Treatment of central nervous system leukemia with intrathecal cytosine arabinoside

Relationship between Protein Binding and Extravascular drug Concentrations of a Water-soluble Drug, Cytosine Arabinoside

The degree of binding of a drug to plasma proteins has a marked effect on its distribution, elimination, and pharmacological effect. Since only the unbound fraction is available for distribution into extravascular space, the ratio of drug in cerebrospinal fluid (CSF) or saliva to that in plasma is often regarded as a physiological measure of the free fraction of a drug. CSF: plasma and saliva: plasma ratios of cytosine arabinoside (araC) have been measured in patients with acute leukaemia and found to be 0.1–0.28, implying a binding of 72–90%.

The protein binding of araC was measured by equilibrium dialysis in the plasma of patients with acute leukaemia at presentation. The mean binding ratio was 2.3 ± 6.8, implying that there was little or no protein binding. There was no correlation between alpha — 1 acid glycoprotein (AAG) levels and protein binding.

The low CSF and saliva: plasma araC ratios found, suggest that drugs such as araC which have low lipid solubility do not pass freely into extravascular space. Thus the CSF or saliva: plasma ratio cannot be considered a good physiological measure of protein binding for drugs with poor lipid solubility.

Intrathecal magnetic drug targeting using gold-coated magnetite nanoparticles in a human spine model

AIM

We aimed to magnetically guide and locally confine nanoparticles in desired locations within the spinal canal to achieve effective drug administration for improved treatment of chronic pain, cancers, anesthesia and spasticity.

MATERIALS & METHODS

We developed a physiologically and anatomically consistent in vitro human spine model to test the feasibility of intrathecal magnetic drug targeting. Gold-coated magnetite nanoparticles were infused into the model and targeted to specific regions using external magnetic fields. Experiments and simulations aiming to determine the effect of key parameters, such as magnet strength, duration of magnetic field exposure, magnet location and ferrous implants, on the collection efficiency of superparamagnetic nanoparticles in targeted regions were performed.

RESULTS

An 891% increase in nanoparticle collection efficiency within the target region was achieved using intrathecal magnetic drug targeting when compared with the control. Nanoparticle collection efficiency at the target region increased with time and reached a steady value within 15 min. Ferrous epidural implants generated sufficiently high-gradient magnetic fields, even when magnets were placed at a distance equal to the space between a patient's epidermis and spinal canal.

CONCLUSION

Our experiments indicate that intrathecal magnetic drug targeting is a promising technique for concentrating and localizing drugs at targeted sites within the spinal canal for treating diseases affecting the CNS.

Acute meningitis and cerebellar dysfunction complicating high-dose cytosine arabinoside therapy

A patient with acute lymphocytic leukemia (ALL) who was treated with high-dose cytosine arabinoside (Ara-C) 3 g/m2 twice daily, developed reversible acute aseptic meningitis and signs of cerebellar dysfunction after a total dose of 24 g Ara-C. To our knowledge this is the first case report of meningitis complicating intravenous high-dose Ara-C therapy.

Evaluation of osmolality and pH of various concentrations of methotrexate, cytarabine, and thiotepa prepared in normal saline, sterile water for injection, and lactated Ringer's solution for intrathecal administration

Background. Neurotoxicity of intrathecal (IT) chemotherapy has been variously attributed to the preservatives, volume, osmolality, and pH of the preparations. There has been little evaluation of how different drug concentrations or diluents can affect the osmolality and pH of the final solution. We conducted a three-part study: survey of cancer centers regarding the drug concentrations and diluent used in preparing IT chemotherapy; review of the literature on common practice of preparing IT chemotherapy; evaluation of the pH and osmolality of commonly used chemotherapy preparations for IT.

Method. We surveyed selected cancer centers to provide information on their standard volume, drug concentrations, and choice of diluents. MEDLINE was searched for clinical reports using the MeSH terms of `cytarabine,' `methotrexate,' or `thiotepa' with the subheading `Cerebrospinal fluid' and combined with `intrathecal' in all database fields. Data retrieved included the choice of diluent, volume, and/or drug concentration. We evaluated the pH and osmolality of methotrexate (1, 2, 5, and 10 mg/mL), cytarabine (2, 5, 10, and 25 mg/mL), and thiotepa (1, 2, and 5 mg/mL) in normal saline, sterile water for injection (SWFI), and lactated Ringer's solution.

Results. Nine centers were surveyed (seven in Canada, one in Australia, one in United Kingdom). Most centers used 5mL of preservative-free normal saline, irrespective of the drug or drug concentration used. Forty-four reports in the literature were reviewed. Most reported 5 mL of preservative-free normal saline. Most information on drug concentrations was provided for methotrexate, with an average concentration of about 1—2.5 mg/ mL. Cytarabine 0.4—20 mg/mL and thiotepa 1 mg/mL were also reported. In our in vitro evaluation, there was a trend of increased pH associated with increasing concentration of methotrexate and cytarabine. There was no apparent impact of thiotepa concentration on the pH values of the final preparations, irrespective of the diluent used. Except for cytarabine 10 and 25 mg/mL, all the tested solutions have pH within 10% of the physiologic range of CSF. There was a concentration-dependent change in osmolality with methotrexate and cytarabine preparations. Osmolality was increased with increased concentrations in all except methotrexate mixed in SWFI and thiotepa mixed in normal saline and lactated Ringer's solution. Except for some thiotepa solutions, all the tested solutions have osmolality within 10% of the physiologic range of CSF.

