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Masuda Y, Nara K, Fujii-Mori A, Shimura A, Taoka K, Watadani T, Morita K, Yamamoto T, Kurokawa M, Takada T. Treatment-related leukoencephalopathy in adults with central nervous system lymphoma: a retrospective analysis of 126 patients. Ann Hematol 2024:10.1007/s00277-024-05989-1. [PMID: 39269476 DOI: 10.1007/s00277-024-05989-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2024] [Accepted: 08/30/2024] [Indexed: 09/15/2024]
Abstract
Neurotoxicity associated with high-dose chemotherapy and whole brain radiotherapy (WBRT) is one of major complications for patients with central nervous system lymphoma (CNSL). Here we determined the incidence and risk factors of treatment-related leukoencephalopathy (tLE) in a clinical setting. We retrospectively reviewed clinical and radiological findings of 126 patients with (CNSL) treated with high-dose methotrexate with or without intrathecal methotrexate administration (IT MTX) and response-adapted WBRT. During the whole observation period with a median of 38.7 months, tLE was found in 33 patients, most of them asymptomatic, with the median time to development 3.0 months, and the cumulative incidence reaching 29.2% (95% confidence interval, 20.6-38.2%) two years post chemotherapy. By multivariable analysis, IT MTX was identified as the only one significant risk factor (hazard ratio, 4.50; P < 0.001), and the number of IT MTX was associated with the increased incidence and severity of tLE. These findings highlight the frequent neurological complications associated with CNS-directed therapy and confirm the neurotoxicity of IT MTX.
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Affiliation(s)
- Yasutaka Masuda
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Katsuhiko Nara
- Department of Pharmacy, The University of Tokyo Hospital, Tokyo, Japan
| | - Alice Fujii-Mori
- Department of Pharmacy, The University of Tokyo Hospital, Tokyo, Japan
| | - Arika Shimura
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuki Taoka
- Clinical Application for Development of Therapy for Rare Disease, The University of Tokyo Hospital, Tokyo, Japan
| | - Takeyuki Watadani
- Department of Radiology, The University of Tokyo Hospital, Tokyo, Japan
| | - Ken Morita
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takehito Yamamoto
- Department of Pharmacy, The University of Tokyo Hospital, Tokyo, Japan.
| | - Mineo Kurokawa
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Cell Therapy and Transplantation Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Tappei Takada
- Department of Pharmacy, The University of Tokyo Hospital, Tokyo, Japan
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2
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Piper K, Kumar JI, Domino J, Tuchek C, Vogelbaum MA. Consensus review on strategies to improve delivery across the blood-brain barrier including focused ultrasound. Neuro Oncol 2024; 26:1545-1556. [PMID: 38770775 PMCID: PMC11376463 DOI: 10.1093/neuonc/noae087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Indexed: 05/22/2024] Open
Abstract
Drug delivery to the central nervous system (CNS) has been a major challenge for CNS tumors due to the impermeability of the blood-brain barrier (BBB). There has been a multitude of techniques aimed at overcoming the BBB obstacle aimed at utilizing natural transport mechanisms or bypassing the BBB which we review here. Another approach that has generated recent interest in the recently published literature is to use new technologies (Laser Interstitial Thermal Therapy, LITT; or Low-Intensity Focused Ultrasound, LIFU) to temporarily increase BBB permeability. This review overviews the advantages, disadvantages, and major advances of each method. LIFU has been a major area of research to allow for chemotherapeutics to cross the BBB which has a particular emphasis in this review. While most of the advances remain in animal studies, there are an increasing number of translational clinical trials that will have results in the next few years.
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Affiliation(s)
- Keaton Piper
- Department of Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Jay I Kumar
- Department of Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Joseph Domino
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Chad Tuchek
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Michael A Vogelbaum
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
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3
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Moreira R, Nóbrega C, de Almeida LP, Mendonça L. Brain-targeted drug delivery - nanovesicles directed to specific brain cells by brain-targeting ligands. J Nanobiotechnology 2024; 22:260. [PMID: 38760847 PMCID: PMC11100082 DOI: 10.1186/s12951-024-02511-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 04/29/2024] [Indexed: 05/19/2024] Open
Abstract
Neurodegenerative diseases are characterized by extensive loss of function or death of brain cells, hampering the life quality of patients. Brain-targeted drug delivery is challenging, with a low success rate this far. Therefore, the application of targeting ligands in drug vehicles, such as lipid-based and polymeric nanoparticles, holds the promise to overcome the blood-brain barrier (BBB) and direct therapies to the brain, in addition to protect their cargo from degradation and metabolization. In this review, we discuss the barriers to brain delivery and the different types of brain-targeting ligands currently in use in brain-targeted nanoparticles, such as peptides, proteins, aptamers, small molecules, and antibodies. Moreover, we present a detailed review of the different targeting ligands used to direct nanoparticles to specific brain cells, like neurons (C4-3 aptamer, neurotensin, Tet-1, RVG, and IKRG peptides), astrocytes (Aquaporin-4, D4, and Bradykinin B2 antibodies), oligodendrocytes (NG-2 antibody and the biotinylated DNA aptamer conjugated to a streptavidin core Myaptavin-3064), microglia (CD11b antibody), neural stem cells (QTRFLLH, VPTQSSG, and NFL-TBS.40-63 peptides), and to endothelial cells of the BBB (transferrin and insulin proteins, and choline). Reports demonstrated enhanced brain-targeted delivery with improved transport to the specific cell type targeted with the conjugation of these ligands to nanoparticles. Hence, this strategy allows the implementation of high-precision medicine, with reduced side effects or unwanted therapy clearance from the body. Nevertheless, the accumulation of some of these nanoparticles in peripheral organs has been reported indicating that there are still factors to be improved to achieve higher levels of brain targeting. This review is a collection of studies exploring targeting ligands for the delivery of nanoparticles to the brain and we highlight the advantages and limitations of this type of approach in precision therapies.
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Grants
- under BrainHealth2020 projects (CENTRO-01-0145-FEDER-000008), through the COMPETE 2020 - Operational Programme for Competitiveness and Internationalization and Portuguese national funds via FCT - Fundação para a Ciência e a Tecnologia, under projects - UIDB/04539/2020 and UIDP/04539/2020, POCI-01-0145-FEDER-030737 (NeuroStemForMJD, PTDC/BTM-ORG/30737/2017), CEECIND/04242/2017, and PhD Scholarship European Regional Development Fund (ERDF) through the Centro 2020 Regional Operational Programme
- under BrainHealth2020 projects (CENTRO-01-0145-FEDER-000008), through the COMPETE 2020 - Operational Programme for Competitiveness and Internationalization and Portuguese national funds via FCT - Fundação para a Ciência e a Tecnologia, under projects - UIDB/04539/2020 and UIDP/04539/2020, POCI-01-0145-FEDER-030737 (NeuroStemForMJD, PTDC/BTM-ORG/30737/2017), CEECIND/04242/2017, and PhD Scholarship European Regional Development Fund (ERDF) through the Centro 2020 Regional Operational Programme
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Affiliation(s)
- Ricardo Moreira
- CNC - Center for Neuroscience and Cell Biology, University of Coimbra, Rua Larga, polo 1, Coimbra, FMUC, 3004-504, Portugal
- CIBB - Center for Innovative Biomedicine and Biotechnology, University of Coimbra, Coimbra, 3004-504, Portugal
- Faculty of Pharmacy, University of Coimbra, Coimbra, 3000-548, Portugal
| | - Clévio Nóbrega
- Algarve Biomedical Center Research Institute (ABC-RI), University of Algarve, Faro, 8005-139, Portugal
- Faculty of Medicine and Biomedical Sciences, University of Algarve, Faro, 8005-139, Portugal
| | - Luís Pereira de Almeida
- CNC - Center for Neuroscience and Cell Biology, University of Coimbra, Rua Larga, polo 1, Coimbra, FMUC, 3004-504, Portugal
- CIBB - Center for Innovative Biomedicine and Biotechnology, University of Coimbra, Coimbra, 3004-504, Portugal
- Faculty of Pharmacy, University of Coimbra, Coimbra, 3000-548, Portugal
- Institute of Interdisciplinary Research, University of Coimbra, Coimbra, 3030-789, Portugal
| | - Liliana Mendonça
- CNC - Center for Neuroscience and Cell Biology, University of Coimbra, Rua Larga, polo 1, Coimbra, FMUC, 3004-504, Portugal.
- CIBB - Center for Innovative Biomedicine and Biotechnology, University of Coimbra, Coimbra, 3004-504, Portugal.
- Institute of Interdisciplinary Research, University of Coimbra, Coimbra, 3030-789, Portugal.
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Hirakawa Y, Kitao A, Watanabe M, Matsumoto S, Komaki R, Sakai R, Morimoto K, Yakushijin K, Minami H. Irreversible Intrathecal Chemotherapy-induced Myelopathy in a Patient with Diffuse Large B-cell Lymphoma. Intern Med 2024; 63:547-551. [PMID: 37380452 PMCID: PMC10937126 DOI: 10.2169/internalmedicine.2031-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 05/17/2023] [Indexed: 06/30/2023] Open
Abstract
Intrathecal chemotherapy is often administered for prophylaxis and treatment of central nervous system involvement in hematological malignancies. However, it may rarely cause neurotoxicity as a side effect. We herein report a 74-year-old woman with diffuse large B-cell lymphoma including a spinal lesion. She received systemic and intrathecal chemotherapy. After five doses of intrathecal chemotherapy, she developed intrathecal chemotherapy-induced myelopathy. Intrathecal treatment was discontinued, and she was administered vitamin B12 and folic acid, along with steroid pulses. However, her symptoms did not improve. Intrathecal chemotherapy-induced myelopathy is rare, but may be irreversible; therefore, clinicians should be aware of this potential complication.
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Affiliation(s)
- Yuri Hirakawa
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Graduate School of Medicine School of Medicine, Japan
| | - Akihito Kitao
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Graduate School of Medicine School of Medicine, Japan
| | - Marika Watanabe
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Graduate School of Medicine School of Medicine, Japan
| | - Sakuya Matsumoto
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Graduate School of Medicine School of Medicine, Japan
| | - Ryohei Komaki
- Division of Neurology, Department of Medicine, Kobe University Graduate School of Medicine School of Medicine, Japan
| | - Rina Sakai
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Graduate School of Medicine School of Medicine, Japan
| | - Kohei Morimoto
- Division of Neurology, Department of Medicine, Kobe University Graduate School of Medicine School of Medicine, Japan
| | - Kimikazu Yakushijin
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Graduate School of Medicine School of Medicine, Japan
| | - Hironobu Minami
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Graduate School of Medicine School of Medicine, Japan
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5
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Lyseight FLS, Dupont COC, Cherubini GB. Intrathecal chemotherapy for the management of lymphoblastic lymphoma in a 4-year-old dog: a case report. Front Vet Sci 2023; 10:1209935. [PMID: 37732143 PMCID: PMC10507905 DOI: 10.3389/fvets.2023.1209935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 07/25/2023] [Indexed: 09/22/2023] Open
Abstract
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).
