1
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Remsik J, Boire A. The path to leptomeningeal metastasis. Nat Rev Cancer 2024; 24:448-460. [PMID: 38871881 PMCID: PMC11404355 DOI: 10.1038/s41568-024-00700-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/29/2024] [Indexed: 06/15/2024]
Abstract
The leptomeninges, the cerebrospinal-fluid-filled tissues surrounding the central nervous system, play host to various pathologies including infection, neuroinflammation and malignancy. Spread of systemic cancer into this space, termed leptomeningeal metastasis, occurs in 5-10% of patients with solid tumours and portends a bleak clinical prognosis. Previous, predominantly descriptive, clinical studies have provided few insights. Recent development of preclinical leptomeningeal metastasis models, alongside genomic, transcriptomic and proteomic sequencing efforts, has provided groundwork for mechanistic understanding and identification of long-needed therapeutic targets. Although previously understood as an anatomically isolated compartment, the leptomeninges are increasingly appreciated as a major conduit of communication between the systemic circulation and the central nervous system. Despite the unique nature of the leptomeningeal microenvironment, the general principles of metastasis hold true: cells metastasizing to the leptomeninges must gain access to the new environment, survive within the space and evade the immune system. The study of leptomeningeal metastasis has the potential to uncover novel site-specific metastatic principles and illuminate the physiology of the leptomeningeal space. In this Review, we provide a biology-focused overview of how metastatic cells reach the leptomeninges, thrive in this nutritionally sparse environment and evade the detection of the omnipresent immune system.
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Affiliation(s)
- Jan Remsik
- Human Oncology & Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Laboratory for Immunology of Metastatic Ecosystems, Center for Cancer Biology, VIB, Leuven, Belgium
- Department of Oncology, KU Leuven, Leuven, Belgium
| | - Adrienne Boire
- Human Oncology & Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Brain Tumour Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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2
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Yim E, Leung D. Leptomeningeal disease in BRIP1-mutated pancreatic adenocarcinoma. BMJ Case Rep 2022; 15:e249837. [PMID: 35675963 PMCID: PMC9185485 DOI: 10.1136/bcr-2022-249837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2022] [Indexed: 12/29/2022] Open
Abstract
Leptomeningeal disease is rare in pancreatic cancer and prognosis remains poor. Mutation profiles are now directing therapy to improve survival. We describe a case of leptomeningeal and brain metastasis in BRCA1 interacting protein 1, or BRIP1-mutated pancreatic adenocarcinoma with progression through several lines of chemotherapy and immunotherapy. A woman in her late 50s presented with metastatic pancreatic adenocarcinoma on liver biopsy. She achieved complete response after modified FOLFIRINOX and started a poly (ADP-ribose) polymerase (PARP) inhibitor for a BRIP1 mutation. She had recurrence at 9 months and started pembrolizumab (programmed cell death protein 1, or PD-1receptor antibody) for tumour mutational burden of 10 muts/Mb. At 10 months, she presented with lower extremity weakness and back pain. MRI revealed leptomeningeal metastases from T11 to cauda equina roots and right occipital metastasis. Cerebrospinal fluid studies revealed elevated pressure (290 mm H2O) and protein (73 mg/dL) with negative cytology. Leptomeningeal carcinomatosis was diagnosed. She began palliative radiation but died at 11 months from initial diagnosis.
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Affiliation(s)
- Eunji Yim
- Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - Denise Leung
- Neurology, University of Michigan, Ann Arbor, Michigan, USA
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3
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Kumar A, Sardhara JC, Singh G, Kanjilal S, Maurya VP, Behari S. Malignant Meningitis Associated with Hydrocephalus. Neurol India 2021; 69:S443-S455. [PMID: 35103001 DOI: 10.4103/0028-3886.332278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Malignant meningitis (MM) is the diffuse involvement of the leptomeninges by infiltrating cancer cells, most frequently from lung and breast cancers. This review is aimed to discuss the current advances in the diagnosis and management of MM, along with management of MM-associated hydrocephalus. We reviewed the literature using PubMed and Google Scholar search engines, focusing on various recent randomized controlled trials and clinical trials on MM. Given the hallmark multifocal involvement, the clinical symptoms and signs are also random and asymmetric. There are three important pillars for establishing a diagnosis of MM: clinical examination, neuroimaging, and CSF cytological findings. Several factors should be considered in decision-making, including performance status, neurological findings (clinical, MRI, and CSF flow dynamic), and evaluation of the primary tumor (nature and systemic dissemination). Response Assessment in Neuro-Oncology (RANO) working group recommended the objective assessment of disease for evaluating the progression and response to therapy. Pillars of current management are mainly focal irradiation and intrathecal or systemic chemotherapy. Symptomatic hydrocephalus is managed with a ventriculoperitoneal shunt, lumboperitoneal shunt, or endoscopic third ventriculostomy as palliative procedures, providing significant improvement in performance scores in the limited survival time of patients with MM. Studies using novel therapeutic approaches, such as new biological or cytotoxic compounds, are ongoing. Despite the use of all the combinations, the overall prognosis remains grim; therefore, decision-making for treatment should predominantly be based on attaining an optimal quality of life.
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Affiliation(s)
- Ashutosh Kumar
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Jayesh C Sardhara
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Guramritpal Singh
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Soumen Kanjilal
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ved P Maurya
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sanjay Behari
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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4
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Holroyd KB, Rubin DB, Vaitkevicius H. Neurologic Complications in Patients with Cancer. Semin Neurol 2021; 41:588-605. [PMID: 34619783 DOI: 10.1055/s-0041-1733788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Neurologic symptoms are commonly seen in patients with cancer and can be among the most challenging to diagnose and manage. It is often difficult to determine if new neurologic symptoms are secondary to direct effects of a malignant lesion, systemic complications of disease, paraneoplastic disorders, or side effects of cancer treatment itself. However, early diagnosis and treatment of each of these conditions can improve patients' quality of life and long-term functional outcomes. In this review, we describe a systematic approach to the diagnosis of new neurologic symptoms in patients with known malignancy. We have categorized the neurologic complications of cancer through a mechanistic approach, with an emphasis on ascertaining underlying pathophysiology to guide treatment choice. This review focuses on the acute neurologic complications of cancer that require hospital admission.
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Affiliation(s)
| | - Daniel B Rubin
- Department of Neurology, Massachusetts General Hospital, Brigham and Women's Hospital, Boston, Massachusetts
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5
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Bandinelli MB, Viezzer Bianchi M, Wronski JG, Santos de Mello L, Blanco DeMartini R, Savi C, Sonne L, Driemeier D, Petinatti Pavarini S. Ophthalmopathologic characterization of multicentric or metastatic neoplasms with an extraocular origin in dogs and cats. Vet Ophthalmol 2020; 23:814-827. [PMID: 32687655 DOI: 10.1111/vop.12803] [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] [Received: 09/10/2019] [Revised: 05/31/2020] [Accepted: 06/17/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To characterize the frequency and distribution of secondary ocular neoplasms in dogs and cats identified during necropsy. METHODS A retrospective analysis of necropsy records of dogs and cats was conducted, and cases with metastatic/multicentric neoplasms with an extraocular origin, involving the eyes, were selected. RESULTS From January 2015 to January 2019, we identified a total of 233 dogs and 100 cats with metastatic disease. Of these, 11.6% (27/233) of the dogs and 13% (13/100) of the cats had ocular metastases. Lymphoma was the most common multicentric neoplasm involving the eyes of both species. In dogs, these neoplasms occurred bilaterally, predominantly in the anterior uvea, and were diffuse large B-cell, T-lymphoblastic, peripheral T-cell not otherwise specified, and lymphocytic B-cell lymphomas. In cats, feline leukemia virus (FeLV)-associated T-cell lymphoma was the most common. Mammary carcinoma was the second most common ocular metastatic neoplasm in bitches, with a predominantly unilateral involvement of the uveal tract. In cats, following lymphoma, pulmonary and squamous cell carcinomas were the most common multicentric/metastatic neoplasms of the eyes. Individual cases of cholangiocarcinoma, hemangiosarcoma, and chemodectoma in dogs, as well as mammary gland cribriform carcinoma, salivary gland carcinoma, and histiocytic sarcoma in cats were detected. CONCLUSIONS The eyes of dogs were mostly affected by lymphoma or mammary gland carcinoma, while those of cats mostly had lymphoma, pulmonary carcinoma, or squamous cell carcinoma as the main metastatic/multicentric neoplasm. To the best of our knowledge, this is the first study to identify intraocular metastatic cholangiocarcinoma and chemodectoma in dogs, aside from identifying salivary gland carcinoma in cats.
