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Sandberg DI, Yu B. Direct Administration of Chemotherapy and Other Agents into the Fourth Ventricle to Treat Recurrent Malignant Brain Tumors in Children. Adv Tech Stand Neurosurg 2024; 53:119-137. [PMID: 39287806 DOI: 10.1007/978-3-031-67077-0_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2024]
Abstract
Direct administration of chemotherapy and other agents into the fourth ventricle of the brain is a novel approach to treating recurrent malignant posterior fossa brain tumors in children. Candidates for this treatment approach include patients with recurrent medulloblastoma, ependymoma, atypical teratoid/rhabdoid tumor, and potentially other neoplasms that originate in the fourth ventricle or elsewhere in the posterior fossa. In this chapter, the authors first explain the rationale for considering fourth ventricular drug infusions in patients with recurrent malignant posterior fossa tumors. We then summarize the results of translational experiments conducted in piglets and non-human primates that demonstrated safety and favorable pharmacokinetics. These translational experiments led to several pilot human clinical trials, and the results of these trials are reviewed. Finally, currently open clinical trials testing infusion of various agents into the fourth ventricle are discussed, and thoughts about potential future directions are shared.
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Affiliation(s)
- David I Sandberg
- Departments of Pediatric Surgery and Neurosurgery, McGovern Medical School and Children's Memorial Hermann Hospital and the University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Bangning Yu
- Department of Pediatric Surgery, McGovern Medical School and Children's Memorial Hermann Hospital, Houston, TX, USA
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Li B, Yabluchanskiy A, Tarantini S, Allu SR, Şencan-Eğilmez I, Leng J, Alfadhel MAH, Porter JE, Fu B, Ran C, Erdener SE, Boas DA, Vinogradov SA, Sonntag WE, Csiszar A, Ungvari Z, Sakadžić S. Measurements of cerebral microvascular blood flow, oxygenation, and morphology in a mouse model of whole-brain irradiation-induced cognitive impairment by two-photon microscopy and optical coherence tomography: evidence for microvascular injury in the cerebral white matter. GeroScience 2023; 45:1491-1510. [PMID: 36792820 PMCID: PMC10400746 DOI: 10.1007/s11357-023-00735-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 01/17/2023] [Indexed: 02/17/2023] Open
Abstract
Whole-brain irradiation (WBI, also known as whole-brain radiation therapy) is a mainstay treatment modality for patients with multiple brain metastases. It is also used as a prophylactic treatment for microscopic tumors that cannot be detected by magnetic resonance imaging. WBI induces a progressive cognitive decline in ~ 50% of the patients surviving over 6 months, significantly compromising the quality of life. There is increasing preclinical evidence that radiation-induced injury to the cerebral microvasculature and accelerated neurovascular senescence plays a central role in this side effect of WBI. To better understand this side effect, male C57BL/6 mice were first subjected to a clinically relevant protocol of fractionated WBI (5 Gy, two doses per week, for 4 weeks). Nine months post the WBI treatment, we applied two-photon microscopy and Doppler optical coherence tomography to measure capillary red-blood-cell (RBC) flux, capillary morphology, and microvascular oxygen partial pressure (PO2) in the cerebral somatosensory cortex in the awake, head-restrained, WPI-treated mice and their age-matched controls, through a cover-glass-sealed chronic cranial window. Thanks to the extended penetration depth with the fluorophore - Alexa680, measurements of capillary blood flow properties (e.g., RBC flux, speed, and linear density) in the cerebral subcortical white matter were enabled. We found that the WBI-treated mice exhibited a significantly decreased capillary RBC flux in the white matter. WBI also caused a significant reduction in capillary diameter, as well as a large (although insignificant) reduction in segment density at the deeper cortical layers (e.g., 600-700 μm), while the other morphological properties (e.g., segment length and tortuosity) were not obviously affected. In addition, we found that PO2 measured in the arterioles and venules, as well as the calculated oxygen saturation and oxygen extraction fraction, were not obviously affected by WBI. Lastly, WBI was associated with a significant increase in the erythrocyte-associated transients of PO2, while the changes of other cerebral capillary PO2 properties (e.g., capillary mean-PO2, RBC-PO2, and InterRBC-PO2) were not significant. Collectively, our findings support the notion that WBI results in persistent cerebral white matter microvascular impairment, which likely contributes to the WBI-induced brain injury and cognitive decline. Further studies are warranted to assess the WBI-induced changes in brain tissue oxygenation and malfunction of the white matter microvasculature as well.
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Affiliation(s)
- Baoqiang Li
- Brain Cognition and Brain Disease Institute, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, Guangdong, China
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, 02129, USA
| | - Andriy Yabluchanskiy
- Vascular Cognitive Impairment and Neurodegeneration Program, Oklahoma Center for Geroscience and Healthy Brain Aging, Department of Biochemistry and Molecular Biology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, USA
- Department of Health Promotion Sciences, College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, USA
- The Peggy and Charles Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, USA
| | - Stefano Tarantini
- Vascular Cognitive Impairment and Neurodegeneration Program, Oklahoma Center for Geroscience and Healthy Brain Aging, Department of Biochemistry and Molecular Biology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, USA
- Department of Health Promotion Sciences, College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, USA
- The Peggy and Charles Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, 1083, Hungary
| | - Srinivasa Rao Allu
- Department of Biochemistry and Biophysics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Department of Chemistry, School of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Ikbal Şencan-Eğilmez
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, 02129, USA
- Biophotonics Research Center, Department of Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Ji Leng
- Brain Cognition and Brain Disease Institute, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, Guangdong, China
| | - Mohammed Ali H Alfadhel
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, 02129, USA
| | - Jason E Porter
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, 02129, USA
| | - Buyin Fu
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, 02129, USA
| | - Chongzhao Ran
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, 02129, USA
| | - Sefik Evren Erdener
- Department of Biomedical Engineering, Boston University, Boston, MA, 02215, USA
| | - David A Boas
- Department of Biomedical Engineering, Boston University, Boston, MA, 02215, USA
| | - Sergei A Vinogradov
- Department of Biochemistry and Biophysics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Department of Chemistry, School of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - William E Sonntag
- Vascular Cognitive Impairment and Neurodegeneration Program, Oklahoma Center for Geroscience and Healthy Brain Aging, Department of Biochemistry and Molecular Biology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, USA
- The Peggy and Charles Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, USA
| | - Anna Csiszar
- Vascular Cognitive Impairment and Neurodegeneration Program, Oklahoma Center for Geroscience and Healthy Brain Aging, Department of Biochemistry and Molecular Biology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, USA
- The Peggy and Charles Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Translational Medicine, Semmelweis University, Budapest, 1083, Hungary
| | - Zoltan Ungvari
- Vascular Cognitive Impairment and Neurodegeneration Program, Oklahoma Center for Geroscience and Healthy Brain Aging, Department of Biochemistry and Molecular Biology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, USA.
- Department of Health Promotion Sciences, College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, USA.
- The Peggy and Charles Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, USA.
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, 1083, Hungary.
| | - Sava Sakadžić
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, 02129, USA.
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3
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Marker DF, Kofler JK, Mettenburg JA, Agha ME, Wiley CA. Multifocal Necrotizing Leukoencephalopathy With Preferential Microglia Toxicity in a Patient Treated With Chimeric Antigen Receptor T-Cells and Review of the Literature. J Neuropathol Exp Neurol 2021; 79:1115-1121. [PMID: 32954433 DOI: 10.1093/jnen/nlaa099] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Neurotoxic side effects of traditional systemic chemotherapy are abundantly described. The introduction of newly developed biologic therapeutics and cellular immune effector therapies has expanded the spectrum of neurotoxicity. Multifocal necrotizing leukoencephalopathy (MNL) is a pathologic condition of unknown etiology that has been observed in patients after prolonged critical illness. We observed a case of MNL in a patient treated with extensive multimodal therapy including chimeric antigen receptor T cells. A month before death, MRI demonstrated signs of inflammation and developing edema in brainstem structures. At autopsy the abnormal MRI regions showed a wave-like loss of microglia with hemorrhagic MNL in regions closest to the brain surface. These findings reiterate the susceptibility of white matter to antineoplastic therapy and suggest new mechanisms of neurotoxicity when traditional chemotherapy is combined with biologic or cellular effector therapy.
