Therapy of leptomeningeal metastasis in solid tumors

Persistent follicular granulosa cell senescence and apoptosis induced by methotrexate leading to oocyte dysfunction and aberrant embryo development

Evidence from clinical cases indicates an association between the low success rate of in vitro fertilization (IVF) and ovarian injury due to previous methotrexate (MTX) administration. Therefore, it is necessary to develop and propose reasonable clinical drug guidelines to improve the quality of oocytes and the development of embryos before pregnancy. In this study, we established a mouse model with previous MTX exposure to validate the effects of MTX on reproductive function in female mice. We observed that MTX administration could result in a decrease in the success rate of fertilization and an aberrant embryonic development in both natural fertilization and IVF, even after completion of five to six ovulation cycles after MTX withdrawal. Further research revealed senescence and apoptosis of follicular granulosa cells (GCs), accompanied by arrested follicle development and aberrant estradiol and anti‐Mullerian hormone levels. Supportive evidence indicated that MTX administration induced senescence and apoptosis of human GCs in vitro, and the effects were consistent with the high levels of p21, p53, and oxidative stress. We further demonstrated that folic acid (FA) could improve oocyte function and embryonic development in vivo and in vitro by protecting GCs against apoptosis and senescence. Based on these findings, we propose the implementation of extended intervals between MTX exposure and conception or IVF and recommend FA as a special dietary supplement during this interval period; however, prospective inquiry in humans is necessary to further understand the relationship between MTX and FA recovery.

Inhibition of Jumonji Histone Demethylases Selectively Suppresses HER2+ Breast Leptomeningeal Carcinomatosis Growth via Inhibition of GMCSF Expression

HER2⁺ breast leptomeningeal carcinomatosis (HER2⁺ LC) occurs when tumor cells spread to cerebrospinal fluid-containing leptomeninges surrounding the brain and spinal cord, a complication with a dire prognosis. HER2⁺ LC remains incurable, with few treatment options. Currently, much effort is devoted toward development of therapies that target mutations. However, targeting epigenetic or transcriptional states of HER2⁺ LC tumors might efficiently target HER2⁺ LC growth via inhibition of oncogenic signaling; this approach remains promising but is less explored. To test this possibility, we established primary HER2⁺ LC (Lepto) cell lines from nodular HER2⁺ LC tissues. These lines are phenotypically CD326⁺CD49f^-, confirming that they are derived from HER2⁺ LC tumors, and express surface CD44⁺CD24^-, a cancer stem cell (CSC) phenotype. Like CSCs, Lepto lines showed greater drug resistance and more aggressive behavior compared with other HER2⁺ breast cancer lines in vitro and in vivo. Interestingly, the three Lepto lines overexpressed Jumonji domain-containing histone lysine demethylases KDM4A/4C. Treatment with JIB04, a selective inhibitor of Jumonji demethylases, or genetic loss of function of KDM4A/4C induced apoptosis and cell-cycle arrest and reduced Lepto cell viability, tumorsphere formation, regrowth, and invasion in vitro. JIB04 treatment of patient-derived xenograft mouse models in vivo reduced HER2⁺ LC tumor growth and prolonged animal survival. Mechanistically, KDM4A/4C inhibition downregulated GMCSF expression and prevented GMCSF-dependent Lepto cell proliferation. Collectively, these results establish KDM4A/4C as a viable therapeutic target in HER2⁺ LC and spotlight the benefits of targeting the tumorigenic transcriptional network. SIGNIFICANCE: HER2⁺ LC tumors overexpress KDM4A/4C and are sensitive to the Jumonji demethylase inhibitor JIB04, which reduces the viability of primary HER2⁺ LC cells and increases survival in mouse models.

[Auxiliary Diagnostic Value of Tumor Markers in the Cerebrospinal Fluid and Blood for Leptomeningeal Metastasis from Non-small Cell Lung Cancer]

背景与目的

软脑膜转移（leptomeningeal metastasis, LM）是指恶性肿瘤细胞浸润软脑膜，并在脑脊液（cerebrospinal fluid, CSF）中播散，预后极差，是晚期非小细胞肺癌（non-small cell lung cancer, NSCLC）患者致死的重要原因之一，因此早期的诊断和及时的治疗具有重要意义，CSF细胞学是LM诊断的金标准，但常常伴随着检测敏感性低、无法评估疗效等问题。本文旨在探讨血清及CSF中肿瘤标志物（tumor markers, TM）在NSCLC伴LM患者诊治的临床价值。

方法

选取NSCLC伴LM患者19例，另选同期27例神经系统良性肿瘤（nonmalignant neurological diseases, NMNDs）患者作为对照组。观察比较两组患者血清和CSF中癌胚抗原（carbohydrate antigen, CEA）、糖类抗原125（carbohydrate antigen-125, CA125）、细胞角蛋白19片断抗原（cytokeratin 19 fragments, CYFRA21-1）和神经元烯醇化酶（neurone specific enolase, NSE）检测水平和检出阳性率，比较不同组TM的敏感性和特异性，并分析血清与CSF中TM检出情况相关性，最后动态监测2例LM患者血清和CSF中TM水平，分别评估颅外和颅内治疗疗效。

结果

LM组CSF和血清中TM水平和检出阳性率均高于对照组（P < 0.05），同时LM组CSF中CEA、CYFRA21-1、NSE水平高于血清，差异有统计学意义（P < 0.05）。CSF中TM检出阳性率与血清差异不具有统计学意义（P > 0.05）。CSF中CYFRA21-1敏感性最高（88.2%），CEA特异性最好（92.3%），联合指标中CEA或NSE任一项超过临界值则敏感性和阴性预测值为100%，特异性为74.1%。CYFRA21-1和NSE同时超过临界值时特异性和阳性预测值为100%，敏感性为78.9%。亚组分析显示，CSF细胞学阳性人群TM检出阳性率超过有磁共振成像（magnetic resonance imaging, MRI）异常的人群，但不具有统计学差异（P > 0.05）。LM组血清与CSF中TM检出阳性率不一致。另外，脑室中CSF与腰穿中CSF具有相同的生化性质，动态监测血清和CSF中TM浓度，可分别评估颅外和颅内病灶的疗效。

结论

血清和CSF中TM为NSCLC伴LM患者增加了一个早期辅助诊断指标，动态监测可评估治疗疗效，值得临床推广应用。

Leptomeningeal disease in pancreas ductal adenocarcinoma: A manifestation of longevity

BACKGROUND

/Objectives: Pancreatic adenocarcinoma (PDAC) metastatic to the leptomeninges is a rare and lethal event. Leptomeningeal disease (LMD) research is limited in PDAC, and insights into clinical descriptors, possible disease predictors, and treatment strategies is necessitated.

METHODS

Memorial Sloan Kettering databases were queried with Institutional Review Board approval to identify patients with LMD and PDAC treated between January 2000 and June 2020. Medical record review was used to abstract clinical, genomic, pathologic, and radiographic data. Overall survival was calculated from date of PDAC diagnosis to date of death. Previously published literature on LMD from PDAC was reviewed.

