Neoplastic meningitis: diagnosis and treatment considerations

Craniospinal irradiation in the treatment of chemotherapy refractory leptomeningeal metastasis from breast cancer: A case report

Background

Leptomeningeal carcinomatosis is a relatively uncommon complication of solid tumors that is associated with significant morbidity and mortality. Prognosis is typically weeks to months and the neurologic complications of this disease can significantly affect quality of life. The role of craniospinal irradiation is unclear as evidence exploring this treatment option is limited. Despite lack of evidence, its use has decreased due to its associated acute toxicities and newer intrathecal alternatives.

Case

Here we report the case of a 50‐year‐old patient who received craniospinal irradiation for chemotherapy‐refractory leptomeningeal disease, with survival well beyond the median and good quality of life for the majority of that time.

Conclusion

This patient's remarkable survival and performance after treatment suggests that craniospinal irradiation could be considered more frequently in the treatment of leptomeningeal metastases. To our knowledge, this is the first case with significant survival following craniospinal irradiation for chemotherapy refractory disease presented. Further study on the use of craniospinal irradiation to treat leptomeningeal metastasis is recommended.

Physical and chemical stability of methotrexate, cytarabine, and hydrocortisone in Elliott’s B Solution for intrathecal use

Intrathecal administration of methotrexate sodium and cytarabine with or without hydrocortisone sodium succinate is commonly used to treat metastatic spread of malignancies to the leptomeninges. The existing stability information on these drug combinations is inadequate due to the clinical use of increased doses of the drugs, as well as a change in the formulation of Elliott’s B Solution. The purpose of this study was to evaluate the physical and chemical stability of simulated high intrathecal doses of the subject drugs in the current formulation of Elliott’s B Solution.

Methotrexate sodium 6, 12, and 15 mg was combined with cytarabine 100 mg with and without hydrocortisone sodium succinate 100 mg using Elliott’s B Solution as the intrathecal vehicle. Samples were stored at 4 and 23°C and evaluated for physical and chemical stability over 48 h.

No precipitation or other evidence of physical instability was observed in any sample. Measured pH was 7.2- 7.5 in the samples and was sufficient to prevent methotrexate precipitation. High-performance liquid chromatography analysis found little or no loss of methotrexate and cytarabine in any sample and hydrocortisone at 4°C. At room temperature, hydrocortisone losses of 6-8% occurred in 48 h.

The high doses of methotrexate sodium and cytarabine with or without hydrocortisone sodium succinate evaluated in this study are physically and chemically stable for 48 h at 4 and 23°C in Elliott’s B Solution.

Safety and efficacy of intrathecal rituximab in children with B cell lymphoid CD20+ malignancies: An international retrospective study

Central nervous system (CNS) involvement in patients with mature B non-Hodgkin lymphoma, post-transplantation proliferative disorder and acute lymphoblastic leukemia confers a significantly inferior prognosis as compared to patients without CNS disease. Intrathecal (IT) or intraventricular administration of rituximab is an option for this group of patients. We report 25 children with CNS involvement of CD20+ B lymphoid malignancies who received in total 163 IT/intraventricular rituximab doses. The median number of doses received by each patient was 6, with a median dose of 25 mg. The most common adverse events were Grades 1 and 2 peripheral neuropathies in five patients (20%), allergy in two patients, and headache in two patients. These events were self-limited, occurring in the 48 hours after treatment and resolving within 24 hr. Three patients presented with more severe though transient side effects, one with a Grade III neuropathy and two with seizure. Eighteen patients (72%) of those treated with IT/intraventricular rituximab, with or without other CNS directed treatment, achieved a CNS remission. This case series suggests that IT/intraventricular rituximab has therapeutic efficacy and relatively limited toxicity. Prospective trials of IT/intraventricular rituximab for patients with CNS involvement of CD20 + B lymphoid malignancies are warranted.

Improving nucleoside analogs via lipid conjugation: Is fatter any better?

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.