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Affiliation(s)
| | | | - Joseph A Mettenburg
- Division of Neuroradiology, Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mounzer E Agha
- Division of Hematology and Oncology, Department of Medicine, Mario Lemieux Center for Blood Cancers, Pittsburgh, Pennsylvania
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4
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Mavrea K, Efthymiou V, Katsibardi K, Tsarouhas K, Kanaka-Gantenbein C, Spandidos DA, Chrousos G, Kattamis A, Bacopoulou F. Cognitive function of children and adolescent survivors of acute lymphoblastic leukemia: A meta-analysis. Oncol Lett 2021; 21:262. [PMID: 33664825 PMCID: PMC7882890 DOI: 10.3892/ol.2021.12523] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 01/14/2021] [Indexed: 11/05/2022] Open
Abstract
Pediatric cancer and its treatment may have an impact on the neurocognitive functions of childhood cancer survivors (CCS). The aim of the present meta-analysis was to compare the intelligence quotient (IQ) scores between CCS of acute lymphoblastic leukemia (ALL) and controls. A comprehensive electronic search identified original research articles that reported scores of the Wechsler Intelligence Scale (WISC; WISC-III, WISC-IV and WISC-R) for children and adolescents, aged 6-16 years at evaluation, survivors of ALL and healthy controls. The included CCS had completed anticancer treatment and were in remission at the time of assessment. A total of 16 studies were included in the meta-analysis, out of 128 extracted studies, and involved a total of 1,676 children and adolescents: 991 CCS (ALL) and 685 healthy controls. Among the studies, a random effects model revealed a moderate estimate of effect size [standardized mean difference (SMD), -0.78; 95% CI, -1.05 to -0.50], indicating that the WISC scores for total IQ were significantly lower in the CCS than in the controls. The mean total IQ range was 85.2-107.2 in the CCS and 88.4-114.1 in the controls. The difference in the mean total IQ between controls and CCS ranged from -13.8 to 20.6. As regards the WISC scores for verbal IQ, 11 studies were included. A random effects model revealed a moderate estimate of effect size (SMD, -0.71; 95% CI, -1.05 to -0.38), indicating that the WISC scores for verbal IQ were significantly lower in the CCS than in the controls. Among the 9 studies that had available data for performance IQ scores, a fixed effect model revealed a moderate estimate of effect size (SMD, -0.80; 95% CI, -1.09 to -0.52), indicating that the WISC scores for performance IQ were significantly lower in the CCS than in the controls. As the survival rates of children and adolescents with ALL are steadily increasing, regular, lifelong follow-up for neurocognitive late effects is imperative in order to improve their education and employment prospects and overall, their quality of life.
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Affiliation(s)
- Kalliopi Mavrea
- Clinic for Assessment of Adolescent Learning Difficulties, Center for Adolescent Medicine and UNESCO Chair on Adolescent Health Care, First Department of Pediatrics, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, Athens 11527, Greece
| | - Vasiliki Efthymiou
- University Research Institute of Maternal and Child Health and Precision Medicine, and UNESCO Chair on Adolescent Health Care, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, Athens 11527, Greece
| | - Katerina Katsibardi
- Pediatric Hematology-Oncology Unit, First Department of Pediatrics, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, Athens 11527, Greece
| | | | - Christina Kanaka-Gantenbein
- Clinic for Assessment of Adolescent Learning Difficulties, Center for Adolescent Medicine and UNESCO Chair on Adolescent Health Care, First Department of Pediatrics, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, Athens 11527, Greece.,University Research Institute of Maternal and Child Health and Precision Medicine, and UNESCO Chair on Adolescent Health Care, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, Athens 11527, Greece
| | - Demetrios A Spandidos
- Laboratory of Clinical Virology, School of Medicine, University of Crete, Heraklion 71409, Greece
| | - George Chrousos
- University Research Institute of Maternal and Child Health and Precision Medicine, and UNESCO Chair on Adolescent Health Care, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, Athens 11527, Greece
| | - Antonis Kattamis
- Pediatric Hematology-Oncology Unit, First Department of Pediatrics, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, Athens 11527, Greece
| | - Flora Bacopoulou
- Clinic for Assessment of Adolescent Learning Difficulties, Center for Adolescent Medicine and UNESCO Chair on Adolescent Health Care, First Department of Pediatrics, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, Athens 11527, Greece.,University Research Institute of Maternal and Child Health and Precision Medicine, and UNESCO Chair on Adolescent Health Care, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, Athens 11527, Greece
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6
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Premji S, Kang L, Rojiani MV, Kresak J, Rojiani AM. Multifocal Necrotizing Leukoencephalopathy: Expanding the Clinicopathologic Spectrum. J Neuropathol Exp Neurol 2020; 78:340-347. [PMID: 30753632 DOI: 10.1093/jnen/nlz003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Multifocal necrotizing leukoencephalopathy (MNL) is a rare condition typically described in patients undergoing chemotherapy or with HIV/AIDS. As a pathologic entity, it is characterized by multiple small foci of necrosis typically within white matter of the pons and occasionally in other areas. Herein we describe findings in 6 patients with MNL, 5 diagnosed at postmortem examination and 1 by surgical biopsy. Histopathologic features were characteristic, with generally small foci of necrosis, most frequently within the pontine base, although larger lesions were seen in the frontal white matter and basal ganglia. Axonal swellings, occasional dystrophic calcification and minimal microglial activity or reactive responses were common. Glial fibrillary acidic protein immunoreactivity was absent or markedly reduced within the lesions although it remained well defined in the surrounding areas. The underlying clinical circumstances ranged from HIV/AIDS, hematologic malignancy, chemotherapy for malignancies to postcardiac transplant, the latter reported for the first time. A significant common thread identified in our cases was altered immune status. A second common factor, which has also been previously implicated, was the presence of significant ongoing infection or sepsis. The role of concurrent inflammatory processes, specifically proinflammatory cytokine release in the context of these complex clinical scenarios is discussed with possible pathogenetic considerations.
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Affiliation(s)
- Sarah Premji
- Department of Pathology, Medical College of Georgia at Augusta University, Augusta, Georgia
| | - Loveleen Kang
- Pathology and Laboratory Medicine Service, James Haley Veteran's Hospital, Tampa, Florida
| | - Mumtaz V Rojiani
- Department of Pathology, Medical College of Georgia at Augusta University, Augusta, Georgia.,Department of Medicine, Medical College of Georgia at Augusta University, Augusta, Georgia
| | - Jesse Kresak
- Department of Pathology, University of Florida College of Medicine, Gainesville, Florida
| | - Amyn M Rojiani
- Department of Pathology, Medical College of Georgia at Augusta University, Augusta, Georgia
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Abstract
Administration of systemic antineoplastic agents can result in adverse neurologic events. We describe the clinicopathologic features and putative mechanisms underlying iatrogenic neuropathology of the central nervous system secondary to chimeric antigen receptor (CAR) T-cell therapy and conventional chemotherapy.
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Affiliation(s)
- Matthew Torre
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Mel B Feany
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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Ghali MGZ, Styler MJ. Etiologies, Cerebral Vasomotion, and Endothelial Dysfunction in the Pathophysiology of Posterior Reversible Encephalopathy Syndrome in Pediatric Patients. JOURNAL OF PEDIATRIC NEUROLOGY 2020. [DOI: 10.1055/s-0040-1702934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
AbstractThe posterior reversible encephalopathy syndrome was characterized by Hinchey and colleagues in the 1990s. The condition frequently afflicts patients suffering from hematologic and solid organ malignancy and individuals undergoing transplantation. Cases are more frequently described in the adult population compared with children. In the pediatric population, malignancy, transplantation, renal disease, and hypertension represent the most common etiologies. Theories on pathogenesis have centered upon cerebrovascular dysautoregulation with increases in blood–brain barrier permeability. This generates vasogenic edema of the cerebral parenchyma and consequent neurologic deficits. The parietal and occipital lobes are affected with greatest prevalence, though frontal and temporal lobe involvement is frequent, and that of the contents of the infratentorial posterior cranial fossa are occasionally described. The clinical presentation involves a characteristic constellation of neurologic signs and symptoms, most typically inclusive of headache, visual-field disturbances, abnormalities of visual acuity, and seizures. Supportive care, withdrawal of the offending agent, antihypertensive therapy, and prophylactic anticonvulsants affect convalescence in majority of cases. The principal challenge lies in identifying the responsible agent precipitating the condition in patients with malignancy and those having undergone transplantation and thus deciding which medication among a multidrug treatment regimen to withhold, the duration of drug cessation required to effect clinical resolution, and the safety of resuming treatment with the compound. We accordingly reviewed and evaluated the literature discussing the posterior reversible encephalopathy syndrome in children.