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Affiliation(s)
| | | | - Giunio Bruto Cherubini
- Neurology and Neurosurgery Service, Dick White Referrals, Part of Linnaeus Veterinary Limited, Cambridgeshire, United Kingdom
- Department of Veterinary Sciences, University of Pisa, Pisa, Italy
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6
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Straehla JP, Reardon DA, Wen PY, Agar NYR. The Blood-Brain Barrier: Implications for Experimental Cancer Therapeutics. ANNUAL REVIEW OF CANCER BIOLOGY 2023; 7:265-289. [PMID: 38323268 PMCID: PMC10846865 DOI: 10.1146/annurev-cancerbio-061421-040433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
The blood-brain barrier is critically important for the treatment of both primary and metastatic cancers of the central nervous system (CNS). Clinical outcomes for patients with primary CNS tumors are poor and have not significantly improved in decades. As treatments for patients with extracranial solid tumors improve, the incidence of CNS metastases is on the rise due to suboptimal CNS exposure of otherwise systemically active agents. Despite state-of-the art surgical care and increasingly precise radiation therapy, clinical progress is limited by the ability to deliver an effective dose of a therapeutic agent to all cancerous cells. Given the tremendous heterogeneity of CNS cancers, both across cancer subtypes and within a single tumor, and the range of diverse therapies under investigation, a nuanced examination of CNS drug exposure is needed. With a shared goal, common vocabulary, and interdisciplinary collaboration, the field is poised for renewed progress in the treatment of CNS cancers.
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Affiliation(s)
- Joelle P Straehla
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
- Division of Hematology/Oncology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Koch Institute for Integrative Cancer Research at MIT, Cambridge, Massachusetts, USA
| | - David A Reardon
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
- Department of Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Patrick Y Wen
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nathalie Y R Agar
- Department of Neurosurgery and Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Cancer Biology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
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7
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Landolfi A, Vinciguerra C, Diana F, Murano F, Russillo MC, Barone P, Serio B, Piscosquito G. Anterior lumbosacral polyradiculoneuropathy following intrathecal methotrexate administration: a case report and literature update. Neurol Sci 2023; 44:715-718. [PMID: 36418611 DOI: 10.1007/s10072-022-06520-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 11/16/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION We describe a case of intrathecal methotrexate toxicity and perform a literature review of existing cases. CASE PRESENTATION A 23-year-old man who received diagnosis of acute lymphoblastic leukemia and started chemotherapy according to the LAL1913 protocol underwent CNS prophylaxis with intrathecal methotrexate. About 1 month after, he developed a flaccid paraparesis. CSF analysis showed albumin/cytological dissociation. Spinal MRI showed thickening of the ventral roots of the cauda equina with contrast enhancement. Nerve conduction studies showed severe lower limb motor axonal neuropathy. Needle examination showed acute denervation involving L3-S1 roots. Methotrexate was stopped, and the patient was treated with intravenous immunoglobulins, followed by high-dose intravenous methylprednisolone, with a gradual improvement. Three months later, the spine MRI was normal. Electrophysiological and imaging findings were indicative of pure motor L3-S1 polyradiculopathy. DISCUSSION Literature review of existing cases confirm the relatively selective involvement of lumbosacral ventral roots in intrathecal methotrexate toxicity. Pathophysiologic mechanisms suggest either a direct toxicity with localized folate deficiency or an immune-mediated mechanism, the latter consistent, in our patient, with the albumin/cytological dissociation and response to immunomodulatory treatments. Pure motor polyradiculopathy of the lower limbs is rare but predictable complication of intrathecal methotrexate, which can benefit from early withdrawal and immunomodulatory treatments.
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Affiliation(s)
- Annamaria Landolfi
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", Neuroscience Section, University of Salerno, Salerno, Italia.
| | - Claudia Vinciguerra
- Neurology Unit, University Hospital "San Giovanni Di Dio E Ruggi d'Aragona", Salerno, Italy
| | - Francesco Diana
- Department of Neuroradiology, University Hospital "San Giovanni Di Dio E Ruggi d'Aragona", Salerno, Italy
| | - Filomena Murano
- Neurology Unit, University Hospital "San Giovanni Di Dio E Ruggi d'Aragona", Salerno, Italy
| | - Maria Claudia Russillo
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", Neuroscience Section, University of Salerno, Salerno, Italia
| | - Paolo Barone
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", Neuroscience Section, University of Salerno, Salerno, Italia
| | - Bianca Serio
- Hematology Unit, University Hospital "San Giovanni Di Dio E Ruggi d'Aragona", Salerno, Italy
| | - Giuseppe Piscosquito
- Neurology Unit, University Hospital "San Giovanni Di Dio E Ruggi d'Aragona", Salerno, Italy
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Tutelman PR, Chambers CT, Cornelissen L, Fernandez CV, Flanders A, MacLeod J, Sherry SB, Stewart SH, Urquhart R, de Gagne S, Guilcher GM, Hashmi J, Heathcote LC, Noel M, Schulte FS, Stinson JN, Stern M. Long-term alterations in somatosensory functioning in survivors of childhood cancer. Pain 2022; 163:1193-1205. [PMID: 34855647 PMCID: PMC9100454 DOI: 10.1097/j.pain.0000000000002486] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 09/06/2021] [Accepted: 09/09/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Cancer and its treatment can have lasting consequences on somatosensation, including pain, which is often underrecognized and undertreated. Research characterizing the impact of cancer on pain and sensory processing in survivors of childhood cancer is scarce. This study aimed to quantify generalized differences in pain and sensory processing in survivors of childhood cancer compared with reference data using a standardized thermal and mechanical quantitative sensory testing (QST) protocol. The association between demographic, clinical (eg, leukemia vs other cancers and treatment exposures), and psychosocial (eg, anxiety and pain catastrophizing) variables and sensitivity to pain and sensory stimuli were also evaluated. Participants were 56 survivors of various types of childhood cancer (52% male, Mage = 13.5 years, SD = 3.2, range = 8-17 years). On average, children were 7 years (SD = 4.1, range = 1.2-16.5) post treatment. Almost all participants (86%) had at least 1 abnormal QST parameter compared with age- and sex-matched reference data; however, few participants self-reported the presence of sensory abnormalities. Generally, participants exhibited reduced sensitivity across the QST parameters examined (Ps < 0.05, ds = 0.40-3.45). A significant minority (45%) also exhibited pain sensitization (P <0.001, d = 0.42). Several risk factors for changes in sensory processing were identified, including current age, history of leukemia, certain treatment exposures (eg, vincristine cumulative dose, major surgery, and bone marrow or stem cell transplant), time off treatment, and higher anxiety and pain catastrophizing scores. Overall, this study demonstrated that somatosensory changes are prevalent in survivors of childhood cancer years after the completion of treatment. Future research is needed to understand long-term implications of altered somatosensation in this complex population.
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Affiliation(s)
- Perri R. Tutelman
- Department of Psychology and Neuroscience, Dalhousie University, Halifax, NS, Canada
- Centre for Pediatric Pain Research, IWK Health Centre, Halifax, NS, Canada
| | - Christine T. Chambers
- Department of Psychology and Neuroscience, Dalhousie University, Halifax, NS, Canada
- Centre for Pediatric Pain Research, IWK Health Centre, Halifax, NS, Canada
| | - Laura Cornelissen
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, Boston, MA, United States
- Department of Anaesthesia, Harvard Medical School, Boston, MA, United States
| | - Conrad V. Fernandez
- Division of Pediatric Hematology‐Oncology, IWK Health Centre, Halifax, NS, Canada
- Departments of Pediatrics and Bioethics, Dalhousie University, Halifax, NS, Canada
| | - Annette Flanders
- Division of Pediatric Hematology‐Oncology, IWK Health Centre, Halifax, NS, Canada
| | | | - Simon B. Sherry
- Department of Psychology and Neuroscience, Dalhousie University, Halifax, NS, Canada
| | - Sherry H. Stewart
- Department of Psychology and Neuroscience, Dalhousie University, Halifax, NS, Canada
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
| | - Robin Urquhart
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS, Canada
| | | | - Gregory M.T. Guilcher
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Haematology, Oncology & Transplant Program, Alberta Children's Hospital, Calgary, AB, Canada
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Javeria Hashmi
- Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
| | - Lauren C. Heathcote
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University Medical School, Stanford, CA, United States
| | - Melanie Noel
- Department of Psychology, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, Calgary, AB, Canada
| | - Fiona S.M. Schulte
- Haematology, Oncology & Transplant Program, Alberta Children's Hospital, Calgary, AB, Canada
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Jennifer N. Stinson
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
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Hill RM, Plasschaert SLA, Timmermann B, Dufour C, Aquilina K, Avula S, Donovan L, Lequin M, Pietsch T, Thomale U, Tippelt S, Wesseling P, Rutkowski S, Clifford SC, Pfister SM, Bailey S, Fleischhack G. Relapsed Medulloblastoma in Pre-Irradiated Patients: Current Practice for Diagnostics and Treatment. Cancers (Basel) 2021; 14:126. [PMID: 35008290 PMCID: PMC8750207 DOI: 10.3390/cancers14010126] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/23/2021] [Accepted: 12/24/2021] [Indexed: 02/07/2023] Open
Abstract
Relapsed medulloblastoma (rMB) accounts for a considerable, and disproportionate amount of childhood cancer deaths. Recent advances have gone someway to characterising disease biology at relapse including second malignancies that often cannot be distinguished from relapse on imaging alone. Furthermore, there are now multiple international early-phase trials exploring drug-target matches across a range of high-risk/relapsed paediatric tumours. Despite these advances, treatment at relapse in pre-irradiated patients is typically non-curative and focuses on providing life-prolonging and symptom-modifying care that is tailored to the needs and wishes of the individual and their family. Here, we describe the current understanding of prognostic factors at disease relapse such as principal molecular group, adverse molecular biology, and timing of relapse. We provide an overview of the clinical diagnostic process including signs and symptoms, staging investigations, and molecular pathology, followed by a summary of treatment modalities and considerations. Finally, we summarise future directions to progress understanding of treatment resistance and the biological mechanisms underpinning early therapy-refractory and relapsed disease. These initiatives include development of comprehensive and collaborative molecular profiling approaches at relapse, liquid biopsies such as cerebrospinal fluid (CSF) as a biomarker of minimal residual disease (MRD), modelling strategies, and the use of primary tumour material for real-time drug screening approaches.