RESULTS

Four patients with LMD from PDAC were identified, two males and two females. Age at diagnosis ranged from 57 to 68 years. All four patients had predominant lung metastasis and a relatively low burden of intra-abdominal disease. Somatic testing indicated alterations typical of PDAC and no PDAC defining pathogenic germline mutations were identified. An extended clinical course prior to LMD diagnosis was observed in all patients, ranging from 16 to 148 months. Upon diagnosis of LMD, three patients elected for supportive care and one patient received a limited course of craniospinal radiation. The median survival following diagnosis of LMD was 1.6 months (range 0.5-2.8 months).

CONCLUSIONS

LMD from PDAC is a rare occurrence that may be more frequent in patients with lung metastasis and/or a more indolent clinical course. Following diagnosis of LMD, prognosis is poor, and survival is short. New treatment strategies for this manifestation of PDAC are needed.

Leptomeningeal disease from melanoma-Poor prognosis despite new therapeutic modalities

OBJECTIVE

The development of leptomeningeal disease (LMD) among melanoma patients is associated with short survival. Unspecific clinical symptoms and imprecise diagnostic criteria often delay diagnosis. Because melanoma patients with LMD have been excluded from most clinical trials, the efficacy of immune checkpoint blockade (ICB) and targeted therapies (TTs) has not been adequately investigated among these patients.

METHODS

We performed a retrospective study in two tertiary-referral skin cancer centres to evaluate the clinical characteristics, diagnostics, treatments, and overall survival (OS) of melanoma patients with LMD between June 2011 and March 2019.

RESULTS

In total, 52 patients were included. The median age at LMD diagnosis was 58 years. Most patients (n = 30, 58%) were men. The median time from the first diagnosis of unresectable disease to the first diagnosis of LMD was 8.5 months (range 0-91.5 months). Most patients (65%, n = 34) were BRAF V600 mutated. Sixteen patients (31%) presented with LMD only, whereas 36 patients (69%) presented with concomitant brain metastases at LMD diagnosis. Eleven patients (21%) showed no evidence of extracranial disease. Forty-four patients (85%) had clinical symptoms at LMD diagnosis. Forty-two patients (81%) had received at least one prior therapy. Forty patients (77%) received at least one treatment after LMD diagnosis, including TT (n = 17), ICB (n = 13), bevacizumab (n = 1), radiotherapy (n = 3), and intrathecal chemotherapy (n = 1); five patients received both TT and ICB. Twelve patients (23%) received no treatment because of rapid progression of LMD. The median OS for the entire cohort was 2.9 months (95% confidence interval [CI] 1.7-4.1). Among patients receiving systemic therapy, OS was 3.7 months (95% CI 2.4-4.9).

CONCLUSIONS

Systemic treatment with TT or ICB seems to improve OS among patients with LMD. However, despite new therapy modalities, the prognosis of LMD remains poor.

Leptomeningeal carcinomatosis from gallbladder cancer after curative resection: A case report and review of literature

Introduction Only 12 cases of gallbladder (GB) cancer associated with leptomeningeal carcinomatosis (LMC) have been reported so far. Herein, we report the first known case of LMC originating from GB cancer after curative resection and discuss the risk factors of LMC associated with GB cancer. Case Presentation An 85-year-old Japanese woman presented with vomiting and impaired awareness 2 years after curative extended cholecystectomy for GB cancer . Computed tomography showed hydronephrosis of the right kidney and ureteral thickening. Magnetic resonance imaging revealed areas of hyperintense reflecting lesions along the cerebral sulci, suggesting meningitis. A spinal tap showed an elevated cerebrospinal fluid pressure of &gt; 270 mmH 2 O, and cytological examination of the spinal fluid revealed the presence of adenocarcinoma cells. The patient was diagnosed with retroperitoneal metastasis and LMC originating from GB cancer. The patient was given palliative care and died 4 weeks after the onset of symptoms. Conclusion The findings of this study show that LMC could occur even after curative resection of GB cancer and should be considered when patients present with neurological symptoms. Retroperitoneal metastases and poorly differentiated tumors are possible risk factors of LMC originating from GB cancer.

Anti-EGFR VHH-armed death receptor ligand-engineered allogeneic stem cells have therapeutic efficacy in diverse brain metastatic breast cancers

Basal-like breast cancer (BLBC) shows brain metastatic (BM) capability and overexpresses EGFR and death-receptors 4/5 (DR4/5); however, the anatomical location of BM prohibits efficient drug-delivery to these targetable markers. In this study, we developed BLBC-BM mouse models featuring different patterns of BMs and explored the versatility of estem cell (SC)-mediated bi-functional EGFR and DR4/5-targeted treatment in these models. Most BLBC lines demonstrated a high sensitivity to EGFR and DR4/5 bi-targeting therapeutic protein, E_VDR_L [anti-EGFR VHH (E_V) fused to DR ligand (DR_L)]. Functional analyses using inhibitors and CRISPR-Cas9 knockouts revealed that the E_V domain facilitated in augmenting DR4/5-DR_L binding and enhancing DR_L-induced apoptosis. E_VDR_L secreting stem cells alleviated tumor-burden and significantly increased survival in mouse models of residual-tumor after macrometastasis resection, perivascular niche micrometastasis, and leptomeningeal metastasis. This study reports mechanism based simultaneous targeting of EGFR and DR4/5 in BLBC and defines a new treatment paradigm for treatment of BM.

Predictors of leptomeningeal disease following hypofractionated stereotactic radiotherapy for intact and resected brain metastases

BACKGROUND

The objective was to evaluate the risk and predictors of developing leptomeningeal disease (LMD) in patients with brain metastases treated with 5-fraction hypofractionated stereotactic radiotherapy (HSRT).

METHODS

Patients treated with HSRT for intact brain metastases and/or surgical cavities were reviewed from a prospectively maintained database. Radiographic patterns of LMD were classified as focal classical, diffuse classical, focal nodular, and diffuse nodular.

RESULTS

HSRT was delivered, most commonly 30 Gy in 5 fractions, to 320 intracranial lesions (57% intact and 43% surgical cavities) in 235 patients. The median follow-up was 13.4 months (range, 0.8 to 60 mo). LMD developed in 19% of patients with a 1-year LMD rate of 12%. From the diagnosis of LMD, the median overall survival (OS) was 3.8 months (range, 2-20.8 mo). The most common LMD pattern was diffuse nodular (44%). No difference in OS was observed between LMD patterns (P = 0.203). Multivariable analysis identified surgical cavities at significantly higher risk of LMD compared with intact lesions (odds ratio [OR] = 2.30, 95% CI: 1.24, 4.29, P = 0.008). For cavities, radiosensitive tumors (OR = 2.35, 95% CI: 1.04, 5.35, P = 0.041) predicted for LMD, while, for intact metastases, patients receiving treatment with targeted agents or immunotherapy (TA/I) were at lower risk (OR = 0.178, 95% CI: 0.04, 0.79, P = 0.023).

CONCLUSIONS

Patients who had a brain metastasis resected were at an increased risk of LMD. OS was poor despite treatment of LMD, and no differences in OS based on the pattern of LMD was observed. Treatment with TA/I was observed to be protective against LMD and requires further study.

Clinical trial of proton craniospinal irradiation for leptomeningeal metastases

BACKGROUND

Leptomeningeal metastases (LM) are associated with limited survival and treatment options. While involved-field radiotherapy is effective for local palliation, it lacks durability. We evaluated the toxicities of proton craniospinal irradiation (CSI), a treatment encompassing the entire central nervous system (CNS) compartment, for patients with LM from solid tumors.