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Affiliation(s)
- Michael G. Z. Ghali
- Department of Neurological Surgery, Houston Methodist Hospital, Houston, Texas, United States
| | - Michael J. Styler
- Department of Hematology and Oncology, Hahnemann University Hospital, Philadelphia, Pennsylvania, United States
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Walker DA, Meijer L, Coyle B, Halsey C. Leptomeningeal malignancy of childhood: sharing learning between childhood leukaemia and brain tumour trials. THE LANCET CHILD & ADOLESCENT HEALTH 2020; 4:242-250. [PMID: 31958415 DOI: 10.1016/s2352-4642(19)30333-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 09/26/2019] [Accepted: 09/30/2019] [Indexed: 01/02/2023]
Abstract
Leptomeningeal malignancy complicates childhood cancers, including leukaemias, brain tumours, and solid tumours. In leukaemia, such malignancy is thought to invade leptomeninges via the vascular route. In brain tumours, dissemination from the primary tumour, before or after surgery, via CSF pathways is assumed; however, evidence exists to support the vascular route of dissemination. Success in treating leptomeningeal malignancy represents a rate-limiting step to cure, which has been successfully overcome in leukaemia with intensified systemic therapy combined with intra-CSF therapy, which replaced cranial radiotherapy for many patients. This de-escalated CNS-directed therapy is still associated with some neurotoxicity. The balanced benefit justifies exploration of ways to further de-escalate CNS-directed therapy. For primary brain tumours, standard therapy is craniospinal radiotherapy, but attendant risk of acute and delayed brain injury and endocrine deficiencies compounds post-radiation impairment of spinal growth. Alternative ways of treating leptomeninges by intensifying drug therapy delivered to CSF are being investigated-preliminary evidence suggests improved outcomes. This Review seeks to describe methods of intra-CSF drug delivery and drugs in use, and consider how the technique could be modified and additional drugs might be selected for this route of administration.
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Affiliation(s)
- David A Walker
- Children's Brain Tumour Research Centre, University of Nottingham, School of Medicine, Queen's Medical Centre, Nottingham, UK.
| | - Lisethe Meijer
- Department of Paediatric Neuro-Oncology, Prinses Maxima Center for Paediatric Oncology, Bilthoven, Netherlands
| | - Beth Coyle
- Children's Brain Tumour Research Centre, University of Nottingham, School of Medicine, Queen's Medical Centre, Nottingham, UK
| | - Christina Halsey
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
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Abstract
Survival rates of children with cancer are steadily increasing. This urges our attention to neurocognitive and psychiatric outcomes, as these can markedly influence the quality of life of these children. Neurobehavioral morbidity in childhood cancer survivors affects diverse aspects of cognitive function, which can include attention, memory, processing speed, intellect, academic achievement, and emotional health. Reasons for neurobehavioral morbidity are multiple with one major contributor being chemotherapy-induced central nervous system (CNS) toxicity. Clinical studies investigating the effects of chemotherapy on the CNS in children with cancer have reported causative associations with the development of leukoencephalopathies as well as smaller regional grey and white matter volumes, which have been found to correlate with neurocognitive deficits.Preclinical work has provided compelling evidence that chemotherapy drugs are potent neuro- and gliotoxins in vitro and in vivo and can cause brain injury via excitotoxic and apoptotic mechanisms. Furthermore, chemotherapy triggers DNA (deoxyribonucleic acid) damage directly or through increased oxidative stress. It can shorten telomeres and accelerate cell aging, cause cytokine deregulation, inhibit hippocampal neurogenesis, and reduce brain vascularization and blood flow. These mechanisms, when allowed to operate on the developing brain of a child, have high potential to not only cause brain injury, but also alter crucial developmental events, such as myelination, synaptogenesis, neurogenesis, cortical thinning, and formation of neuronal networks.This short review summarizes key publications describing neurotoxicity of chemotherapy in pediatric cancers and potential underlying pathomechanisms.
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Affiliation(s)
- Chrysanthy Ikonomidou
- Department of Neurology, Section of Child Neurology, University of Wisconsin Madison, Madison, WI, 53705, USA.
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11
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Ly KNI, Arrillaga-Romany IC. Neurologic Complications of Systemic Anticancer Therapy. Neurol Clin 2018; 36:627-651. [DOI: 10.1016/j.ncl.2018.04.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Morris AD, Hopewell JW. Combined Effects of Radiation and Methotrexate on the Cells of the Rat Subependymal Plate. J R Soc Med 2018; 76:848-52. [PMID: 6631862 PMCID: PMC1439615 DOI: 10.1177/014107688307601009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The brains of 20-week-old rats were locally irradiated with single doses of X-rays (400–1400 cGy). A similar group of animals received an intraventricular injection of methotrexate (MTX) prior to irradiation with single doses of X-rays (600–1400 cGy). Animals were killed six weeks after irradiation. A group of unirradiated age-matched animals acted as controls. In irradiated animals, the most severe effect on the subependymal plate (SEP) of the brain was denoted by the fall in the mitotic count (MC) and the number of small dark (SD) nucleated cells. SD nucleated cells are believed to represent the proliferative compartment of the subependymal layer. Other cell types in the SEP, believed to arise from the SD nucleated population, were affected to a lesser degree. After combination treatment with MTX, the decline in the MC and the SD nuclear density was more severe. The data for the dose-related decline in SD nuclear density and the MC fitted equally well on log-linear and linear plots. From the log-linear plots of the data it was concluded that MTX was radiation dose modifying (DMF 1.25–1.44). However, on the basis of the linear plots the effect of radiation and MTX was apparently additive. While no firm conclusions could be drawn regarding the mechanism of action of MTX on the radiation response of SEP cells, the possible mechanisms are discussed.
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Liu J, Wang Y, Sun X, Liu S, Yu Z, Ji N, Sun S, Liu Y. Lesions of the central nervous system in leukemia: Pathological and magnetic resonance imaging features at presentation in 14 patients. Oncol Lett 2017; 14:8162-8170. [PMID: 29344259 DOI: 10.3892/ol.2017.7192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 01/26/2017] [Indexed: 10/18/2022] Open
Abstract
The present study aimed to characterize the specific pathology and magnetic resonance imaging (MRI) findings observed in patients with leukemia with central nervous system (CNS) lesions, and to determine their value in the management of such patients. Lesions of the CNS were observed during and following treatment of leukemia. The data from stereotactic biopsy-proven pathology (12 patients) and MRI examinations (14 patients) were retrospectively evaluated. Proton-magnetic resonance-spectroscopy was performed in three patients. Factors that predisposed to lesions of the CNS were reviewed from the patient medical records. Among the 14 patients, eight had CNS leukemia, four had a CNS infection and two had a neurodegenerative disorder (one leukoencephalopathy and one glial cell hyperplasia). The clinical diagnosis based on clinical symptoms, signs and MRI features was not consistent with the pathological diagnosis in two patients. In one patient, the clinical diagnosis was a CNS infection; however, the patient's pathological diagnosis was CNS leukemia. In the other patient, the clinical diagnosis was CNS leukemia, but the pathological diagnosis was glial cell hyperplasia. CNS lesions in leukemia have a wide range of causes. Apart from the relapse of leukemia in the CNS, there are treatment-associated neurotoxicities and infections that are caused by immunocompromised states. As numerous leukemia-associated CNS lesions are treatable, early diagnosis is essential.
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Affiliation(s)
- Jing Liu
- Department of Hematology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, P.R. China
| | - Yaming Wang
- Department of Neurosurgery, Navy General Hospital, Beijing 100048, P.R. China
| | - Xuefei Sun
- Department of Hematology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, P.R. China
| | - Shuo Liu
- Duke Clinical Research Institute, Duke University, Durham, NC 27705, USA
| | - Zhenkun Yu
- Department of Otorhinolaryngology, Head and Neck Surgery, Nanjing Tongren Hospital, Southeast University, Nanjing 211100, P.R. China
| | - Nan Ji
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, P.R. China
| | - Shengjun Sun
- Neuroimaging Center, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, P.R. China
| | - Yuanbo Liu
- Department of Hematology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, P.R. China
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The Use of Pediatric Patient-Derived Xenografts for Identifying Novel Agents and Combinations. MOLECULAR AND TRANSLATIONAL MEDICINE 2017. [DOI: 10.1007/978-3-319-57424-0_11] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Disseminated Necrotizing Leukoencephalopathy Complicating Septic Shock in an Immunocompetent Patient. Case Rep Crit Care 2017; 2017:1092537. [PMID: 28523195 PMCID: PMC5420918 DOI: 10.1155/2017/1092537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 04/03/2017] [Indexed: 11/18/2022] Open
Abstract
Disseminated necrotizing leukoencephalopathy (DNL) is characterized by multiple microscopic foci of white matter necrosis. DNL was initially thought to be exclusively associated with immunosuppression conditions but it has been recently described in immunocompetent patients in septic shock. A 90-year-old immunocompetent woman with no previous neurological impairment presented with septic shock and drowsiness that responded well to therapy with clinical improvement and a full neurological recovery. Unexpectedly deterioration with progression to coma occurred. Investigation excluded other causes and Magnetic Resonance Imaging (MRI) was consistent with the diagnosis of DNL showing bilateral multifocal white matter lesions with a nonvascular pattern with restricted diffusion. Neurological impairment persisted with progression to death. DNL is an unexpected diagnosis in an immunocompetent patient. We compared the present case to those found in the literature of DNL complicating septic shock and discuss the antemortem diagnosis based on MRI findings.
