Early blindness and coma during intrathecal chemotherapy for meningeal carcinomatosis

Retinal toxicities of systemic anticancer drugs

Newer anticancer drugs have revolutionized cancer treatment in the last decade, but conventional chemotherapy still occupies a central position in many cancers, with combination therapy and newer methods of delivery increasing their efficacy while minimizing toxicities. We discuss the retinal toxicities of anticancer drugs with an emphasis on the mechanism of toxicity. Uveitis is seen with the use of v-raf murine sarcoma viral oncogene homolog B editing anticancer inhibitors as well as immunotherapy. Most of the cases are mild with only anterior uveitis, but severe cases of posterior uveitis, panuveitis, and Vogt-Koyanagi-Harada-like disease may also occur. In the retina, a transient neurosensory detachment is observed in almost all patients on mitogen-activated protein kinase kinase (MEK) inhibitors. Microvasculopathy is often seen with interferon α, but vascular occlusion is a more serious toxicity caused by interferon α and MEK inhibitors. Crystalline retinopathy with or without macular edema may occur with tamoxifen; however, even asymptomatic patients may develop cavitatory spaces seen on optical coherence tomography. A unique macular edema with angiographic silence is characteristic of taxanes. Delayed dark adaptation has been observed with fenretinide. Interestingly, this drug is finding potential application in Stargardt disease and age-related macular degeneration.

Blindness due to leptomeningeal carcinomatosis as an initial manifestation of recurrent acute lymphoblastic leukemia

Leptomeningeal carcinomatosis (LC) is an uncommon presentation of acute lymphoblastic leukemia (ALL), and it is a devastating and life-threatening complication. The disease affects all levels of the central nervous system, and most patients present with different multifocal neurological symptoms. This case was a 34-year-old male who had acute bilateral blindness secondary to recurrent ALL with meningeal infiltration. Diagnosis of LC is made based on the clinical symptoms and the test results including cranial and spinal magnetic resonance imaging and cerebrospinal fluid (CSF) survey. The differential diagnosis of meningeal enhancement and early treatment are also important for prognosis. This case had a good visual recovery after treatment.

Optic neuritis as isolated manifestation of leptomeningeal carcinomatosis: a case report and systematic review of ocular manifestations of neoplastic meningitis

Introduction. Leptomeningeal carcinomatosis occurs in about 5% of cancer patients. Ocular involvement is a common clinical manifestation and often the presenting clinical feature. Materials and Methods. We report the case of a 52-year old lady with optic neuritis as isolated manifestation of neoplastic meningitis and a review of ocular involvement in neoplastic meningitis. Ocular symptoms were the presenting clinical feature in 34 patients (83%) out of 41 included in our review, the unique manifestation of meningeal carcinomatosis in 3 patients (7%). Visual loss was the presenting clinical manifestation in 17 patients (50%) and was the most common ocular symptom (70%). Other ocular signs were diplopia, ptosis, papilledema, anisocoria, exophthalmos, orbital pain, scotomas, hemianopsia, and nystagmus. Associated clinical symptoms were headache, altered consciousness, meningism, limb weakness, ataxia, dizziness, seizures, and other cranial nerves involvement. All patients except five underwent CSF examination which was normal in 1 patient, pleocytosis was found in 11 patients, increased protein levels were observed in 16 patients, and decreased glucose levels were found in 8 patients. Cytology was positive in 29 patients (76%). Conclusion. Meningeal carcinomatosis should be considered in patients with ocular symptoms even in the absence of other suggestive clinical symptoms.

Chemotherapy-induced polyneuropathy. Part I. Pathophysiology

Chemotherapy-induced peripheral neuropathy (CIPN) is a toxic neuropathy, a syndrome consisting of highly distressing symptoms of various degrees of severity. It includes numbness of distal extremities, long-term touch, heat, and cold dysaesthesia and, in more severe cases, motor impairment affecting daily functioning. Each form of the syndrome may be accompanied by symptoms of neuropathic stinging, burning, and tingling pain. In the case of most chemotherapeutic agents, the incidence and severity of CIPN are dependent on the cumulative dose of the drug. The syndrome described is caused by damage to the axons and/or cells of the peripheral nervous system.

Chemotherapeutic agents have distinct mechanisms of action in both neoplastic tissue and the peripheral nervous system; therefore, CIPN should not be regarded as a homogeneous disease entity. The present article is an attempt to systematize the knowledge about the toxic effects of chemotherapy on the peripheral nervous system.