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Affiliation(s)
- Rebecca M. Hill
- Wolfson Childhood Cancer Research Centre, Newcastle University Centre for Cancer, Newcastle upon Tyne NE1 7RU, UK; (S.C.C.); (S.B.)
| | - Sabine L. A. Plasschaert
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands; (S.L.A.P.); (M.L.); (P.W.)
| | - Beate Timmermann
- Department of Particle Therapy, West German Proton Therapy Centre Essen (WPE), West German Cancer Center (WTZ), University Hospital Essen, 45147 Essen, Germany;
| | - Christelle Dufour
- Department of Pediatric and Adolescent Oncology, Gustave Roussy, 94800 Villejuif, France;
| | - Kristian Aquilina
- Department of Neurosurgery, Great Ormond Street Hospital, London WC1N 3JH, UK;
| | - Shivaram Avula
- Department of Radiology, Alder Hey Children’s NHS Foundation Trust, Liverpool L12 2AP, UK;
| | - Laura Donovan
- UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK;
| | - Maarten Lequin
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands; (S.L.A.P.); (M.L.); (P.W.)
| | - Torsten Pietsch
- Institute of Neuropathology, DGNN Brain Tumor Reference Center, University of Bonn, 53127 Bonn, Germany;
| | - Ulrich Thomale
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany;
| | - Stephan Tippelt
- Department of Pediatrics III, Center for Translational Neuro- and Behavioral Sciences (CTNBS), University Hospital of Essen, 45147 Essen, Germany;
| | - Pieter Wesseling
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands; (S.L.A.P.); (M.L.); (P.W.)
- Department of Pathology, Amsterdam University Medical Centers/VUmc, 1081 HV Amsterdam, The Netherlands
| | - Stefan Rutkowski
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany;
| | - Steven C. Clifford
- Wolfson Childhood Cancer Research Centre, Newcastle University Centre for Cancer, Newcastle upon Tyne NE1 7RU, UK; (S.C.C.); (S.B.)
| | - Stefan M. Pfister
- Hopp Children’s Cancer Center Heidelberg (KiTZ), 69120 Heidelberg, Germany;
- Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- Department of Pediatric Oncology and Hematology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Simon Bailey
- Wolfson Childhood Cancer Research Centre, Newcastle University Centre for Cancer, Newcastle upon Tyne NE1 7RU, UK; (S.C.C.); (S.B.)
| | - Gudrun Fleischhack
- Department of Pediatrics III, Center for Translational Neuro- and Behavioral Sciences (CTNBS), University Hospital of Essen, 45147 Essen, Germany;
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10
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Rodrigues PGB, Lima TTD, Duarte FB, Nóbrega PR. Myelopathy associated with intrathecal methotrexate. Pract Neurol 2021; 22:141-144. [PMID: 34716225 DOI: 10.1136/practneurol-2021-003154] [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] [Accepted: 10/03/2021] [Indexed: 11/04/2022]
Abstract
A 21-year-old man developed progressive and bilateral lower limb numbness, gait impairment and urinary incontinence over 10 days. He had received intrathecal methotrexate 20 days previously for acute lymphoblastic B-cell leukaemia, following 7 months of systemic chemotherapy. MR scan of the spinal cord showed bilateral symmetric and extensive T2/fluid attenuated inversion recovery (FLAIR) increased signal involving the dorsal columns in the thoracic cord. His serum folate concentration was at the lower end of the normal range. We stopped the intrathecal chemotherapy and gave folate; after a few days, he progressively improved. Myelopathy is an important adverse effect of intrathecal methotrexate, which may cause clinical and imaging features resembling subacute combined degeneration of the spinal cord. CNS infiltration must be excluded, intrathecal chemotherapy stopped and deficiency of folate or vitamin B12 treated as appropriate.
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Affiliation(s)
| | - Talles Tavares de Lima
- Department of Clinical Medicine, Hospital Universitário Lauro Wanderley, João Pessoa, Paraíba, Brazil
| | - Fernando Barroso Duarte
- Department of Surgery, Universidade Federal do Ceará, Fortaleza, Ceará, Brazil.,Division of Cell Processing, Centro de Hematologia e Hemoterapia do Ceara, Fortaleza, Ceará, Brazil
| | - Paulo Ribeiro Nóbrega
- Division of Neurology, Department of Clinical Medicine, Universidade Federal do Ceará, Fortaleza, Ceará, Brazil
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11
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Oldenburg M, Rüchel N, Janssen S, Borkhardt A, Gössling KL. The Microbiome in Childhood Acute Lymphoblastic Leukemia. Cancers (Basel) 2021; 13:cancers13194947. [PMID: 34638430 PMCID: PMC8507905 DOI: 10.3390/cancers13194947] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/24/2021] [Accepted: 09/28/2021] [Indexed: 12/30/2022] Open
Abstract
For almost 30 years, the term "holobiont" has referred to an ecological unit where a host (e.g., human) and all species living in or around it are considered together. The concept highlights the complex interactions between the host and the other species, which, if disturbed may lead to disease and premature aging. Specifically, the impact of microbiome alterations on the etiology of acute lymphoblastic leukemia (ALL) in children is not fully understood, but has been the focus of much research in recent years. In ALL patients, significant reductions in microbiome diversity are already observable at disease onset. It remains unclear whether such alterations at diagnosis are etiologically linked with leukemogenesis or simply due to immunological alteration preceding ALL onset. Regardless, all chemotherapeutic treatment regimens severely affect the microbiome, accompanied by severe side effects, including mucositis, systemic inflammation, and infection. In particular, dominance of Enterococcaceae is predictive of infections during chemotherapy. Long-term dysbiosis, like depletion of Faecalibacterium, has been observed in ALL survivors. Modulation of the microbiome (e.g., by fecal microbiota transplant, probiotics, or prebiotics) is currently being researched for potential protective effects. Herein, we review the latest microbiome studies in pediatric ALL patients.
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Affiliation(s)
- Marina Oldenburg
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Medical Faculty, Center of Child and Adolescent Health, Heinrich-Heine-University, 40225 Düsseldorf, Germany; (M.O.); (N.R.); (A.B.)
| | - Nadine Rüchel
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Medical Faculty, Center of Child and Adolescent Health, Heinrich-Heine-University, 40225 Düsseldorf, Germany; (M.O.); (N.R.); (A.B.)
| | - Stefan Janssen
- Algorithmic Bioinformatics, Department of Biology and Chemistry, Justus Liebig University Gießen, 35390 Gießen, Germany;
| | - Arndt Borkhardt
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Medical Faculty, Center of Child and Adolescent Health, Heinrich-Heine-University, 40225 Düsseldorf, Germany; (M.O.); (N.R.); (A.B.)
| | - Katharina L. Gössling
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Medical Faculty, Center of Child and Adolescent Health, Heinrich-Heine-University, 40225 Düsseldorf, Germany; (M.O.); (N.R.); (A.B.)
- Correspondence:
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12
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Xie J, Jang A, Uemura M, Nakazawa S, Calimeri T, Ferreri AJ, Chen SR, Schmid JL, Brown TC, Socola F, Safah H, Saba NS. Systemic vs. intrathecal central nervous system prophylaxis in primary adrenal/renal diffuse large b-cell LYMPHOMA: A multi-institution retrospective analysis and systematic review. Leuk Res Rep 2021; 16:100263. [PMID: 34401320 PMCID: PMC8355911 DOI: 10.1016/j.lrr.2021.100263] [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: 04/04/2021] [Accepted: 07/28/2021] [Indexed: 11/24/2022] Open
Abstract
Primary adrenal lymphoma (PAL) and primary renal lymphoma (PRL) are rare extranodal lymphomas, predominantly of diffuse large B-cell lymphoma subtype. Primary adrenal and renal lymphomas (PARL) exhibit a high predilection for the central nervous system (CNS). Therefore, current guidelines support the use of CNS prophylaxis in PARL, particularly in cases of high-risk Central Nervous System International Prognostic Index (CNS-IPI). However, the route of administration (i.e. systemic vs. intrathecal chemotherapy) has not been clearly elucidated. With this in mind, we initiated an international collaboration and literature review to analyze 50 patient cases, 20 of which received CNS prophylaxis. Based on our analysis, we conclude that PARL may indicate a need for CNS chemo-prophylaxis in the form of systemic high-dose methotrexate (HD-MTX) over intrathecal methotrexate (IT-MTX), although IT-MTX may still have utility in certain cases.
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Affiliation(s)
- John Xie
- Deming Department of Medicine, Tulane University School of Medicine, New Orleans, LA, United States
| | - Albert Jang
- Deming Department of Medicine, Tulane University School of Medicine, New Orleans, LA, United States
| | - Motohide Uemura
- Department of Urology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Shigeaki Nakazawa
- Department of Urology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Teresa Calimeri
- Lymphoma Unit, Dept of Onco-hematology, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Andres Jm Ferreri
- Lymphoma Unit, Dept of Onco-hematology, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Shuang R Chen
- Deming Department of Medicine, Tulane University School of Medicine, New Orleans, LA, United States
| | - Janet L Schmid
- Department of Pathology, Tulane University, New Orleans, LA, United States
| | - Theresa C Brown
- Hayward Genetics Center, Tulane University School of Medicine, New Orleans, Louisiana, United States
| | - Francisco Socola
- Section of Hematology and Medical Oncology, Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, United States
| | - Hana Safah
- Section of Hematology and Medical Oncology, Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, United States
| | - Nakhle S Saba
- Section of Hematology and Medical Oncology, Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, United States
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13
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Patel N, RIch BJ, Patel S, Watts JM, Benveniste R, Abramowitz M, Markoe A, Eichberg DG, Komotar RJ, De La Fuente M, Pasol J, Diwanji T. Emergent Radiotherapy for Leukemia-Induced Cranial Neuropathies Refractory to Intrathecal Therapy. Cureus 2021; 13:e15212. [PMID: 34178531 PMCID: PMC8221003 DOI: 10.7759/cureus.15212] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Neurologic symptoms from leukemic infiltration of the central nervous system are an oncologic emergency, and expeditious treatment is required to preserve function. We report the case of a 44-year-old patient with relapsed acute myeloid leukemia (AML) who developed sub-acute cranial neuropathies refractory to treatment with intrathecal (IT) chemotherapy. The patient was therefore treated with an emergent course of whole-brain radiotherapy, resulting in immediate improvement and subsequent resolution of cranial neuropathies. This case illustrates that while central nervous system involvement by AML is rare, radiotherapy remains an effective modality to avoid long-term morbidity in patients failing to respond to systemic or IT chemotherapy.