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Metz I, Rieckmann P, Kallmann BA, Brück W. Disseminated necrotizing leukoencephalopathy eight months after alemtuzumab treatment for multiple sclerosis. Acta Neuropathol Commun 2016; 4:81. [PMID: 27503238 PMCID: PMC4977646 DOI: 10.1186/s40478-016-0352-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 07/25/2016] [Indexed: 11/22/2022] Open
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Abstract
Neurologic complications of cancer are common and are frequently life-threatening events. Certain neurologic emergencies occur more frequently in the cancer population, specifically elevated intracranial pressure, epidural cord compression, status epilepticus, ischemic and hemorrhagic stroke, central nervous system infection, and treatment-associated neurologic dysfunction. These emergencies require early diagnosis and prompt treatment to ensure the best possible outcome and are best managed in the intensive care unit. This article reviews the presentation, pathophysiology, and management of the most common causes of acute neurologic decompensation in the patient with cancer.
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Affiliation(s)
- Andrew L Lin
- 1 Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Edward K Avila
- 1 Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Intraventricular etoposide safety and toxicity profile in children and young adults with refractory or recurrent malignant brain tumors. J Neurooncol 2016; 128:463-71. [PMID: 27147083 DOI: 10.1007/s11060-016-2133-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 04/19/2016] [Indexed: 10/21/2022]
Abstract
Systemic administration of etoposide is effective in treating metastatic, recurrent or refractory brain tumors, but penetration into the cerebrospinal fluid is extremely poor. This study was designed to determine the safety and toxicity profile of intraventricular etoposide administration and was affiliated with the prospective, multicenter, nonblinded, nonrandomized, multi-armed HIT-REZ-97 trial. The study enrolled 68 patients, aged 1.1-34.6 (median age 11 years). Adverse events that could possibly be related to intraventricular etoposide therapy were documented and analyzed. Intraventricular etoposide was simultaneously administered with either oral or intravenous chemotherapy in 426 courses according to three major schedules varying in dosing (0.25-1 mg), frequency of administration (bolus injection, every 12 or 24 h), course duration (5-10 days) and length of interval between courses (2-5 weeks). Potential treatment-related adverse effects included transient headache, seizures, infection of the reservoir, nausea and neuropsychological symptoms. Hematological side effects were not observed. One patient, with history of multiple prior therapies, who received long-term intraventricular and oral etoposide treatment developed acute myeloid leukemia as a secondary malignancy. Overall intraventricular etoposide is well tolerated. The results of this study have warranted a phase II trial to determine the effectiveness of this regimen in disease stages with very limited therapeutic options.
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Yap SM, MacEneaney P, Ryan C, O'Toole O. Alternating hemiparesis and orolingual apraxia as manifestations of methotrexate neurotoxicity in a paediatric case of acute lymphoblastic leukaemia. BMJ Case Rep 2016; 2016:bcr-2016-214677. [PMID: 27113788 DOI: 10.1136/bcr-2016-214677] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 15-year-old girl with a recent diagnosis of acute lymphoblastic leukaemia was admitted to hospital with pancytopaenia after having received high-dose intrathecal methotrexate 1 day prior. During the next week she had intermittent episodes of alternating hemiparesis associated with speech arrest lasting minutes to hours at a time. The episodes were not associated with altered level of consciousness or headache. MRI of the brain showed features consistent with methotrexate encephalopathy. This report discusses the typical clinical and radiological features of methotrexate neurotoxicity in addition to differential diagnoses and the proposed pathophysiological mechanisms.
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Affiliation(s)
- Siew Mei Yap
- Department of Neurology, Mercy University Hospital, Cork, Ireland
| | - Peter MacEneaney
- Department of Radiology, Mercy University Hospital, Cork, Ireland
| | - Clodagh Ryan
- Department of Haematology, Mercy University Hospital, Cork, Ireland
| | - Orna O'Toole
- Department of Neurology, Mercy University Hospital, Cork, Ireland
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Ventricular access device placement in the fourth ventricle to treat malignant fourth ventricle brain tumors: technical note. Childs Nerv Syst 2016; 32:703-7. [PMID: 26597683 PMCID: PMC4819733 DOI: 10.1007/s00381-015-2969-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 11/18/2015] [Indexed: 10/29/2022]
Abstract
PURPOSE Ventricular access devices (VADs) are commonly placed in the lateral ventricle but rarely placed in other ventricular compartments. This manuscript describes technical aspects of VAD placement into the fourth ventricle for the purpose of treating malignant posterior fossa brain tumors. METHODS As part of a pilot clinical trial to treat recurrent malignant brain tumors in children, seven patients underwent posterior fossa craniotomy and placement of a ventricular catheter under direct vision into the fourth ventricle. The catheter was placed without passing through any brain parenchyma. It was then connected to a VAD placed subcutaneously at the inferior aspect of the incision. Three of the seven patients underwent simultaneous subtotal resection of recurrent tumor located in the fourth ventricle or cerebellum, and one patient underwent simultaneous tumor biopsy. The VAD was used to administer chemotherapy (methotrexate) in five of the seven patients. RESULTS Six patients had no new neurological deficits after surgery, and one patient had partial left-sided facial weakness that was attributed to resection of tumor close to the floor of the fourth ventricle. No new neurological deficits were caused by VAD placement or by methotrexate infusions into the fourth ventricle. CONCLUSIONS A VAD for chemotherapy infusion can be placed safely into the fourth ventricle without damaging the brainstem or cerebellum. Attention to anatomical details specific to the fourth ventricle are important when placing a fourth ventricle VAD and when using it to administer chemotherapy.
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Sandberg DI, Rytting M, Zaky W, Kerr M, Ketonen L, Kundu U, Moore BD, Yang G, Hou P, Sitton C, Cooper LJ, Gopalakrishnan V, Lee DA, Thall PF, Khatua S. Methotrexate administration directly into the fourth ventricle in children with malignant fourth ventricular brain tumors: a pilot clinical trial. J Neurooncol 2015; 125:133-41. [PMID: 26255071 PMCID: PMC4592494 DOI: 10.1007/s11060-015-1878-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 08/03/2015] [Indexed: 11/30/2022]
Abstract
We hypothesize that chemotherapy can be safely administered directly into the fourth ventricle to treat recurrent malignant brain tumors in children. For the first time in humans, methotrexate was infused into the fourth ventricle in children with recurrent, malignant brain tumors. A catheter was surgically placed into the fourth ventricle and attached to a ventricular access device. Cerebrospinal fluid (CSF) flow was confirmed by CINE MRI postoperatively. Each cycle consisted of 4 consecutive daily methotrexate infusions (2 milligrams). Disease response was monitored with serial MRI scans and CSF cytologic analysis. Trough CSF methotrexate levels were sampled. Five patients (3 with medulloblastoma and 2 with ependymoma) received 18, 18, 12, 9, and 3 cycles, respectively. There were no serious adverse events or new neurological deficits attributed to methotrexate. Two additional enrolled patients were withdrawn prior to planned infusions due to rapid disease progression. Median serum methotrexate level 4 h after infusion was 0.04 µmol/L. Range was 0.02–0.13 µmol/L. Median trough CSF methotrexate level 24 h after infusion was 3.18 µmol/L (range 0.53–212.36 µmol/L). All three patients with medulloblastoma had partial response or stable disease until one patient had progressive disease after cycle 18. Both patients with ependymoma had progressive disease after 9 and 3 cycles, respectively. Low-dose methotrexate can be infused into the fourth ventricle without causing neurological toxicity. Some patients with recurrent medulloblastoma experience a beneficial anti-tumor effect both within the fourth ventricle and at distant sites.
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Affiliation(s)
- David I Sandberg
- Division of Pediatric Neurosurgery, Departments of Pediatric Surgery and Neurosurgery, University of Texas Health Science Center at Houston and Mischer Neuroscience Center, 6431 Fannin Street, MSB 5.144, Houston, TX, 77030, USA. .,Divisions of Neurosurgery and Pediatrics, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Michael Rytting
- Division of Pediatrics, Unit 87, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Wafik Zaky
- Division of Pediatrics, Unit 87, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Marcia Kerr
- Division of Neurosurgery, Department of Pediatric Surgery, University of Texas Health Science Center at Houston, 6431 Fannin St., MSB 5.146, Houston, TX, 77030, USA
| | - Leena Ketonen
- Unit 1482, Department of Diagnostic Imaging, Section of Neuroradiology, FCT 16.5020, University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX, 77030, USA
| | - Uma Kundu
- Unit 85, Department of Pathology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Bartlett D Moore
- Division of Pediatrics, Unit 87, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Grace Yang
- Division of Pediatrics, Unit 87, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Ping Hou
- Unit 1472, Department of Imaging Physics, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Clark Sitton
- Department of Diagnostic & Interventional Imaging, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 2.130B, Houston, TX, 77030, USA
| | - Laurence J Cooper
- Division of Pediatrics, Unit 87, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA.,Ziopharm Oncology Inc., 1 First Avenue; Parris Building, #34, Navy Yard Plaza, Boston, MA, 02129, USA
| | - Vidya Gopalakrishnan
- Division of Pediatrics, Unit 87, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Dean A Lee
- Division of Pediatrics, Unit 87, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Peter F Thall
- Department of Biostatistics, Office FCT 4.614, MD Anderson Cancer Center, Houston, TX, 77230-1402, USA
| | - Soumen Khatua
- Division of Pediatrics, Unit 87, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
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Shintaku M, Toyooka N, Koyama T, Teraoka S, Tsudo M. Methotrexate myelopathy with extensive transverse necrosis: Report of an autopsy case. Neuropathology 2014; 34:547-53. [DOI: 10.1111/neup.12135] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 05/08/2014] [Indexed: 11/29/2022]
Affiliation(s)
| | - Nao Toyooka
- Department of Hematology; Osaka Red Cross Hospital; Osaka Japan
| | - Takashi Koyama
- Diagnostic Radiology; Osaka Red Cross Hospital; Osaka Japan
| | | | - Mitsuru Tsudo
- Department of Hematology; Osaka Red Cross Hospital; Osaka Japan
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Kao HW, Pare L, Kim R, Hasso AN. Toxic leukoencephalopathy with atypical MRI features following a lacquer thinner fire. J Clin Neurosci 2013; 21:878-80. [PMID: 24291481 DOI: 10.1016/j.jocn.2013.06.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 06/05/2013] [Accepted: 06/15/2013] [Indexed: 11/24/2022]
Abstract
Toxic leukoencephalopathy is a structural alteration of the white matter following exposure to various toxic agents. We report a 49-year-old man exposed to an explosion of lacquer thinner with brain MRI features atypical from those of chronic toxic solvent intoxication.