Conclusions. There is limited published literature on the potential impact of diluent and drug concentration on the pH and osmolality of IT chemotherapy preparation. Most cancer centers conventionally prepare IT chemotherapy with 5mL of preservative diluent normal saline, irrespective of the specific drug or dose used. The conventional practice means that most methotrexate preparations are likely to have comparable pH and osmolality to CSF. In contrast, cytarabine preparations may show significantly higher pH than the CSF, while thiotepa preparations generally have lower osmolality than the CSF. J Oncol Pharm Practice (2009) 15: 45—52.

Inflammatory mass lesions associated with intrathecal drug infusion catheters: report and observations on 41 patients

OBJECTIVE

Several reports have described inflammatory mass lesions at the tip of intraspinal drug administration catheters. We evaluated the number of patients reported with this condition and whether data support hypotheses that have been put forth regarding the cause of these lesions.

METHODS

Information that was reported in the medical literature, and by Medtronic, Inc., to the United States Food and Drug Administration as of November 30, 2000, was reviewed.

RESULTS

Forty-one cases were identified, including 16 from the literature and 25 that were not published previously in the literature. Because of voluntary reporting and other methodological limitations, the actual number of cases must be higher than reported. All of the patients had chronic pain. The mean duration of therapy was 24.5 months. Most masses were located in the thoracic region. Intrathecal drugs included morphine or hydromorphone, either alone or mixed with other drugs, in 39 of 41 cases. No masses were reported in patients who received baclofen as the only intrathecal medication. Thirty patients underwent surgery to relieve spinal cord or cauda equina compression. Eleven patients were nonambulatory at last follow-up, and one died of a pulmonary embolus. Surgical specimens revealed noninfectious chronic inflammation, granuloma formation, and fibrosis or necrosis.

DISCUSSION

The most plausible hypothesis with regard to the cause of intrathecal catheter tip mass lesions implicates the administration of relatively high-concentration or high-dose opiate drugs or the use of drugs and admixtures that are not labeled for intrathecal use.

CONCLUSION

Patients who require high-dose intraspinal opioid therapy and those who receive drugs or admixtures that are not approved for intrathecal use should be monitored closely for signs of an extra-axial mass or catheter malfunction. Prompt diagnosis and treatment may preserve neurological function.

Bacillus cereus bacteremia and meningitis in immunocompromised children

Two cases of Bacillus cereus meningitis in immunocompromised children at our hospital within a 2-month period prompted us to review B. cereus--related invasive disease. We identified 12 patients with B. cereus isolated in blood cultures from September 1988 through August 2000 at our institution. Three of these patients also had B. cereus isolated from CSF specimens; 1 additional patient had possible CNS involvement (33%, group A), whereas 8 patients had no evidence of CNS involvement (67%, group B). Patients in group A were more likely to have neutropenia at the onset of sepsis and were more likely to have an unfavorable outcome. They were also more likely to have received intrathecal chemotherapy in the week before the onset of their illness. Two patients from group A died. One survived with severe sequelae. The fourth patient had mild sequelae at follow-up. No sequelae or deaths occurred among patients in group B. In patients with unfavorable outcomes, the interval from the time of recognition of illness to irreversible damage or death was short, which demonstrates a need for increased awareness, early diagnosis, and more-effective therapy, particularly that which addresses B. cereus toxins.

Drug-induced aseptic meningitis: diagnosis and management

Drug-induced aseptic meningitis (DIAM) has been reported as an uncommon adverse reaction with numerous agents. It is a diagnosis of exclusion, and clinical signs and CSF findings vary greatly. The body of evidence regarding DIAM is largely in the form of anecdotal case reports and must be interpreted carefully bearing this in mind. The major categories of causative agents are nonsteroidal anti-inflammatory drugs, antimicrobials, intravenous immunoglobulin, intrathecal agents, vaccines and a number of other less frequently reported agents. There appears to be an association between DIAM and connective tissue disease, particularly systemic lupus erythematosus, and ibuprofen. There are 2 major proposed mechanisms for DIAM. The first involves direct irritation of the meninges by intrathecal administration of the drug, and the second involves immunological hypersensitivity to the drug, most likely type III and type IV hypersensitivity. Recognition and diagnosis of DIAM is important, as it is treatable by withdrawal of the drug and recurrence is prevented. The outcome of DIAM is generally good, usually without long term sequelae. This article describes the case reports of DIAM in the current literature and discusses the diagnosis and management of this rare complication.

Central nervous system directed therapy in acute lymphoblastic leukaemia

CNS-directed treatment is an essential component of therapy for both children and adults with acute lymphoblastic leukaemia. The choice between combinations of i.t. drugs, radiotherapy and high-dose systemic chemotherapy is not a clear one and will depend on the age of the patient, the type of leukaemia and indeed the available treatment facilities. A plea is made for any prospective trials of CNS-directed therapy to incorporate formal assessment of neuropsychological performance, and in the young child, of growth and pubertal progression.