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Affiliation(s)
- Nirav Patel
- Radiation Oncology, University of Miami Sylvester Comprehensive Cancer Center, Miami, USA
| | - Benjamin J RIch
- Radiation Oncology, University of Miami Sylvester Comprehensive Cancer Center, Miami, USA
| | - Shareen Patel
- Radiation Oncology, University of Miami Miller School of Medicine, Miami, USA
| | - Justin M Watts
- Hematology/Oncology, University of Miami Sylvester Comprehensive Cancer Center, Miami, USA
| | - Ronald Benveniste
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, USA
| | - Matthew Abramowitz
- Radiation Oncology, University of Miami Sylvester Comprehensive Cancer Center, Miami, USA
| | - Arnold Markoe
- Radiation Oncology, University of Miami Sylvester Comprehensive Cancer Center, Miami, USA
| | - Daniel G Eichberg
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, USA
| | - Ricardo J Komotar
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, USA
| | | | - Joshua Pasol
- Ophthalmology, University of Miami Sylvester Comprehensive Cancer Center, Miami, USA
| | - Tejan Diwanji
- Radiation Oncology, University of Miami Sylvester Comprehensive Cancer Center, Miami, USA
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14
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Hartl N, Adams F, Merkel OM. From adsorption to covalent bonding: Apolipoprotein E functionalization of polymeric nanoparticles for drug delivery across the blood-brain barrier. ADVANCED THERAPEUTICS 2021; 4:2000092. [PMID: 33542947 PMCID: PMC7116687 DOI: 10.1002/adtp.202000092] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Indexed: 12/17/2022]
Abstract
The blood-brain barrier (BBB) is composed of brain endothelial cells, pericytes, and astrocytes, which build a tight cellular barrier. Therapeutic (macro)molecules are not able to transit through the BBB in their free form. This limitation is bypassed by apolipoprotein E (ApoE)-functionalized polymeric nanoparticles (NPs) that are able to transport drugs (e.g. dalargin, loperamide, doxorubicin, nerve growth factor) across the BBB via low density lipoprotein (LDL) receptor mediated transcytosis. Coating with polysorbate 80 or poloxamer 188 facilitates ApoE adsorption onto polymeric NPs enabling recognition by LDL receptors of brain endothelial cells. This effect is even enhanced when NPs are directly coated with ApoE without surfactant anchor. Similarly, covalent coupling of ApoE to NPs that bear reactive groups on their surface leads to significantly improved brain uptake while avoiding the use of surfactants. Several in vitro BBB models using brain endothelial cells or co-cultures with astrocytes/pericytes/glioma cells are described which provide first insights regarding the ability of a drug delivery system to cross this barrier. In vivo models are employed to simulate central nervous system-relevant diseases such as Alzheimer's or Parkinson's disease and cerebral cancer.
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Affiliation(s)
| | | | - Olivia M. Merkel
- Pharmaceutical Technology and Biopharmaceutics, Department Pharmacy, Ludwig-Maximilians-University, Butenandtstr. 5-13, 81377 Munich, Germany
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15
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Yu WJ, Huang DX, Liu S, Sha YL, Gao FH, Liu H. Polymeric Nanoscale Drug Carriers Mediate the Delivery of Methotrexate for Developing Therapeutic Interventions Against Cancer and Rheumatoid Arthritis. Front Oncol 2020; 10:1734. [PMID: 33042817 PMCID: PMC7526065 DOI: 10.3389/fonc.2020.01734] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 08/03/2020] [Indexed: 01/21/2023] Open
Abstract
Methotrexate (MTX) is widely used as an anticancer and anti-inflammtory drug for treating various types of cancer and autoimmune diseases. The optimal dose of MTX is known to inhibit the dihydrofolatereductase that hinders the replication of purines. The nanobiomedicine has been extensively explored in the past decade to develop myriad functional nanostructures to facilitate the delivery of therapeutic agents for various medical applications. This review is focused on understanding the design and development of MTX-loaded nanoparticles alongside the inclusion of recent findings for the treatment of cancers. In this paper, we have made a coordinated effort to show the potential of novel drug delivery systems by achieving effective and target-specific delivery of methotrexate.
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Affiliation(s)
- Wen-Jun Yu
- The Eastern Division, Department of Hand and Foot Surgery, The First Hospital of Jilin University, Changchun, China
| | - Dong-Xu Huang
- The Eastern Division, Department of Hand and Foot Surgery, The First Hospital of Jilin University, Changchun, China
| | - Shuang Liu
- The Eastern Division, Department of Nursing Management, The First Hospital of Jilin University, Changchun, China
| | - Ying-Li Sha
- The Eastern Division, Department of Pediatrics, The First Hospital of Jilin University, Changchun, China
| | - Feng-Hui Gao
- The Eastern Division, Department of Orthopaedics, The First Hospital of Jilin University, Changchun, China
| | - Hong Liu
- The Eastern Division, Department of Otolaryngology, The First Hospital of Jilin University, Changchun, China
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16
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Umana GE, Raudino G, Alberio N, Inserra F, Giovinazzo G, Fricia M, Chiriatti S, Nicoletti GF, Cicero S, Scalia G. Slit-like hypertensive hydrocephalus: Report of a late, complex, and multifactorial complication in an oncologic patient. Surg Neurol Int 2020; 11:219. [PMID: 32874722 PMCID: PMC7451176 DOI: 10.25259/sni_145_2020] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 07/07/2020] [Indexed: 01/08/2023] Open
Abstract
Background: Several sophisticated techniques and many chemotherapy drugs have improved life expectancy of oncologic patients allowing us to observe late complications which present many years after the initial treatment. Case Description: We present a unique case of a patient affected by acute lymphoblastic leukemia at the age of 6 years, treated with whole brain radiotherapy and intrathecal chemotherapy, developing meningiomatosis and leptomeningeal alterations as late complications and the interaction of these two entities caused a peculiar form of hydrocephalus without ventricular dilation. The diagnosis of pseudotumor cerebri was excluded due the postradio/chemotherapy development of meningiomatosis, not present in a previously head magnetic resonance imaging, that exerted compression to the Sylvian aqueduct causing intracranial hypertension with papillary stasis without ventricles enlargement due to brain stiffness. Moreover, a peculiar intraoperative rubbery consistency of brain parenchyma was detected strengthening this complex diagnosis. Conclusion: At the best of our knowledge, this is the first report of obstructive hydrocephalus without ventricles dilation caused by brain stiffness related to late alterations of oncologic treatments. This report could be a guide for further complex patients diagnoses and for improving treatments efficacy.
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Affiliation(s)
| | - Giuseppe Raudino
- Department of Neurosurgery, Hospital "San Gerardo," Via G. B. Pergolesi 33, Monza, Italy
| | - Nicola Alberio
- Department of Neurosurgery, Cannizzaro Hospital, Via Messina 829, Catania
| | - Francesco Inserra
- Department of Neurosurgery, Cannizzaro Hospital, Via Messina 829, Catania
| | - Giuseppe Giovinazzo
- Department of Amethyst Radiotherapy Center, San Giovanni Calibita Fatebenefratelli Hospital, Tiber Island, Rome
| | - Marco Fricia
- Department of Neurosurgery, Cannizzaro Hospital, Via Messina 829, Catania
| | - Stefano Chiriatti
- Department of Neurosurgery, Cannizzaro Hospital, Via Messina 829, Catania
| | - Giovanni Federico Nicoletti
- Neurosurgery Unit, Highly Specialized Hospital and of National Importance "Garibaldi", Piazza Santa Maria di Gesù 5, Catania, Italy
| | - Salvatore Cicero
- Department of Neurosurgery, Cannizzaro Hospital, Via Messina 829, Catania
| | - Gianluca Scalia
- Neurosurgery Unit, Highly Specialized Hospital and of National Importance "Garibaldi", Piazza Santa Maria di Gesù 5, Catania, Italy
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17
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Anastasopoulou S, Heyman M, Eriksson MA, Niinimäki R, Taskinen M, Mikkel S, Vaitkeviciene GE, Johannsdottir IM, Myrberg IH, Jonsson OG, Als-Nielsen B, Schmiegelow K, Banerjee J, Ranta S, Harila-Saari A. Seizures during treatment of childhood acute lymphoblastic leukemia: A population-based cohort study. Eur J Paediatr Neurol 2020; 27:72-77. [PMID: 32340855 DOI: 10.1016/j.ejpn.2020.04.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 03/18/2020] [Accepted: 04/11/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Seizures are common in children with acute lymphoblastic leukemia (ALL). As ALL survival rates are improving, the challenge to minimize treatment related side effects and late sequelae rises. Here, we studied the frequency, timing, etiology and risk factors of seizures in ALL patients. METHODS The study included children aged 1-17.9 years at diagnosis of B-cell-precursor and T cell ALL who were treated according to the Nordic Society of Pediatric Hematology and Oncology (NOPHO) ALL2008 protocol between 2008 and 2015. Detailed patient data were acquired from the NOPHO ALL2008 registry and by review of medical records. RESULTS Seizures occurred in 81/1464 (5.5%) patients. The cumulative incidence of seizures at one months was 1.7% (95% CI: 1.2-2.5) and at one year 5.3% (95% CI 4.2-6.5%). Patients aged 10-17.9 years, those with T cell immunophenotype, CNS involvement, or high-risk induction with dexamethasone had higher risk for seizures in univariable analyses. Only age remained a risk factor in multivariable analyses (the cumulative incidence of seizures for patients 10-17.9 years old at one year was 9.0% (95% CI: 6.2-12.9)). Of the 81 patients with seizures, 43 had posterior reversible encephalopathy syndrome (PRES), 15 had isolated seizures, nine had sinus venous thrombosis (SVT), three had stroke-like syndrome, and 11 had other neurotoxicities. Epilepsy diagnosis was reported in totally 11 ALL survivors at last follow up. CONCLUSION Seizures are relatively common in ALL patients and occur most often in patients with PRES, SVT, or as an isolated symptom. Older children have higher risk of seizures.
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Affiliation(s)
- Stavroula Anastasopoulou
- Karolinska Institutet, Department of Women's and Children's Health, Stockholm, Sweden; Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden.
| | - Mats Heyman
- Karolinska Institutet, Department of Women's and Children's Health, Stockholm, Sweden; Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden
| | - Mats A Eriksson
- Karolinska Institutet, Department of Women's and Children's Health, Stockholm, Sweden; Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden
| | - Riitta Niinimäki
- Oulu University Hospital, Department of Children and Adolescents, and University of Oulu, PEDEGO Research Unit, Oulu, Finland
| | - Mervi Taskinen
- Division of Pediatric Hematology and Oncology and Stem Cell Transplantation, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Sirje Mikkel
- University of Tartu, Department of Hematology and Oncology, Tartu, Estonia
| | - Goda E Vaitkeviciene
- Children's Hospital, Affiliation of Vilnius University Hospital Santaros Klinikos and Vilnius University, Lithuania
| | | | - Ida Hed Myrberg
- Karolinska Institutet, Department of Women's and Children's Health, Stockholm, Sweden
| | | | - Bodil Als-Nielsen
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Denmark
| | - Joanna Banerjee
- Division of Pediatric Hematology and Oncology and Stem Cell Transplantation, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Susanna Ranta
- Karolinska Institutet, Department of Women's and Children's Health, Stockholm, Sweden; Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden
| | - Arja Harila-Saari
- University of Uppsala, Department of Women's and Children's Health, Uppsala, Sweden
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18
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Messinger YH, Maxa KL, Hennen EM, Gossai NP, Hoff DS. Intrathecal Methotrexate Containing the Preservative Benzyl Alcohol Erroneously Administered in Pediatric Leukemia Patients: Clinical Course and Preventive Process. J Pediatr Pharmacol Ther 2020; 25:328-331. [DOI: 10.5863/1551-6776-25.4.328] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Administration of intrathecal chemotherapy for leukemia is a common procedure in pediatric oncology. The direct delivery of drug into the cerebral spinal fluid requires that no preservative be used. Preserved drugs administered in error can result in significant neurotoxicity. A case series is described where preservative-containing methotrexate was incidentally administered intrathecally. All patients were treated at Children's Hospitals and Clinics of Minnesota. Medical records of the patients affected were reviewed and abstracted for this report. Four children with acute lymphoblastic leukemia received 1 dose of intrathecal methotrexate that contained 0.07% benzyl alcohol in January 2019. Overall, minimal to no symptoms were seen after dosing. The error was traced to a drug shortage in which benzyl alcohol–containing methotrexate was obtained and incorrectly stocked. A novel replacement drug procurement process was developed within our institution. The process includes sequestered queues where a drug awaits evaluation and independent double check of entry accuracy in the electronic health record and pharmacy parenteral dose preparation software prior to release and use. In contrast to IV administration, intrathecal benzyl alcohol at concentrations ≥ 0.9% can cause significant neurotoxicity. Although minimal, if any, neurotoxicity was seen in patients who received a 10-fold lower concentration of benzyl alcohol than previously associated with complications, all institutions should recognize the potential for this error and implement similar safety precautions to ensure that this type of error will not occur.