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Affiliation(s)
- Hung-Wen Kao
- Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC; Department of Radiological Sciences, University of California, Irvine Medical Center, 101 City Drive South, Route 140, Orange, CA 92868, USA
| | - Laura Pare
- Department of Neurosurgery, University of California, Irvine Medical Center, Orange, CA, USA
| | - Ronald Kim
- Department of Pathology, University of California, Irvine Medical Center, Orange, CA, USA
| | - Anton N Hasso
- Department of Radiological Sciences, University of California, Irvine Medical Center, 101 City Drive South, Route 140, Orange, CA 92868, USA.
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Sandberg DI, Peet MM, Johnson MD, Cole P, Koru-Sengul T, Luqman AW. Chemotherapy administration directly into the fourth ventricle in a nonhuman primate model. J Neurosurg Pediatr 2012; 9:530-41. [PMID: 22546032 DOI: 10.3171/2012.1.peds11410] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors hypothesized that chemotherapy infusions directly into the fourth ventricle might potentially play a role in treating malignant fourth ventricular tumors. The study tested the safety and pharmacokinetics of short- and long-term infusions of methotrexate into the fourth ventricle in a new nonhuman primate model. METHODS Six rhesus monkeys underwent posterior fossa craniectomy and catheter insertion into the fourth ventricle. In Group I (3 animals), catheters were externalized, and lumbar drain catheters were placed simultaneously to assess CSF distribution after short-term methotrexate infusions. In 2 animals, methotrexate (0.5 mg) was infused into the fourth ventricle daily for 5 days. Serial CSF and serum methotrexate levels were measured. The third animal had a postoperative neurological deficit, and the experiment was aborted prior to methotrexate administration. In Group II (3 animals), catheters were connected to a subcutaneously placed port for subsequent long-term methotrexate infusions. In 2 animals, 4 cycles of intraventricular methotrexate, each consisting of 4 daily infusions (0.5 mg), were administered over 8 weeks. The third animal received 3 cycles, and then the experiment was terminated due to self-inflicted wound breakdown. All animals underwent detailed neurological evaluations, MRI, and postmortem histological analysis. RESULTS No neurological deficits were noted after intraventricular methotrexate infusions. Magnetic resonance images demonstrated catheter placement within the fourth ventricle and no signal changes in the brainstem or cerebellum. Histologically, two Group I animals, one of which did not receive methotrexate, had several small focal areas of brainstem injury. Two Group II animals had a small (≤ 1-mm) focus of axonal degeneration in the midbrain. Intraventricular and meningeal inflammation was noted in 4 animals after methotrexate infusions (one from Group I and all three from Group II). In all Group II animals, inflammation extended minimally into brainstem parenchyma. Serum methotrexate levels were undetectable or negligible in both groups, ranging from 0.00 to 0.06 μmol/L. In Group I, the mean peak methotrexate level in fourth ventricle CSF exceeded that in the lumbar CSF by greater than 10-fold. Statistically significant differences between fourth ventricle and lumbar AUC (area under the concentration-time curve) were detected at peaks (p = 0.04) but not at troughs (p = 0.50) or at all time collection points (p = 0.12). In Group II, peak fourth ventricle CSF methotrexate levels ranged from 84.62 to 167.89 μmol/L (mean 115.53 ± 15.95 μmol/L [SD]). Trough levels ranged from 0.06 to 0.55 μmol/L (mean 0.22 ± 0.13 μmol/L). CONCLUSIONS Methotrexate can be infused into the fourth ventricle in nonhuman primates without clinical or radiographic evidence of injury. Observed inflammatory and other histological changes had no clinical correlate. This approach may have pharmacokinetic advantages over current treatment paradigms. Further experiments are warranted to determine if fourth ventricular chemotherapy infusions may benefit patients with malignant fourth ventricular tumors.
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Affiliation(s)
- David I Sandberg
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
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25
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Al-Hasani OH, Smith C. Traumatic white matter injury and toxic leukoencephalopathies. Expert Rev Neurother 2012; 11:1315-24. [PMID: 21864077 DOI: 10.1586/ern.11.119] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
White matter injury may be secondary to a range of neurodegenerative disorders, such as the common dementing disorders of the elderly, or may be a consequence of specific white matter disorders, such as multiple sclerosis and the rare leukodystrophies. This article will focus on two relatively common primary groups of disorders of the white matter, traumatic white matter injury and toxic leukoencephalopathies. Traumatic axonal injury may be focal or diffuse, and is associated with a clinical spectrum ranging from concussion through to coma and death. The molecular mechanisms underlying axonal degeneration secondary to traumatic axonal degeneration are being elucidated and may give an insight into potential therapeutic targets. Toxic leukoencephalopathy may be secondary to exposure to a wide range of compounds, including chemotherapeutic drugs. These toxins may produce white matter injury through a range of mechanisms, and the potential toxic effects of compounds need to be considered when assessing a patient with a nonspecific leukoencephalopathy.
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Affiliation(s)
- Omer Hussain Al-Hasani
- University Department of Pathology, University of Edinburgh, Wilkie Building, Teviot Place, Edinburgh, EH8 9AG, UK
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26
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Hasegawa T, Abe K, Sakuma R, Itoyama Y. Marked improvement of delayed methotrexate-induced leukoencephalopathy treated with high-dose folinic acid. Eur J Neurol 2011. [DOI: 10.1111/j.1468-1331.1997.tb00395.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Hasan A, Palumbo M, Atkinson J, Carret AS, Farmer JP, Montes J, Albrecht S, Saint-Martin C, Freeman CR. Treatment-related morbidity in atypical teratoid/rhabdoid tumor: multifocal necrotizing leukoencephalopathy. Pediatr Neurosurg 2011; 47:7-14. [PMID: 21613772 DOI: 10.1159/000323412] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Accepted: 12/03/2010] [Indexed: 11/19/2022]
Abstract
BACKGROUND Atypical teratoid/rhabdoid tumor (AT/RT) is an aggressive malignant brain tumor that, since it was first identified, has been treated with aggressive treatment regimens, e.g. high-dose chemotherapy with stem cell rescue and early radiotherapy. We reviewed our experience because of concerns with respect to treatment-related toxicity in our patients. METHODS Seven patients with a median age at presentation of 18 months were diagnosed with AT/RT between 1996 and 2006. Tumor location was supratentorial in 2 patients, in the posterior fossa in 4 and spinal in 1. Gross total resection was performed in 1 patient, subtotal resection in 5 and biopsy only in 1. Adjuvant treatment consisted of chemotherapy and radiotherapy in 5 patients. RESULTS Median progression-free survival was 4 months, and median overall survival was 7 months. Two children are alive at 44 and 102 months. Significant surgical and chemotherapy-related morbidity was seen. Biopsy-proven multifocal necrotizing leukoencephalopathy (MNL) was seen in one patient who is alive 44 months after diagnosis. Another patient who was thought to have recurrent tumor in the brainstem 9 months after diagnosis had imaging findings compatible with MNL. CONCLUSION Although improving results are reported for AT/RT using intensive treatment regimens, treatment-related morbidity is considerable in this young patient population.