Clinical neurological findings of children with acute lymphoblastic leukaemia at diagnosis and during treatment

Serial neurological evaluation was performed on 40 consecutive children with acute lymphoblastic leukaemia (ALL) at the time of diagnosis and during treatment. Abnormal neurological signs were found in 23% of the patients, including some without neurological symptoms on admission. Six patients (15%) had abnormal funduscopy findings, papilloedema or preretinal haemorrhages, and 3 of them had increased intracranial pressure measured in connection with a diagnostic lumbar puncture but without blasts in their CSF. The reason for the increased intracranial pressure remained unclear. The development of neurological symptoms caused by peripheral neuropathy during induction therapy was related to the total dose and duration of vincristine therapy. The most severe walking difficulties, patients moving about on all fours for as long as 6 weeks-5 months, occurred in a group who were significantly younger than the other children (P < 0.03). Fine and gross motor disturbances occurred in 18% and 30% of the whole patient group, respectively, after 2-3 years of therapy. Impaired short-term memory was observed in 21% of the patients after 2-3 years of therapy, indicating impaired CNS function. The results indicate that chemotherapy also seems to influence CNS abilities, since there was no significant difference between the patients treated with or without cranial irradiation. Neurological evaluation of children with ALL at diagnosis and during treatment is of value with respect to abnormal findings which persist and are not caused by leukaemia, in order to determine the types of difficulties involved and to consider intervention.

Acute neurotoxicity after intrathecal cytosine arabinoside in two adolescents with acute lymphoblastic leukemia of B-cell type

BACKGROUND

Two adolescents with acute B-cell leukemia (Burkitt leukemia) had acute severe neurotoxicity after treatment with intrathecal (IT) cytosine arabinoside (AraC) at a dose of 50 mg/day for three consecutive days.

RESULTS

A 16-year-old boy had a rapidly ascending myelopathy and encephalopathy 20 hours after receiving the third dose of IT AraC. He remained quadriplegic and required ventilatory assistance for 10 months until his death from progressive tumor. A 12-year-old girl had acute encephalopathy, seizures, and focal neuroimaging abnormalities in the cerebellum and brain stem within 32 hours of the third AraC dose and 8 hours after IT methotrexate (MTX, 12 mg). Her clinical neurologic deficits resolved during the ensuing month. Patient 1 represents the first report to the authors' knowledge of acute severe neurotoxicity after AraC administered as the only IT drug. In Patient 2, IT AraC neurotoxicity may have been potentiated by the single dose of MTX.

CONCLUSION

IT AraC administered for 3 or more consecutive days may lead to profound neurologic dysfunction and require discontinuation of therapy.

Drug- and chemical-induced aseptic meningitis: a review of the literature

OBJECTIVE

The primary objective of this article is to provide readers with case reports of drug- or chemical-induced aseptic meningitis (DCAM) described in the medical literature. Background information regarding the classification of DCAM, incidence, proposed mechanisms, associated risk factors, clinical management, and sequelae is presented.

DATA SOURCES

A MEDLINE search was used to identify pertinent background literature and case reports of DCAM.

DATA EXTRACTION

All case reports of DCAM involve anecdotal information. A critical analysis of a causal relationship to the implicated drug or chemical and the appearance of meningeal involvement is presented. Animal data are included when pertinent.

DATA SYNTHESIS

DCAM is a rare adverse event associated with numerous agents. Patients present with a variety of clinical signs and symptoms and laboratory findings of cerebral spinal fluid, when obtained, vary greatly. Most patients fully recover without sequelae.

CONCLUSIONS

Numerous drugs and chemicals have been implicated in the medical literature as producing DCAM. Two proposed mechanisms of DCAM have been theorized: a delayed hypersensitivity-type reaction and direct meningeal irritation. The nonsteroidal antiinflammatory drugs, certain antibiotics, radiographic agents, and muromonab-CD3 have been most frequently implicated. There appears to be an association between the occurrence of the hypersensitivity-type reactions and underlying collagen vascular or rheumatologic disease.

Acute fatal myeloencephalopathy after combined intrathecal chemotherapy in a child with acute lymphoblastic leukemia

We report a case of a fatal toxic encephalomyelopathy in a 12-year-old girl due to prophylactic intrathecal injection of methotrexate and cytosine arabinoside, with a characteristic progressive symptomatology leading to death after 28 days. The location and type of neuropathological changes support the hypothesis of a direct toxic effect of methotrexate and/or cytosine arabinoside on structures directly exposed to the cerebrospinal fluid.