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19
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Mauler D, Richter K, Merrill S, Valencia‑S�nchez C, Krishna C, Mrugala M. Troubleshooting an unusual complication following intrathecal chemotherapy delivered via Ommaya catheter: A case report. Mol Clin Oncol 2020; 13:76-79. [DOI: 10.3892/mco.2020.2032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 03/26/2020] [Indexed: 11/06/2022] Open
Affiliation(s)
- David Mauler
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ 85259, USA
| | - Kent Richter
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ 85259, USA
| | - Sarah Merrill
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ 85259, USA
| | | | - Chandan Krishna
- Department of Neurosurgery, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Maciej Mrugala
- Department of Neurology, Mayo Clinic, Phoenix, AZ 85054, USA
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20
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Zhou F, Wen Y, Jin R, Chen H. New attempts for central nervous infiltration of pediatric acute lymphoblastic leukemia. Cancer Metastasis Rev 2020; 38:657-671. [PMID: 31820149 DOI: 10.1007/s10555-019-09827-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The cure rate of acute lymphoblastic leukemia (ALL), the commonest childhood cancer, has been sharply improved and reached almost 90% ever since the central nervous system (CNS)-directed therapy proposed in the 1960s. However, relapse, particularly in the central nervous system (CNS), is still a common cause of treatment failure. Up to now, the classic CNS-directed treatment for CNS leukemia (CNSL) has been aslant from cranial radiation to high-dose system chemotherapy plus intrathecal (IT) chemotherapy for the serious side effects of cranial radiation. The neurotoxic effects of chemotherapy and IT chemotherapy have been reported in recent years as well. For better prevention and treatment of CNSL, plenty of studies have tried to improve the detection sensitivity for CNSL and prevent CNSL from happening by targeting cytokines and chemokines which could be key factors for the traveling of ALL cells into the CNS. Other studies also have aimed to completely kill ALL cells (including dormant cells) in the CNS by promoting the entering of chemotherapy drugs into the CNS or targeting the components of the CNS niche which could be in favor of the survival of ALL cells in CNS. The aim of this review is to discuss the imperfection of current diagnostic methods and treatments for CNSL, as well as new attempts which could be significant for better elimination of CNSL.
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Affiliation(s)
- Fen Zhou
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yuxi Wen
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Runming Jin
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Hongbo Chen
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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21
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Garwood MJ, Hawkes EA, Churilov L, Chong G. Patient selection and tolerability of high-dose methotrexate as central nervous system prophylaxis in diffuse large B-cell lymphoma. Cancer Chemother Pharmacol 2019; 85:133-140. [PMID: 31848681 DOI: 10.1007/s00280-019-04007-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 12/04/2019] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Central nervous system (CNS) relapse in diffuse large B-cell lymphoma (DLBCL) is usually fatal. Risk stratification of patients has historically been poorly defined, and CNS prophylaxis with high-dose methotrexate (HDMTX) can be associated with multiple toxicities. The CNS International Prognostic Index (IPI) defines three patient risk groups for CNS disease. The aims of this study were to evaluate the toxicity of HDMTX and describe outcomes in HDMTX and non-HDMTX patients according to the CNS-IPI. METHODS 205 patients diagnosed with DLBCL between 2004 and 2014, initially treated with RCHOP-like chemotherapy and considered for HDMTX CNS prophylaxis were identified by pharmacy records at two teaching hospitals. Patient records were retrospectively reviewed for HDMTX toxicity, CNS-IPI calculation and CNS relapse. RESULTS 28 patients with DLBCL were selected for two doses of HDMTX. Two of 28 patients received only one dose, and three had their second dose reduced due to renal impairment. 28% of patients experienced nephrotoxicity. 24 HDMTX and 122 non-HDMTX patients were evaluable for the CNS-IPI. No significant difference in the CNS-IPI distribution between the two groups was identified (p = 0.695). Five patients had CNS relapse, two who received HDMTX and three who did not. No significant difference in CNS relapse rate was identified between 24 HDMTX patients propensity-matched to 24 non-HDMTX patients. CONCLUSIONS HDMTX was well-tolerated by patients. Application of the CNS-IPI identifies a different population of candidates for CNS prophylaxis compared to traditional criteria.
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Affiliation(s)
| | - Eliza A Hawkes
- Departments of Haematology and Oncology, Olivia Newton John Cancer, Wellness and Research Centre, Austin Hospital, Heidelberg, VIC, Australia
- Department of Medical Oncology, Eastern Health, Box Hill, VIC, Australia
| | - Leonid Churilov
- Florey Institute of Neuroscience and Mental Health, Melbourne, Australia
| | - Geoffrey Chong
- The University of Melbourne, Parkville, VIC, Australia.
- Departments of Haematology and Oncology, Olivia Newton John Cancer, Wellness and Research Centre, Austin Hospital, Heidelberg, VIC, Australia.
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22
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Householder KT, Dharmaraj S, Sandberg DI, Wechsler-Reya RJ, Sirianni RW. Fate of nanoparticles in the central nervous system after intrathecal injection in healthy mice. Sci Rep 2019; 9:12587. [PMID: 31467368 PMCID: PMC6715675 DOI: 10.1038/s41598-019-49028-w] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 07/24/2019] [Indexed: 12/21/2022] Open
Abstract
Cerebrospinal fluid (CSF) is produced in the cerebral ventricles and circulates within the subarachnoid space (SAS) of the brain and spinal cord, where it exchanges with interstitial fluid of the parenchyma. The access of CSF to the entire central nervous system (CNS) makes it an attractive medium for drug delivery. However, few intrathecal (IT) therapies have reached the clinic due, in part, to limited distribution and rapid clearance. Given the success of nanoparticle (NP) carriers in prolonging circulation and improving delivery of systemically administered agents, we sought to evaluate the distribution of IT injected NPs within the CNS. We administered fluorescent, 100 nm PEGylated-NPs into the cisterna magna of healthy mice and studied their distribution along the brain and spinal cord. Our data demonstrate that NPs are capable of distributing rapidly through the SAS along the entire neuraxis with reproducible, anatomically defined patterns of delivery. NPs were well retained within the leptomeninges for over 3 weeks, showing preference for ventral surfaces and minimal penetration into the CNS parenchyma. Clearance of NPs occurred across the cribriform plate into the nasal mucosa, with a small fraction of NPs localizing with nerve roots exiting the spinal column. Larger 10 µm particles were also capable of moving through the SAS but did not achieve as widespread distribution. These studies demonstrate the ability of NPs to achieve widespread delivery along the neuraxis and highlight IT administration as a potentially significant route of administration for delivery of nanomedicine to the subarachnoid space.
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Affiliation(s)
- K T Householder
- Vivian L. Smith Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin St, Houston, TX, 77030, USA.,Barrow Brain Tumor Research Center, Barrow Neurological Institute, 350W. Thomas Rd, Phoenix, AZ, 85013, USA.,School of Biological and Health Systems Engineering, Ira A. Fulton Schools of Engineering, Arizona State University, P.O Box 879709, Tempe, AZ, 85287, USA
| | - S Dharmaraj
- Vivian L. Smith Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin St, Houston, TX, 77030, USA.,Barrow Brain Tumor Research Center, Barrow Neurological Institute, 350W. Thomas Rd, Phoenix, AZ, 85013, USA.,School of Biological and Health Systems Engineering, Ira A. Fulton Schools of Engineering, Arizona State University, P.O Box 879709, Tempe, AZ, 85287, USA
| | - D I Sandberg
- Vivian L. Smith Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin St, Houston, TX, 77030, USA.,Departments of Pediatric Surgery and Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin St, MSB 5.144, Houston, TX, 77030, USA
| | - R J Wechsler-Reya
- NCI-Designated Cancer Center, Sanford-Burnham Medical Research Institute, 10901N Torrey Pines Rd, La Jolla, CA, 92037, USA
| | - R W Sirianni
- Vivian L. Smith Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin St, Houston, TX, 77030, USA. .,Barrow Brain Tumor Research Center, Barrow Neurological Institute, 350W. Thomas Rd, Phoenix, AZ, 85013, USA. .,School of Biological and Health Systems Engineering, Ira A. Fulton Schools of Engineering, Arizona State University, P.O Box 879709, Tempe, AZ, 85287, USA.
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23
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Complications of Intrathecal Chemotherapy in Adults: Single-Institution Experience in 109 Consecutive Patients. JOURNAL OF ONCOLOGY 2019; 2019:4047617. [PMID: 31186634 PMCID: PMC6521528 DOI: 10.1155/2019/4047617] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/26/2019] [Accepted: 04/11/2019] [Indexed: 11/17/2022]
Abstract
Acute lymphoblastic leukemia and other aggressive lymphoid malignancies like Burkitt leukemia/lymphoma have high incidence of central nervous system (CNS) involvement. Various solid tumors, most notably breast cancer, can also metastasize into the CNS as a late stage complication causing devastating effects. Intrathecal (IT) chemotherapy consisting of methotrexate, cytarabine, or the two in combination is frequently used for the prophylaxis and treatment of CNS metastasis. Because of the high toxicity of these chemotherapeutic agents, however, their side effect profiles are potentially catastrophic. The incidence of neurotoxicity secondary to IT chemotherapy is well defined in the pediatric literature but is poorly reported in adults. Here, we investigated the incidence of neurologic and nonneurologic side effects secondary to IT chemotherapy in 109 consecutive adult patients over a two-year time period at hospitals associated with our institution. Of 355 IT chemotherapy treatments received by these patients, 11 (3.10%) resulted in paresthesias or paralysis, which we defined as significant neurologic events in our analysis. We also examined minor events that arose after IT chemotherapy, including back pain, headache, fever, vomiting, and asthenia. At least one of these occurred after 30.70% of IT chemotherapy doses. Clinicians involved in the care of patients receiving IT chemotherapy should be aware of these findings and consider treatment options lower rate of neurotoxicity such as high-dose systemic methotrexate.