Ocular manifestations of meningeal carcinomatosis: a case report and literature review

BACKGROUND

Meningeal carcinomatosis (MC) is a devastating and frequently fatal complication of cancer, affecting approximately 5% of patients with systemic malignancies. The disease is characterized by diffuse infiltration of the meninges and cerebrospinal fluid by metastatic tumor cells. The disease affects all levels of the central nervous system, with the most common symptoms of the disease being headache, change in mental status, diplopia, hearing loss, facial numbness, and vision loss. Ocular or visual symptoms have been reported in 91% of patients with MC and may progress to total blindness.

CASE REPORT

This report presents a case of MC with multiple ocular manifestations and a review of the literature regarding diagnosis and treatment of the disease.

CONCLUSION

Eye care professionals can play a critical role in directing care and achieving an early diagnosis of MC and should be educated about this rare condition.

Effects on the visual system might contribute to some of the cognitive deficits of cancer chemotherapy-induced 'chemo-fog'

The diminution in certain aspects of cognitive function that is reported to occur in some patients during or after adjuvant cancer chemotherapy is variously known as 'chemo-fog', 'chemo-brain' or other such term. In addition to reported deficits in attention, concentration and other functions, most, if not all, of the studies report deficits involving visual-spatial function or visual memory. Since the visual system is part of the nervous system, it seems reasonable to ask if it is susceptible to some of the deleterious effects produced by adjuvant chemotherapeutic drugs. We propose here the possibility that some portion of the vision-related aspects of the 'chemo-fog' spectrum of cognitive deficits results from a direct action of the adjuvant drugs on the visual system or from drug/drug or site/site interaction between effects on the visual system and other critical brain regions.

Chemotherapy-induced neuropathy

Neurotoxic side effects of cancer therapy are second in frequency to hematological toxicity. Unlike hematological side effects that can be treated with hematopoietic growth factors, neuropathies cannot be treated and protective treatment strategies have not been effective. For the neurologist, the diagnosis of a toxic neuropathy is primarily based on the case history, the clinical and electrophysiological findings, and knowledge of the pattern of neuropathy associated with specific agents. In most cases, toxic neuropathies are length-dependent, sensory, or sensorimotor neuropathies often associated with pain. The platinum compounds are unique in producing a sensory ganglionopathy. Neurotoxicity is usually dependent on cumulative dose. Severity of neuropathy increases with duration of treatment and progression stops once drug treatment is completed. The platinum compounds are an exception where sensory loss may progress for several months after cessation of treatment ("coasting"). As more effective multiple drug combinations are used, patients will be treated with several neurotoxic drugs. Synergistic neurotoxicity has not been extensively investigated. Pre-existent neuropathy may influence the development of a toxic neuropathy. Underlying inherited or inflammatory neuropathies may predispose patients to developing very severe toxic neuropathies. Other factors such as focal radiotherapy or intrathecal administration may enhance neurotoxicity. The neurologist managing the cancer patient who develops neuropathy must answer a series of important questions as follows: (1) Are the symptoms due to peripheral neuropathy? (2) Is the neuropathy due to the underlying disease or the treatment? (3) Should treatment be modified or stopped because of the neuropathy? (4) What is the best supportive care in terms of pain management or physical therapy for each patient? Prevention of toxic neuropathies is most important. In patients with neuropathy, restorative approaches have not been well established. Symptomatic and other management are necessary to maintain and improve quality of life.

Irreversible paraplegia following one time prophylactic intrathecal chemotherapy in an adult patient with acute lymphoblastic leukemia

We present an adult female patient who developed irreversible paraplegia and areflexia four days post intrathecal chemotherapy with methotrexate, cytosine arabinoside and hydrocortisone. On magnetic resonance imaging (MRI) of the lumbar spine, diffuse gadolinium enhancement of the anterior spinal nerve roots (ventral roots) was detected. Methylprednisolone was intravenously administered at a daily dose of 30mg/kg for three days. Despite this treatment, flaccid weakness in the lower extremities and urinary retention persisted. Following consolidation chemotherapy, no improvement in neurologic status was noted. Six months later, a follow-up MRI revealed severe atrophy of the thoracic spinal cord.