Plasma and cerebrospinal fluid pharmacokinetics of cytosine arabinoside in dogs

Cytosine arabinoside (ara-C) is a component of many protocols for the treatment of CNS (central nervous system) leukemia and lymphoma in humans and dogs. It is also used for the prophylaxis of CNS metastasis in acute lymphoblastic leukemia. Although ara-C enters the cerebrospinal fluid (CSF) of human cancer patients after i.v. administration, it is unclear whether a similar CNS distribution occurs in humans whose blood-brain barrier has not been compromised by invasive disease. No information on the penetration of ara-C into the CSF in dogs is available. We studied the plasma and CSF pharmacokinetics of 600 mg/m2 ara-C in ten healthy male dogs after its administration as a rapid i.v. bolus (six dogs) or as a 12-h i.v. infusion (four dogs). Ara-C concentration in blood and CSF samples was determined by high-performance liquid chromatography (HPLC). After an i.v. bolus of ara-C, the mean plasma distribution half-life was 7.1 +/- 4.5 min and the mean elimination half-life was 69 +/- 28 min. The mean plasma clearance was 227 +/- 125 ml min-1 m-2. The peak concentration of ara-C in the CSF was 29 +/- 11 microM, which occurred at 57 +/- 13 min after the ara-C bolus. The CSF elimination half-life was 113 +/- 26 min. During a 12-h infusion of ara-C (50 mg m-2 h-1), the plasma steady-state concentration was 14.1 +/- 4.2 microM, the CSF steady-state concentration was 8.3 +/- 1.1 microM, and the CSF: plasma ratio was 0.62 +/- 0.14. The plasma elimination half-life was 64 +/- 19 min and the plasma clearance was 214 +/- 69 ml min-1 m-2. The CSF elimination half-life was 165 +/- 28 min. No clinically significant toxicity was observed over a 21-day period following drug administration in either of the treatment groups. Our data indicate that ara-C crosses the blood-brain barrier in normal dogs and that i.v. administration of this drug has potential as a treatment modality for neoplasia involving the CNS.

The toxicity of cytarabine

The principal toxicity of standard induction regimens for acute non-lymphocytic leukemia (ANLL) [including cytarabine (ARA-C) 100 mg/m2 for 7 days plus an anthracycline] is myelotoxicity, leading to death in at least 25% of cases during induction in non-selected patients. The complete remission rate is less than 35% in patients over 65 years of age, due in part to an age-related increase of myelotoxicity. The other important adverse effect of standard-dose cytarabine is gastrointestinal toxicity, especially oral mucositis, diarrhoea, intestinal ulceration, ileus and subsequent Gram-negative septicaemia. Idiosyncratic reactions like exanthema, fever and elevation of hepatic enzymes are relatively frequent, but do not represent therapeutic problems. Intermittent high-dose cytarabine (3 g/m2 in 8 to 12 doses) is extremely myelosuppressive. Similarly, the gastrointestinal toxicity is formidable and dose-limiting. Severe, and sometimes irreversible, cerebellar/cerebral toxicity in 5 to 15% of courses of treatment limits the peak dose of cytarabine. The pathogenesis, prophylactic and therapeutic measures are unknown. These major toxicities are age-related and prohibitive to the use of high-dose cytarabine therapy in patients older than 55 to 60 years. Subacute noncardiogenic pulmonary oedema occurs in some patients, with an incidence of about 20%, and seems to have an intriguing coincidence with precedent streptococcal septicaemia; high-dose systemic steroids may be beneficial. Corneal toxicity is very frequent in high-dose cytarabine therapy but is always reversible. It is largely preventable with prophylactic steroid or 2-deoxycytidine eyedrops. Fever, exanthema and hepatic toxicity have an incidence similar to that in standard dosage. The maximum tolerable cumulated dose of cytarabine is significantly lower when the agent is administered as a continuous infusion, due to myelosuppression and gastrointestinal toxicity. Conversely, continuous infusion may be less neurotoxic. The antileukaemic effect of continuous infusion high-dose cytarabine is less well established. The only significant toxicity of low-dose cytarabine is myelosuppression. Given the generally poor condition of leukaemia patients, low-dose cytarabine therapy is well tolerated, although occasional cases of diarrhoea, reversible cerebellar symptoms, peritoneal and pericardial reactions, and ocular toxicity have been reported. Continuous infusion may be more toxic than the usual intermittent dosage. It is concluded that the toxicity of the standard induction regimen for ANLL is acceptable in patients younger than 60 to 65 years with no concurrent disease. Low dose cytarabine is tolerable for virtually all ANLL patients, but the overall therapeutic efficacy still needs to be defined and compared to standard therapy in the relevant age groups.(ABSTRACT TRUNCATED AT 400 WORDS)

Metabolism of pyrimidine analogues and their nucleosides

The pyrimidine antimetabolite drugs consist of base and nucleoside analogues of the naturally occurring pyrimidines uracil, thymine and cytosine. As is typical of antimetabolites, these drugs have a strong structural similarity to endogenous nucleic acid precursors. The structural differences are usually substitutions at one of the carbons in the pyrimidine ring itself or substitutions at on of the hydrogens attached to the ring of the pyrimidine or sugar (ribose or deoxyribose). Despite the differences noted above, these analogues, can still be taken up into cells and then metabolized via anabolic or catabolic pathways used by endogenous pyrimidines. Cytotoxicity results when the antimetabolite either is incorporated in place of the naturally occurring pyrimidine metabolite into a key molecule (such as RNA or DNA) or competes with the naturally occurring pyrimidine metabolite for a critical enzyme. There are four pyrimidine antimetabolites that are currently used extensively in clinical oncology. These include the fluoropyrimidines fluorouracil and fluorodeoxyuridine, and the cytosine analogues, cytosine arabinoside and azacytidine.