METHODS

We enrolled patients with LM to receive hypofractionated proton CSI in this phase I prospective trial. The primary endpoint was to describe treatment-related toxicity, with dose-limiting toxicity (DLT) defined as any radiation-related grade 3 non-hematologic toxicity or grade 4 hematologic toxicity according to the Common Terminology Criteria for Adverse Events that occurred during or within 4 weeks of completion of proton CSI. Secondary endpoints included CNS progression-free survival (PFS) and overall survival (OS).

RESULTS

We enrolled 24 patients between June 2018 and April 2019. Their median follow-up was 11 months. Twenty patients were evaluable for protocol treatment-related toxicities and 21 for CNS PFS and OS. Two patients in the dose expansion cohort experienced DLTs consisted of grade 4 lymphopenia, grade 4 thrombocytopenia, and/or grade 3 fatigue. All DLTs resolved without medical intervention. The median CNS PFS was 7 months (95% CI: 5-13) and the median OS was 8 months (95% CI: 6 to not reached). Four patients (19%) were progression-free in the CNS for more than 12 months.

CONCLUSION

Hypofractionated proton CSI using proton therapy is a safe treatment for patients with LM from solid tumors. We saw durable disease control in some patients.

Health care resource utilization and treatment of leptomeningeal carcinomatosis in the United States

Background

The economic burden of cancer in the United States is substantial, and better understanding it is essential in informing health care policy and innovation. Leptomeningeal carcinomatosis (LC) represents a late complication of primary cancer spreading to the leptomeninges.

Methods

The IBM MarketScan Research databases were queried for adults diagnosed with LC from 2001 to 2015, secondary to 4 primary cancers (breast, lung, gastrointestinal, and melanoma). Health care resource utilization (HCRU) and treatment utilization were quantified at baseline (1-year pre-LC diagnosis) and 30, 90, and 365 days post-LC diagnosis.

Results

We identified 4961 cases of LC (46.3% breast cancer, 34.8% lung cancer, 13.5% gastrointestinal cancer, and 5.4% melanoma). The median age was 57.0 years, with 69.7% female and 31.1% residing in the South. Insurance status included commercial (71.1%), Medicare (19.8%), and Medicaid (9.1%). Median follow-up was 66.0 days (25th percentile: 24.0, 75th percentile: 186.0) and total cumulative costs were highest for the gastrointestinal subgroup ($167 768) and lowest for the lung cancer subgroup ($145 244). There was considerable variation in the 89.6% of patients who used adjunctive treatments at 1 year, including chemotherapy (64.3%), radiotherapy (57.6%), therapeutic lumbar puncture (31.5%), and Ommaya reservoir (14.5%). The main cost drivers at 1 year were chemotherapy ($62 026), radiation therapy ($37 076), and specialty drugs ($29 330). The prevalence of neurologic impairments was 46.9%, including radiculopathy (15.0%), paresthesia (12.3%), seizure episode/convulsive disorder not otherwise specified (11.0%), and ataxia (8.0%).

Conclusions

LC is a devastating condition with an overall poor prognosis. We present the largest study of LC in this real-world study, including current treatments, with an emphasis on HCRU. There is considerable variation in the treatment of LC and significant health care costs.

T2-SPACE imaging of the cauda equina for the assessment of leptomeningeal metastatic disease

The diagnosis of leptomeningeal metastatic disease (LMD) is frequently challenging and MRI of the spine is an important part of the diagnostic paradigm. We sought to examine the value of adding 3-dimensional, heavily T2-weighted, Sampling Perfection with Application optimised Contrasts using different flip angle Evolution (T2-SPACE) imaging of the lumbar spine to the MRI protocol for patients with suspected LMD. MRI spine examinations including T2-SPACE imaging of the lumbar spine performed for suspected or known LMD were retrospectively reviewed by a neuroradiologist to determine the additional benefit of the T2-SPACE sequence. The accuracy of T2-SPACE was also compared to contrast-enhanced T1-weighted imaging (ceT1WI) and standard T2-weighted imaging (T2WI). 59 patients with T2-SPACE were identified over a 20-month period, 17 having abnormal appearances on ceT1WI, including 12 with appearances consistent with LMD. In eight of these 12 patients, nodules visible on T2-SPACE were visible on T2WI, though T2-SPACE improved the temporal comparison of slowly progressive cauda equina nodules in two cases. In three patients, T2-SPACE identified nodules which were not readily identifiable on T2WI, though were visible on ceT1WI. In one patient, LMD visible on ceT1WI was not appreciable on T2-SPACE or T2WI due to the lack of a nodular component. In six patients, T2WI showed equivocal nodularity, which could be confidently attributed to facet joint arthropathy or a tortuous vessel. In conclusion, T2-SPACE has high sensitivity and specificity for the detection of nodular lesions of the cauda equina and can confidently characterise equivocal findings on standard T2WI.

Diagnosing Primary Malignancy in Leptomeningeal Carcinomatosis by Using CSF Cytology and Immunohistochemistry: A Case Report

We present a rare case of recurrent carcinoma of gallbladder with leptomeningeal carcinomatosis. Cerebrospinal fluid (CSF) cytology showed atypical cells, which were suspicious for malignancy on initial reporting. Diagnosis of malignancy and primary from hepatobiliary source was confirmed by doing immunohistochemistry on CSF cell block.

High Cell-Free DNA Levels in Cerebrospinal Fluid Predict Leptomeningeal Seeding of Hematologic Malignancy

Background and Purpose

The main difficulty when diagnosing leptomeningeal metastases (LMSs) is the low sensitivity of cytology. Cancer cells release cell-free DNA (cfDNA) during proliferation and apoptosis, and so we analyzed the cfDNA level as a biomarker for LMSs in hematologic malignancy.

Methods

This study prospectively enrolled 20 patients with hematologic malignancy who underwent cerebrospinal fluid (CSF) analysis. LMS was diagnosed based on both CSF cytology and clinical findings.

Results

The CSF level of cfDNA was higher in patients with LMSs (108.17±84.84 ng/mL, mean±standard deviation) than in non-LMS patients (14.23±2.78 ng/mL). The sensitivity of cfDNA was higher than that of cytology (100% vs. 87%).

Conclusions

The cfDNA level in the CSF can be used as a supplemental marker for diagnosing LMS in hematologic malignancy patients.

Knockdown of IKKβ Inhibits Tumor Development in a Leptomeningeal Metastasis Mouse Model and Proliferation of Lung Cancer Cells

Objective

This study will explore the role of IKKβ in the leptomeningeal metastasis (LM) of lung cancer cells.

Methods

In vitro studies were conducted in mouse Lewis lung carcinoma (LLC) cells with IKKβ knockdown. Cell proliferation was explored using CCK-8 and tumor colony-forming assays. The expression of the extracellular signal-regulated kinase (ERK) signaling pathway was detected by Western blot. Tumor cell apoptosis was identified through Western blot detection of Bax and Bcl-2. The migration of tumor cells was identified by a wound healing assay. In vivo studies used an LM mouse model developed by injecting LLC cells with or without IKKβ knockdown into the cisterna magna. Mouse brain and spinal samples were sectioned for hematoxylin and eosin staining.