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24
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Deoxycholate-TPGS mixed nanomicelles for encapsulation of methotrexate with enhanced in vitro cytotoxicity on breast cancer cell lines. J Drug Deliv Sci Technol 2019. [DOI: 10.1016/j.jddst.2019.01.041] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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25
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Assi HI, Mahmoud T, Saadeh FS, El Darsa H. Management of leptomeningeal metastasis in breast cancer. Clin Neurol Neurosurg 2018; 172:151-159. [PMID: 30015053 DOI: 10.1016/j.clineuro.2018.07.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 06/22/2018] [Accepted: 07/01/2018] [Indexed: 10/28/2022]
Abstract
Leptomeningeal metastasis (LM), which occurs when malignant cells spread to the central nervous system, is becoming an increasingly common complication in patients with breast cancer. Diagnosis and treatment of LM is challenging. Moreover, prognosis of patients with LM is poor, with a median survival of 6 months after diagnosis. This review highlights the strengths and limitations of currently available diagnostic tools and therapies for LM. The current treatments for LM, including radiotherapy, systemic therapy, and intrathecal treatment, aim to maintain the quality of life of patients by correcting neurological deficits and arresting neurological degeneration. However, there is no standardized therapy for LM because of a lack of randomized trials on this condition.
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Affiliation(s)
- Hazem I Assi
- Department of Internal Medicine, Naef K. Basile Cancer Institute, American University of Beirut Medical Center, Lebanon.
| | - Tala Mahmoud
- Faculty of Medicine, University of Balamand, Lebanon.
| | - Fadi S Saadeh
- Faculty of Medicine, American University of Beirut, Lebanon.
| | - Haidar El Darsa
- Department of Internal Medicine, Naef K. Basile Cancer Institute, American University of Beirut Medical Center, Lebanon.
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26
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Pinnix CC, Yahalom J, Specht L, Dabaja BS. Radiation in Central Nervous System Leukemia: Guidelines From the International Lymphoma Radiation Oncology Group. Int J Radiat Oncol Biol Phys 2018; 102:53-58. [PMID: 30102203 DOI: 10.1016/j.ijrobp.2018.05.067] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 05/08/2018] [Accepted: 05/20/2018] [Indexed: 10/14/2022]
Affiliation(s)
- Chelsea C Pinnix
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Joachim Yahalom
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lena Specht
- Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Bouthaina Shbib Dabaja
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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27
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Hu H, Zhang W, Wang Y, Huang D, Shi J, Li B, Zhang Y, Zhou Y. Characterization, treatment and prognosis of retinoblastoma with central nervous system metastasis. BMC Ophthalmol 2018; 18:107. [PMID: 29685116 PMCID: PMC5914066 DOI: 10.1186/s12886-018-0772-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 04/13/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Retinoblastoma is the most common primary intraocular tumor and more and more attention has been paid to the developing countries. This study was aimed to evaluate the clinical features, treatment, and prognosis of retinoblastoma patients with central nervous system (CNS) metastasis in Beijing Tongren Hospital, one of the largest tertiary eye centers in China. METHODS Clinical data of 31 consecutive retinoblastoma patients with CNS metastases, who were diagnosed at the Department of Pediatrics in Beijing Tongren Hospital between September 2005 and December 2015, were retrospective analyzed. RESULTS The median age at presentation was 29 months (range from 5 to 108 months). Magnetic resonance imaging (MRI) results indicated that 16 patients (56.6%, 16/31) presented with meningeal involvement, 12 (38.7%, 12/31) presented with intracranial mass, 11 (35.5%, 11/31) presented with thickened optic nerve, and 5 (16.1%, 5/31) presented with concurrent meningeal and spinal cord membrane involvement. Retinoblastoma cells were detected in the cerebrospinal fluid (CSF) of 12 patients (44.4%, 12/27). Laboratory examinations on the blood and CSF were performed for 11 patients who had received six cycles of systemic chemotherapy, indicated that the serum level of neurone-specific enolase (NSE) after chemotherapy was significantly lower than that before chemotherapy (P < 0.05). At the end of the follow-up, 25 patients were dead with a median survival time of 6 months (1 d - 21 months), and 6 cases were alive and continued to receive treatment. CONCLUSION Our results were basically consistent with previous reports in the developing countries, and it could be guidance for clinical treatment, prognosis and prevention of CNS metastases in retinoblastoma.
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Affiliation(s)
- Huimin Hu
- Department of Pediatrics, Beijing Tongren Hospital, West South road 2, Yizhuang Economic and Technological Development Zone, Daxing District, Beijing, 100176, China
| | - Weiling Zhang
- Department of Pediatrics, Beijing Tongren Hospital, West South road 2, Yizhuang Economic and Technological Development Zone, Daxing District, Beijing, 100176, China
| | - Yizhuo Wang
- Department of Pediatrics, Beijing Tongren Hospital, West South road 2, Yizhuang Economic and Technological Development Zone, Daxing District, Beijing, 100176, China
| | - Dongsheng Huang
- Department of Pediatrics, Beijing Tongren Hospital, West South road 2, Yizhuang Economic and Technological Development Zone, Daxing District, Beijing, 100176, China.
| | - Jitong Shi
- Department of Ophthalmology, Beijing Tongren Hospital, Capital Medical University, Beijing, 100176, China
| | - Bin Li
- Department of Ophthalmology, Beijing Tongren Hospital, Capital Medical University, Beijing, 100176, China
| | - Yi Zhang
- Department of Pediatrics, Beijing Tongren Hospital, West South road 2, Yizhuang Economic and Technological Development Zone, Daxing District, Beijing, 100176, China
| | - Yan Zhou
- Department of Pediatrics, Beijing Tongren Hospital, West South road 2, Yizhuang Economic and Technological Development Zone, Daxing District, Beijing, 100176, China
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28
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Glasser CL. Tumor Lysis Syndrome (TLS) following intrathecal chemotherapy in a child with acute myelogenous leukemia (AML). Leuk Res Rep 2017; 8:19-20. [PMID: 29159035 PMCID: PMC5678818 DOI: 10.1016/j.lrr.2017.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 10/19/2017] [Accepted: 10/23/2017] [Indexed: 11/26/2022] Open
Abstract
Tumor Lysis Syndrome (TLS) is a well-known complication of induction therapy for hematologic malignancies. It is characterized by rapid breakdown of malignant white blood cells (WBCs) leading to metabolic derangements and serious morbidity if left untreated. Most commonly, TLS is triggered by systemic chemotherapy, however, there have been case reports of TLS following intrathecal (IT) chemotherapy, all in patients with acute lymphoblastic leukemia (ALL)/lymphoma. Here, we report the first case of a patient with acute myelogenous leukemia (AML) who developed TLS following a single dose of IT cytosine arabinoside (Ara-C).
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Affiliation(s)
- Chana L Glasser
- Department of Pediatric Hematology/Oncology, NYU Winthrop University Hospital, 120 Mineola Boulevard, Suite #460, Mineola, NY, United States
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29
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Schlatter J, Nguyen D, Zamy M, Kabiche S, Fontan JE, Cisternino S. Safety of intrathecal route: focus to methylprednisolone acetate (Depo-Medrol) use. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 28:21-30. [DOI: 10.1007/s00586-017-5387-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 07/24/2017] [Accepted: 11/05/2017] [Indexed: 11/24/2022]
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30
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Abstract
Methotrexate is an antifolate agent used in the treatment of autoimmune diseases and various types of cancers. It is a unique antiproliferative agent because it can be administered by multiple routes with a wide variation of dosing. Methotrexate pharmacokinetics have generated numerous papers focusing on descriptive data and pharmacodynamics. Methotrexate is one of the rare anticancer agents which pharmacokinetics are routinely monitoring to control excessive toxicity when administrated at high dose (>1 g/m2). The identification of transporters involved in its disposition has permitted the understanding and the prevention of most drug interactions. Pharmacogenetic factors affecting the expression of MRP2 and OATP1B1 partly explain the interindividual variability of methotrexate clearance. The remaining challenge in methotrexate pharmacokinetics is to further understand unexplained delayed renal elimination despite the implementation of preventive measures.
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31
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Montalva-Iborra A, Alcanyis-Alberola M, Grao-Castellote C, Torralba-Collados F, Giner-Pascual M. Risk factors in iatrogenic spinal cord injury. Spinal Cord 2017; 55:818-822. [PMID: 28374810 DOI: 10.1038/sc.2017.21] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 12/30/2016] [Accepted: 01/23/2017] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN In the last years, there has been a change in the aetiology of spinal cord injury. There has been an increase in the number of elderly patients with spinal cord injuries caused by diseases or medical procedures. OBJECTIVE The aim of this study is to investigate the frequency of the occurrence of iatrogenic spinal cord injury in our unit. The secondary aim is to study what variables can be associated with a higher risk of iatrogenesis. METHODS A retrospective, descriptive, observational study of patients with acute spinal cord injury admitted from June 2009 to May 2014 was conducted. The information collected included the patient age, aetiology, neurological level and grade of injury when admitted and when discharged, cardiovascular risk factors, a previous history of depression and any prior treatment with anticoagulant or antiplatelet drugs. We applied a logistic regression. The grade of statistical significance was established as P<0.05. RESULTS In total, 265 patients were included. In 48 of the cases, the cause was iatrogenic (18.18%±4.6% IC). The most frequent level of injury was the thoracic level (48%). The main aetiology of spinal cord injury caused by iatrogenesis was surgery for degenerative spine disease, in patients under the age of 30 were treated with intrathecal chemotherapy. CONCLUSIONS Iatrogenic spinal cord injury is a frequent complication. A statistically significant association between a patient history of depression and iatrogenic spinal cord injury was found as well as with anticoagulant and antiplatelet drug use prior to iatrogenic spinal cord injury.
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Affiliation(s)
- A Montalva-Iborra
- Department of Physical Medicine and Rehabilitation Hospital Universitario y Politécnico la Fe, Valencia, Spain
| | - M Alcanyis-Alberola
- Department of Physical Medicine and Rehabilitation, Hospital Francesc de Borja Gandia, Valencia, Spain
| | - C Grao-Castellote
- Department of Physical Medicine and Rehabilitation Hospital Universitario y Politécnico la Fe, Valencia, Spain
| | - F Torralba-Collados
- Department of Physical Medicine and Rehabilitation Hospital Universitario y Politécnico la Fe, Valencia, Spain
| | - M Giner-Pascual
- Department of Physical Medicine and Rehabilitation Hospital Universitario y Politécnico la Fe, Valencia, Spain.,Department of Physical Medicine and Rehabilitation, Faculty of Physiotherapy in University of Valencia, Valencia, Spain
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Abstract
Intrathecal methotrexate is a standard option for central nervous system-directed therapy in patients with stage III and IV diffuse large B-cell lymphoma. We present a case of a 50-year-old man with stage IV diffuse large B-cell lymphoma with widespread lymphomatous involvement including the central nervous system, who received 7 doses of intrathecal methotrexate via Ommaya catheter. Posttherapy F-FDG-PET/CT imaging demonstrated diffuse, intense intrathecal FDG avidity, without correlative findings on MR spinal imaging. FDG avidity resolved on follow-up. These PET/CT findings are most consistent with methotrexate-induced thecal inflammation, which needs to be distinguished from intrathecal malignancy.