Survival following Ommaya reservoir placement for neoplastic meningitis

The objective of this study was to evaluate the outcomes of patients with neoplastic meningitis (NM) following Ommaya reservoir placement in order to determine whether any patient factors are associated with longer survival. NM is a devastating late manifestation of cancer, and given its dismal prognosis, identifying appropriate patients for Ommaya reservoir placement is difficult. The authors performed a retrospective review of 80 patients who underwent Ommaya reservoir placement at three medical centers from September 2001 through September 2012. The primary outcome was death. Differences in survival were assessed with Kaplan-Meier survival analyses. The Cox proportional hazards and logistic regression modeling were performed to identify factors associated with survival. The primary diagnoses were solid organ, hematologic, and primary central nervous system tumors in 53.8%, 41.3%, and 5%, respectively. The median overall survival was 72.5 days (95% confidence interval 36-122) with 30% expiring within 30 days and only 13.8% surviving more than 1 year. There were no differences in median overall survival between sites (p=0.37) despite differences in time from diagnosis of NM to Ommaya reservoir placement (p<0.001). Diagnosis of hematologic malignancy was inversely associated with death within 90 days (p=0.04; odds ratio 0.34), older age was associated with death within 90 days (p=0.05; odds ratio 1.5, per 10 year increase in age). The prognosis of NM remains poor despite the available treatment with intraventricular chemotherapy. There exists significant variability in treatment algorithms among medical centers and consideration of this variability is crucial when interpreting existing series of Ommaya reservoir use in the treatment of patients with NM.

The prognostic significance of surgically treated hydrocephalus in leptomeningeal metastases

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.

Phase 2 clinical trial of intrathecal topotecan in children with refractory leptomeningeal leukemia: a Children's Oncology Group trial (P9962)

PURPOSE

We performed a phase 2 study in children with recurrent or refractory leptomeningeal leukemia to determine the objective response rate after treatment with intrathecal (IT) topotecan.

PATIENTS AND METHODS

Patients received age-adjusted IT topotecan (0.4 mg/dose for patients >3 years of age) administered twice weekly (every 3-4 days) for 6 weeks during induction, weekly for 4 weeks during consolidation, and twice monthly for 4 months and then monthly thereafter during maintenance.

RESULTS

Twenty-two patients enrolled in the study, of whom 20 were eligible and assessable for toxicity and 16 were assessable for response. Of 16 patients, 6 (38%) had a complete response, 8 (50%) had stable disease, and 2 (13%) had progressive disease. The median event-free survival time (95% CI) was 3.1 (1.6-10.3) months and the median overall survival time (95% CI) was 18.0 (7.3-38.3) months. Eight patients (40%) experienced grade 3 or 4 adverse events. There were no grade 4 neurological events (Table III). Four patients experienced a total of 6 grade 3 neurological events including an olfactory seizure, a headache, transient grade 3 speech impairment, muscle weakness, motor neuropathy, and ataxia. Headache was the most common grade ≤2 neurologic event and two patients developed grade ≤2 arachnoiditis.

CONCLUSION

IT administration of topotecan was tolerable on this dose and schedule. The majority of adverse events were mild to moderate, reversible side effects. Complete central nervous system remissions were achieved in a subset of children with recurrent or refractory central nervous system leukemia.

Leptomeningeal metastasis

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.

Phase I clinical trial of intrathecal gemcitabine in patients with neoplastic meningitis

PURPOSE

A phase I study of intrathecal (IT) gemcitabine was performed to define a safe dose and characterize the toxicity profile and CSF pharmacokinetics of gemcitabine and its major metabolite 2',2'-difluoro-deoxyuridine (dFdU) in patients 3 years of age and older with neoplastic meningitis.

EXPERIMENTAL DESIGN

Gemcitabine was administered via Ommaya reservoir or lumbar puncture at three dose levels: 5 mg weekly, 5 mg twice-weekly, and 10 mg twice-weekly using a standard phase I dose escalation design. Serial CSF samples were obtained for pharmacokinetic studies in seven patients with Ommaya reservoirs. Serial blood samples for pharmacokinetic studies were also obtained from three patients.