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Affiliation(s)
- Marcele Bettim Bandinelli
- Department of Clinical Pathology, Faculty of Veterinary, Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Matheus Viezzer Bianchi
- Department of Clinical Pathology, Faculty of Veterinary, Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Júlia Gabriela Wronski
- Department of Clinical Pathology, Faculty of Veterinary, Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Lauren Santos de Mello
- Department of Clinical Pathology, Faculty of Veterinary, Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Renata Blanco DeMartini
- Department of Clinical Pathology, Faculty of Veterinary, Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Caroline Savi
- Department of Clinical Pathology, Faculty of Veterinary, Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Luciana Sonne
- Department of Clinical Pathology, Faculty of Veterinary, Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - David Driemeier
- Department of Clinical Pathology, Faculty of Veterinary, Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Saulo Petinatti Pavarini
- Department of Clinical Pathology, Faculty of Veterinary, Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
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Sugaoka S, Kanda T, Ito M, Takeuchi M. A Case of Meningeal Carcinomatosis Due to Signet-Ring Cell Carcinoma That Developed Severe Visual Impairment with Papillary Swelling. Int Med Case Rep J 2020; 13:153-158. [PMID: 32523382 PMCID: PMC7234965 DOI: 10.2147/imcrj.s241026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 02/27/2020] [Indexed: 11/25/2022] Open
Abstract
Purpose To report a case of meningeal carcinomatosis by metastasis of signet-ring cell carcinoma resulting in severe visual impairment. Case Presentation A 49-year-old man visited our hospital complaining of blurred vision in his left eye since 2 months ago. There was no particular history. Best corrected visual acuity (BCVA) was 25/20 in the right eye and 20/20 in the left eye. Papillary swelling in both eyes and disc hemorrhage in the left eye were observed. Gradually, the frequency of dizziness increased, and magnetic resonance imaging (MRI) suggested ventricular enlargement, infiltration around the optic nerve, and meningeal carcinomatosis. Increased cerebrospinal fluid pressure was found, and metastatic adenocarcinoma cells were observed by cerebrospinal fluid cytology. A gastroduodenal biopsy confirmed the diagnosis of poorly differentiated adenocarcinoma with signet-ring cells. Visual acuity at the final visit was 4/200 in both eyes. Conclusion If papillary swelling is observed in both eyes, meningeal carcinomatosis should be considered as a differential diagnosis.
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Affiliation(s)
- Shimpei Sugaoka
- Department of Ophthalmology, National Defense Medical College, Tokorozawa City, Saitama 359-8513, Japan
| | - Takayuki Kanda
- Department of Ophthalmology, National Defense Medical College, Tokorozawa City, Saitama 359-8513, Japan
| | - Masataka Ito
- Department of Developmental Anatomy, National Defense Medical College, Tokorozawa City, Saitama 359-8513, Japan
| | - Masaru Takeuchi
- Department of Ophthalmology, National Defense Medical College, Tokorozawa City, Saitama 359-8513, Japan
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7
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Prabhash K, Vallathol D, Patil V, Noronha V, Joshi A, Menon N. Leptomeningeal metastasis from extracranial solid tumors. CANCER RESEARCH, STATISTICS, AND TREATMENT 2020. [DOI: 10.4103/crst.crst_38_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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8
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Abstract
Leptomeningeal metastasis (LM) results from dissemination of cancer cells to both the leptomeninges (pia and arachnoid) and cerebrospinal fluid (CSF) compartment. Breast cancer, lung cancer, and melanoma are the most common solid tumors that cause LM. Recent approval of more active anticancer therapies has resulted in improvement in survival that is partly responsible for an increased incidence of LM. Neurologic deficits, once manifest, are mostly irreversible, and often have a significant impact on patient quality of life. LM-directed therapy is based on symptom palliation, circumscribed use of neurosurgery, limited field radiotherapy, intra-CSF and systemic therapies. Novel methods of detecting LM include detection of CSF circulating tumor cells and tumor cell-free DNA. A recent international guideline for a standardization of response assessment in LM may improve cross-trial comparisons as well as within-trial evaluation of treatment. An increasing number of retrospective studies suggest that molecular-targeted therapy, such as EGFR and ALK inhibitors in lung cancer, trastuzumab in HER2+ breast cancer, and BRAF inhibitors in melanoma, may be effective as part of the multidisciplinary management of LM. Prospective randomized trials with standardized response assessment are needed to further validate these preliminary findings.
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9
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Bento LC, Correia RP, Alexandre AM, Nosawa ST, Pedro EDC, Vaz ADC, Schimidell D, Fernandes GBP, Duarte CAS, Barroso RDS, Bacal NS. Detection of Central Nervous System Infiltration by Myeloid and Lymphoid Hematologic Neoplasms Using Flow Cytometry Analysis: Diagnostic Accuracy Study. Front Med (Lausanne) 2018; 5:70. [PMID: 29876349 PMCID: PMC5974033 DOI: 10.3389/fmed.2018.00070] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 03/01/2018] [Indexed: 12/17/2022] Open
Abstract
Introduction Infiltration of the central nervous system (CNS) by hematologic or lymphoid malignant cells can cause extensive neurological damage, be progressive and fatal. However, usually, the cerebrospinal fluid (CSF) has low cellularity and rapid cell degeneration, which can impair cytometry analysis. Storage and transport measures, sample preparation, and staining protocols can interfere with diagnostic accuracy. Objective To calculate the diagnostic performance of flow cytometry (FC) using a cell stabilizer for sample preservation compared to cytomorphology in the detection of CNS infiltration by lymphoid and hematologic neoplasms. Methods Cell samples from all consecutive patients with suspected infiltration by hematological malignancies evaluated between January 2014 and December 2016 were included. Cases were analyzed by FC using a cell preservation medium and cytomorphology. Sensitivity and specificity were calculated. Results From 414 CSF samples, 72 had a phenotype compatible with characteristics of infiltration by hematological disease, whereas cytology was positive for 35 cases. FC showed higher sensitivity and specificity when compared to cytomorphology, particularly in cases with cellularity under 5 leukocytes/mm3. Conclusion We demonstrated that collecting CSF in a medium that preserves the stability of the sample improves accuracy when compared to cytomorphology, particularly in low-volume and low-cellularity samples.