Results

In vitro: IKKβ knockdown inhibits tumor cell proliferation, initiates apoptosis, and attenuates cell migration. In vivo: IKKβ knockdown inhibits tumor growth in the LM mouse model. In addition, the in vitro results showed that IKKβ knockdown attenuated the expression of ERK phosphorylation in LLC cells.

Conclusion

Blocking the NF-κB signaling pathway by IKKβ knockdown in LLC cells inhibited tumor growth in the LM mouse model. IKKβ supports leptomeningeal tumor progression by promoting cancer cell proliferation and migration and inhibiting cancer cell apoptosis, and these actions may be correlated to ERK signaling.

αvβ8 integrin adhesion and signaling pathways in development, physiology and disease

Cells must interpret a complex milieu of extracellular cues to modulate intracellular signaling events linked to proliferation, differentiation, migration and other cellular processes. Integrins are heterodimeric transmembrane proteins that link the extracellular matrix (ECM) to the cytoskeleton and control intracellular signaling events. A great deal is known about the structural and functional properties for most integrins; however, the adhesion and signaling pathways controlled by αvβ8 integrin, which was discovered nearly 30 years ago, have only recently been characterized. αvβ8 integrin is a receptor for ECM-bound forms of latent transforming growth factor β (TGFβ) proteins and promotes the activation of TGFβ signaling pathways. Studies of the brain, lung and immune system reveal that the αvβ8 integrin-TGFβ axis mediates cell-cell contact and communication within complex multicellular structures. Perturbing components of this axis results in aberrant cell-cell adhesion and signaling leading to the initiation of various pathologies, including neurodegeneration, fibrosis and cancer. As discussed in this Review, understanding the functions for αvβ8 integrin, its ECM ligands and intracellular effector proteins is not only an important topic in cell biology, but may lead to new therapeutic strategies to treat human pathologies related to integrin dysfunction.

Leptomeningeal Disease as a Rare Complication of Primary Penile Urethral Cancer

Primary penile urethral cancer is a rare genitourinary malignancy arising from the epithelial lining of the urethra. Our patient is a 63-year-old male with newly diagnosed penile urethral carcinoma who presented with headache and was found to have leptomeningeal disease on imaging and cerebral spinal fluid analysis. He was treated with systemic and intrathecal chemotherapy with some response and improvement in symptoms. This is the first reported case of leptomeningeal disease as a complication of penile urethral carcinoma. Recognition and prompt treatment are important; however, overall prognosis of this entity remains poor.

Neoplastic meningitis in solid tumours: Updated review of diagnosis, prognosis, therapeutic management, and future directions

Neoplastic meningitis (NM) is a relatively frequent metastatic complication of cancer associated with high levels of neurological morbidity and generally poor prognosis. It appears in 5%-15% of patients with solid tumours, the most frequent being breast and lung cancer and melanoma. Symptoms are caused by involvement of the cerebral hemispheres, cranial nerves, spinal cord, and nerve roots, and are often multifocal or present with signs and symptoms of intracranial hypertension. The main diagnostic tools are the neurological examination, brain and spinal cord contrast-enhanced magnetic resonance imaging, and cerebrospinal fluid analysis including cytology, although studies have recently been conducted into the detection of tumour cells and DNA in the cerebrospinal fluid, which increases diagnostic sensitivity. With the currently available therapies, treatment aims not to cure the disease, but to delay and ameliorate the symptoms and to preserve quality of life. Treatment of NM involves a multimodal approach that may include radiotherapy, intrathecal and/or systemic chemotherapy, and surgery. Treatment should be individualised, and is based mainly on clinical practice guidelines and expert opinion. Promising clinical trials are currently being conducted to evaluate drugs with molecular and immunotherapeutic targets. This article is an updated review of NM epidemiology, clinical presentation, diagnosis, prognosis, management, and treatment; it is aimed at general neurologists and particularly at neurologists practicing in hospital settings with oncological patients.

Therapeutic management of neuro-oncologic patients - potential relevance of CSF liquid biopsy

Background: In the era of precision medicine, cancer treatment is increasingly tailored according to tumor-specific genomic alterations. The analysis of tumor-derived circulating nucleic acids in cerebrospinal fluid (CSF) by next generation sequencing (NGS) may facilitate precision medicine in the field of CNS cancer. We therefore evaluated whether NGS from CSF of neuro-oncologic patients reliably detects tumor-specific genomic alterations and whether this may help to guide the management of patients with CNS cancer in clinical practice.

Patient and methods: CSF samples from 27 patients with various primary and secondary CNS malignancies were collected and evaluated by NGS using a targeted, amplicon-based NGS-panel (Oncomine Focus Assay). All cases were discussed within the framework of a molecular tumor board at the Comprehensive Cancer Center Munich.

Results: NGS was technically successful in 23/27 patients (85%). Genomic alterations were detectable in 20/27 patients (74%), 11/27 (40%) of which were potentially actionable. After discussion in the MTB, a change of therapeutic management was recommended in 7/27 (26%) of the cases. However, due to rapid clinical progression, only 4/27 (15%) of the patients were treated according to the recommendation. In a subset of patients (6/27, 22%), a high number of mutations of unknown significance suggestive of a high tumor mutational burden (TMB) were detected.

Conclusions: NGS from cerebrospinal fluid is feasible in routine clinical practice and yields therapeutically relevant alterations in a large subset of patients. Integration of this approach into a precision cancer medicine program might help to improve therapeutic options for patients with CNS cancer.

Osimertinib for Patients With Leptomeningeal Metastases Associated With EGFR T790M-Positive Advanced NSCLC: The AURA Leptomeningeal Metastases Analysis

INTRODUCTION

Osimertinib has shown promising activity in patients with leptomeningeal metastases (LMs) of EGFR-positive NSCLC at 160 mg once daily (qd) (BLOOM; NCT02228369). We report LM activity with osimertinib (80 mg qd) in a retrospective analysis of studies across the AURA program (AURA extension, AURA2, AURA17, and AURA3).

METHODS

Patients with EGFR T790M-positive advanced NSCLC and progression after previous EGFR-tyrosine kinase inhibitor therapy received osimertinib (80 mg qd). Patients with central nervous system (CNS) metastases (including LMs) were eligible if the lesions were neurologically asymptomatic and stable. Patients with evidence of LMs at the study entry were retrospectively included for the analysis; brain scans were assessed for radiologic LM response by neuroradiologically blinded, independent central review per the modified Response Assessment in Neuro-Oncology LM criteria. LM objective response rate, duration of response, progression-free survival, and overall survival were assessed. A longitudinal analysis was performed to investigate the relationship between changes from the baseline in non-CNS tumor sizes and LM responses at each visit of patients in AURA LM and BLOOM studies.

RESULTS

For the 22 patients included in the analysis, LM objective response rate was 55% (95% confidence interval [CI]: 32-76). Median LM duration of response was not reached (95% CI: 2.8-not calculable [NC]). Median LM progression-free survival and overall survival were 11.1 months (95% CI: 4.6-NC) and 18.8 months (95% CI: 6.3-NC), respectively. The longitudinal analysis revealed similar non-CNS and LM responses between the patients in AURA LM and BLOOM programs.

CONCLUSIONS

Patients with EGFR T790M-positive NSCLC and radiologically detected LM obtained clinical benefit from osimertinib (80 mg qd).