Effects of high dose intraperitoneal cytosine arabinoside on the radiation tolerance of the rat spinal cord

The effect of intraperitoneal high dose (9 g/kg) Cytosine Arabinoside (Ara-C) on the early delayed radiation response of the rat cervical spinal cord has been studied. When given 2 hrs before irradiation, systemically administered Ara-C significantly reduces the isoeffect doses for the induction of paralysis due to white matter necrosis by a factor of approximately 1.2 for both a single irradiation treatment and for a two fraction irradiation with 24 hr interval. No effect on the latency time to develop paralysis was recorded.

Phase I/II study of intraventricular and intrathecal ACNU for leptomeningeal neoplasia

A total of 27 patients with leptomeningeal neoplasia were treated with the water-soluble nitrosourea ACNU given intraventricularly or intrathecally in a phase I/II study. Patients were entered in the study if they showed evidence of either a positive CSF cytology or neurodiagnostic evidence of leptomeningeal disease, or both. Patients were evaluated for toxicity and efficacy; additionally, in 13 patients ACNU pharmacokinetic studies were carried out. A variety of tumor types were represented in the study group, including primary and metastatic CNS tumors. Toxicity was mild and included pain at the injection site (four patients), transient radicular symptoms at a short distance from the injection site (three patients), and nausea and vomiting (one patient). No myelotoxicity was seen. Of 21 patients who presented with positive cytology, 8 (38%) had a conversion from positive to negative cytology, with a range of response durations from 1 to 20+ months. Of the remaining six patients with negative cytology but other neurodiagnostic evidence of leptomeningeal disease, one patient showed an improvement seen on the myelogram and one underwent a brief reduction in CSF protein. ACNU elimination from the ventricular system is rapid, with a beta slope of 0.028 min-1 and a computed elimination constant, Ko of 13 min. The mean clearance was 3.8 ml/min (range, 1.0-6.2 ml/min). Peak ACNU levels varied between 108 and 620 micrograms/ml, with the AUC being 1.4-14.7 mg.min/ml. The total dose of ACNU given was between 9 and 104 mg, and the single dose range was 4-16.5 mg. We conclude that ACNU can be given safely with minimal toxicity as intra-CSF therapy, that it demonstrates efficacy in some patients with leptomeningeal disease, and that further studies are warranted to evaluate more fully alternative dosing and drug delivery approaches.

Pyrimidine pathways enzymes in human tumors of brain and associated tissues: potentialities for the therapeutic use of N-(phosphonacetyl-L-aspartate and 1-beta-D-arabinofuranosylcytosine

The activities of aspartate transcarbamylase (de novo pyrimidine biosynthesis pathway) and of deoxycytidine kinase as well as deoxycytidine deaminase (salvage pyrimidine biosynthesis pathway) were determined in extracts prepared from 40 brain tumors of different types in comparison with extracts from normal nervous tissues. Aspartate transcarbamylase, which is undetectable in normal brain tissue, is present in all tumor samples and in some cases rises to very high activities. Deoxycytidine kinase activity is present in all tissues but its level is generally higher in tumors. Deoxycytidine deaminase is present in all the tissues which were analyzed, although its activity is lower in some of the tumor samples. 1-beta-D-Arabinofuranosylcytosine is a substrate for both deoxycytidine kinase and deaminase in all the samples used except one. These results suggest some potential for the utilization of 1-beta-D-arabinofuranosylcytosine and N-(phosphonacetyl)-L-aspartate in the treatment of brain tumors.

Non-Hodgkin's lymphoma involving the central nervous system

In 44 out of 758 patients (5.8%) with non-Hodgkin's lymphoma presenting between 1971 and 1982, the central nervous system (CNS) was involved. Patients with a diffuse histology had a 7.6% (34/449) incidence of CNS involvement compared to 3.9% (10/257) for patients with nodular lymphoma. In 63% of patients there was evidence of progressive systemic lymphoma at the time of diagnosis of CNS disease and in 23% CNS relapse occurred in clinical remission. Bone marrow was involved in 34% of patients at diagnosis and in 52% at some time prior to the onset of CNS complications. Cerebrospinal fluid cytology was positive in 63% and an elevated protein level was found in 95% of patients. The median length of survival of the 44 patients was only 3.2 months, but patients who responded to treatment of CNS lymphoma survived significantly longer than those who showed no response or progressed on therapy. Complete response to CNS treatment was achieved in five patients, of whom none relapsed in the CNS and two are long-term disease-free survivors. CNS prophylaxis appears justified for patients with lymphoblastic lymphoma, Burkitt's tumour, and diffuse undifferentiated lymphoma, who are at high risk of developing CNS complications. Patients with diffuse histiocytic, and diffuse poorly differentiated lymphocytic, lymphoma who have bone marrow involvement may also benefit from CNS prophylaxis.