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Affiliation(s)
- Laiz Cameirão Bento
- Clinical Pathology Laboratory, Division of Hematology and Flow Cytometry, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Rodolfo Patussi Correia
- Clinical Pathology Laboratory, Division of Hematology and Flow Cytometry, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Anderson Marega Alexandre
- Clinical Pathology Laboratory, Division of Hematology and Flow Cytometry, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Sonia Tsukasa Nosawa
- Clinical Pathology Laboratory, Division of Hematology and Flow Cytometry, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Eduardo de Carvalho Pedro
- Clinical Pathology Laboratory, Division of Hematology and Flow Cytometry, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Andressa da Costa Vaz
- Clinical Pathology Laboratory, Division of Hematology and Flow Cytometry, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Daniela Schimidell
- Clinical Pathology Laboratory, Division of Hematology and Flow Cytometry, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Gustavo Bruniera Peres Fernandes
- Clinical Pathology Laboratory, Division of Hematology and Flow Cytometry, Hospital Israelita Albert Einstein, São Paulo, Brazil.,Senne Liquor Laboratório, São Paulo, Brazil
| | - Carlos Augusto Senne Duarte
- Clinical Pathology Laboratory, Division of Hematology and Flow Cytometry, Hospital Israelita Albert Einstein, São Paulo, Brazil.,Senne Liquor Laboratório, São Paulo, Brazil
| | - Rodrigo de Souza Barroso
- Clinical Pathology Laboratory, Division of Hematology and Flow Cytometry, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Nydia Strachman Bacal
- Clinical Pathology Laboratory, Division of Hematology and Flow Cytometry, Hospital Israelita Albert Einstein, São Paulo, Brazil.,Hematology Laboratory, Centro de Hematologia de São Paulo, São Paulo, Brazil
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10
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Murakami Y, Ichikawa M, Bakhit M, Jinguji S, Sato T, Fujii M, Sakuma J, Saito K. Palliative shunt surgery for patients with leptomeningeal metastasis. Clin Neurol Neurosurg 2018; 168:175-178. [PMID: 29567579 DOI: 10.1016/j.clineuro.2018.03.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Revised: 03/01/2018] [Accepted: 03/06/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Leptomeningeal metastasis (LM) is associated with poor prognosis and affects the quality of life (QOL) of end-stage cancer patients. Severe headache associated with hydrocephalus causes reduced QOL. We investigated the clinical value of surgical treatment for hydrocephalus in LM patients. PATIENTS AND METHODS The medical records of 11 consecutive patients who underwent lumboperitoneal shunt (LPS) or ventriculoperitoneal shunt (VPS) at our institution between 2007 and 2016 were investigated. Primary brain tumor patients were excluded. We assessed the neurological status and therapeutic effects at 1 month after the shunt surgery. RESULTS The patients were three males and eight females with a median age of 58 years (interquartile range [IR] 52-68 years). The median preoperative neutrophil-to-lymphocyte ratio was 6.4 (IR 4.8-9.2). Symptom improvement was observed in nine patients, and severe headache was relieved in seven (88%) out of eight patients. The median Karnofsky performance status scale increased from 40 to 60, and the median overall survival after primary malignancy diagnosis was 27.4 months (IR 19.6-63.1 months). The median survival after the diagnosis of brain parenchymal metastasis, LM, and shunt surgery were 7.2 months (IR 5.1-14.1 months), 3.9 months (IR 3.5-6.3 months), and 3.3 months (IR 2.9-5.7 months), respectively. CONCLUSION Shunt surgery for hydrocephalus could offer an effective palliative surgical option for symptom relief especially relief of severe headache, contributing improvement of QOL in LM patients.
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Affiliation(s)
- Yuta Murakami
- Department of Neurosurgery, Fukushima Medical University, Fukushima City, Fukushima, Japan.
| | - Masahiro Ichikawa
- Department of Neurosurgery, Fukushima Medical University, Fukushima City, Fukushima, Japan.
| | - Mudathir Bakhit
- Department of Neurosurgery, Fukushima Medical University, Fukushima City, Fukushima, Japan.
| | - Shinya Jinguji
- Department of Neurosurgery, Fukushima Medical University, Fukushima City, Fukushima, Japan.
| | - Taku Sato
- Department of Neurosurgery, Fukushima Medical University, Fukushima City, Fukushima, Japan.
| | - Masazumi Fujii
- Department of Neurosurgery, Fukushima Medical University, Fukushima City, Fukushima, Japan.
| | - Jun Sakuma
- Department of Neurosurgery, Fukushima Medical University, Fukushima City, Fukushima, Japan.
| | - Kiyoshi Saito
- Department of Neurosurgery, Fukushima Medical University, Fukushima City, Fukushima, Japan.
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11
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Le Rhun E, Weller M, Brandsma D, Van den Bent M, de Azambuja E, Henriksson R, Boulanger T, Peters S, Watts C, Wick W, Wesseling P, Rudà R, Preusser M. EANO-ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up of patients with leptomeningeal metastasis from solid tumours. Ann Oncol 2017; 28:iv84-iv99. [PMID: 28881917 DOI: 10.1093/annonc/mdx221] [Citation(s) in RCA: 240] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Affiliation(s)
- E Le Rhun
- Neuro-Oncology, Department of Neurosurgery, Lille University Hospital, Lille
- Neurology, Medical Oncology Department, Oscar Lambret Center, Lille
- Lille University, Inserm U-1192, Villeneuve d'Ascq, France
| | - M Weller
- Department of Neurology and Brain Tumour Center, University Hospital, Zurich, Switzerland
| | - D Brandsma
- Department of Neuro-Oncology, Netherlands Cancer Institute, Amsterdam
| | - M Van den Bent
- The Brain Tumour Center at the Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - E de Azambuja
- Medical Oncology Department, Institut Jules Bordet and L'Université Libre de Bruxelles (U.L.B), Brussels, Belgium
| | - R Henriksson
- Regional Cancer Center, Stockholm
- Department of Radiation Sciences and Oncology, University, Umea, Sweden
| | - T Boulanger
- Neuroradiology, Imaging Department, Oscar Lambret Center, Lille, France
| | - S Peters
- Department of Oncology, University Hospital, Lausanne, Switzerland
| | - C Watts
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - W Wick
- Neurology Clinic, Heidelberg University Hospital, Heidelberg
- Clinical Cooperation Unit Neuro-Oncology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Centre (DKFZ), Heidelberg, Germany
| | - P Wesseling
- Department of Pathology, VU University Medical Centre and Brain Tumour Center, Amsterdam
- Department of Pathology, Princess Máxima Center for Paediatric Oncology and University Medical Centre Utrecht, Utrecht, The Netherlands
| | - R Rudà
- Department of Neuro-Oncology, City of Health and Science Hospital, University of Turin, Turin, Italy
| | - M Preusser
- Clinical Division of Oncology, Department of Medicine 1, CNS Unit Comprehensive Cancer Centre (CCC-CNS), Medical University, Vienna, Austria
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12
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Custódio-Santos T, Videira M, Brito MA. Brain metastasization of breast cancer. Biochim Biophys Acta Rev Cancer 2017; 1868:132-147. [PMID: 28341420 DOI: 10.1016/j.bbcan.2017.03.004] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 03/17/2017] [Accepted: 03/18/2017] [Indexed: 01/15/2023]
Abstract
Central nervous system metastases have been reported in 15-25% of breast cancer patients, and the incidence is increasing. Moreover, the survival of these patients is generally poor, with reports of a 1-year survival rate of 20%. Therefore, a better knowledge about the determinants of brain metastasization is essential for the improvement of the clinical outcomes. Here, we summarize the current data about the metastatic cascade, ranging from the output of cancer cells from the primary tumour to their colonization in the brain, which involves the epithelial-mesenchymal transition, invasion of mammary tissue, intravasation into circulation, and homing into and extravasation towards the brain. The phenotypic change in malignant cells, and the importance of the microenvironment in the formation of brain metastases are also inspected. Finally, the importance of genetic and epigenetic changes, and the recently disclosed effects of microRNAs in brain metastasization of breast cancer are highlighted.
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Affiliation(s)
- Tânia Custódio-Santos
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, Universidade de Lisboa, Av. Prof. Gama Pinto, 1649-003 Lisboa, Portugal
| | - Mafalda Videira
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, Universidade de Lisboa, Av. Prof. Gama Pinto, 1649-003 Lisboa, Portugal; Department of Galenic Pharmacy and Pharmaceutical Technology, Faculty of Pharmacy, Universidade de Lisboa, Av. Prof. Gama Pinto, 1649-003 Lisboa, Portugal
| | - Maria Alexandra Brito
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, Universidade de Lisboa, Av. Prof. Gama Pinto, 1649-003 Lisboa, Portugal; Department of Biochemistry and Human Biology, Faculty of Pharmacy, Universidade de Lisboa, Av. Prof. Gama Pinto, 1649-003 Lisboa, Portugal.