Simultaneous primary cancer occurrence of melanoma and pulmonary adenocarcinoma in leptomeningeal metastases: a case report

Background

Leptomeningeal metastasis (LM) is a predominantly late stage, devastating complication of a variety of malignant solid tumors. Diagnosis relies predominantly on neurological, radiographic, and cerebrospinal fluid (CSF) assessments. Recently, liquid biopsy tests derived from CSF has shown to be a feasible, noninvasive promising approach to tumor molecular profiling for proper brain cancer diagnostic treatment, thereby providing an opportunity for CSF-based personalized medicine. However, LM is typically misleadingly assumed to originate from only one primary tumor type.

Case presentation

In this case report, we provide first evidence of the co-occurrence of LM originating from more than one primary tumor types.

Discussion and conclusions

Based on this patient case profile, the co-occurrence of LM from two or more primary tumor types should be accounted for when deriving diagnostic conclusions from liquid biopsy tests.

Leptomeningeal Metastases in Renal Cell Carcinoma at Initial Diagnosis: 2 Case Reports and Literature Review

Leptomeningeal metastasis (LM) in solid tumors are rare, even more in renal cell carcinoma (RCC). To date there is a lack of consensual treatment modalities of leptomeningeal metastasis. Furthermore, with the improvement of outcomes and more effective systemic targeted therapies, the management of leptomeningeal metastasis becomes a real challenge. We here report two cases of RCC with leptomeningeal metastasis at initial diagnosis. Both patients had concurrent adjacent skull bone metastasis. Therapeutic management of both patients consisted in surgical resection, followed by radiotherapy in one case. Systemic treatment was delayed according to current recommendations for the management of metastatic RCC. The aim of this work is to report the therapeutic approach and related outcomes and also provide a review of the currently available literature on leptomeningeal disease in renal cell carcinoma. Indeed, local treatment with curative outcome of meningeal location in RCC should be performed specially in LM at initial diagnosis.

Marine-Derived Anticancer Agents: Clinical Benefits, Innovative Mechanisms, and New Targets

The role of the marine environment in the development of anticancer drugs has been widely reviewed, particularly in recent years. However, the innovation in terms of clinical benefits has not been duly emphasized, although there are important breakthroughs associated with the use of marine-derived anticancer agents that have altered the current paradigm in chemotherapy. In addition, the discovery and development of marine drugs has been extremely rewarding with significant scientific gains, such as the discovery of new anticancer mechanisms of action as well as novel molecular targets. Approximately 50 years since the approval of cytarabine, the marine-derived anticancer pharmaceutical pipeline includes four approved drugs and eighteen agents in clinical trials, six of which are in late development. Thus, the dynamic pharmaceutical pipeline consisting of approved and developmental marine-derived anticancer agents offers new hopes and new tools in the treatment of patients afflicted with previously intractable types of cancer.

Complications of Intrathecal Chemotherapy in Adults: Single-Institution Experience in 109 Consecutive Patients

Acute lymphoblastic leukemia and other aggressive lymphoid malignancies like Burkitt leukemia/lymphoma have high incidence of central nervous system (CNS) involvement. Various solid tumors, most notably breast cancer, can also metastasize into the CNS as a late stage complication causing devastating effects. Intrathecal (IT) chemotherapy consisting of methotrexate, cytarabine, or the two in combination is frequently used for the prophylaxis and treatment of CNS metastasis. Because of the high toxicity of these chemotherapeutic agents, however, their side effect profiles are potentially catastrophic. The incidence of neurotoxicity secondary to IT chemotherapy is well defined in the pediatric literature but is poorly reported in adults. Here, we investigated the incidence of neurologic and nonneurologic side effects secondary to IT chemotherapy in 109 consecutive adult patients over a two-year time period at hospitals associated with our institution. Of 355 IT chemotherapy treatments received by these patients, 11 (3.10%) resulted in paresthesias or paralysis, which we defined as significant neurologic events in our analysis. We also examined minor events that arose after IT chemotherapy, including back pain, headache, fever, vomiting, and asthenia. At least one of these occurred after 30.70% of IT chemotherapy doses. Clinicians involved in the care of patients receiving IT chemotherapy should be aware of these findings and consider treatment options lower rate of neurotoxicity such as high-dose systemic methotrexate.

Leptomeningeal Carcinomatosis: A Case Report of Metastatic Triple-negative Breast Adenocarcinoma

A 55-year-old female presented to the emergency department with seizures, left hemiparesis, and memory loss. Her past medical history was notable for a right triple-negative breast adenocarcinoma that was diagnosed approximately two years prior. She underwent treatment with chemotherapy, right breast lumpectomy, and radiation near her rural hometown. Radiologic studies were performed in the emergency department. Brain imaging revealed a new 2-cm mass in the left breast and a 4-cm left frontal lobe brain lesion. She underwent an urgent craniotomy. Immunohistochemical staining of the brain tumor tissue suggested metastatic triple-negative breast adenocarcinoma. She was discharged with recommendations to follow up with her prior oncologist near her home for systemic chemotherapy. Three months after metastatic breast cancer to the brain was diagnosed, the patient experienced headaches, fever, and nuchal rigidity. MRI of the brain showed new leptomeningeal enhancement. A lumbar puncture with a cerebrospinal fluid analysis revealed the presence of malignant cells. Together with imaging and cerebrospinal fluid findings, leptomeningeal carcinomatosis was diagnosed. This case report presents an uncommon but well-known complication of breast cancer.

A molecular graded prognostic assessment (molGPA) model specific for estimating survival in lung cancer patients with leptomeningeal metastases

OBJECTIVES

Leptomeningeal metastases (LM) had increased in advanced non-small-cell lung cancer (NSCLC) over the last 10 years. The survival outcome remained overall poor, heterogeneous and was reported in association with genotypes in lung cancer patients with LM. Graded prognostic assessment model integrated with molecular alterations (molGPA) might be accurate for outcome prediction of LM patients, but needs to be established.

MATERIALS AND METHODS

We retrospectively screened 8921 consecutive lung cancer patients from January 2011 to March 2018. A total of 301 patients diagnosed as LM were enrolled, and randomly divided into training and validation sets after stratified by gender and age. A molGPA score for each patient was calculated based on the weighted significant parameters including gene mutations.

RESULT

The median OS for the 301 patients was 9.2 months (95%CI: 7.9-10.5). In the training set, EGFR/ALK positivity, Karnofsky performance score (KPS) score≥60 and absence of extracranial metastasis (ECM) independently predicted better OS. We developed a molGPA model based on above significant prognostic factors. This molGPA model classified LM patients into three prognosis groups of high, intermediate and low risk (molGPA score of 0, 0.5-1.0 and 1.5-2.0, respectively. The median OS of high, intermediate and low risk LM patients in the training set was 0.3, 3.5 and 15.9 months, respectively (p < 0.001). In the validation set, the median OS was 0.9, 5.8 and 17.7 months in the three molGPA subgroups, accordingly (p < 0.001). The C-index of this model in training and validation sets was 0.70 (95%CI: 0.66-0.73) and 0.64 (95%CI: 0.58-0.70) respectively.

CONCLUSION

The LM molGPA model with integration of gene status, KPS and ECM can accurately classify lung cancer patients with LM into diverse prognosis.

A Novel Implantable Cerebrospinal Fluid Reservoir : A Pilot Study

Objective

The purpose of this pilot study was to examine the safety and function of the newly developed cerebrospinal fluid (CSF) reservoir called the V-Port.