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Abstract
Patients with brain tumors and systemic malignancies are subject to diverse neurologic complications that require urgent evaluation and treatment. These neurologic conditions are commonly due to the tumor's direct effects on the nervous system, such as cerebral edema, increased intracranial pressure, seizures, spinal cord compression, and leptomeningeal metastases. In addition, neurologic complications can develop as a result of thrombocytopenia, coagulopathy, hyperviscosity syndromes, infection, immune-related disorders, and adverse effects of treatment. Patients may present with typical disease syndromes. However, it is not uncommon for patients to have more subtle, nonlocalizing manifestations, such as alteration of mental status, that could be attributed to other systemic, nonneurologic complications. Furthermore, neurologic complications are at times the initial manifestations of an undiagnosed malignancy. Therefore a high index of suspicion is essential for rapid assessment and management. Timely intervention may prolong survival and improve quality of life. In this chapter, we will discuss the common neuro-oncologic emergencies, including epidemiology, pathophysiology, clinical presentation, diagnosis, and treatment.
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Affiliation(s)
- J T Jo
- Neuro-Oncology Center, University of Virginia, Charlottesville, VA, USA
| | - D Schiff
- Neuro-Oncology Center, University of Virginia, Charlottesville, VA, USA.
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34
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Cordelli DM, Masetti R, Zama D, Toni F, Castelli I, Ricci E, Franzoni E, Pession A. Central Nervous System Complications in Children Receiving Chemotherapy or Hematopoietic Stem Cell Transplantation. Front Pediatr 2017; 5:105. [PMID: 28555178 PMCID: PMC5430164 DOI: 10.3389/fped.2017.00105] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 04/25/2017] [Indexed: 01/19/2023] Open
Abstract
Therapy-related neurotoxicity greatly affects possibility of survival and quality of life of pediatric patients treated for cancer. Central nervous system (CNS) involvement is heterogeneous, varying from very mild and transient symptoms to extremely severe and debilitating, or even lethal syndromes. In this review, we will discuss the broad scenario of CNS complications and toxicities occurring during the treatment of pediatric patients receiving both chemotherapies and hematopoietic stem cell transplantation. Different types of complications are reviewed ranging from therapy related to cerebrovascular with a specific focus on neuroradiologic and clinical features.
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Affiliation(s)
- Duccio Maria Cordelli
- Child Neurology and Psychiatry Unit, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Riccardo Masetti
- Department of Pediatrics, "Lalla Seràgnoli", Hematology-Oncology Unit, University of Bologna, Bologna, Italy
| | - Daniele Zama
- Department of Pediatrics, "Lalla Seràgnoli", Hematology-Oncology Unit, University of Bologna, Bologna, Italy
| | - Francesco Toni
- Neuroradiology Department, IRCCS Institute of Neurological Sciences, Bellaria Hospital, Bologna, Italy
| | - Ilaria Castelli
- Department of Pediatrics, "Lalla Seràgnoli", Hematology-Oncology Unit, University of Bologna, Bologna, Italy
| | - Emilia Ricci
- Child Neurology and Psychiatry Unit, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Emilio Franzoni
- Child Neurology and Psychiatry Unit, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Andrea Pession
- Department of Pediatrics, "Lalla Seràgnoli", Hematology-Oncology Unit, University of Bologna, Bologna, Italy
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35
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Gilchrist LS, Tanner LR, Ness KK. Short-term recovery of chemotherapy-induced peripheral neuropathy after treatment for pediatric non-CNS cancer. Pediatr Blood Cancer 2017; 64:180-187. [PMID: 27567009 DOI: 10.1002/pbc.26204] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 07/12/2016] [Accepted: 07/22/2016] [Indexed: 11/08/2022]
Abstract
PURPOSE Chemotherapy-induced peripheral neuropathy (CIPN) is a frequent side effect of pediatric cancer treatment. The presentation of CIPN, trajectory and completeness of recovery over the first 6 months postchemotherapy, and the influence of patient and treatment characteristics on recovery are described. PATIENTS AND METHODS Sixty-seven children and adolescents treated for non-CNS cancers were evaluated for CIPN using the pediatric modified total neuropathy score (ped-mTNS) while on treatment and 3 and 6 months postchemotherapy. Differences between diagnostic groups and treatment type were evaluated as well as change in scores over time. Risk factors for on-treatment and persistent CIPN at 6 months were identified. RESULTS Overall, ped-mTNSs were in the abnormal range for 86.5% during treatment and scores decreased over time (initial 9.3 ± 0.6, 6 months 4.3 ± 0.4; F = 38.14, P < 0.001). By 6 months posttreatment, mean scores and percentage of children with abnormal scores were reduced to 2.4 ± 0.3 and 11.5%, respectively, in the ALL group, but remained higher at 5.7 ± 0.7 and 57%, respectively, for lymphoma, and 5.2 ± 1.0 and 60%, respectively, for other solid tumors. At 6 months posttreatment, light touch deficits and foot strength deficits remained in 19.4 and 59.7%, respectively, compared with only 4.9 and 9.8% of the control population. Subjects who were older at exposure, female, or who received etoposide in addition to vincristine were at higher risk for on-treatment CIPN. On-treatment sensory abnormalities were associated with increased risk of persistent CIPN. CONCLUSION While CIPN improves in most pediatric patients, significant numbers, especially those treated for lymphoma or other solid tumors, have remaining neuropathic signs and symptoms 6 months posttreatment.
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Affiliation(s)
- Laura S Gilchrist
- Department of Physical Therapy, St Catherine University, Minneapolis, Minnesota.,Cancer and Blood Disorders Program, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| | - Lynn R Tanner
- Developmental and Rehabilitation Services, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| | - Kirsten K Ness
- Department of Epidemiology and Cancer Control, St Jude Research Hospital, Memphis, Tennesee
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Ernst F, Klausner F, Kleindienst W, Bartsch H, Taylor N, Trinka E. Diagnostic challenges in vacuolar myelopathy: a didactic case report. Spinal Cord Ser Cases 2016; 2:16020. [PMID: 28053763 DOI: 10.1038/scsandc.2016.20] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 05/15/2016] [Accepted: 06/23/2016] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Because of the diagnostic complexity and potential pitfalls in interpreting test results, HIV-vacuolar myelopathy (HIVM) is far more often diagnosed postmortem than in vivo. In the era of highly active antiretroviral therapy (HAART), the topic of neuro-AIDS has become increasingly important. This case report covers some of the diagnostic problems encountered in vacuolar myelopathy based on magnetic resonance imaging (MRI) fiber-tracking pictures of the spine in a patient with HIVM, including a 1-year follow-up. CASE PRESENTATION A 49-year-old man felt progressive weakness, and difficulties while walking, and he suffered from incomplete voiding. A week before admission, follicles appeared on the right side of his neck and shoulder. His medical history included a chronic HIV infection treated with HAART and a B-cell lymphoma in complete remission after chemotherapy. The initial exam revealed thoracic hyposensitivity level distal to dermatome Th9, spastic paraparesis of the lower limbs and herpes zoster infection in dermatome C3/C4. A lesion of the thoracic myelon could be ruled out in the MRI scan, chemotherapy-induced polyneuropathy was stable, and no acute opportunistic infection of the CNS was found. HIV load in cerebrospinal fluid (CSF) was markedly elevated. An HIV-associated vacuolar myelopathy was diagnosed, revealing the HIV itself as etiology. DISCUSSION A negative or unspecific MRI scan excludes possible other causes, but by no means rules out HIV-related myelopathy. Furthermore, peripheral and central viral load should always be assessed to avoid missing a possible 'CSF HIV-escape'.
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Affiliation(s)
- Florian Ernst
- Department of Neurology, Paracelsus Medical University Salzburg, Salzburg, Austria; Spinal Cord Injury and Tissue Regeneration Center Salzburg (SCITReCS), Salzburg, Austria
| | - Fritz Klausner
- Division of Neuroradiology, Paracelsus Medical University Salzburg , Salzburg, Austria
| | - Waltraud Kleindienst
- Department of Neurology, Paracelsus Medical University Salzburg, Salzburg, Austria; Spinal Cord Injury and Tissue Regeneration Center Salzburg (SCITReCS), Salzburg, Austria
| | - Heinrich Bartsch
- Department of Neurology, Paracelsus Medical University Salzburg , Salzburg, Austria
| | - Ninon Taylor
- Department of Internal Medicine III with Hematology, Medical Oncology, Hemostaseology, Infectious Diseases, Rheumatology, Oncologic Center, Laboratory of Immunological and Molecular Cancer Research, Paracelsus Medical University Salzburg , Salzburg, Austria
| | - Eugen Trinka
- Department of Neurology, Paracelsus Medical University Salzburg, Salzburg, Austria; Spinal Cord Injury and Tissue Regeneration Center Salzburg (SCITReCS), Salzburg, Austria
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De la Riva P, Andres-Marín N, Gonzalo-Yubero N, Tainta-Cuezva M, Caminos N, Urtasun-Ocariz MÁ, Martí-Massó JF. Headache and other complications following intrathecal chemotherapy administration. Cephalalgia 2016; 37:1109-1110. [DOI: 10.1177/0333102416668658] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | - Nerea Caminos
- Hematology Department, Donostia University Hospital, San Sebastián, Spain
| | | | - Jose Félix Martí-Massó
- Neurology Department, Donostia University Hospital, San Sebastián, Spain
- Neurosciences Area, Biodonostia Institute, San Sebastián, Spain
- Center for Biomedical Research in Neurodegenerative Diseases Network (CIBERNED), San Sebastián, Spain
- Neurosciences Area, University of the Basque Country, San Sebastián, Spain
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Almajed MM, Esfahani K, Pelmus M, Panasci L. Complete response and long-term survival of leptomeningeal carcinomatosis from breast cancer with maintenance endocrine therapy. BMJ Case Rep 2016; 2016:bcr-2016-215525. [PMID: 27256996 DOI: 10.1136/bcr-2016-215525] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Leptomeningeal carcinomatosis carries a poor prognosis in breast cancer. Treatment modalities are geared towards tumour molecular characteristics, as well as symptoms and patient performance status. It has previously been postulated that endocrine treatments used for the treatment of metastatic breast cancer do cross the blood-brain barrier and can achieve antineoplastic effects in the central nervous system. We report a case of metastatic breast cancer in a 65-year-old woman who developed leptomeningeal carcinomatosis. She was initially treated with intrathecal methotrexate, which was stopped due to toxicity, followed by maintenance endocrine therapy. She achieved a sustained complete radiological and cerebrospinal fluid cytological response for over 9 years. She eventually passed away of ischaemic bowel unrelated to her cancer.
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Affiliation(s)
- Muneera Majed Almajed
- Jewish General Hospital, McGill University, Montreal, Quebec, Canada Oncology Department, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | | | - Manuela Pelmus
- Pathology Department, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Lawrence Panasci
- Jewish General Hospital, McGill University, Montreal, Quebec, Canada
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Nair A. Implications of Intrathecal Chemotherapy for Anaesthesiologists: A Brief Review. SCIENTIFICA 2016; 2016:3759845. [PMID: 27123363 PMCID: PMC4830729 DOI: 10.1155/2016/3759845] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Accepted: 03/14/2016] [Indexed: 06/02/2023]
Abstract
Intrathecal chemotherapy is routinely prescribed in medical oncology practice, either for prophylaxis or for treatment of leptomeningeal disease due to a primary haematological disease or a metastatic disease due to any other malignancy. As these groups of patients are coagulopathic either because of the disease per se or due to systemic chemotherapy, lumbar puncture in them is considered challenging and is expected to be performed by an anaesthesiologist because of their expertise in this procedure. However, the challenge is not only in performing the lumbar puncture safely but also in dealing with other issues like explaining and handling complications that can happen either due to the drug injected intrathecally or due to a neurodeficit occurring either due to the underlying coagulopathy or due to the progression of leptomeningeal disease.