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13
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Alexander P, Kucera G, Pardee TS. Improving nucleoside analogs via lipid conjugation: Is fatter any better? Crit Rev Oncol Hematol 2016; 100:46-56. [PMID: 26829896 DOI: 10.1016/j.critrevonc.2016.01.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 12/22/2015] [Accepted: 01/16/2016] [Indexed: 10/22/2022] Open
Abstract
In the past few decades, nucleoside analog drugs have been used to treat a large variety of cancers. These anti-metabolite drugs mimic nucleosides and interfere with chain lengthening upon incorporation into the DNA or RNA of actively replicating cells. However, efficient delivery of these drugs is limited due to their pharmacokinetic properties, and tumors often develop drug resistance. In addition, nucleoside analogs are generally hydrophilic, resulting in poor bioavailability and impaired blood-brain barrier penetration. Conjugating these drugs to lipids modifies their pharmacokinetic properties and may improve in vivo efficacy. This review will cover recent advances in the field of conjugation of phospholipids to nucleoside analogs. This includes conjugation of myristic acid, 12-thioethyldodecanoic acid, 5-elaidic acid esters, phosphoramidate, and self-emulsifying formulations. Relevant in vitro and in vivo data will be discussed for each drug, as well as any available data from clinical trials.
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Affiliation(s)
- Peter Alexander
- Cancer Biology, Comprehensive Cancer Center of Wake Forest University, Winston-Salem, NC, United States
| | - Gregory Kucera
- Internal Medicine, Wake Forest Baptist Health, Winston-Salem, NC, United States; Cancer Biology, Comprehensive Cancer Center of Wake Forest University, Winston-Salem, NC, United States
| | - Timothy S Pardee
- Internal Medicine, Wake Forest Baptist Health, Winston-Salem, NC, United States; Cancer Biology, Comprehensive Cancer Center of Wake Forest University, Winston-Salem, NC, United States.
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14
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Doval DC, Azam S, Sinha R, Batra U, Mehta A, Rao A. A Report of Two Cases of Leptomeningeal Carcinomatosis Arising from Gallbladder Carcinoma. J Gastrointest Cancer 2015; 46:417-20. [PMID: 25863810 DOI: 10.1007/s12029-015-9719-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Dinesh Chandra Doval
- Department of Medical Oncology, Rajiv Gandhi Cancer Institute & Research Centre, Sector-5, Rohini, Delhi, India. .,Department of Research, Rajiv Gandhi Cancer Institute & Research Centre, Delhi, India.
| | - Saud Azam
- Department of Research, Rajiv Gandhi Cancer Institute & Research Centre, Delhi, India
| | - Rupal Sinha
- Department of Research, Rajiv Gandhi Cancer Institute & Research Centre, Delhi, India
| | - Ullas Batra
- Department of Medical Oncology, Rajiv Gandhi Cancer Institute & Research Centre, Sector-5, Rohini, Delhi, India
| | - Anurag Mehta
- Department of Laboratory Services, Rajiv Gandhi Cancer Institute & Research Centre, Delhi, India
| | - Avinash Rao
- Department of Radiology, Rajiv Gandhi Cancer Institute & Research Centre, Delhi, India
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Jung TY, Chung WK, Oh IJ. The prognostic significance of surgically treated hydrocephalus in leptomeningeal metastases. Clin Neurol Neurosurg 2014; 119:80-3. [PMID: 24635931 DOI: 10.1016/j.clineuro.2014.01.023] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 01/16/2014] [Accepted: 01/18/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The median survival of leptomeningeal metastases is short despite therapy and is sometime associated with hydrocephalus. We investigated the prognostic significance of surgically treated hydrocephalus in leptomeningeal metastases. MATERIALS AND METHODS Between December 2005 and November 2012, 1343 patients had brain metastases from systemic solid tumors. Of these, 71 patients (5.3%) experienced leptomeningeal metastases from 45 lung cancers, 14 breast cancers, 4 gastric cancers and 8 other cancers. The mean age was 60 years (range 37-89). The clinical symptoms presented in the cerebral hemisphere and cerebellum in 58 patients, cranial nerve in 7 patients and spinal cord and nerves in 6 patients. Twenty-nine (40.8%) patients were Radiation Therapy Oncology Group recursive partitioning analysis (RTOG-RPA) class II and 42 (59.2%) were class III. Hydrocephalus was associated in 18 (25.4%) patients and 7 patients underwent ventriculoperioneal shunt. The primary cancer, clinical symptoms, RTOG-RPA class, surgically treated hydrocephalus and systemic chemotherapy were analyzed as the prognostic factors for overall survival. RESULTS The overall incidence of leptomeningeal seeding was 5.0% of the brain metastases. The median duration of leptomeningeal metastases from first brain metastasis was 4.0 months and 24 (33.8%) patients showed leptomeningeal metastases as the first form of brain metastasis. The median overall survival (OS) was 2.1 months. Based on the univariate and multivariate analyses, RTOG-RPA class II patients, treatment of leptomeningeal metastases (such as radiotherapy or intrathecal chemotherapy) and systemic chemotherapy improved OS with statistical significance. Surgically untreated hydrocephalus (median OS, 1.7 months) showed poor OS compared with surgically treated hydrocephalus (median OS, 5.7 months) and no hydrocephalus (median OS, 2.3 months) without statistical significance. CONCLUSIONS The leptomeningeal metastases were often associated with hydrocephalus and the surgical treatment was helpful in limited patients. The prognosis was related with RTOG-RPA class and treatment of local and systemic treatment.
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Affiliation(s)
- Tae-Young Jung
- Department of Neurosurgery, Chonnam National University Hwasun Hospital & Medical School, Gwangju, South Korea.
| | - Woong-Ki Chung
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital & Medical School, Gwangju, South Korea
| | - In-Jae Oh
- Department of Internal Medicine, Chonnam National University Hwasun Hospital & Medical School, Gwangju, South Korea
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Le Rhun E, Taillibert S, Chamberlain MC. Carcinomatous meningitis: Leptomeningeal metastases in solid tumors. Surg Neurol Int 2013; 4:S265-88. [PMID: 23717798 PMCID: PMC3656567 DOI: 10.4103/2152-7806.111304] [Citation(s) in RCA: 180] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 04/11/2013] [Indexed: 11/04/2022] Open
Abstract
Leptomeningeal metastasis (LM) results from metastatic spread of cancer to the leptomeninges, giving rise to central nervous system dysfunction. Breast cancer, lung cancer, and melanoma are the most frequent causes of LM among solid tumors in adults. An early diagnosis of LM, before fixed neurologic deficits are manifest, permits earlier and potentially more effective treatment, thus leading to a better quality of life in patients so affected. Apart from a clinical suspicion of LM, diagnosis is dependent upon demonstration of cancer in cerebrospinal fluid (CSF) or radiographic manifestations as revealed by neuraxis imaging. Potentially of use, though not commonly employed, today are use of biomarkers and protein profiling in the CSF. Symptomatic treatment is directed at pain including headache, nausea, and vomiting, whereas more specific LM-directed therapies include intra-CSF chemotherapy, systemic chemotherapy, and site-specific radiotherapy. A special emphasis in the review discusses novel agents including targeted therapies, that may be promising in the future management of LM. These new therapies include anti-epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors erlotinib and gefitinib in nonsmall cell lung cancer, anti-HER2 monoclonal antibody trastuzumab in breast cancer, anti-CTLA4 ipilimumab and anti-BRAF tyrosine kinase inhibitors such as vermurafenib in melanoma, and the antivascular endothelial growth factor monoclonal antibody bevacizumab are currently under investigation in patients with LM. Challenges of managing patients with LM are manifold and include determining the appropriate patients for treatment as well as the optimal route of administration of intra-CSF drug therapy.