Methods

The newly developed V-Port consists of a non-collapsible reservoir outlined with a titanium cage and a connector for the ventricular catheter to be assembled. It is designed to be better palpated and more durable to multiple punctures than the Ommaya reservoir. A total of nine patients diagnosed with leptomeningeal carcinomatosis were selected for V-Port insertion. Each patient was followed up for evaluation for a month after the operation.

Results

The average operation time for V-Port insertion was 42 minutes and the average incision size was 6.6 cm. The surgical technique of V-Port insertion was found to be intuitive by all neurosurgeons who participated in the pilot study. There was no obstruction or leakage of the V-Port during intrathecal chemotherapy or CSF drainage. Also, there were no complications including post-operative intracerebral hemorrhage, infection and skin problems related to the V-Port.

Conclusion

V-Port is a safe and an easy to use implantable CSF reservoir that addresses problems of other implantable CSF reservoirs. Further multicenter clinical trial is needed to prove the safety and the function of the V-Port.

Application of 3D Fast Spin-Echo T1 Black-Blood Imaging in the Diagnosis and Prognostic Prediction of Patients with Leptomeningeal Carcinomatosis

BACKGROUND AND PURPOSE

Contrast-enhanced 3D fast spin-echo T1 black-blood imaging selectively suppresses the signal of blood flow and could provide a higher contrast-to-noise ratio compared with contrast-enhanced 3D ultrafast gradient recalled echo (contrast-enhanced gradient recalled echo) and 2D spin-echo T1WI (contrast-enhanced spin-echo). The purpose of our study was to evaluate whether black-blood imaging can improve the diagnostic accuracy for leptomeningeal carcinomatosis compared with contrast-enhanced gradient recalled-echo and contrast-enhanced spin-echo and, furthermore, to determine whether the grade of leptomeningeal carcinomatosis evaluated on black-blood imaging is a significant predictor of progression-free survival.

MATERIALS AND METHODS

Leptomeningeal carcinomatosis (n = 78) and healthy (n = 31) groups were enrolled. Contrast-enhanced gradient recalled-echo, contrast-enhanced spin-echo, and black-blood imaging were separately reviewed, and a diagnostic rating (positive, indeterminate, or negative) and grading of leptomeningeal carcinomatosis were assigned. The diagnostic accuracies of the 3 imaging sequences were compared in terms of leptomeningeal carcinomatosis detection. The Kaplan-Meier and the Cox proportional hazards model analyses were performed to determine the relationship between the leptomeningeal carcinomatosis grade evaluated on black-blood imaging and progression-free survival.

RESULTS

Black-blood imaging showed a significantly higher sensitivity (97.43%) than contrast-enhanced gradient recalled-echo (64.1%) and contrast-enhanced spin-echo (66.67%) (P < .05). In terms of specificities, we did not find any significant differences among contrast-enhanced gradient recalled-echo (90.32%), contrast-enhanced spin-echo (90.32%), and black-blood imaging (96.77%) (P > .05). A Cox proportional hazards model identified the time to metastasis, Karnofsky Performance Scale status, and a combination of the leptomeningeal carcinomatosis grade with a linear pattern as independent predictors of progression-free survival (P < .05).

CONCLUSIONS

Black-blood imaging can improve the diagnostic accuracy and predict progression-free survival in patients with leptomeningeal carcinomatosis.

Great efficacy of bevacizumab plus erlotinib for leptomeningeal metastases from non-small cell lung cancer with initially positive EGFR mutation: a case report

Leptomeningeal metastases (LMs) were devastating metastatic complications of non-small cell lung cancer (NSCLC). Management of LMs relied on conventional therapy but with poor survival, lacking effective treatment strategies. We present the case of a 52-year-old female non-smoker with advanced lung adenocarcinoma and initially positive EGFR-mutation, who failed to the treatment of standard first-line chemotherapy (pemetrexed plus cisplatin) and bevacizumab (BEV), and maintenance therapy with pemetrexed plus BEV. Under the progression-free survival of 6 months, suffered from LMs, then erlotinib combined with BEV were delivered, and symptoms were significantly alleviated, remained stable and even relieved slightly for at least 18 months. The combination of bevacizumab and erlotinib could be an optional effective management strategy for patients with LMs from NSCLC and harboring EGFR-mutation.

Management of Leptomeningeal Metastases in Non-oncogene Addicted Non-small Cell Lung Cancer

Brain metastases in non-small cell lung cancer (NSCLC) patients are more often detected due to imaging modalities improvements but also emerge because of improved treatments of the primary tumor which lead to a longer survival. In this context, development of leptomeningeal metastases (LM) is a devastating complication and its prognosis remains poor despite advances in systemic and local approaches. Histology characterization of NSCLC and molecular expression influence LM management. For those with “oncogene addiction,” new generation epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) tyrosine kinase inhibitors (TKIs) were developed to strongly penetrate the blood-brain barrier (BBB) with the aim to prevent central nervous system cancer dissemination, eventually impacting on LM appearance and its subsequent management. Systemic chemotherapy, often combined with intrathecal chemotherapy (when possible), was one of common indications for lung cancer patients affected by LM, without driver mutations and a good performance status but currently, with the advent of innovative systemic approaches treatment solutions in this subgroup of patients are rapidly evolving. Whole brain radiation therapy (WBRT) is the conventional treatment for patients with brain metastases. Furthermore, modern radiation techniques, as stereotactic radiotherapy (SRT), improve outcomes in those cases with a limited number of lesions. However, LM represent a minority of CNS metastases and few literature data are available to drive the radiotherapy approach. Considering all relevant progress made in this setting, after a literature review, the aim of this paper is to discuss about recent developments and therapeutic options in LM management of non-oncogene addicted NSCLC.

Seminoma with Neoplastic Meningitis Treated with Craniospinal Irradiation

Pure seminoma is a histological subtype of testicular cancer that accounts for 50% of testicular germ cell tumors. It has a very low rate of metastasis to the central nervous system, with only one previously reported case of neoplastic meningitis (cancer that has spread to the cerebrospinal fluid). Traditionally, neoplastic meningitis has an ominous prognosis when associated with primary tumors that commonly spread to the leptomeninges, like breast and lung. This article highlights a unique case of pure seminoma with neoplastic meningitis and illustrates the effectiveness of craniospinal irradiation as a treatment modality.

Cancer Pain Syndromes

Patients with cancer experience many acute and chronic pain syndromes, the identification of which may be helpful in the assessment and treatment of pain. Syndromes are defined by the relationship with the cancer, the pain pathophysiology, and the clinical characteristics of the pain. The most common pain syndromes are directly related to the tumor; bone pain syndromes are most common. Neuropathic pain syndromes may involve cancer-related injury at any level of the peripheral nervous system. Treatment-related pain syndromes may follow any type of antineoplastic therapy. This article reviews the phenomenology of common acute and chronic cancer pain syndromes.

Rapid symptomatic relief of HER2-positive gastric cancer leptomeningeal carcinomatosis with lapatinib, trastuzumab and capecitabine: a case report

BACKGROUND

Gastric cancer patients with widespread metastasis, especially meningeal metastases, have an extremely prognosis and limited therapeutic choices.

