Current treatment of leptomeningeal metastases: systemic chemotherapy, intrathecal chemotherapy and symptom management

Treatment pattern and outcomes of leptomeningeal carcinomatosis in India - a retrospective study

Background

Leptomeningeal carcinomatosis (LMC), the metastatic spread of cancer to the leptomeninges, is a rare complication and has a dismal prognosis. Due to limited data available on LMC from India, we conducted a country-wise audit of LMC across 15 centres in India.

Methods

The current study conducted in 2020, was a retrospective, multicentric audit of adult patients (aged ≥18 years) with diagnosis of LMC and who received treatment during 2010-2020. Baseline characteristics, details related to previous treatments, cancer sites, LMC diagnosis, treatment pattern and overall survival (OS) were collected. Descriptive statistics were performed, and Kaplan Meier analysis was performed for the estimation of OS.

Findings

Among the patients diagnosed with LMC (n = 84), diagnosis was confirmed in 52 patients (61.9%) and 'probable' in 32 (38.1%) patients. The three most common cause of malignancy were non-small cell lung cancer (NSCLC), breast cancer and gastrointestinal cancer with 45 (53.6%), 22 (26.1%) and 9 (10.7%) patients respectively. Intrathecal therapy was offered in 33 patients (39.3%). The most common intrathecal agent was methotrexate in 23 patients (27.4%). The median OS was 90 days (95% CI 48-128). Among tested variables, intrathecal therapy administration (hazard ratio [HR] = 0.36, 95% CI 0.19-0.68) and primary in lung (HR = 0.43, 95% CI 0.23-0.83) had a favourable impact on OS.

Interpretation

Prognosis with leptomeningeal carcinomatosis is poor with a significant burden of morbidity and mortality in India. This data aims to highlight the current outcomes and facilitate further research on LMC.

Funding

None.

Intrathecal chemotherapy for the management of lymphoblastic lymphoma in a 4-year-old dog: a case report

Intrathecal chemotherapy is used in human medicine for the treatment or prophylaxis of CNS hematopoietic neoplasia. However, the clinical benefits in veterinary medicine have been scarcely documented. A 4-year-old male entire cross-breed dog presented with a 24-h history of severe lethargy, pelvic limb weakness, and urinary retention. Examination revealed generalized peripheral lymphadenomegaly, and the neurological findings were suggestive of a myelopathy in the region of T3-L3. Following the diagnosis of multicentric lymphoblastic B-cell lymphoma (stage Vb), a modified L-LOP with cytosine arabinoside was started, and complete clinical remission was achieved. After 4 weeks, there was acute neurological deterioration (spinal pain and proprioceptive deficits) without peripheral lymphadenomegaly. MRI findings and CSF analysis were consistent with meningeal and spinal cord lymphoma infiltration at the level of L3. Intrathecal chemotherapy (cytosine arabinoside and methotrexate) were administered in the cisterna magna with systemic dexamethasone and analgesia. Clinical signs were resolved within 24 h, and the patient remained asymptomatic for 3.5 weeks. After this period, CNS relapse (proprioceptive deficits and severe thoracolumbar pain) was suspected, and repeat intrathecal chemotherapy was declined. The patient was humanely euthanized 9 weeks after the initial diagnosis. This is the first report on the clinical benefit of intrathecal chemotherapy with a combination of methotrexate and cytarabine for the management of CNS lymphoma in dogs. Based on our case, intrathecal chemotherapy with methotrexate and cytarabine can induce a short-lasting CNS clinical remission (3 weeks).

Ovarian Adenocarcinoma With Leptomeningeal Metastases

Leptomeningeal carcinomatosis (LMC) is an uncommon disease that unfortunately has a rapid deterioration and a very poor prognosis with a devastating outcome. There has been an associated increase in the incidence of the leptomeningeal disease recently. There is a low percentage of LMC, around five percent of patients with metastatic disease. LMC has been presented in solid tumors such as breast cancer, lung cancer, melanoma, and GI malignancies. LMC is less likely reported in ovarian cancers. The clinical presentation of LMC is variable and will express according to where the cancer cells infiltrate. The malignant cells can travel with the cerebrospinal fluid (CSF) and deposit on the brain, cerebellum, spinal cord, cranial nerves, and spinal roots. We report this case as a clinical anatomical exercise for healthcare professionals.

A case report of endometrial adenocarcinoma with leptomeningeal metastases

In patients with a history of solid tumors, any new onset of neurological symptoms should be assessed for central nervous system involvement even in rare cases such as gynecological malignancies that nervous system involvement is a rare event.

Palliative care and pediatric surgical oncology

Survival rate for childhood cancer has increased in recent years, reaching as high as 70% in developed countries compared with 54% for all cancers diagnosed in the 1980s. In the remaining 30%, progression or metastatic disease leads to death and in this framework palliative care has an outstanding role though not well settled in all its facets. In this landscape, surgery has a supportive actor role integrated with other welfare aspects from which are not severable. The definition of surgical palliation has moved from the ancient definition of noncurative surgery to a group of practices performed not to cure but to alleviate an organ dysfunction offering the best quality of life possible in all the aspects of life (pain, dysfunctions, caregivers, psychosocial, etc.). To emphasize this aspect a more modern definition has been introduced: palliative therapy in whose context is comprised not only the care assistance but also the plans of care since the onset of illness, teaching the matter to surgeons in training and share paths. Literature is very poor regarding surgical aspects specifically dedicated and all researches (PubMed, Google Scholar, and Cochrane) with various meshing terms result in a more oncologic and psychosocial effort.