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Affiliation(s)
- Emilie Le Rhun
- Breast Unit, Department of Medical Oncology, Centre Oscar Lambret and Department of Neuro Oncology, Roger Salengro Hospital, University Hospital, Lille, France
| | - Sophie Taillibert
- Neurology, Mazarin and Radiation Oncology, Pitié Salpétrière Hospital, University Pierre et Marie Curie, Paris VI, Paris, France
| | - Marc C. Chamberlain
- Neurology and Neurological Surgery, University of Washington, Fred Hutchinson Research Cancer Center, Seattle, WA, USA
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Leptomeningeal seeding in patients with brain metastases treated by gamma knife radiosurgery. J Neurooncol 2012; 109:293-9. [PMID: 22610938 DOI: 10.1007/s11060-012-0892-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Accepted: 04/25/2012] [Indexed: 10/28/2022]
Abstract
To characterize the development of leptomeningeal seeding (LMS) in patients with brain metastases after gamma knife radiosurgery (GKRS). Eight hundred and twenty-seven patients that underwent GKRS as a part of an initial treatment plan for brain metastases between January 2002 and December 2010 were included in the study. Six hundred and fifty patients were treated with GKRS alone and 177 patients received GKRS combined with upfront whole brain radiation therapy (WBRT). Actuarial curves for overall survival (OS) and the development of LMS were plotted using the Kaplan-Meier method. Median overall survival for all patients was 55 weeks (95 % CI, 47.8-62.2), and the overall incidence of LMS was 5.3 %. The actuarial rates for LMS at 6 and 12 months were 3.1 and 5.8, respectively. Uni- and multivariate analysis suggested that breast cancer and a large number of metastases (n ≥ 4) are significant risk factors of LMS (P < 0.05). Regarding treatment modalities, the addition of WBRT was found to have a significant impact on lowering the risk of LMS by multivariate analysis (P = 0.045). LMS is an important pattern of CNS failure. The risk of LMS following GKRS may be associated with multiple lesions, breast cancer, and the omission of WBRT. Additional data from large-scale, randomized controlled trials are required to identify risk factors associated with the LMS more accurately.
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Aregawi DG, Sherman JH, Schiff D. Neurological complications of solid tumors. HANDBOOK OF CLINICAL NEUROLOGY 2012; 105:683-710. [PMID: 22230528 DOI: 10.1016/b978-0-444-53502-3.00018-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Dawit G Aregawi
- Department of Neurology, University of Virginia, Charlottesville, VA, USA
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19
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Affiliation(s)
- Marc C Chamberlain
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA.
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20
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Abstract
PURPOSE OF REVIEW Leptomeningeal metastasis occurs in approximately 5% of all patients with cancer. This review summarizes recent literature regarding methods of diagnosis and treatment of leptomeningeal metastasis. RECENT FINDINGS Staging of leptomeningeal metastasis should include contrast-enhanced brain and spine MRI, and though controversial, radionuclide cerebrospinal fluid (CSF) flow study. Treatment of leptomeningeal metastasis often requires involved-field radiotherapy to bulky or symptomatic disease sites as well as intra-CSF and systemic chemotherapy. The use of high-dose systemic therapy may benefit patients with leptomeningeal metastasis and obviate the need for intra-CSF chemotherapy. Intra-CSF drug therapy primarily utilizes one of three chemotherapeutic agents [i.e. methotrexate, cytosine arabinoside (both free and liposomal) and thio-tetraethylenepentamine] administered by a variety of schedules either by intralumbar or intraventricular drug delivery. Novel intra-CSF agents increasingly utilized in the treatment of leptomeningeal metastasis are targeted mAbs such as rituximab and trastuzumab. SUMMARY Although treatment of leptomeningeal metastasis is palliative with median patient survival of 2-3 months, treatment may afford stabilization and protection from further neurologic deterioration in patients with leptomeningeal metastasis.
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22
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Chuang TY, Yu CJ, Shih JY, Yang PC, Kuo SH. Cytologically Proven Meningeal Carcinomatosis in Patients with Lung Cancer: Clinical Observation of 34 Cases. J Formos Med Assoc 2008; 107:851-6. [DOI: 10.1016/s0929-6646(08)60201-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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23
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24
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Altered consciousness associated with brain neoplasms. HANDBOOK OF CLINICAL NEUROLOGY 2008. [PMID: 18631828 DOI: 10.1016/s0072-9752(07)01715-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register]
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25
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26
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Hammerer V. Diagnostic et traitement des méningites carcinomateuses en cancérologie bronchique. Rev Mal Respir 2007. [DOI: 10.1016/s0761-8425(07)78158-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Boogerd W. Leptomeningeal metastasis in solid tumours: Is there a role for intrathecal therapy? EJC Suppl 2007. [DOI: 10.1016/s1359-6349(07)70022-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Abstract
BACKGROUND Neoplastic meningitis (NM) is a common problem in neuro-oncology, occurring in approximately 5% of all patients with cancer. REVIEW SUMMARY Notwithstanding frequent focal signs and symptoms in NM, NM is a disease affecting the entire neuraxis, and therefore staging and treatment need encompass all cerebrospinal fluid (CSF) compartments. RESULTS Central nervous system (CNS) staging of NM includes contrast-enhanced cranial computed tomography (CE-CT) or magnetic resonance imaging (MR-Gd), contrast-enhanced spine magnetic resonance imaging (MR-S) or computed tomographic myelography (CT-M), and radionuclide CSF flow study (FS). Treatment of NM incorporates involved-field radiotherapy of bulky or symptomatic disease sites and intra-CSF drug therapy. The inclusion of concomitant systemic therapy may benefit patients with NM and may obviate the need for intra-CSF chemotherapy. At present, intra-CSF drug therapy is confined to 3 chemotherapeutic agents (ie, methotrexate, cytosine arabinoside, and thio-TEPA) administered by a variety of schedules either by intralumbar or intraventricular drug delivery. CONCLUSIONS Although treatment of NM is palliative, with an expected median patient survival of 2 to 6 months, it often affords stabilization and protection from further neurologic deterioration in patients with NM.
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Affiliation(s)
- Marc C Chamberlain
- Department of Interdisciplinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, University of Southern Florida, Neuro-Oncology Program, Tampa, Florida 33612, USA.
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29
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Abstract
Long-term survival is occasionally observed in patients with neoplastic meningitis (NM) accompanying breast cancer (13% one-year and 6% 2-year survival), melanoma, and lymphoma, but in general the survival of most patients is short and averages only 3 to 4 months. The incidence of NM appears to be increasing, in part due to earlier detection by magnetic resonance imaging (MRI), and in part due to development of more effective therapies for systemic cancer, which has resulted in a larger subset at risk for late-stage development of this complication. Survival of NM patients is negatively affected by concomitant progression of systemic disease despite multiple prior therapies. However, there are certain prognostic factors that have been identified as "favorable" in retrospective series, including age less than 60 years, long symptom duration, controlled systemic disease, Karnofsky performance status (KPS) > or =70, lack of encephalopathy or cranial nerve deficits, low initial cerebrospinal fluid (CSF) protein level, history of breast primary tumor, and lack of evidence of CSF compartmentalization or bulky meningeal disease as determined by CSF flow studies. Standard treatment has traditionally involved radiotherapy (RT) to sites of symptomatic or bulky disease, as detected by neuroimaging, and in selected patients, the administration of intrathecal, intraventricular, or systemic chemotherapy. However, treatment remains palliative and many patients and physicians choose supportive care only. Future hope is provided by studies that have improved our understanding of the disease pathogenesis, have identified prognostic variables associated with outcome, and have provided new therapeutic approaches, such as administration of high-dose systemic chemotherapy and investigations of novel therapeutic agents.
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Affiliation(s)
- Kurt A Jaeckle
- Department of Neurology and Oncology, Mayo Clinic Jacksonville, Jacksonsville, FL 32224, USA.