Ascending myelopathy after chemotherapy for central nervous system acute lymphoblastic leukemia: correlation with cerebrospinal fluid myelin basic protein

Ascending myelopathy developed in a previously irradiated 10-year-old boy after intraventricular methotrexate and cytosine arabinoside were given for central nervous system relapse of acute lymphoblastic leukemia. The course was fatal in 10 weeks. Cerebrospinal fluid myelin basic protein levels, indicating a demyelinative process, rose prior to the onset of clinical symptoms and remained at very high levels until death. Myelin basic protein may be useful as a predictor of chemotherapy-associated neurotoxicity.

Acute cerebellar dysfunction with high-dose ARA-C therapy

The authors report a patient with clinical and morphologic evidence of acute cerebellar toxicity after receiving high-dose cytosine arabinoside (ARA-C) (3000 mg/m2/12 hours) for refractory AML. Damage of Purkinje cells and dentate nucleus was demonstrated. Reversible cerebellar toxicity has previously been noted in patients on an identical regimen. Signs of cerebellar dysfunction mandate immediate cessation of high-dose ARA-C therapy.

Diagnosis and treatment of leptomeningeal metastases from solid tumors: experience with 90 patients

The clinical findings and response to treatment of leptomeningeal metastases from solid tumors are analyzed in 90 patients treated at Memorial Sloan-Kettering Cancer Center during the period from January 1975 to February 1980. Patients included those who had either typical clinical findings of leptomeningeal tumor or conclusive laboratory evidence supporting the diagnosis. Carcinoma of the breast (46 patients), lung (23 patients) and melanoma (11 patients) were the common primary tumors. Symptoms of leptomeningeal metastasis occurred as the presenting sign in five patients and as late as ten years after the primary tumor was diagnosed in four other patients. Most patients had active systemic disease outside the nervous system. Signs and symptoms could be classified as involving either the brain, cranial nerves, or spinal nerves. Most patients had either symptoms or signs in more than one area at the time the diagnosis was established. The initial spinal fluid examination was abnormal in all but three patients, but only 49 had cytologic evidence of leptomeningeal metastases. Repeated spinal fluid assay yielded a positive cytology in 82 patients. Measurement of biochemical markers, including beta-glucuronidase, carcinoembryonic antigen and lactic dehydrogenase, assisted in the diagnosis. Approximately half of the patients treated by intraventricular methotrexate experienced improvement or stabilization of neurological symptoms for more than a month; median survival was 5.8 months after diagnosis, with a range of 1--29 months. In 18 patients disease was limited to the nervous system, and median survival was eight months, with four patients surviving one year and two patients for two years. Side effects of therapy were, for the most part, minor. We conclude that vigorous treatment of leptomeningeal metastases with intrathecal chemotherapeutic agents improves symptomatology in some patients, and at times prolongs survival.

Central nervous system toxicity of high-dose systemic cytosine arabinoside

Forty-nine adult patients with acute leukemia in relapse, refractory to conventional therapy, were studied. Increasing quantities of i.v. bolus high-dose cytosine arabinoside (cytarabine) were administered using the following schedules: 3 g/m2 every 12 hrs for 4-16 consecutive doses, or 4.5 g/m2 every 12 hrs for 12 consecutive doses. Patients ages ranged 16-76 year (median: 38). Thirty-seven patients had previously received either induction or maintainance therapy with conventional doses of cytarabine. Cerebral or cerebellar dysfunction attributable to cytarabine was observed in eight patients and appeared 6-8 days (mean: 6.6) after the first dose and lasted 3-7 days (mean: 4.7). None of 12 patients receiving up to 24 g/m2 total dose of 48 g/m2 developed reversible neurologic dysfunction. Four of six patients receiving 54 g/m2 developed CNS toxicity (irreversible in two cases), a significantly greater incidence compared to toxicity in patients receiving less than or equal to 48 g/m2 total dose (P less than 0.01). CNS toxicity was dose-related since patients treated for 12 consecutive doses of 4.5 g/m2 had significantly greater CNS toxicity than 12 consecutive doses at 3 g/m2 (P less than 0.04). Systemic cytarabine doses less than 54 g/m2 can be administered with minimal CNS side-effects.

Central and peripheral myelinopathy associated with systemic neoplasia and chemotherapy

Three adult patients with leukemia and a patient with cutaneous melanoma were treated with a variety of therapeutic agents administered systemically. Three of these patients received either cytosine arabinoside or thio-TEPA, by intrathecal injection and radiotherapy to the cranium or spine. Three patients developed progressive motor and sensory deficits and the fourth became confused and disoriented. These symptoms were chronologically related to the time when chemotherapy was begun. Death occurred 11/2, 2, 5 and 7 months, respectively, after the beginning of neurologic deficit. The spinal white matter showed vacuolation, myelin disintegration, axonal swelling, fibrillary gliosis, and infiltration by macrophages. Vesicular disintegration of the myelin lamellae seems to be the earliest lesion affecting both central and peripheral myelin. Gliosis and macrophages were visible only in the two patients who survived at least five months from the time of the neurologic deficit.