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Affiliation(s)
- A Hasan
- Department of Neurosurgery, McGill University Health Centre/Montreal Children's Hospital, Montréal, Québec, Canada
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Safety and pharmacokinetic analysis of methotrexate administered directly into the fourth ventricle in a piglet model. J Neurooncol 2010; 100:397-406. [PMID: 20440538 DOI: 10.1007/s11060-010-0210-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2009] [Accepted: 04/14/2010] [Indexed: 10/19/2022]
Abstract
We have developed a piglet model to assess chemotherapy administration directly into the fourth ventricle as a potential treatment for medulloblastoma and other malignant posterior fossa tumors. The objective of this study was to assess safety and pharmacokinetics after methotrexate infusions into the fourth ventricle. Catheters were inserted into the fourth ventricle and lumbar cistern in five piglets. Two milligrams of Methotrexate (MTX) was infused into the fourth ventricle on five consecutive days. Safety was assessed by neurological examination, 4.7 T MRI, and post-mortem pathological analysis. MTX levels in serum and cerebrospinal fluid (CSF) were measured, and area under the concentration-time curve (AUC) was calculated for CSF samples. No neurological deficits were caused by MTX infusions. One piglet died from complications of anesthesia induction for MRI scanning. MRI scans showed accurate catheter placement without signal changes in the brainstem or cerebellum. One piglet had asymptomatic ventriculomegaly. Pathological analysis demonstrated meningitis and choroid plexitis consisting predominantly of CD-3 positive T-lymphocytes in all piglets and a small focal area of subependymal necrosis in one. In all piglets, mean peak MTX level in fourth ventricular CSF exceeded that in lumbar CSF by greater than five-fold. Serum MTX levels were undetectable or negligible. Statistically significant differences between fourth ventricle and lumbar AUC were detected at peaks (P = 0.01) and at all collection time points (P = 0.01) but not at troughs (P = 0.36). MTX can be infused into the fourth ventricle without clinical or radiographic evidence of damage. An inflammatory response without clinical correlate is observed. Significantly higher peak MTX levels are observed in the fourth ventricle than in the lumbar cistern.
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29
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Mahadeo KM, Dhall G, Panigrahy A, Lastra C, Ettinger LJ. Subacute methotrexate neurotoxicity and cerebral venous sinus thrombosis in a 12-year-old with acute lymphoblastic leukemia and methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism: homocysteine-mediated methotrexate neurotoxicity via direct endothelial injury. Pediatr Hematol Oncol 2010; 27:46-52. [PMID: 20121554 DOI: 10.3109/08880010903341904] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
From as early as the 1970s methotrexate has been associated with disseminated necrotizing leukoencephalopathy and other neurotoxic sequelae. Yet, a clear mechanism for methotrexate-induced neurotoxicity has not been established. The authors describe the case of a 12-year-old male with acute lymphoblastic leukemia and a homozygous methylenetetrahydrofolate reductase C677T mutation, who developed subacute methotrexate-induced toxicity and cerebral venous thrombosis after receiving intrathecal methotrexate. The role of homocysteine as a possible mediator in methotrexate-induced neurotoxicity via direct endothelial injury is discussed.
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Affiliation(s)
- Kris M Mahadeo
- Division of Pediatric Hematology-Oncology, Children's Hospital at Montefiore, Bronx, New York 10467, USA.
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Intracranial tumor lysis and cerebral edema after administration of intrathecal methotrexate: a case report and discussion. Med Oncol 2009; 27:1079-81. [DOI: 10.1007/s12032-009-9338-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2009] [Accepted: 10/06/2009] [Indexed: 10/20/2022]
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Sandberg DI, Crandall KM, Koru-Sengul T, Padgett KR, Landrum J, Babino D, Petito CK, Solano J, Gonzalez-Brito M, Kuluz JW. Pharmacokinetic analysis of etoposide distribution after administration directly into the fourth ventricle in a piglet model. J Neurooncol 2009; 97:25-32. [PMID: 19688296 DOI: 10.1007/s11060-009-9998-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2009] [Accepted: 08/10/2009] [Indexed: 11/28/2022]
Abstract
We hypothesize that infusion of chemotherapeutic agents directly into the fourth ventricle potentially may play a role in treating malignant posterior fossa brain tumors. Accordingly, we used a piglet model developed in our laboratory to test the safety of etoposide infusions into the fourth ventricle and to study the pharmacokinetics associated with these infusions. In 5 piglets, closed-tip silicone catheters were inserted into the fourth ventricle and lumbar cistern. Five consecutive daily infusions of etoposide (0.5 mg) were administered via the fourth ventricle catheter. Serum and CSF from both catheters were sampled for measurement of etoposide level by reversed-phase high performance liquid chromatography (HPLC). For CSF samples, area under the concentration-time curve (AUC) was calculated. Piglets underwent daily neurological examinations, a 4.7 Tesla MRI scan, and then were sacrificed for post-mortem brain examination. No neurological deficits or signs of meningitis were caused by intraventricular chemotherapy infusions. MRI scans showed catheter placement within the fourth ventricle but no signal changes in the brain stem or cerebellum. In all piglets, the mean fourth ventricular CSF peak etoposide level exceeded the mean peak lumbar etoposide levels by greater than 10-fold. Statistically significant differences between fourth ventricle and lumbar AUC were noted at peaks (DeltaAUC = 3384196 ng h/ml with 95%CI: 1758625, 5009767, P = 0.0044) and at all collection time points (DeltaAUC = 1422977 ng h/ml with 95%CI: 732188, 2113766, P = 0.0046) but not at troughs (DeltaAUC = -29546 ng h/ml (95%CI: -147526, 88434.2, P = 0.5251). Serum etoposide was absent at two and four hours after intraventricular infusions in all animals. Pathological analysis demonstrated meningitis, choroid plexitis, and ependymitis in the fourth and occasionally lateral ventricles. Etoposide can be infused directly into the fourth ventricle without clinical or radiographic evidence of damage. Autopsy examination revealed ventriculitis and meningitis which did not have a clinical correlate. Etoposide does not distribute evenly throughout CSF spaces after administration into the fourth ventricle, and higher peak CSF levels are observed in the fourth ventricle than in the lumbar cistern.
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Affiliation(s)
- David I Sandberg
- Department of Neurological Surgery, University of Miami Miller School of Medicine and Miami Children's Hospital, Ambulatory Care Building Suite 3109, Miami, FL 33155, USA.
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Marcon G, Giovagnoli AR, Mangiapane P, Erbetta A, Tagliavini F, Girotti F. Regression of chronic posterior leukoencephalopathy after stop of methotrexate treatment. Neurol Sci 2009; 30:375-8. [DOI: 10.1007/s10072-009-0119-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2009] [Accepted: 06/29/2009] [Indexed: 10/20/2022]
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Intractable epilepsy in patients treated for childhood acute lymphocytic leukemia. Seizure 2009; 18:298-302. [DOI: 10.1016/j.seizure.2008.10.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2008] [Accepted: 10/23/2008] [Indexed: 12/17/2022] Open
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Matsubayashi J, Tsuchiya K, Matsunaga T, Mukai K. Methotrexate-related leukoencephalopathy without radiation therapy: Distribution of brain lesions and pathological heterogeneity on two autopsy cases. Neuropathology 2009; 29:105-15. [DOI: 10.1111/j.1440-1789.2008.00945.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Early CNS toxicity after intrathecal methotrexate. Indian J Hematol Blood Transfus 2009; 24:186-7. [PMID: 23100961 DOI: 10.1007/s12288-008-0045-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2008] [Accepted: 09/06/2008] [Indexed: 10/21/2022] Open
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Smith SW, Nelson LS. Case files of the New York City Poison Control Center: antidotal strategies for the management of methotrexate toxicity. J Med Toxicol 2008; 4:132-40. [PMID: 18570175 PMCID: PMC3550133 DOI: 10.1007/bf03160968] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Silas W Smith
- New York City Poison Control Center, New York, NY, USA.
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Sandberg DI, Crandall KM, Petito CK, Padgett KR, Landrum J, Babino D, He D, Solano J, Gonzalez-Brito M, Kuluz JW. Chemotherapy administration directly into the fourth ventricle in a new piglet model. Laboratory Investigation. J Neurosurg Pediatr 2008; 1:373-80. [PMID: 18447671 DOI: 10.3171/ped/2008/1/5/373] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors hypothesized that chemotherapy infusions directly into the fourth ventricle may potentially play a role in treating malignant posterior fossa tumors. In this study the safety and pharmacokinetics of etoposide administration into the fourth ventricle was tested using an indwelling catheter in piglets. METHODS A closed-tip silicone lumbar drain catheter was inserted into the fourth ventricle via a posterior fossa craniectomy and 5 daily infusions of etoposide (0.5 mg in 5 animals) or normal saline (in 2 animals) were instilled. Piglets (10-18 kg, 2-3 months of age) underwent daily neurological examinations and 4.7-T magnetic resonance (MR) imaging after the final infusion and were then killed for postmortem examination. Pharmacokinetics were studied using reversed-phase high-performance liquid chromatography on cerebrospinal fluid (CSF) samples at 0.25, 1, 2, 4, 8, 12, and 24 hours after etoposide infusion. Peak and trough CSF etoposide levels were measured for each subsequent infusion. Serum etoposide levels were obtained at 2 and 4 hours after infusion. RESULTS All piglets remained neurologically intact, and MR images demonstrated catheter placement within the fourth ventricle without signal changes in the brainstem or cerebellum. Serum etoposide was absent at 2 and 4 hours after intraventricular infusions. When adequate samples could be obtained for analysis, CSF etoposide levels peaked 15 minutes after infusion and progressively decreased. Cytotoxic levels (> 0.1 microg/ml) were maintained for 5 consecutive peak and trough measurements with 1 exception. Etoposide-related neuropathology included moderate-to-severe T-lymphocytic meningitis and fourth and lateral ventricular choroid plexitis with associated subependymal inflammation. CONCLUSIONS Etoposide can be infused directly into the fourth ventricle without clinical or imaging evidence of damage. Cytotoxic CSF etoposide levels can be maintained for 24 hours with a single daily infusion into the fourth ventricle using an indwelling catheter. Intraventricular etoposide elicits an inflammatory response, the long-term effects of which are as yet undetermined.