Continuous intrathecal treatment with methotrexate via subcutaneous port: implication for leptomeningeal dissemination of malignant tumors

Use of intrathecal (IT) chemotherapy combined with radiotherapy can extend survival of patients with untreated leptomeningeal dissemination of malignant tumors from one month to two to six months. The goal of the present study was to determine the effect of continuous IT (CIT) via a subcutaneous port that was placed using a neuronavigation system. Twenty patients with leptomeningeal dissemination (primary disease: 10 cancers, 6 gliomas and 4 lymphomas) were given 2-7 cycles of continuous IT (CIT) with methotrexate (MTX; 10 mg) administered into the lateral ventricle for 5 consecutive days biweekly. The concentration of MTX in the lateral ventricle was 7 to 10 x 10(-6 )M from Day 1 to 4. Response to this therapy included 6 patients with complete remission, 7 with progressive disease, and 7 with stable disease. Kaplan-Meier analysis revealed a median overall survival of 8 months while the overall survival rate for leptomeningeal specific death or for metastasis from cancer was 13 or 5 months, respectively. Complications of CIT with MTX were relatively low (<0.5%), and nausea and vomiting did not occur in any of the patients. In conclusion, CIT with 10 mg MTX via subcutaneous port for 5 days may improve the therapeutic effect and reduce the complications associated with treatment of leptomeningeal dissemination from malignant tumors. This would be a safe technique with possible implications that bear repeating more patients.

Update on ocular complications of systemic cancer chemotherapy

The constantly growing list of cytotoxic chemotherapeutics requires a new survey of ophthalmic complications, which are often underestimated. Based on the review by Imperia et al (1989), an update on ophthalmic complications of currently used cytotoxic chemotherapeutics in oncology was written. Vision is a quality of life issue, which must be nurtured, especially if loss of vision can be prevented. The broad spectrum of ophthalmic complications induced by cytotoxic chemotherapy includes reversible and irreversible acute and chronic disorders. Mild to moderate ophthalmic complications are very common and reversible after cessation of anti-cancer therapy. Some major ocular toxicities may require a dose reduction or the discontinuation of cytotoxic chemotherapy in order to prevent visual loss. Ocular toxicities can be treated or even prevented, if detected early enough. That is why an ophthalmic baseline examination for patients receiving cytosine arabinoside, 5-fluorourocil, methotrexate, or docetaxel should be taken into consideration, and a consultation with an ophthalmologist has to be done as soon as symptoms are recognized. Oncologists and ophthalmologists must be aware of potential ophthalmic complications during cytotoxic chemotherapy, and should work together.

Leptomeningeal metastases

LM is an increasingly common neurologic complication of cancer with variable clinical manifestations. Although there are no curative treatments, currently available therapies can preserve neurologic function and potentially improve quality of life. Further research into the mechanisms of leptomeningeal metastasis will elucidate molecular and cellular pathways that may allow identification of potential targets to interrupt this process early or to prevent this complication. Animal models are needed to further define the pathophysiology of LM and to provide an experimental system to test novel treatments [242-245]. There is an urgent need to develop new drug-based or radiation-based treatments for patients with LM. Randomized clinical trials are the appropriate study design to determine the efficacy of new treatments for LM. However, surrogate markers for response must be developed to facilitate the identification of effective regimens. Survival is not the optimal end point for such studies as most patients who develop this complication already have advanced, incurable cancer. Prevention of or delay in neurologic progression is one objective that has been utilized in recent randomized trials in patients with LM, and this end point deserves further attention. Although the development of LM represents a poor prognostic marker in patients with cancer it is important for physicians to recognize the symptoms and signs of the disease and establish the diagnosis as early in the disease course as possible. This may provide an opportunity for effective intervention that can improve quality of life, prevent further neurologic deterioration and, for a subset of patients, improve survival.

Methotrexate-induced optic neuropathy

A 53-year-old Caucasian woman with long-standing, well controlled, severe rheumatoid arthritis, treated with methotrexate, salazopyrin, naprosyn, prednisone and plaquenil, presented with progressive visual loss in each eye. She had a past history of non-necrotizing anterior scleritis that was treated with increased doses of prednisone. She developed left then right central scotomas, reduced vision and optic atrophy. Eventually a diagnosis of methotrexate-induced optic atrophy was made.