Central nervous system involvement at presentation in acute granulocytic leukemia. A prospective cytocentrifuge study

We have undertaken a perspective study of the prevelance of the central nervous disease in acute granulocytic leukemia (AGL). Thirty-nine newly diagnosed patients with AGL underwent cytocentrifuge examination of cerebral spinal fluid. Seven of the 39 patients had blast cells in their cerebral spinal fluid. All seven of these patients had acute myelomonocytic leukemia (AMML). No patients with other variants of AGL demonstrated blast cells in their cerebral spinal fluid. Other high risk factors associated with meningeal infiltration were elevated serum lysozyme levels, high peripheral white blood cell count, low age, splemomegaly and the presence of infiltration in other organs. The admission rates for patients with meningeal leukemia were lower and the survival time was shorter than in both the 32 noninvolved patients and the noninvolved patients with AMML. We believe that a lumbar puncture is indicated in all patients with newly diagnosed AMML.

Paraplegia following intrathecal cytosine arabinoside

Paraplegia following prophylactic intrathecal cytosine arabinoside (Ara-C) is described in a patient with acute myelogenous leukemia in remission who received doses of 100 mg/m2/d for 5 consecutive days. Cerebrospinal fluid examination prior to the last dosage of cytosine arabinoside revealed a mononuclear pleocytosis and increased protein. The neurological manifestations developed within one week after the last dose of Ara-C and persisted for over 8 weeks. Administration of intrathecal Ara-C in the same dose over longer intervals within 3-5 days between consecutive doses resulted in mild, transient neurological symptoms (paresthesias) in only one of 30 patients so treated.

Seizures following intrathecal cytosine arabinoside in young children with acute lymphoblastic leukemia

Two young children (3 1/2 years and 19 months) developed seizures within 24 hours of receiving intrathecal cytosine arabinoside. Both had previously received intrathecal cytosine and methotrexate as well as cranial irradiation without untoward effect. Possible mechanisms of causation are discussed and caution is stressed for use of intrathecal cytosine arabinoside in young children.

The management of adult acute lymphoblastic leukaemia

The important advances made in recent years in the therapy of adult ALL have been reviewed. The definition of bad-prognosis patients has been improved and includes those with T-ALL, ABLL, and Ph1+ALL, in addition to those presenting with evidence of extensive disease. In contrast to childhood ALL, induction chemotherapy should include another drug (or drugs) in addition to VCR and prednisolone, and one of the anthracycline drugs (ADR or DNR) has been employed most frequently in this context. Such therapy should result in a CR rate of 70 to 75%. Similar to the experience in childhood ALL, the improvement in haematological response rate has led to an apparent increase in CNS leukaemia, and the need for adequate CNS prophylaxis is stressed. Despite these improvements, the outlook for adults with ALL is not yet as good as it is for childhood ALL. Controlled studies involving large numbers of patients are urgently needed to provide answers to a number of questions. In induction therapy, the use of higher drug dosage, the use of more and other drugs, and the use of an individual patient's risk factors to determine drug dosage, must be assessed. The benefits of consolidation therapy and the optimal duration and intensity of maintenance therapy have yet to be established. Methods of CNS prophylaxis other than cranial irradiation and IT MTX must be carefully studied. These important questions require that adult patients with ALL should be concentrated in centres capable of providing optimal overall care and, at the same time, able to conduct the necessary clinical trials.

Maintenance therapy of adult acute nonlymphoblastic leukemia: an argument against the need for central nervous system prophlyaxis

The need for prophylactic therapy of the central nervous system in adult acute nonlymphoblastic leukemia has been suggested but no proven. Over a 4-year period from January 1973, to December 1976, we have maintained 40 patients achieving complete remission on a regimen consisting of monthly courses of Cytosine Arabinoside and 6-thioguanine. Twenty patients remain in remission with a predicted median remission duration for the entire group of 14.5 months. Thirty nine of the patients did not have central nervous system leukemia at diagnosis, and only one of these patients (2.6%) has had remission tenance regimen there is little need for central nervous system prophylaxis in adult acute nonlymphoblastic leukemia.

Paraparesis following intrathecal cytosine arabinoside: a case report with neuropathologic findings

A 65-year-old white male with acute myelogenous leukemia received whole brain irradiation (2550 rads) and intrathecal cytosine arabinoside for CNS prophylaxis. Bone marrow remission had been previously achieved with systemic chemotherapy (vincristine, Adriamycin, prednisone, and cytosine arabinoside). Two weeks following the last intrathecal cytosine arabinoside treatment, the patient developed a spastic paraparesis requiring the use of a walker. A gas myelogram was normal and CSF examination revealed a protein of 50 mg/100 ml but was otherwise unremarkable. Five months later, the patient had improved in that he could stand on his own. A relapse of his leukemia subsequently occurred and the patient died the following month. Striking degenerative changes were found in the spinal cord at postmortem examination. These included microvacuolization, axonal swellings, and loss of myelin with scattered macrophages laden with fat.