CASE PRESENTATION

We reported the case of a 39-year-old male patient with HER2-positive gastric cancer with bone and meningeal metastases. He presented with multiple bone metastases and received 3 cycles of docetaxel plus S1. However, he complained with headache and imaging examinations revealed leptomeningeal carcinomatosis. FISH revealed that tumor cells in the cerebrospinal fluid were HER-positive. Herceptin was added to the regimen, but the symptoms were not relieved, the patient suffered from dizziness and nausea. The chemotherapy regimen was switched d to lapatinib (orally at 1250 mg/day, every day), capecitabine (orally at 1000 mg/m2, bid for 2 weeks, followed by a 1-week rest interval, as 1 cycle) and Herceptin (390 mg/3 weeks). After 3 weeks of the new treatment, all the symptoms relieved. The clinical complete response was maintained for 3 months.

CONCLUSIONS

Lapatinib/Capecitabine combination therapy is an alternative treatment strategy for leptomeningeal carcinomatosis of HER2-positive gastric cancer in which trastuzumab and/or chemotherapy essentially has no effect.

Intracranial Leptomeningeal Carcinomatosis: A Diagnostic Study with 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography

Leptomeningeal carcinomatosis (LC) diagnosis is based on cerebrospinal fluid (CSF) cytological analysis and contrast-enhanced magnetic resonance imaging (MRI); however, low sensitivity was evidenced in some cases delaying prompt and adequate treatments. Brain ¹⁸F-fluorodeoxyglucose positron emission tomography (¹⁸F-FDG PET) was also employed in doubtful cases. We retrospectively described 4 suspected LC cases with uncertain or undetectable MRI and initially negative CSF cytology. Whole-body (WB) and brain ¹⁸F-FDG PET/computed tomography (CT) were used, the latter showing intracranial tracer uptakes suspected for LC in 3/4 cases. In 2 of these 3 cases, WB scan also evidenced spinal cord lesion and pulmonary tumor, respectively, while both procedures were true negative in the fourth case. CSF cytology became positive after repeated exams in the 3 PET/CT-positive cases. In 1 of these 3 patients, it was also confirmed at MRI, while it stayed negative in the remaining PET/CT-negative case with uncertain MRI. ¹⁸F-FDG PET/CT could be a useful supportive diagnostic tool in doubtful intracranial and spinal LC.

Overview of metastatic disease of the central nervous system

In 2016, the American Society of Clinical Oncology reported that 1.7 million Americans were diagnosed with cancer; this number will rise to 2.3 million in the United States and 22 million worldwide in 2030. This rising need is being met by an explosion of new cancer therapies, including: immune checkpoint inhibitors, T-cell therapies, tumor vaccines, antiangiogenic therapies, and various targeted therapies. This armamentarium of targeted therapies has led to better systemic control of disease and longer patient overall survival (OS). The incidence of metastatic disease to the central nervous system (CNS) is rising as patients are living longer with these more effective systemic therapies. Prolonged OS allows increased time to develop CNS metastases. The CNS is also a sanctuary for metastatic tumor cells that are protected from full exposure to therapeutic concentrations of most anticancer agents by the blood-brain barrier, the tumor microenvironment, and immune system. In addition, CNS metastases often develop late in the course of the disease, so patients are frequently heavily pretreated, resulting in drug resistance. Although genomic profiling has led to more effective therapies for systemic disease, the same therapy may not be effective in treating CNS disease, not only due to failure of blood-brain barrier penetration, but from discordance between the molecular profile in systemic and CNS tumor.

Clinical significance of detecting CSF-derived tumor cells in breast cancer patients with leptomeningeal metastasis

Despite marked advances in breast cancer therapy, breast cancer-associated leptomeningeal metastasis (LM), a particularly aggressive syndrome with multifocal seeding of the leptomeninges by tumor cells, still carries an abysmal prognosis. A major problem with breast cancer LM surveillance is the lack of an effective and sensitive means to track dynamic changes of the disease. Cytology detection of cerebrospinal fluid (CSF) is considered the gold standard for LM diagnosis but has a high false-negative rate with a limited sensitivity. Here we applied subtraction enrichment and immunostaining-fluorescence in situ (SE-i•FISH) method, a technique previously used for isolating circulating tumor cells (CTCs) from the peripheral blood, to detect, enumerate, and track cerebrospinal fluid-derived tumor cells (CSFTCs) in CSF samples from 8 breast cancer patients. Comparing with cytology test, we found SE-i•FISH method can accurately and feasibly detect CSFTCs for the diagnosis of breast cancer-associated LM and monitor the disease progression. We also isolated and cultured CSFTCs from these cancer patients and performed genomic sequencing on CSFTCs of two patients. Genomic analysis of CSFTCs against corresponding archival primary breast tumors revealed clonal relationships with some ongoing evolution. Further drug sensitivity test on cultured CSFTCs based on genomic analysis data helped identify promising treatment options for the patient tested. Together, our results suggest that CSFTCs detection using SE-i•FISH platform could serve as a sensitive and accurate method to make the diagnosis and a promising approach to monitor tumor dynamics and treatment response for breast cancer-associated LM.

Postoperative radiosurgery for the treatment of metastatic brain tumor: Evaluation of local failure and leptomeningeal disease

In patients undergoing surgical resection of a metastatic brain tumor, whole brain radiation therapy reduces the risk of recurrence and neurologic death. Focal radiation has the potential to mitigate neurocognitive side effects. We present an institutional experience of postoperative radiosurgery for the treatment of brain metastases. A retrospective review of a prospectively maintained institutional radiosurgery database was performed for the years 2005-2015 identifying all adult patients treated with postoperative radiosurgery to the tumor bed. Primary endpoints include local recurrence and postoperative LMD. Kaplan-Meier curves and Cox regression were used to evaluate time to local recurrence and postoperative LMD. Ninety-one patients received adjuvant focal radiation for a brain metastasis. Median radiographic follow-up among patients who had not developed a local failure was 9 months. Of the 91 patients, 20 (22%) developed local recurrence and 32 (35%) experienced postoperative LMD. Freedom from local recurrence and LMD at 1 year was 84% and 69%, respectively. In multivariable models, predictors of local failure included the presence of more than one brain metastasis (HR = 2.65, p = .04) with a preoperative tumor diameter of >3 cm (HR = 4.16, p = .06) trending toward significance. There was a trend to a higher risk of LMD with >1 tumor (HR 2.07, p = .06) and breast cancer (HR 2.37, p = .07). More than one metastasis is an independent predictor of local and leptomeningeal failure following postoperative radiosurgery. The high rate of LMD was likely related to the liberal definition of LMD to include focal dural recurrences.

Leptomeningeal Carcinomatosis in Colorectal Cancer: The Mayo Clinic Experience

BACKGROUND

Leptomeningeal metastasis (LM) is an uncommon form of metastatic disease in many cancers. There remains a paucity of literature with regard to the course and management of LM in colorectal cancers (CRCs). The aim of this study was to estimate the incidence of LM in patients with CRC seen at our institution over a 15-year period, and to describe the clinical course and outcome of these cases.

METHODS

LM in CRC primary cases between 2000 and 2014 were identified in the Mayo Clinic databases. The charts were retrospectively reviewed.