Ventral polyradiculopathy with pediatric acute lymphocytic leukemia

A 3-year-old girl with acute lymphocytic leukemia (ALL) in remission developed lower extremity paraparesis and areflexia 15 days after receiving intrathecal methotrexate, cytarabine, and hydrocortisone. Cerebrospinal fluid protein was 107 mg/dl. Compound muscle action potential amplitudes were reduced, F waves were absent, and sensory conduction studies were normal. Needle electromyography (EMG) revealed reduced motor unit potential recruitment. Magnetic resonance imaging (MRI) showed lumbosacral ventral root enhancement. She was treated with intravenous immunoglobulin and slowly recovered. Nerve conduction and EMG abnormalities correlated with MRI root enhancement, facilitated early diagnosis, and distinguished this from a myelopathy or distal polyneuropathy. These findings could represent selective ventral nerve root vulnerability to intrathecal chemotherapy. A selective autoimmune process cannot be excluded.

Seesaw nystagmus following whole brain irradiation and intrathecal methotrexate

A patient developed pendular seesaw nystagmus after receiving radiation and intrathecal methotrexate treatment for central nervous system lymphoma. Nystagmus developed without evidence of a brainstem lesion on magnetic resonance imaging. This case expands the causes of seesaw nystagmus and lends further support to the notion that midbrain lesions are not a prerequisite for its development.

Interventricular methotrexate therapy for carcinomatous meningitis due to breast cancer: a case with leukoencephalopathy

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.

Meningeal metastases: clinical aspects and diagnosis

The authors review the clinical and diagnostic aspects involved in leptomeningeal disease due to solid tumours, leukaemias and lymphomas. The importance of the combination of clinical findings with cerebral spinal fluid (CSF) examination and imaging studies in making an early diagnosis is underlined. The raising prevalence of this complication of systemic cancer deserves specific attention on the part of neurologists involved in consultation liason with general medicine and oncology.

Central nervous system metastases

OBJECTIVES

To provide an overview and up-to-date information on the presentation and treatment of central nervous system (CNS) metastases, including brain metastases, spinal cord compression, and leptomeningeal metastases.

DATA SOURCES

Published articles, research reports, and book chapters pertaining to CNS metastases.

CONCLUSIONS

Most patients with CNS metastases have a limited life expectancy. Therapies are palliative, except in select patients who have improved chances for long-term control or occasional cures. In general, early detection and treatment of CNS metastases prevents devastating neurological disabilities.

IMPLICATIONS FOR NURSING PRACTICE

Nurses across all health care settings can play an important role in early recognition of signs and symptoms of CNS metastases, and assist patients and families in preventing devastating neurological disabilities. Nurses are also frontline care providers for patients requiring various treatments and rehabilitation for metastatic CNS disease.

Carcinomatous meningitis in solid tumours

Carcinomatous meningitis (CM) is an uncommon but devastating complication of malignancy. The management is controversial and clear recommendations cannot be made because: 1) Most series include patients with CM that has arisen from different primary malignancies which are associated with different median survival intervals. 2) There have been no prospective randomised investigations of treatment modalities in patients with CM from a particular tumour type. 3) The definition of response varies from one report to another so that some response rates refer to cytological changes in the CSF while others take clinical, cytological and biochemical parameters into account. 4) Reports include patients with and without parenchymal metastases and the natural history of carcinomatous meningitis in the two situations may differ. The median survival of solid tumour carcinomatous meningitis (excluding leukaemia and lymphoma) is approximately 2-3 months and patients with breast cancer have the longest survival (median 3 months). Currently patients are treated with radiotherapy to part or all of the neuraxis with either intrathecal or intravenous chemotherapy but the relative contribution of these modalities to survival or quality of life remains unknown. Approximately 50% of patients with carcinomatous meningitis die from other causes, including systemic disease. The two most important endpoints for the patient, neurological improvement and overall survival, are seldom used in isolation in the literature. Many reports have focused on surrogate markers of response, namely biochemical and cytological data points but the correlation between clinical status and these parameters is poor because of differences between lumbar and ventricular CSF and disturbances of CSF flow in CM. The current literature does not provide clear guidelines for the treatment of this condition. Multicentre, prospective, randomised trials should be conducted that address questions of most relevance to the patient, namely neurological status and overall survival.

Central nervous system metastasis in breast cancer

BACKGROUND AND PURPOSE

Central nervous system (CNS) metastasis occurs in at least 30% of patients with breast cancer. Standard treatment is the same as in other solid tumors, though clinical behavior, and sensitivity to radiation therapy (RT) and to chemotherapy may differ considerably. Most of these patients die within a few months, but a substantial subgroup may survive a year or more. The last decade has given rise to new diagnostic methods, new surgical and radiotherapeutic techniques, and the clinical evidence of a chemotherapy permissive blood-brain barrier in CNS metastases. The literature was reviewed to assess the clinical impact of early diagnosis, recognition of prognostic factors, and of the recently developed therapeutic approaches.