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Affiliation(s)
- David I Sandberg
- Department of Neurological Surgery, University of Miami Miller School of Medicine and Miami Children's Hospital, Miami, Florida 33155, USA.
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Bradley K, Ian Robins H. Neurologic Complications of Therapy. Oncology 2007. [DOI: 10.1007/0-387-31056-8_79] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Yokoo H, Nakazato Y, Harigaya Y, Sasaki N, Igeta Y, Itoh H. Massive myelinolytic leukoencephalopathy in a patient medicated with low-dose oral methotrexate for rheumatoid arthritis: an autopsy report. Acta Neuropathol 2007; 114:425-30. [PMID: 17357801 DOI: 10.1007/s00401-007-0214-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2007] [Revised: 02/23/2007] [Accepted: 02/23/2007] [Indexed: 10/23/2022]
Abstract
The authors describe a 68-year-old female who developed a rapidly progressing leukoencephalopathy involving the cerebrum and brain stem. The disease appeared during low-dose oral methotrexate (MTX) therapy for rheumatoid arthritis. An extensive clinical investigation discounted other possible causes of white matter lesions. Autopsy identified an uninterrupted severe demyelinating, partially liquefactive necrosis-like lesion in the white matter accompanied by astrogliosis and occasional swollen axons therein. The lesion was generally symmetrical, and distributed throughout the whole cerebral white matter except for the bilateral temporal lobes and the rostral part of the frontal lobes. The internal capsules and cerebral peduncles were spongy, and the central and lateral parts of the pons, especially the transverse cerebellopontine tracts, were affected similarly. It was of note that the lesion was accompanied by neither vascular diseases nor lymphocyte infiltration. Thus, the pathological findings were similar to those of a severe form of central and extrapontine myelinolysis, and clearly different from ordinary MTX leukoencephalopathy reported in patients receiving intrathecal or intravenous MTX therapy, known as "disseminated necrotizing leukoencephalopathy". Another possibility is that synergistic effects of several white-matter-damaging disorders may have contributed to the hitherto unknown lesion. To our knowledge, this is the first autopsy record that describes an oral MTX-associated neurological disorder.
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Affiliation(s)
- Hideaki Yokoo
- Department of Human Pathology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan.
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Pande AR, Ando K, Ishikura R, Nagami Y, Ogawa M, Kamikonya N, Kaneda Y, Tanizawa T, Nakao N. Disseminated necrotizing leukoencephalopathy following chemoradiation therapy for acute lymphoblastic leukemia. ACTA ACUST UNITED AC 2007; 24:515-9. [PMID: 17058146 DOI: 10.1007/s11604-006-0059-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2005] [Accepted: 04/11/2006] [Indexed: 10/24/2022]
Abstract
Disseminated necrotizing leukoencephalopathy (DNL) is a potentially fatal complication of treatment involving intrathecal administration of chemotherapeutic agents such as methotrexate (MTX) alone or in combination with cranial radiotherapy (RT). We describe a case of acute lymphoblastic leukemia (ALL) treated with high-dose intravenous and intrathecal methotrexate combined with craniospinal RT resulting in DNL. Typical MR imaging features of progressive deep white matter lesions showing a characteristic pattern of enhancement after contrast was seen in this case. Deep white matter lesions with ring-like enhancement and calcifications were seen on CT; it showed a mass effect at one stage, which is not typical for DNL. Long-term clinical and imaging follow-up were helpful for the diagnosis in this case.
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Affiliation(s)
- Ajaya R Pande
- Department of Radiology, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo 663-8501, Japan.
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Ruben JD, Dally M, Bailey M, Smith R, McLean CA, Fedele P. Cerebral radiation necrosis: incidence, outcomes, and risk factors with emphasis on radiation parameters and chemotherapy. Int J Radiat Oncol Biol Phys 2006; 65:499-508. [PMID: 16517093 DOI: 10.1016/j.ijrobp.2005.12.002] [Citation(s) in RCA: 332] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2005] [Revised: 11/30/2005] [Accepted: 12/01/2005] [Indexed: 11/29/2022]
Abstract
PURPOSE To investigate radiation necrosis in patients treated for glioma in terms of incidence, outcomes, predictive and prognostic factors. METHODS AND MATERIALS Records were reviewed for 426 patients followed up until death or for at least 3 years. Logistic regression analysis was performed to identify predictive and prognostic factors. Multivariate survival analysis was conducted using Cox proportional hazards regression. Separate analyses were performed for the subset of 352 patients who received a biologically effective dose (BED) > or =85.5 Gy2 (> or =45 Gy/25 fractions) who were at highest risk for radionecrosis. RESULTS Twenty-one patients developed radionecrosis (4.9%). Actuarial incidence plateaued at 13.3% after 3 years. In the high-risk subset, radiation parameters confirmed as risk factors included total dose (p < 0.001), BED (p < 0.005), neuret (p < 0.001), fraction size (p = 0.028), and the product of total dose and fraction size (p = 0.001). No patient receiving a BED <96 Gy2 developed radionecrosis. Subsequent chemotherapy significantly increased the risk of cerebral necrosis (p = 0.001) even when adjusted for BED (odds ratio [OR], 5.8; 95% confidence interval [CI], 1.6-20.3) or length of follow-up (OR, 5.4; 95% CI, 1.5-19.3). Concurrent use of valproate appeared to delay the onset of necrosis (p = 0.013). The development of radionecrosis did not affect survival (p = 0.09). CONCLUSIONS Cerebral necrosis is unlikely at doses below 50 Gy in 25 fractions. The risk increases significantly with increasing radiation dose, fraction size, and the subsequent administration of chemotherapy.
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Affiliation(s)
- Jeremy D Ruben
- William Buckland Radiotherapy Centre, Melbourne, Australia
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Perry A, Schmidt RE. Cancer therapy-associated CNS neuropathology: an update and review of the literature. Acta Neuropathol 2006; 111:197-212. [PMID: 16463065 DOI: 10.1007/s00401-005-0023-y] [Citation(s) in RCA: 161] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2005] [Revised: 12/08/2005] [Accepted: 12/09/2005] [Indexed: 01/28/2023]
Abstract
Standard therapeutic options for brain tumors include surgery, radiation, and chemotherapy. Unfortunately, these same therapies pose risks of neurotoxicity, the most common long-term complications being radiation necrosis, chemotherapy-associated leukoencephalopathy, and secondary neoplasms. These side effects remain difficult to predict, but are associated with risk factors that include patient age, therapeutic modality and dosage, genetic background, and idiosyncratic predispositions. Experimental treatments designed to enhance efficacy and to minimize neurotoxicity include molecularly targeted, genetic, stem cell, and immune therapies. Newer modifications in radiation and drug delivery include stereotactic radiosurgery, interstitial therapy such as intracavitary brachytherapy and gliadel wafer placement, 3D conformal radiation, boron neutron capture therapy, radiosensitizers, blood-brain barrier disrupting agents, and convection enhanced delivery. Toxicities associated with these newer modalities have yet to be fully investigated and documented. Additionally, a number of recently implemented radiographic techniques such as PET and SPECT imaging have enhanced the ability to distinguish recurrent tumor from radiation necrosis. Nevertheless, post-therapeutic brain biopsies and autopsies remain the gold standard for assessing neurotoxicity, therapeutic efficacy, tumor progression, and the development of secondary neoplasms. At the same time, treatment-associated changes such as tumor necrosis, vasculopathy, inflammation, and cytologic atypia can pose significant diagnostic pitfalls, particularly if the pathologist is not provided a detailed therapeutic history. Therefore, it is critical to recognize the full spectrum of cancer therapy-associated neuropathology, the topic of the current review.
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Affiliation(s)
- Arie Perry
- Division of Neuropathology, Washington University School of Medicine, St. Louis, MO 63110-1093, USA.