RESULTS

Of 17,095 CRC primaries, we identified 10 patients with LM (0.058%) in this 15-year period. Nine cases were included in the analysis. Four had metastatic disease at the time of their initial CRC diagnosis. Median overall survival after CRC diagnosis was 25.7 months (range, 4.7-74.8 months). Median time to diagnosis of LM after CRC diagnosis was 25.3 months (range, 0-68.1 months). All patients had magnetic resonance imaging findings consistent with LM: 3 patients with spinal LM, 5 patients with intracranial LM, and 1 with both. Neurologic symptoms correlated with site of the lesions, with headache, cranial nerve palsy, lower extremity weakness, and gait disturbance among the most frequently reported. However, not all patients had neurologic findings, with LM lesions found incidentally in 2 cases. Seven patients (78%) had palliative radiotherapy for LM. Three patients continued to receive systemic chemotherapy after diagnosis of LM. Median survival after LM diagnosis was 7 weeks (range, 2-39 weeks).

CONCLUSIONS

LM is an exceedingly rare development in the natural course of CRC. It confers a poor prognosis with limited treatment options. At our institution, most patients had their disease addressed by palliative means, with many receiving radiotherapy to control their neurologic symptoms. Based on our series, supportive care remains a sensible approach to the management of LM in CRC.

Modernizing Clinical Trial Eligibility Criteria: Recommendations of the American Society of Clinical Oncology-Friends of Cancer Research Brain Metastases Working Group

Purpose Broadening trial eligibility to improve accrual and access and to better reflect intended-to-treat populations has been recognized as a priority. Historically, patients with brain metastases have been understudied, because of restrictive eligibility across all phases of clinical trials. Methods In 2016, after a literature search and series of teleconferences, a multistakeholder workshop was convened. Our working group focused on developing consensus recommendations regarding the inclusion of patients with brain metastases in clinical trials, as part of a broader effort that encompassed minimum age, HIV status, and organ dysfunction. The working group attempted to balance the needs of protecting patient safety, facilitating access to investigational therapies, and ensuring trial integrity. On the basis of input at the workshop, guidelines were further refined and finalized. Results The working group identified three key populations: those with treated/stable brain metastases, defined as patients who have received prior therapy for their brain metastases and whose CNS disease is radiographically stable at study entry; those with active brain metastases, defined as new and/or progressive brain metastases at the time of study entry; and those with leptomeningeal disease. In most circumstances, the working group encourages the inclusion of patients with treated/stable brain metastases in clinical trials. A framework of key considerations for patients with active brain metastases was developed. For patients with leptomeningeal disease, inclusion of a separate cohort in both early-phase and later-phase trials is recommended, if CNS activity is anticipated and when relevant to the specific disease type. Conclusion Expanding eligibility to be more inclusive of patients with brain metastasis is justified in many cases and may speed the development of effective therapies in this area of high clinical need.

Preclinical Modeling and Therapeutic Avenues for Cancer Metastasis to the Central Nervous System

Metastasis is the dissemination of cells from the primary tumor to other locations within the body, and continues to be the predominant cause of death among cancer patients. Metastatic progression within the adult central nervous system is 10 times more frequent than primary brain tumors. Metastases affecting the brain parenchyma and leptomeninges are associated with grave prognosis, and even after successful control of the primary tumor the median survival is a dismal 2-3 months with treatment options typically limited to palliative care. Current treatment options for brain metastases (BM) and disseminated brain tumors are scarce, and the improvement of novel targeted therapies requires a broader understanding of the biological complexity that characterizes metastatic progression. In this review, we provide insight into patterns of BM progression and leptomeningeal spread, outlining the development of clinically relevant in vivo models and their contribution to the discovery of innovative cancer therapies. In vivo models paired with manipulation of in vitro methods have expanded the tools available for investigators to develop agents that can be used to prevent or treat metastatic disease. The knowledge gained from the use of such models can ultimately lead to the prevention of metastatic dissemination and can extend patient survival by transforming a uniformly fatal systemic disease into a locally controlled and eminently more treatable one.

Chemical meningitis related to intra-CSF liposomal cytarabine

Therapeutic options of leptomeningeal metastases include intra-cerebrospinal fluid (CSF) chemotherapy. Among intra-CSF agents, liposomal cytarabine has advantages but can induce specific toxicities. A BRAF-V600E-mutated melanoma leptomeningeal metastases patient, treated by dabrafenib and liposomal cytarabine, presented after the first injection of liposomal cytarabine with hyperthermia and headaches. Despite sterile CSF/blood analyses, extended intravenous antibiotics were given and the second injection was delayed. The diagnosis of chemical meningitis was finally made. Dose reduction and appropriate symptomatic treatment permitted the administration of 15 injections of liposomal cytarabine combined with dabrafenib. A confirmation of the diagnosis of chemical meningitis is essential in order (1) not to delay intra-CSF or systemic chemotherapy or (2) to limit the administration of unnecessary but potentially toxic antibiotics.

Leptomeningeal disease: current diagnostic and therapeutic strategies

Leptomeningeal disease has become increasingly prevalent as novel therapeutic interventions extend the survival of cancer patients. Although a majority of leptomeningeal spread occurs secondary to breast cancer, lung cancer, and melanoma, a wide variety of malignancies have been reported as primary sources. Symptoms on presentation are equally diverse, often involving a combination of neurological deficits with the possibility of obstructive hydrocephalus. Diagnosis is definitively made via cerebrospinal fluid cytology for malignant cells, but neuro-imaging with high quality T1-weighted magnetic resonance imaging can aid diagnosis and localization. While leptomeningeal disease is still a terminal, late-stage complication, a variety of treatment modalities, such as intrathecal chemotherapeutics and radiation therapy, have improved median survival from 4–6 weeks to 3–6 months. Positive prognosticative factors for survival include younger age, high performance scores, and controlled systemic disease. In looking to the future, diagnostics that improve early detection and chemotherapeutics tailored to the primary malignancy will likely be the most significant advances in improving survival.

Efficacy of Liposomal Cytarabine in the Treatment of Leptomeningeal Metastasis of Breast Cancer

BACKGROUND

Breast cancer is one of the most frequent causes of leptomeningeal metastasis (LM) among solid tumors in adults. The prognosis of patients with LM is poor. A treatment option is the intrathecal administration of liposomal cytarabine.

CASE REPORTS

The first case represents a 53-year-old woman with LM of breast cancer. A neurological response was achieved shortly after the start of the multimodal treatment including intrathecal liposomal cytarabine. The response duration reached 79 days. The second case represents a 48-year-old woman with LM of breast cancer treated with intrathecal liposomal cytarabine as a part of a multimodal treatment approach. A neurological response was achieved in the first 2 weeks of treatment and is still lasting after 18 months.

CONCLUSION

These cases suggest that a rapid response to a prompt start of treatment with intrathecal liposomal cytarabine in patients with LM of breast cancer is feasible. In 1 case an extremely long progression-free survival (18+ months) was achieved. The cases support the efficacy of liposomal cytarabine in the management of LM in breast cancer patients as a part of a multimodal treatment approach and underline the need for further investigations in this specific cohort.

Metronomic Capecitabine Effectively Blocks Leptomeningeal Carcinomatosis From Breast Cancer: A Case Report and Literature Review

Patient: Female, 57

Final Diagnosis: Meningeal carcinomatosis from breast cancer

Symptoms: Seizures

Medication: —

Clinical Procedure: —

Specialty: Oncology