Neurotoxicity due to CNS therapy for leukemia

CNS symptoms ranging from mild to lethal have occurred following CNS radiotherapy and intrathecal chemotherapy. Cranial radiotherapy often produces signs of mild encephalopathy, with predominance of somnolence. In rare cases, it appears that CNS radiotherapy may be followed by progressive encephalopathy. Intrathecal methotrexate frequently causes symptoms of meningeal irritation. Occasionally cases of weakness and paralysis, and rare instances of severe encephalopathy, may occur. However, in leukemic children treated with intensive chemotherapy and CNS radiotherapy who develop neurological complications, it is often difficult to determine which of many possible factors may be causing the CNS symptoms. The pathogenesis of the various forms of methotrexate neurotoxicity is poorly understood. The best-established cause for these symptoms is high concentrations of methotrexate in the CSF or porlonged exposure of the brain to low CSF concentrations of methotrexate. These elevated concentrations of the drug may in turn be due to impaired elimination of the drug from the cerebrospinal fluid (usually due to overt CNS leukemia) or to increased dosage in relation to cerebrospinal fluid volume (due to adolescent age). Leukoencephalopathy is occasionally found at autopsy in children given intensive therapy with CNS radiotherapy and intrathecal methotrexate, together with intensive systemic chemotherapy. It was proposed that alteration of the blood-brain barrier by cranial radiotherapy allows systemically administered anti-leukemic drugs to enter the brain and to cause necrotic changes in the CNS white matter. Leukoencephalopathy also occurs following intraventricular administration of methotrexate. CNS-toxicity due to intrathecal cytosine arabinoside is clinically similar to the symptoms seen following intrathecal methotrexate.

Blindness during remission in two patients with acute lymphoblastic leukemia: a possible complication of multimodality therapy

Two patients with acute lymphoblastic leukemia treated on the same protocol became blind during complete remission. Therapy consisted of systemic combination chemotherapy, prophylactic central nervous system irradiation and monthly intrathecal cytosine arabinoside. Eight months after CNS irradiation visual acuity in both patients began to decrease. Meningeal leukemia in the area of the chiasm was suspected but despite additional radiotherapy, steroids and continued intrathecal therapy, both patients were blind within 6 months. Numerous lumbar punctures were negative for leukemic cells. Extensive investigation, including craniotomy in one case, failed to reveal the cause of blindness. Biopsy of the optic nerve in one case was compatible with radiation toxicity. We postulate that potentiation of radiation toxicity to the optic nerves and chiasm by systemic chemotherapy, intrathecal chemotherapy, or both, may have led to blindness. The patients continue in complete hemotologic and CNS remission 12 and 29 months after becoming blind.

Optic atrophy following prophylactic chemotherapy and cranial radiation for acute lymphocytic leukemia

Two patients with acute lymphocytic leukemia developed progressive optic nerve and chiasmal lesions eight to nine months after the initiation of identical chemotherapy protocols that included intrathecal medication and prophylactic radiation of only 2,400 rads to the central nervous system. Both patients eventually lost all vision despite additional radiotherapy, and there was no evidence of leukemia involving the central nervous system after acute lymphocytic leukemia was diagnosed. Optic nerve biopsy in one case showed changes consistent with radiation necrosis.

Intrathecal N, N', N"-triethylenethiophosphoramide [thio-TEPA (NSC 6396)] in the treatment of malignant meningeal disease: phase I-II study

N, N', N"-Triethylenethiophosphoramide [Thio-TEPA (NSC 6396)] is the third drug to be evaluated for the treatment of meningeal neoplasia. Eleven patients with meningeal leukemia, lymphoma, or ependymoma were treated with intrathecal thio-TEPA in doses from 1 to 10 mg/m2 of body surface area. There was no hematologic toxicity definitely attributable to thio-TEPA, and neurologic toxcity was limited to mild transient paresthesias of the lower extremities during lumbar sac injection in three patients. Two of those experiencing such paresthesias received concentrated drug solutions to decrease the large injected volumes associated with the higher dosages of thio-TEPA. Three patients achieved complete meningeal remission, and five others had a partial response to therapy.

Disseminated necrotizing leukoencephalopathy: a complication of treated central nervous system leukemia and lymphoma

This report describes a form of disseminated necrotizing leukoencephalopathy that has been observed in four children with acute lymphoblastic leukemia, and one child with Burkitt's lymphoma terminating in a leukemic phase. In addition to systemic vincristine, cytosine arabinoside, cyclophosphamide, and steroids, these patients received courses of intrathecal methotrexate, cytosine arabinoside, and hydrocortisone, because of meningeal tumor cell infiltration. Whole brain radiation was also given either before or during intrathecal therapy. Three of the children had a progressive irreversible neurologic illness, which developed either at or shortly after the completion of combined triple intrathecal therapy, death ensuing approximately 2 months later. The neuropathologic lesions consisted of discrete multifocal necroses of coagulative type, apparently extending by confluence, and disseminated in the cerebral white matter in a random manner. In one case, extensive symmetrical demyelinating and necrotizing lesions involved the centrum ovale bilaterally. There was a remarkable absence of inflammatory cellular response and a relative paucity of macrophage reaction, with usually little or no tissue breakdown. In addition to demyelination and glial cell loss, there was striking axonal damage, with conspicuous axonal swelling both within and around the necrotizing lesions. The surrounding white matter showed focal status spongiosus and a moderate astrocytic response. Vascular fibrinoid necrosis was inconstant and, except in one case, rarely observed. The possible causal relationship of these lesions to combined triple intrathecal antimetabolite therapy and brain radiation is discussed.