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30
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Mukhopadhyay S, Mukhopadhyay S, El-Zammar O, Khurana KK, Graziano SL. CASE 2. Meningeal Metastases From Ovarian Carcinoma. J Clin Oncol 2006; 24:1010-1. [PMID: 16484706 DOI: 10.1200/jco.2005.01.2427] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Surabhi Mukhopadhyay
- Department of Medicine, and the Division of Hematology-Oncology, State University of New York Upstate Medical University, Syracuse, NY, USA
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31
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Seute T, Leffers P, ten Velde GPM, Twijnstra A. Leptomeningeal metastases from small cell lung carcinoma. Cancer 2006; 104:1700-5. [PMID: 16080173 DOI: 10.1002/cncr.21322] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The current study was performed to investigate the frequency of leptomeningeal metastases (LMM) in patients with small cell lung carcinoma (SCLC) as well as the effect of LMM on survival, any correlation between the location of the LMM and survival, and a possible increased risk of LMM among patients with brain metastases (BM) located in the posterior fossa. METHODS Between 1980-2003, 458 consecutive patients with SCLC were enrolled in the current study. Patients underwent regular neurologic examination and imaging of the brain before, during, and after treatment. The diagnosis of LMM was established by either the presence of malignant cells in the cerebrospinal fluid or positive clinical symptoms and signs supported by radiologic findings on magnetic resonance imaging. RESULTS The group of patients in the current study had a 2% prevalence of LMM and the 2-year cumulative incidence of LMM was found to be 10%. The median survival after the diagnosis of LMM was reported to be 1.3 months. The median survival among patients with LMM located in the spinal cord was 2.4 months. The reported LMM-free survival 2 years after the diagnosis of SCLC was 78% for patients without BM and 61% for those patients with BM. Approximately 15% of the patients with BM located in the posterior fossa developed LMM, whereas only 10% of patients with cerebral BM did. CONCLUSIONS The current prospective study found a 2-year cumulative incidence of LMM of 10%, with a prevalence of 2%. Patients with LMM located in the spinal cord appeared to survive longer than patients with cranial LMM. SCLC patients with BM located in the posterior fossa may be at a higher risk of developing LMM compared with patients with cerebral BM.
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Affiliation(s)
- Tatjana Seute
- Department of Neurology, University Hospital Maastricht, Maastricht, The Netherlands.
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32
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Taillibert S, Laigle-Donadey F, Chodkiewicz C, Sanson M, Hoang-Xuan K, Delattre JY. Leptomeningeal metastases from solid malignancy: a review. J Neurooncol 2005; 75:85-99. [PMID: 16215819 DOI: 10.1007/s11060-004-8101-x] [Citation(s) in RCA: 125] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Leptomeningeal metastases (LMM) consist of diffuse involvement of the leptomeninges by infiltrating cancer cells. In solid tumors, the most frequent primary sites are lung and breast cancers, two tumors where the incidence of LMM is apparently increasing. Careful neurological examination is required to demonstrate multifocal involvement of the central nervous system (CNS), cranial nerves, and spinal roots, which constitute the clinical hallmark of the disease. Cerebro-spinal fluid (CSF) analysis is almost always abnormal but only a positive cytology or demonstration of intrathecal synthesis of tumor markers is diagnostic. T1-weighted gadolinium-enhanced sequence of the entire neuraxis (brain and spine) plays an important role in supporting the diagnosis, demonstrating the involved sites and guiding treatment. Radionuclide CSF flow studies detect CSF compartmentalization and are useful for treatment planning. Standard therapy relies mainly on focal irradiation and intrathecal or systemic chemotherapy. Studies using other therapeutic approaches such as new biological or cytotoxic compounds are ongoing. The overall prognosis remains grim and quality of life should remain the priority when deciding which treatment option to apply. However, a sub-group of patients, tentatively defined here, may benefit from an aggressive treatment.
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Affiliation(s)
- Sophie Taillibert
- Fédération de Neurologie, Batîment Mazarin, Groupe hospitalier Pitié-Salpétrière, 47-83 bd de l'Hôpital, 75013, Paris, France
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Berg SL, Chamberlain MC. Current treatment of leptomeningeal metastases: systemic chemotherapy, intrathecal chemotherapy and symptom management. Cancer Treat Res 2005; 125:121-46. [PMID: 16211887 DOI: 10.1007/0-387-24199-x_8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Treatment of leptomeningeal metastases is multifaceted and includes symptomatic therapy, intrathecal and systemic chemotherapy, and radiotherapy. As the majority of patients have widespread incurable systemic tumor, treatment is predominantly palliative; however, some patients with leukemia, lymphoma or breast cancer may have prolonged remissions and the possibility of cure.
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Affiliation(s)
- Stacey L Berg
- Norris Cancer Center, University of Southern California, Los Angeles, Ca. 90089, USA
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Abstract
Neoplastic meningitis (NM) is a common problem in neuro-oncology occurring in approximately 5% of all patients with cancer, and is the third most common site of CNS metastases. NM is a disease affecting the entire neuraxis, and therefore clinical manifestations are pleomorphic affecting the spine, cranial nerves, and cerebral hemispheres. Because of craniospinal disease involvement, staging and treatment need to encompass all CSF compartments. Treatment of NM utilizes involved-field radiotherapy of bulky or symptomatic disease sites and intra-CSF drug therapy. The inclusion of concomitant systemic therapy may benefit patients with NM and may obviate the need for intra-CSF chemotherapy. At present, intra-CSF drug therapy is confined to three chemotherapeutic agents (ie, methotrexate, cytarabine, and thiotepa) administered by a variety of schedules either by intralumbar or intraventricular drug delivery. Although treatment of NM is palliative with an expected median patient survival of 2 to 6 months, it often affords stabilization and protection from further neurologic deterioration in patients with NM.
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Affiliation(s)
- Marc C Chamberlain
- Department of Neuro-Oncology, University of S Florida, H. Lee Moffitt Cancer Center & Research Institute, 12902 Magnolia Dr, Suite 3136, Tampa, FL 33612, USA.
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35
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Pavlidis N. The diagnostic and therapeutic management of leptomeningeal carcinomatosis. Ann Oncol 2005; 15 Suppl 4:iv285-91. [PMID: 15477323 DOI: 10.1093/annonc/mdh941] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- N Pavlidis
- School of Medicine, University of Ioannina, Greece
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Cheung W, Maksymiuk A. A diagnosis dilemma of back pain in non-Hodgkin lymphoma. Pediatr Blood Cancer 2005; 44:100-1. [PMID: 15459962 DOI: 10.1002/pbc.20195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Rustamzadeh E, Li C, Doumbia S, Hall WA, Vallera DA. Targeting the over-expressed urokinase-type plasminogen activator receptor on glioblastoma multiforme. J Neurooncol 2004; 65:63-75. [PMID: 14649886 DOI: 10.1023/a:1026238331739] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
A recombinant fusion protein targeting the urokinase-type plasminogen activator receptor (uPAR) and delivering a potent catalytic toxin has the advantage of simultaneously targeting both over-expressed uPAR on glioblastoma cells and on the tumor neovasculature. Such a hybrid protein was synthesized consisting of the noninternalizing amino-terminal fragment (ATF) of urokinase-type plasminogen activator (uPA) for binding, and the catalytic portion of diphtheria toxin (DT) for killing, and the translocation enhancing region (TER) of DT for internalization. The protein was highly selective for human glioblastoma in vitro and in vivo. In vivo, this DT/ATF hybrid called DTAT caused the regression of small subcutaneous uPAR-expressing tumors with minimal toxicity to critical organs. In vitro, DTAT killed only uPAR-positive glioblastoma cell lines and human endothelial cells in the form of the HUVEC cell line. Killing was selective and blockable with specific antibody. DTAT was highly effective against tumor cells cultured from glioblastoma multiforme patients and in vitro mixing experiments combining DTAT with DTIL13 another highly effective anti-glioblastoma agent showed that the mixture was as toxic as the most potent immunotoxin. In this article, we review our progress to date with DTAT.