RESULTS

Ten patients were enrolled in this study. Significant neurological toxicities occurred in two patients including myelitis in a patient at the 5 mg twice-weekly dose level and somnolence in a patient at the 10 mg twice-weekly dose level. No complete responses were seen; however, three patients had stable disease. Gemcitabine was rapidly eliminated from the CSF with a terminal half-life of 61 +/- 50 min. No gemcitabine or dFdU was detected in plasma.

CONCLUSIONS

IT gemcitabine was associated with significant neurotoxicity; therefore, its further development for IT use is not recommended.

Plasma and cerebrospinal fluid pharmacokinetics of nelarabine in nonhuman primates

INTRODUCTION

Nelarabine is a water-soluble prodrug of the cytotoxic deoxyguanosine analog ara-G, to which it is rapidly converted in vivo by adenosine deaminase. Nelarabine has shown activity in the treatment of T-cell malignancies, especially T-cell acute lymphoblastic leukemia. Preliminary data suggested that nelarabine might penetrate into the CSF. We therefore studied the CSF penetration of nelarabine and ara-G in a nonhuman primate model that has been highly predictive of anticancer drug distribution in humans.

METHODS

Nelarabine (35 mg/kg, approximately 700 mg/m2) was administered over 1 h through a surgically implanted central venous catheter to four nonhuman primates. Blood (four animals) and ventricular CSF (three animals) samples were obtained at intervals for 24 h for determination of nelarabine concentrations, which were measured by HPLC-mass spectrometry.

RESULTS

The nelarabine plasma AUC (median+/-s.d.) was 2,820+/-1,140 microM min and the ara-G plasma AUC was 20,000+/-8,100 microM min. The terminal half-life of nelarabine in plasma was 25+/-5.2 min and clearance was 42+/-61 ml/min/kg. The terminal half-life of ara-G in plasma was 182+/-45 min. In CSF the terminal half-life of nelarabine was 77+/-28 min and of ara-G was 232+/-79 min. The AUCcsf:AUCplasma was 29+/-11% for nelarabine and 23+/-12% for ara-G.

CONCLUSION

The excellent CSF penetration of nelarabine and ara-G supports further study of the contribution of nelarabine to the prevention and treatment of CNS leukemia.

Plasma and cerebrospinal fluid pharmacokinetics of clofarabine in nonhuman primates

INTRODUCTION

Clofarabine (2-chloro-2'fluoro-2'-deoxy-9-beta-d-arabinofuranosyladenine) is a purine nucleoside analogue that is active in the treatment of acute leukemia. We studied the pharmacokinetics and cerebrospinal fluid penetration of clofarabine in a nonhuman primate model.

METHODS

A dose of 2.3 mg/kg of clofarabine was given i.v. over 2 hours to each of four animals. Plasma and cerebrospinal fluid (CSF) samples were obtained at specified intervals and the clofarabine concentration determined by reverse-phase high-pressure liquid chromatography with mass spectroscopy.

RESULTS

The median clofarabine clearance was 17 mL/min/kg (range, 15-20), the median plasma area under the concentration-time curve was 452 mumol/L minutes (range, 380-487), and the median terminal half-life was 105 minutes (range, 78-138). Concentrations of clofarabine in CSF could not be modeled reliably because the terminal rate constant was not well defined. The median CSF penetration was 5% (range, 3-26%).

CONCLUSION

Clofarabine penetrates into the CSF only modestly, but the concentrations obtained may approach those that are cytotoxic in vitro. Evaluation of the contribution of clofarabine to central nervous system preventive therapy should be considered in future studies.

Leptomeningeal cancer in the pediatric patient

The treatment and prophylaxis of leptomeningeal leukemia and lymphoma in children has dramatically improved disease control and long-term survival. However, the treatment of other leptomeningeal cancers has been less successful and the neurologic morbidity associated with central nervous system-directed therapy has a significant long-term impact on quality of life. Further research is critical to identify new therapeutic strategies for children with or at high risk for leptomeningeal cancer.

Phase II Study of Nelarabine (compound 506U78) in Children and Young Adults With Refractory T-Cell Malignancies: A Report From the Children’s Oncology Group

Purpose

Nelarabine (compound 506U78), a water soluble prodrug of 9-b-d-arabinofuranosylguanine, is converted to ara-GTP in T lymphoblasts. We sought to define the response rate of nelarabine in children and young adults with refractory or recurrent T-cell disease.

