocyte colony-stimulating factor (G-CSF) after 12 weeks' infusional induction chemotherapy and the subsequent efficacy of the haematopoietic reconstitution after conditioning with melphalan and either etoposide or thiotepa. PBPC mobilisation was successful in 28/32 (88%) patients, and there was a rapid post-transplantation haematopoietic recovery: median time to neutrophils > 0.5 x 10(9) l-1 was 14 days and to platelets > 20 x 10(9) l-1 was 10 days. There was no procedure-related mortality, and the major morbidity was mucositis (WHO grade 3-4) in 18/32 patients (56%). In a patient group of which the majority had very poor prognostic features, the median survival from start of induction chemotherapy was 15 months. Thus, PBPC mobilisation and support of high-dose chemotherapy is feasible after infusional induction chemotherapy for patients with metastatic breast cancer, although the optimum drug combination has not yet been determined.

The use of single fraction Leksell stereotactic radiosurgery in the treatment of uveal melanoma

Fourteen patients with posterior uveal melanomas were treated using single fraction stereotactic radiosurgery. In each case a dose of 70 Gy was administered to the periphery of the tumour. Regression of the tumour has been observed in 13 patients, whilst the lesion has remained unchanged in one patient. The visual acuity has deteriorated in all 14 patients. Significant radiation induced adverse reactions were noted in 13 patients and include; retinopathy, optic neuropathy, rubeosis iridis, and secondary glaucoma. Two patients have required enucleation because of intractable rubeotic glaucoma. One patient has died from proven metastases. Although stereotactic radiosurgery appears to be a practical and effective method of treating uveal melanomas, its usefulness is limited by a high incidence of radiation induced adverse reactions. Further work is required to refine the current treatment protocol and establish an optimal prescription dose.

A glossary for reporting complications of treatment in gynecological cancers

Reporting and scoring treatment complications in gynecological cancers is difficult because of the variety of normal tissues, anatomical structures and treatment disciplines involved, making it impossible to compare series of patients treated in different institutions even with the same strategy. An international group of experts (gynecologists, radiotherapists and surgeons) developed a multidisciplinary database to identify, score and report early and late normal tissue damage regardless of treatment strategy. The principles involve: (1) The identification of relevant organs and tissues; (2) An accurate definition of the type and score of each complication; (3) Reporting combinations of complications of various degrees; (4) A computerized format for data acquisition, update and retrieval. In the present version, the "Glossary" describes five degrees of increasing severity (0 to 4) in 14 organs and/or normal tissues. The rationale of the glossary leaves it open for as yet undescribed types of complications. This paper contains the definition and scoring for each type of complication, general guidelines for their use.

Radiation therapy in the treatment of early glottic carcinoma: the experience of Villejuif

A retrospective analysis of 197 early glottic carcinoma treated with small field irradiation to a dose of 65 Gy is presented. The 5-year survival rate was 77.3%. Thirty-eight local failures have been observed, and the 5-year local control rate was 85.7%. Suspicion of extra glottic extension was the main prognostic factor. Final local control rate, taking into account the salvage treatment, was 90% at 5 years. Excellent functional results were observed.