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Affiliation(s)
- Edward Rustamzadeh
- Department of Neurosurgery, University of Minnesota Cancer Center, Minneapolis, MN 55455, USA
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Abstract
Surgery, chemotherapy, and radiation therapy have become standard of practice in treating malignant brain tumors. Unfortunately, the prognosis of these malignant tumors still remains poor. Immunotoxins are a relatively new adjuvant treatment for brain tumors. Within the last few years an increased amount of clinically-oriented research involving immunotoxins has been published. This has led to numerous clinical trials which although encouraging have not yet born out the "magic bullet" concept envisioned for immunotoxins. In this review article the history, design, toxicity, and pharmokinetics of immunotoxins will be discussed in detail.
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Affiliation(s)
- Edward Rustamzadeh
- Department of Neurosurgery, Graduate School, University of Minnesota, Minneapolis, MN, USA.
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Cole BF, Glantz MJ, Jaeckle KA, Chamberlain MC, Mackowiak JI. Quality-of-life-adjusted survival comparison of sustained-release cytosine arabinoside versus intrathecal methotrexate for treatment of solid tumor neoplastic meningitis. Cancer 2003; 97:3053-60. [PMID: 12784341 DOI: 10.1002/cncr.11449] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The authors compared the quality of life of patients with solid tumor neoplastic meningitis treated in a controlled trial that compared conventional intrathecal methotrexate with a depot cytosine arabinoside liposomal injection (DepoCyt). The authors evaluated the trade-off between toxicity and improved clinical outcome. METHODS Quality-adjusted time without symptoms or toxicity (Q-TWiST) analysis was used to evaluate data collected prospectively from a randomized clinical trial that compared DepoCyt with methotrexate. Sixty-one patients with confirmed solid tumor neoplastic meningitis were randomized to receive either methotrexate or DepoCyt. RESULTS Within the 12-month follow-up, the average patient in the DepoCyt arm (compared with the methotrexate arm) achieved 71 more days of neurologic progression-free survival and 52 more days of overall survival, but experienced slightly more days with toxicity. The DepoCyt regimen provided greater quality-adjusted survival regardless of the quality-of-life valuations placed on time with toxicity and time following disease progression (range, 44-79 days). This gain was significant (P < 0.05) for all patients except for those who placed a high relative value on time following disease progression. CONCLUSIONS The clinical benefits of DepoCyt offset a trend toward additional toxicity among patients with sold tumor neoplastic meningitis. The magnitude of the benefit depends on how the patient values time spent in toxicity and disease progression. The results of this analysis can be used at the bedside to make evidence-based individual treatment decisions.
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Affiliation(s)
- Bernard F Cole
- Department of Community and Family Medicine, Dartmouth Medical School, Lebanon, New Hampshire, USA
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Bussani R, Cova M, Pozzi-Mucelli R, Camilot D, Silvestri F. Extensive metastatic leptomeningeal melanomatosis as the first clinical sign of a cutaneous melanoma: morphological correlations between magnetic resonance imaging and autopsy findings. A case report. Hum Pathol 2003; 34:625-8. [PMID: 12827619 DOI: 10.1016/s0046-8177(03)00120-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In recent years, the diagnosis and management of leptomeningeal carcinomatosis have gained increased attention as patients with neoplasms live longer and the condition becomes more common. Conclusive hallmarks of this disease have yet to be identified. We report and discuss a case of massive invasion of the cerebral leptomeninges by neoplastic cells from a malignant melanoma in a shoulder. Symptoms of cerebral dysfunction were the first indication of neoplasm. The onset of symptoms, magnetic resonance imaging, and patient death all occurred within a brief time span. To our knowledge, this is the first case of meningeal melanomatosis in a patient not treated with chemotherapeutic drugs in which the radiologic evidence is virtually synchronous with direct anatomic observation. Thus the images provided with this report may be of use in the radiographic diagnosis of cerebrospinal metastatic colonization.
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Affiliation(s)
- Rossana Bussani
- Department of Pathological Anatomy, University of Trieste, Italy
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Miyagui T, Luchemback L, Teixeira GHMDC, de Azevedo KML. Meningeal carcinomatosis as the initial manifestation of a gallbladder adenocarcinoma associated with a Krukenberg tumor. REVISTA DO HOSPITAL DAS CLINICAS 2003; 58:169-72. [PMID: 12894314 DOI: 10.1590/s0041-87812003000300007] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A case of malignant neoplasm is described in which the initial manifestations were mental dysfunction and meningeal irritation, mimicking chronic or subacute meningitis. Physical examination showed cranial nerve involvement and a pelvic tumor. There was progressive deterioration, and death occurred in 2 weeks. The autopsy revealed a gallbladder adenocarcinoma, meningeal carcinomatosis, and ovarian metastasis presenting as a Krukenberg tumor. The authors emphasize the importance of including meningeal carcinomatosis as a possibility in the differential diagnosis of non-characteristic clinical pictures, as well as the importance of the cerebrospinal fluid cytologic examination, repeated as needed, in order to confirm this diagnosis.
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Affiliation(s)
- Tizuko Miyagui
- Departments of Pathology and Clinical Medicine, Infectious and Parasitic Disease Service, Antonio Pedro University Hospital, Faculty of Medicine, Fluminense Federal University, Rio de Janeiro, RJ, Brazil
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Berg SL, Chamberlain MC. Systemic chemotherapy, intrathecal chemotherapy, and symptom management in the treatment of leptomeningeal metastasis. Curr Oncol Rep 2003; 5:29-40. [PMID: 12493148 DOI: 10.1007/s11912-003-0084-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Metastasis to the leptomeninges occurs in many common cancers, including leukemia; lung, breast, and gastrointestinal cancers; and tumors of the brain. By way of the flow of cerebrospinal fluid, leptomeningeal metastasis spreads throughout the neuraxis. Consequently, therapy for leptomeningeal metastasis must be directed to the entire central nervous system (CNS). Treatment often consists of involved-field radiotherapy, systemic chemotherapy, and intrathecal chemotherapy. However, because meningeal spread occurs most often in advanced disease, treatment is mainly palliative, except in childhood leukemia, where durable remission has been reported. This article outlines the role of systemic and intrathecal chemotherapy in patients with leptomeningeal metastases. Strategies for symptom management in these patients are also described.
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Affiliation(s)
- Stacey L Berg
- Department of Pediatric Oncology, Texas Children's Cancer Center, Baylor College of Medicine, USA
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Abstract
Neoplastic meningitis (NM) is a dreaded metastatic complication occurring in 5% to 10% of cancer patients. Survival is limited, usually ranging from 4 to 16 weeks. The pathogenesis of NM has not been extensively investigated but can be considered from the anatomic and molecular biologic standpoints. Malignant cells reach the cerebrospinal fluid (CSF) and meninges by direct invasion from tumors located near or within the central nervous system (CNS), or via the bloodstream or other pathways that contact the CNS. Symptoms of NM are caused by malignant cells invading and damaging nervous tissue, obstructing the vascular supply to nervous tissue, or obstructing CSF pathways. The molecular changes responsible for the development of NM are not well delineated, but it is likely that they involve changes in molecules responsible for tumor cell adhesion, migration, and proliferation. An understanding of the pathogenesis of NM will allow for its earliest possible diagnosis and ultimately lead to therapies targeted at the underlying molecular causes of this devastating condition.
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Affiliation(s)
- Morris D Groves
- Department of Neuro-Oncology, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Boulevard, Box 431, Houston, TX 77030, USA.
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Abstract
Neoplastic meningitis, which is the diffuse involvement of the leptomeninges by infiltrating cancer cells, may be caused by many systemic tumors. The treatment options for neoplastic meningitis disease remain unsatisfactory. In this review article, we discuss the pathogenesis and cytology of neoplastic meningitis and the options for treatment, including intrathecal chemotherapy, systemic chemotherapy, and newer agents such as cytokines and monoclonal antibodies.