Patients and Methods

We performed a phase II study with patients stratified as follows: stratum 1: ≥ 25% bone marrow blasts in first relapse; stratum 2: ≥ 25% bone marrow blasts in ≥ second relapse; stratum 3: positive CSF; stratum 4: extramedullary (non-CNS) relapse. The initial nelarabine dose was 1.2 g/m2 daily for 5 consecutive days every 3 weeks. There were two dose de-escalations due to neurotoxicity on this or other studies. The final dose was 650 mg/m2/d for strata 1 and two patients and 400 mg/m2/d for strata 3 and four patients.

Results

We enrolled 121 patients (106 assessable for response) at the final dose levels. Complete plus partial response rates at the final dose levels were: 55% in stratum 1; 27% in stratum 2; 33% in stratum 3; and 14% in stratum 4. There were 31 episodes of ≥ grade 3 neurologic adverse events in 27 patients (18% of patients).

Conclusion

Nelarabine is active as a single agent in recurrent T-cell leukemia, with a response rate more than 50% in first bone marrow relapse. The most significant adverse events associated with nelarabine administration are neurologic. Further studies are planned to determine whether the addition of nelarabine to front-line therapy for T-cell leukemia in children will improve survival.

Improving the outcome of patients with leptomeningeal cancer: new clinical trials and experimental therapies

Current therapy for leptomeningeal metastases is predominantly palliative. In an effort to improve disease control and patient outcome, new strategies are being developed to target the cerebrospinal space. These include new intrathecal formulations of systemic chemotherapy as well as the development of radiolabeled immunoconjugates and antitumor antibodies. Furthermore, there is debate as to the optimal strategy of drug delivery for leptomeningeal tumor.

Radiation therapy for leptomeningeal cancer

Radiotherapy has multiple roles in the treatment of leptomeningeal cancer. While it is uncommon for patients to experience regression of neurologic deficits due to leptomeningeal cancer, focal radiotherapy often provides significant palliation of pain, increased intracranial pressure and other focal symptoms. Focal radiotherapy may also be used to eliminate blockages of cerebrospinal fluid (CSF) and allow for safe administration of intrathecal chemotherapy. Craniospinal irradiation (CSI) is most often used as prophylaxis for patients at high risk of leptomeningeal tumor dissemination, but may result in symptom palliation and prolonged disease control for patients with active leptomeningeal tumor.

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.

Innovations in design and delivery of chemotherapy for brain tumors

Effectiveness of chemotherapy in patients with brain tumors is hampered by the presence of the blood-brain barrier and drug resistance. In recent years, significant progress has been made in devising innovative methods of design and delivery of chemotherapy for brain tumors. This article has surveyed the issues of blood-brain barrier and drug resistance and explored some of the strategies used to circumvent problems associated with chemotherapy failure in patients with brain tumors.

Optic neuropathy in cancer patients. Report of a case possibly related to 5 fluorouracil toxicity and review of the literature

We report the case of a 72-year-old woman suffering from bone metastatic breast cancer and treated with continuous intravenous 5 fluorouracil (5FU) chemotherapy, who presented with a bilateral asymmetric anterior optic neuropathy (ON). A deficiency of dihydropyrimidine dehydrogenase (DPD) was documented. Patients with DPD deficiency are at increased risk for developing unusual and/or severe toxicity to 5FU. We discuss the differential diagnosis of anterior ON and we suggest that 5FU can be responsible for optic nerve toxicity in patients with DPD deficiency.

Macrocephaly and epidural involvement of T-cell acute lymphoblastic leukemia

We describe a 2-year-old female who presented with macrocephaly and anemia. Magnetic resonance imaging revealed a diffusely enhancing epidural lesion over the sagittal frontoparietal region. Bone marrow examination confirmed the diagnosis of T-cell acute lymphoblastic leukemia. Induction chemotherapy led to hematologic remission and neuroimaging resolution of the mass. This report suggested macrocephaly could be a rare and early manifestation of leukemia in children.