MATERIAL AND METHODS

Review of the literature on CNS involvement in breast cancer focusing on clinical studies on early diagnosis, new modes of treatment, and factors influencing outcome.

RESULTS

Although randomized studies are still awaited, systemic chemotherapy seems a valuable alternative for RT of brain metastases in selected cases. In meningeal carcinomatosis, long survival may be independent of intraventricular chemotherapy. Neurotoxicity of intensive intraventricular treatment is considerable. In epidural metastasis, early diagnosis with prompt start of treatment remains the crucial factor for outcome. Radiation therapy is the mainstay of treatment of epidural metastasis, but new surgical techniques and even systemic chemotherapy should be considered in selected cases.

CONCLUSIONS

Recognition of prognostic factors combined with appropriate use of various recently developed therapeutic possibilities will improve the clinical outcome including better local tumor control and less treatment-induced neurotoxicity in a considerable number of patients with CNS metastasis from breast cancer.

"Locked-in syndrome" after intrathecal cytosine arabinoside therapy for malignant immunoblastic lymphoma

A 22-year-old man with malignant immunoblastic lymphoma had "locked-in" syndrome within 48 hours of receiving a single (100 mg) dose of intrathecal cytosine arabinoside (ara-C) in conjunction with intravenous ara-C, cisplatin, and doxorubicin. Eight hours after therapy, the patient had central hypoventilation and blurred vision that progressed to blindness within 3 hours. During the next 10 hours, he became completely quadriplegic but remained intermittently alert and was able to respond to commands by eye or head movements. Radiographic studies showed necrosis of the medulla and swelling of the entire spinal cord. The patient persisted in a locked-in state until his death 3 weeks later, after removal of life support systems. Autopsy confirmed extensive necrosis of the lower medulla, optic chiasm, cranial nerves I and IV, and spinal cord. This case was unusual for its severity. The temporal relationship to ara-C instillation favors a toxic idiosyncratic response to chemotherapy. The authors advocate caution when bolus intrathecal and intravenous ara-C are administered to a patient within a short time of each other.

Meningeal carcinomatosis in breast cancer. Prognostic factors and influence of treatment

In 58 breast cancer patients with meningeal carcinomatosis (MC) pretreatment characteristics, clinical course, and response to treatment were evaluated. Forty-four patients were uniformly treated with intraventricular chemotherapy. Fourteen patients did not receive intraventricular treatment. In the intraventricularly treated group the median survival was 12 weeks. Multivariate analysis of the pretreatment characteristics of the intraventricularly treated patients demonstrated a prognostic significance with respect to survival for age older than 55 years, lung metastases, cranial nerve involvement, cerebrospinal fluid (CSF) glucose less than 2.5 mmol/l, and CSF protein 0.51 to 1.0 g/l. Based on the significance of these predicting factors a prognostic index (PI) identified four groups of patients with a median survival of 43 weeks, 22 weeks, 11 weeks, and 3 weeks, respectively. After 6 weeks of intraventricular treatment 22 patients showed a neurologic improvement or stabilization, and nine patients showed a worsening of the neurologic signs, whereas 13 patients (30%) had already died. The responders had a median additional survival of 5 months versus 1 month for nonresponders. No relation was found between survival and intensity of the intraventricular treatment after the first 6 weeks of treatment. Almost all long survivors had also received systemic treatment for systemic disease, whereas most patients who died within 6 months did not receive systemic therapy. Radiation therapy had no influence on the survival time. Early death due to the intensive treatment occurred in three patients. In 11 of the 17 patients who survived more than 4 months an often seriously debilitating late neurotoxicity developed. The survival curve of the nonintraventricularly treated patients appeared to be essentially the same as the curve of the intraventricularly treated patients. Using the same PI the predicted survival time was also the same as in the intraventricularly treated group. It is concluded that survival in MC from breast carcinoma may be more dependent on some pretreatment characteristics than on treatment intensity. On the basis of these pretreatment characteristics the survival time seems to be predictable. Finally, late neurotoxicity due to aggressive treatment leads to impairment of the quality of life in more than 50% of the long survivors. The exact value of intraventricular and systemic therapy in patients with MC still has to be determined.