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Affiliation(s)
- Ilkcan Cokgor
- Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA
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Abstract
Neoplastic meningitis (NM) is a common problem in neuro-oncology, occurring in approximately 5% of all patients with cancer. Notwithstanding frequent focal signs and symptoms, NM is a disease that affects the entire neuraxis; therefore, staging and treatment need to encompass all cerebrospinal fluid (CSF) compartments. Central nervous system (CNS) staging of NM includes contrast-enhanced cranial computerized tomography or magnetic resonance imaging, contrast-enhanced spine magnetic resonance imaging or computerized tomographic myelography, and radionuclide CSF flow study. Treatment of NM involves involved-field radiotherapy of bulky or symptomatic disease sites and intra-CSF drug therapy. The inclusion of concomitant systemic therapy may benefit patients with NM and may obviate the need for intra-CSF chemotherapy. At present, intra-CSF drug therapy is confined to three chemotherapeutic agents (ie, methotrexate, cytosine arabinoside, and thio-triethylene thiophosphoramide) administered by a variety of schedules either by intralumbar or intraventricular drug delivery. Although treatment of NM is palliative with an expected median patient survival of 2 to 6 months, it often affords stabilization and protection from further neurologic deterioration in patients with NM.
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Affiliation(s)
- Ana Aparicio
- Department of Medical Oncology, University of Southern California, Norris Comprehensive Cancer Center and Hospital, 1441 Eastlake Avenue, Room 3459, Los Angeles, CA 90033-0804, USA
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Kosmas C, Malamos NA, Tsavaris NB, Stamataki M, Stefanou S, Gregoriou A, Rokana S, Vartholomeou M, Antonopoulos MJ. Leptomeningeal carcinomatosis after major remission to taxane-based front-line therapy in patients with advanced breast cancer. J Neurooncol 2002; 56:265-73. [PMID: 12061734 DOI: 10.1023/a:1015018808804] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
AIM To determine the incidence of leptomeningeal carcinomatosis (LMC), as the first manifestation of systemic progression, in breast cancer patients after obtaining a major response (complete response, CR or >80% partial response, PR) to first-line taxane-based chemotherapy treated between 1996 and 2000 in our Medical Oncology Unit. PATIENTS AND METHODS Patients with histologically proven breast cancer having either metastatic disease, or high-risk locoregional disease that were entered into treatment protocols with first-line taxane (paclitaxel or docetaxel) plus anthracyclines or mitoxantrone combinations and developed LMC as the first evidence of progression after major response (CR or >80% PR) were analyzed in the present study (n = 155). RESULTS Seven patients with a median age of 54 (range: 40-70) years developed LMC as their first evidence of progression after taxane-based regimens with a median interval of 6 months (range: 2-18) from start of treatment to diagnosis of LMC. Five patients received intrathecal (i.t.) methotrexate treatment and whole brain radiotherapy (RT), while one patient received i.t. methotrexate and RT to lumbar spine. Two patients responded to treatment for LMC, while two achieved stable disease and three progressed. Two patients had elevated cerebrospinal fluid tumor markers (more than serum marker levels) that proved useful in monitoring response to treatment. Median survival after LMC was 3.6 months (range: 1-31+) and correlated positively to the interval from the initiation of taxane-based therapy to LMC (r = 0.84, P = 0.019). Seven out of 86 responders (8.1%; 95% confidence interval, 2.4-13.9) developed LMC as the first sign of progression after a major response to first-line chemotherapy. CONCLUSIONS LMC after a major response to front-line taxane-based regimens represents a grave disease manifestation and its incidence appears increased when compared in retrospect to non-taxane-treated patients. Prospective evaluation of the incidence of LMC after taxane versus non-taxane-based treatment from large randomized multiinstitutional trials is warranted and identification of potential prognostic factors might help identify patients requiring appropriate prophylactic therapy.
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Affiliation(s)
- Christos Kosmas
- Department of Medicine, Helena-Venizelous Hospital, Athens University School of Medicine, Greece.
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Hara H, Igarashi A, Yano Y, Yashiro T, Ueno E, Aiyoshi Y. Interventricular methotrexate therapy for carcinomatous meningitis due to breast cancer: a case with leukoencephalopathy. Breast Cancer 2001; 7:247-51. [PMID: 11029806 DOI: 10.1007/bf02967468] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A 46-year-old woman presented with paraplegia and severe lumbago. She had had a radical mastectomy for left breast cancer 10 years earlier, and 6 months prior to presentation she completed CMF chemotherapy for treatment of retroperitoneal metastasis. CT and MRI to identify potential causes of the paraplegia and lumbago showed leptomeningeal carcinomatosis due to dissemination from invasive recurrence of the retroperitoneal tumor. An Ommaya reservoir was inserted, and infusion of intrathecal methotrexate (MTX; 5 mg twice weekly) began. Her clinical symptoms improved after receiving 53 mg MTX. However, after receiving 83 mg MTX, the patient became dizzy from leukoencephalopathy. Although administration of prednisolone mostly resolved her symptom, the patient died 9 months after the diagnosis of carcinomatous meningitis.
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Affiliation(s)
- H Hara
- Department of Surgery, Institute of Clinical Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba-shi, Ibaraki 305-8575, Japan
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Abstract
Neoplastic meningitis is a disease of the entire neuraxis and is pleomorphic in its clinical presentation. Diagnosis is achieved by recognition of the clinical manifestations of neoplastic meningitis followed by neuroradiography of the brain and spinal cord and examination of the cerebrospinal fluid. Treatment, if clinically warranted, includes irradiation of symptomatic or bulky disease and intracerebrospinal fluid chemotherapy following an assessment of the extent of metastatic disease treatment is based on the results of four randomized intracerebrospinal fluid chemotherapy trials.
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Affiliation(s)
- M C Chamberlain
- Southern California Permanente Medical Group, Department of Neurology, Baldwin Park, California 91706, USA.
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Kosmas C, Malamos NA, Tsavaris N, Antonopoulos M. Chemotherapy-induced complete regression of choroidal metastases and subsequent isolated leptomeningeal carcinomatosis in advanced breast cancer: a case report and literature review. J Neurooncol 2000; 47:161-5. [PMID: 10982158 DOI: 10.1023/a:1006449215047] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Choroidal metastases from breast cancer represent an unusual metastatic presentation that has been traditionally treated with radiation therapy. Herein, we report a case of metastatic breast cancer presenting with pulmonary, cutaneous, lymph node and symptomatic choroidal metastases treated with systemic combination chemotherapy incorporating docetaxel and mitoxantrone without induction or consolidation radiation therapy to control visual symptoms from choroidal metastases. The patient experienced a durable complete remission in all metastatic sites that was maintained for 21 months since the initiation of chemotherapy, afterwhich she developed isolated leptomeningeal carcinomatosis managed successfully with intensive intrathecal methotrexate and whole brain irradiation leading to a new complete remission maintained until this report; 11 months after its presentation. This is the first case to our knowledge reporting complete regression of choroidal metastases with docetaxel-based chemotherapy as the only treatment modality and subsequent isolated leptomeningeal carcinomatosis recurrence.
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Affiliation(s)
- C Kosmas
- Department of Medicine, Helena-Venizelou Hospital, Athens, Greece.
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Loizaga Iriarte A, Arciniega García JM, Infante Riaño R, Ullate Jaime V, García Sastre E, Flores Corral N. [Meningeal carcinomatosis in bladder tumor]. Actas Urol Esp 1999; 23:873-5. [PMID: 10670130 DOI: 10.1016/s0210-4806(99)72387-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We report a strange case of a bladder whose first metastasic manifestation, after two years of the diagnosis, was a peripheric polyneuropathia. This patient was treated with immunotherapy with BCG for superficial carcinoma of the bladder during one year. Gradually central neurological symptoms appeared and the patient died one month later. A meningeal carcinomatosis was identify as the cause. No bone metastases existed, which is the most frequent way of tumours extension towards leptomeninges. We argue about the way to arrive at meninges.
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