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Wong ET. Management of Central Nervous System Lymphomas Using Monoclonal Antibodies: Challenges and Opportunities. Clin Cancer Res 2005; 11:7151s-7157s. [PMID: 16203815 DOI: 10.1158/1078-0432.ccr-1004-0002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Monoclonal antibodies (mAb) may change the management of central nervous system (CNS) lymphomas. This is due to the fact that traditional chemotherapies lack specificity for B-lymphoma cells and blood-brain barrier prevents adequate chemotherapy dosing in the CNS without significant systemic side effects. But in the past 5 years, the emergence of mAbs against specific receptors on B-lymphoma cells, either as a single agent or in combination with cytotoxic chemotherapies, may offer a better therapeutic index than conventional chemotherapies. The advantages of mAbs include high affinity to targets on lymphoma cells, their lack of pharmacodynamic or pharmacokinetic interactions with other drugs, and a potential for a synergistic therapeutic response when combined with conventional chemotherapies. Our review summarizes the biological behaviors of CNS lymphomas and the challenges and opportunities in using mAbs for CNS lymphomas.
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Affiliation(s)
- Eric T Wong
- Department of Neurology and Neuro-Oncology Unit, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA.
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Wong ET. Monoclonal antibody therapy for central nervous system lymphomas: an emerging treatment paradigm. Expert Opin Pharmacother 2005; 6:1107-14. [PMID: 15957965 DOI: 10.1517/14656566.6.7.1107] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The management of CNS lymphomas is poised for another revolution due to the emergence of therapeutic monoclonal antibodies. As the technology for generating monoclonal antibodies matures and obstacles are solved, therapeutic monoclonal antibodies will play an increasing role in the management of cancer. This article will review the biology of CNS lymphomas, monoclonal antibody technology, limitation of existing chemotherapies and the application of therapeutic monoclonal antibodies for the treatment of CNS lymphomas.
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MESH Headings
- Alemtuzumab
- Animals
- Antibodies, Monoclonal/immunology
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Humanized
- Antibodies, Monoclonal, Murine-Derived
- Antibodies, Neoplasm/immunology
- Antibodies, Neoplasm/therapeutic use
- Antigens, CD/immunology
- Antigens, CD20/immunology
- Antigens, Neoplasm/immunology
- Antineoplastic Agents/therapeutic use
- CD52 Antigen
- Central Nervous System Neoplasms/drug therapy
- Central Nervous System Neoplasms/immunology
- Clinical Trials as Topic
- Genetic Engineering
- Glycoproteins/immunology
- Humans
- Lymphoma/drug therapy
- Lymphoma/immunology
- Peptide Library
- Rituximab
- Sialic Acid Binding Ig-like Lectin 2/immunology
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Affiliation(s)
- Eric T Wong
- Department of Neurology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA.
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Finkelstein Y, Zevin S, Raikhlin-Eisenkraft B, Bentur Y. Intrathecal methotrexate neurotoxicity: clinical correlates and antidotal treatment. ENVIRONMENTAL TOXICOLOGY AND PHARMACOLOGY 2005; 19:721-725. [PMID: 21783548 DOI: 10.1016/j.etap.2004.12.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
The neurotoxicity of methotrexate (MTX) is more severe when administered intrathecally (IT) than by the oral and intravenous (IV) routes, and has been reported even with a single administration of therapeutic doses of 12 or 15mg. Prompt recognition and treatment are essential to improve the outcome after massive IT-MTX overdose. Treatment options include CSF drainage or CSF exchange, ventriculolumbar perfusion, IT corticosteroids to reduce CSF inflammation and IV leucovorin to reduce systemic toxicity. Toxicity resulting from IT injection of leucovorin is controversial. CSF drainage and exchange are particularly effective if performed soon after the overdose. In this paper we describe a protocol of treatment for severe cases of IT-MTX overdose in excess of 100mg. The mainstay of treatment is dilution and removal from CSF of excessive methotrexate alongside with specific antidotal therapy.
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Affiliation(s)
- Yoram Finkelstein
- Department of Neurology, Shaare Zedek Medical Center and Faculty of Health Sciences, Ben-Gurion University, Jerusalem 91031, Israel
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Porto L, Kieslich M, Schwabe D, Zanella FE, Lanfermann H. Central nervous system imaging in childhood leukaemia. Eur J Cancer 2004; 40:2082-90. [PMID: 15341983 DOI: 10.1016/j.ejca.2004.04.024] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2003] [Revised: 03/08/2004] [Accepted: 04/20/2004] [Indexed: 11/21/2022]
Abstract
The aim of this study was to document the imaging abnormalities seen in the central nervous system (CNS) in cases of childhood leukaemia or as complications of its treatment. Magnetic Resonance (MR) images and Computed Tomographic (CT) scans were reviewed retrospectively in 22 children and adolescents with neurological manifestations/complications of leukaemia or its treatment. Among the 22 patients, nine had two or more different CNS abnormalities. The imaging abnormalities seen in 15 patients before or during treatment included sinus thrombosis, cortical vein thrombosis, cerebral haemorrhage, meningeal leukaemia, infections, skull leukaemic infiltration and treatment-related neurotoxicity. After therapy, seven patients had CNS abnormalities, including secondary brain tumours, skull tumour, mineralising microangiopathy, leucoencephalopathy, transient white matter abnormalities, spinal intradural haematoma, chronic subdural haematoma, radiation necrosis, meningeal leukaemia and leukaemic infiltration at the vertebral body. CNS complications are related to the inherent risk of leukaemia itself, to the treatment method and to the duration of survival.
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Affiliation(s)
- L Porto
- Neuroradiology Department, Johann Wolfgang Goethe University, Schleusenweg 2-16, D-60528 Frankfurt am Main, Germany.
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Slavc I, Schuller E, Falger J, Günes M, Pillwein K, Czech T, Dietrich W, Rössler K, Dieckmann K, Prayer D, Hainfellner J. Feasibility of long-term intraventricular therapy with mafosfamide (n = 26) and etoposide (n = 11): experience in 26 children with disseminated malignant brain tumors. J Neurooncol 2003; 64:239-47. [PMID: 14558599 DOI: 10.1023/a:1025633704071] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Treatment options for leptomeningeal disseminated brain tumors are limited by the lack of effective drugs for intrathecal therapy of non-hematologic malignancies. We report on our experience with an intraventricular therapy consisting of mafosfamide, a preactivated cyclophosphamide derivative, and etoposide. Between May 1994 and 2002, 26 patients aged 2-19 years with various intensely pretreated disseminated brain tumors received intraventricular mafosfamide via an indwelling subcutaneous reservoir. Twenty-three of them received a dose of 20 mg. Mafosfamide was administered once or twice weekly until remission was achieved and every 2-6 weeks thereafter as maintenance therapy for a total of 736 administrations (2-63/patient). Since March 1998, two patients were switched to receive intraventricular etoposide and nine received etoposide alternating with mafosfamide. Etoposide was given at a dose of 0.5 mg x 5 d every 3-6 weeks for a total of 122 courses (1-29/patient). Immediate toxicities such as transient headaches, nausea, and vomiting occurred with mafosfamide but were manageable with premedication. Etoposide did not cause any discomfort. No long-term toxicities attributable to intrathecal therapy as evidenced by magnetic resonance imaging or neurologic evaluation were observed. Since all patients received some sort of concurrent anti-cancer therapy, the efficacy of intrathecal therapy cannot be assessed independently. However, seven of 13 patients evaluable for response by cerebrospinal fluid (CSF) cytology developed CSF dissemination under systemic chemotherapy and cleared their CSF only after administration of intrathecal mafosfamide. In conclusion, intraventricularly administered mafosfamide at a dose of 20 mg and etoposide at a dose of 0.5 mg x 5 d for patients over 2 years of age are feasible and safe and may produce responses.
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Affiliation(s)
- Irene Slavc
- Department of Pediatrics, University of Vienna, Vienna, Austria.
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Abstract
The central neurotoxicity of cytotoxic drugs depends on their ability to cross the blood-brain barrier (BBB). The drugs with the highest neurotoxicity are therefore those that cross the BBB most easily: alkylating agents (metabolites of cyclophosphamide and ifosfamide, thiotepa and high-dose melphalan), busulfan, platinum derivatives, aracytine and methotrexate. Apart from aracytine-induced cerebellar toxicity, the clinical signs suggestive of chemotherapy neurotoxicity are relatively nonspecific: altered level of consciousness, seizures, behavioural disorders and motor deficits. Nevertheless, a good knowledge of the various neurological syndromes likely to occur can allow them to be attributed to a drug-induced cause. However, as patients may be receiving several potentially neurotoxic treatments (chemotherapy, concomitant drugs, neurosurgery, radiotherapy), it is difficult to formally confirm the responsibility of the drug, which should only be considered after confirming the absence of radiological and metabolic abnormalities. A specific antagonist treatment can be administered in rare cases (ifosfamide-induced encephalopathy).
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Affiliation(s)
- D Orbach
- Département de pédiatrie, institut Curie, 26, rue d'Ulm, 75005 Paris, France.
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