Novel approaches to treating leptomeningeal metastases

Leptomeningeal metastasis is a devastating complication of the central nervous system in patients with late-stage solid or hematological cancers. Leptomeningeal metastasis results from the multifocal seeding of the leptomeninges by malignant cancer cells. Although central nervous system metastasis usually presents in patients with widely disseminated and progressive late-stage cancer, malignant cells may spread to the cerebrospinal fluid during earlier disease stages in particularly aggressive cancers. Treatment of leptomeningeal metastasis is largely palliative but will often provide stabilization and protection from further neurological deterioration and improve quality of life. There is a need to raise awareness of the impact of leptomeningeal metastases on cancer patients and its known and putative biological basis. Novel diagnostic approaches include identification of biomarkers that may stratify the risk for developing leptomeningeal metastasis. Current therapies can be used more effectively while waiting for advanced treatments to be developed.

Subarachnoid hemorrhage and the distribution of drugs delivered into the cerebrospinal fluid. Laboratory investigation

OBJECT

Investigators in experimental and clinical studies have used the intrathecal route to deliver drugs to prevent or treat vasospasm. However, a clot near an artery or arteries after subarachnoid hemorrhage (SAH) may hamper distribution and limit the effects of intrathecally delivered compounds. In a primate model of right middle cerebral artery (MCA) SAH, the authors examined the distribution of Isovue-M 300 and 3% Evans blue after infusion into the cisterna magna CSF.

METHODS

Ten cynomolgus monkeys were assigned to SAH and sham SAH surgery groups (5 in each group). Monkeys received CSF injections as long as 28 days after SAH and were killed 3 hours after the contrast/Evans blue injection. The authors assessed the distribution of contrast material on serial CT within 2 hours after contrast injection and during autopsy within 3 hours after Evans blue staining.

RESULTS

Computed tomography cisternographies showed no contrast in the vicinity of the right MCA (p < 0.05 compared with left); the distribution of contrast surrounding the entire right cerebral hemisphere was substantially reduced. Postmortem analysis demonstrated much less Evans blue staining of the right hemisphere surface compared with the left. Furthermore, the Evans blue dye did not penetrate into the right sylvian fissure, which occurred surrounding the left MCA. The authors observed the same pattern of changes and differences in contrast distribution between SAH and sham SAH animals and between the right and the left hemispheres on Days 1, 3, 7, 14, 21, and 28 after SAH.

CONCLUSIONS

Intrathecal drug distribution is substantially limited by SAH. Thus, when using intrathecal drug delivery after SAH, vasoactive drugs are unlikely to reach the arteries that are at the highest risk of delayed cerebral vasospasm.

Leptomeningeal neoplasms

Leptomeningeal metastasis is becoming an increasingly important late complication of cancer as survival from systemic disease increases, and due to the fact that many novel cancer drugs fail to achieve therapeutic concentrations in the central nervous system. It occurs when neoplastic cells enter cerebrospinal fluid (CSF) pathways, causing diffuse infiltration of the subarachnoid space of the brain and spinal cord. Definitive diagnosis is established by the demonstration of malignant cells in the CSF. However, in certain circumstances the presence of leptomeningeal enhancement on brain or spinal MRI may be sufficient to make the diagnosis. Early diagnosis and aggressive treatment may delay neurologic progression and can lead to prolonged survival and improvement of neurologic function in certain patients. The prognosis depends on the underlying malignancy but is often poor, with a median survival of 4 months, and most treatment interventions are palliative. Nevertheless, some patients respond to treatment, and some survive beyond 1 or 2 years after diagnosis. Areas of radiographic bulky disease or symptomatic tumor should receive radiotherapy. Intrathecal chemotherapy is most effective in patients with lymphoma, leukemia, or breast cancer and without evidence of bulky disease on neuroimaging. Intrathecal chemotherapy requires normal CSF flow, and the most commonly used agents are methotrexate, cytarabine, and thiotepa. In lieu of intrathecal therapy, systemic chemotherapy may occasionally be indicated in select patients in part based on its ability to penetrate into bulky disease. When hydrocephalus occurs, ventriculoperitoneal shunting frequently leads to rapid clinical improvement. There is hope that progress in diagnostic modalities and the development of more effective intrathecal antineoplastic drugs may decrease neurologic morbidity and improve quality of life and survival.

Kinetic modeling of tumor growth and dissemination in the craniospinal axis: implications for craniospinal irradiation

Background

Medulloblastoma and other types of tumors that gain access to the cerebrospinal fluid can spread throughout the craniospinal axis. The purpose of this study was to devise a simple multi-compartment kinetic model using established tumor cell growth and treatment sensitivity parameters to model the complications of this spread as well as the impact of treatment with craniospinal radiotherapy.

Methods

A two-compartment mathematical model was constructed. Rate constants were derived from previously published work and the model used to predict outcomes for various clinical scenarios.

Results

The model is simple and with the use of known and estimated clinical parameters is consistent with known clinical outcomes. Treatment outcomes are critically dependent upon the duration of the treatment break and the radiosensitivity of the tumor. Cross-plot analyses serve as an estimate of likelihood of cure as a function of these and other factors.

Conclusion

The model accurately describes known clinical outcomes for patients with medulloblastoma. It can help guide treatment decisions for radiation oncologists treating patients with this disease. Incorporation of other treatment modalities, such as chemotherapy, that enhance radiation sensitivity and/or reduce tumor burden, are predicted to significantly increase the probability of cure.