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Affiliation(s)
- Abhijit Nair
- Department of Anaesthesiology, Basavatarakam Indo-American Cancer Institute and Research Centre, Hyderabad 500034, India
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Abstract
BACKGROUND The central nervous system is a unique sanctuary site for malignant disease. To ensure optimal disease control, intrathecal (IT) chemotherapy is commonly given in conjunction with standard chemotherapy protocols, thus providing the opportunity for medication errors. OBJECTIVE A systematic review of the current literature on medication errors associated with the administration of IT chemotherapy was conducted. METHODS English-language literature published from January 1960 through June 2013 was accessed. Case reports, clinical studies, and review articles pertaining to IT medication errors were included in the review. References of all relevant articles were searched for additional citations. RESULTS Twenty-two cases of accidental IT overdoses have been reported with methotrexate and 1 with cytarabine. There have been numerous cases of antineoplastic agents intended for administration by the parenteral route being inadvertently given intrathecally. Vincristine has been implicated 31 times (25 deaths), as well as vindesine, asparaginase, bortezomib, daunorubicin, and dactinomycin. This has led to profound toxicity and, commonly, death. Unfortunately, many cases go unrecognized or unreported. CONCLUSIONS The best method for eliminating the risk of IT medication errors is to develop effective methods of prevention and incorporate them into oncology and hematology practice internationally. Strategies include abolishing the syringe as a method of vinca alkaloid administration and substituting small-volume intravenous bags, and developing novel methods for intraspinal drug administration. IMPLICATIONS FOR PRACTICE The nursing profession is in a unique position to influence change and lead the way in establishing preventative strategies into current practice.
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Chan TSY, Pang A, Kwong YL. Integrity of blood-brain barrier in primary CNS NK/T cell lymphoma: implications in the treatment of other primary CNS lymphomas. Ann Hematol 2015; 95:359-60. [PMID: 26482464 DOI: 10.1007/s00277-015-2530-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Accepted: 10/08/2015] [Indexed: 11/26/2022]
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Stone JB, DeAngelis LM. Cancer-treatment-induced neurotoxicity--focus on newer treatments. Nat Rev Clin Oncol 2015; 13:92-105. [PMID: 26391778 DOI: 10.1038/nrclinonc.2015.152] [Citation(s) in RCA: 162] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Neurotoxicity caused by traditional chemotherapy and radiotherapy is widely recognized in patients with cancer. The adverse effects of newer therapeutics, such as biological and immunotherapeutic agents, are less well established, and are associated with considerable neurotoxicity in the central and peripheral nervous systems. This Review addresses the main neurotoxicities of cancer treatment with a focus on the newer therapeutics. Recognition of these patterns of toxicity is important because drug discontinuation or dose adjustment might prevent further neurological injury. Knowledge of these toxicities also helps to differentiate treatment-related symptoms from progression of cancer or its involvement of the nervous system. Familiarity with the neurological syndromes associated with cancer treatments enables clinicians to use the appropriate treatment for the underlying malignancy while minimizing the risk of neurological damage, which might preserve patients' quality of life.
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Affiliation(s)
- Jacqueline B Stone
- Department of Neurology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Lisa M DeAngelis
- Department of Neurology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
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Bortz H, Coutsouvelis J, Corallo CE, Spencer A, Patil S. Modifying chemotherapeutic management of a patient with Burkitt's lymphoma and pre-existing motor neurone disease. J Clin Pharm Ther 2015; 40:483-5. [PMID: 26073601 DOI: 10.1111/jcpt.12293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2015] [Accepted: 05/07/2015] [Indexed: 11/28/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Intensive chemotherapy for treatment of Burkitt's lymphoma (BL) - a high-grade lymphoproliferative disorder (LPD) - can cause neurotoxicity. An association between motor neurone disease (MND) and LPDs has previously been described, but there is a lack of recommendations available to guide management of such patients. This report aims to describe suitable management of BL in a patient with MND. CASE DESCRIPTION A 66-year-old woman with a history of MND affecting her limbs was diagnosed with bulky, extranodal, high-risk gastric BL. Standard chemotherapy is with multiple non-cross-resistant cytotoxic agents. To avoid exacerbation of neuropathy, six cycles of a modified regimen was planned, aiming to minimize exposure to the most neurotoxic agents. A PET-FDG-negative remission was obtained at 12 months, without the signs of central neurotoxicity, peripheral neuropathy or muscle weakness. WHAT IS NEW AND CONCLUSION High-intensity chemotherapy, minimizing known neurotoxic agents, was delivered safely and effectively in a patient with BL and pre-existing MND. More case descriptions are required to guide management decisions.
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Affiliation(s)
- H Bortz
- Pharmacy Department, Alfred Health, The Alfred Hospital, Melbourne, Vic., Australia
| | - J Coutsouvelis
- Pharmacy Department, Alfred Health, The Alfred Hospital, Melbourne, Vic., Australia.,Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, The Alfred Hospital, Melbourne, Vic., Australia
| | - C E Corallo
- Pharmacy Department, Alfred Health, The Alfred Hospital, Melbourne, Vic., Australia
| | - A Spencer
- Department of Malignant Haematology and Stem Cell Transplantation, The Alfred Hospital, Melbourne, Vic., Australia
| | - S Patil
- Department of Malignant Haematology and Stem Cell Transplantation, The Alfred Hospital, Melbourne, Vic., Australia
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Law MF, Chan HN, Lai HK, Ha CY, Ng C, Yeung YM, Yip SF. Effects of addition of rituximab to chemotherapy on central nervous system events in patients with diffuse large B-cell lymphoma. Mol Clin Oncol 2015; 3:747-752. [PMID: 26171174 DOI: 10.3892/mco.2015.546] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 03/27/2015] [Indexed: 01/17/2023] Open
Abstract
The aim of this study was to evaluate whether the addition of rituximab to chemotherapy reduces central nervous system (CNS) events and to identify the risk factors associated with CNS involvement. Patients who were diagnosed with diffuse large B-cell lymphoma (DLBCL) between January, 1995 and December, 2012, without prior CNS disease, were recruited in this study. The patients received chemotherapy with cyclophosphamide, doxorubicin, vincristine and prednisolone (CHOP) or CHOP with rituximab (R-CHOP), with curative intent. The incidence rate of subsequent CNS events was compared between the two groups. A total of 110 patients were recruited, 45 (41%) of whom received CHOP and 65 (59%) R-CHOP. A total of 12 patients (10.9%) subsequently exhibited CNS involvement. The median time from the initial DLBCL diagnosis to CNS disease was 6.7 months (range, 1.3-23.8 months). The CNS disease rate was 15.5% (7/45) in the CHOP group vs. 7.6% (5/65) in the R-CHOP group. The projected 3-year CNS disease rate was 18% in the CHOP group vs. 9% in the R-CHOP group (P=0.15). The survival of patients with CNS disease was poor, with a median survival of 5.8 months. On multivariate analysis using the Cox proportional model, stage IV disease remained an independent predictor of CNS disease (hazard ratio = 7.75, 95% confidence interval: 1.67-35.92, P=0.009). In conclusion, the addition of rituximab to chemotherapy did not appear to reduce the risk of CNS events in our study. Other effective prophylactic measures are required to reduce the incidence of CNS events. High-dose intravenous methotrexate crosses the blood-brain barrier and may be used as CNS prophylaxis in high-risk patients.
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Affiliation(s)
- Man Fai Law
- Department of Medicine, Tuen Mun Hospital, Hong Kong SAR 999077, P.R. China ; Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong SAR 999077, P.R. China
| | - Hay Nun Chan
- Department of Medicine, Tuen Mun Hospital, Hong Kong SAR 999077, P.R. China
| | - Ho Kei Lai
- Department of Medicine, Tuen Mun Hospital, Hong Kong SAR 999077, P.R. China
| | - Chung Yin Ha
- Department of Medicine, Tuen Mun Hospital, Hong Kong SAR 999077, P.R. China
| | - Celia Ng
- Department of Medicine, Tuen Mun Hospital, Hong Kong SAR 999077, P.R. China
| | - Yiu Ming Yeung
- Department of Medicine, Tuen Mun Hospital, Hong Kong SAR 999077, P.R. China
| | - Sze Fai Yip
- Department of Medicine, Tuen Mun Hospital, Hong Kong SAR 999077, P.R. China
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Abstract
Intrathecal (IT) chemotherapy is an established method of preventing and treating CNS leukemia. Although this intervention is beneficial and necessary, understanding the potential adverse effects of IT chemotherapy is important so that these potential effects can be anticipated and prevented. Tumor lysis syndrome is a known complication of systemic chemotherapy and has also been reported as a rare complication after IT chemotherapy in patients with CNS disease. We report the first case of tumor lysis syndrome occurring in a patient with T-cell acute lymphoblastic leukemia without CNS disease. The systemic effects of the IT chemotherapy were confirmed by the decreased size of the presenting mediastinal mass.
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Affiliation(s)
- Lenore R Simangan
- *Children's Hospital of Central California, Madera, CA †Department of Pediatrics, University of Nevada School of Medicine, Las Vegas, NV ‡Department of Clinical Education, Touro University Nevada School of Osteopathic Medicine, Henderson, NV
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van der Plas E, Nieman BJ, Butcher DT, Hitzler JK, Weksberg R, Ito S, Schachar R. Neurocognitive Late Effects of Chemotherapy in Survivors of Acute Lymphoblastic Leukemia: Focus on Methotrexate. JOURNAL OF THE CANADIAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY = JOURNAL DE L'ACADEMIE CANADIENNE DE PSYCHIATRIE DE L'ENFANT ET DE L'ADOLESCENT 2015; 24:25-32. [PMID: 26336377 PMCID: PMC4357331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 07/30/2014] [Indexed: 06/05/2023]
Abstract
Childhood cancer survivors frequently experience long-lasting consequences of chemotherapy on health outcomes. Neurocognitive late effects of chemotherapy occur in 40 - 60% of acute lymphoblastic leukemia (ALL) survivors. These deficits affect mental health, school performance, job success, and are associated with poor quality of life, therefore presenting a clinical challenge for psychiatrists. However, not all cancer survivors are impacted by treatment in the same manner and emerging evidence suggests that genetic variation may modulate neurocognitive outcomes. Much like other complex psychopathologies, neurocognitive deficits in cancer survivors are the result of complex interactions between genetic and environmental variables. This review describes adverse neurocognitive outcomes observed in survivors of acute lymphoblastic leukemia (ALL) and discusses genetic variability in biochemical pathways targeted by chemotherapeutic agents as a possible mechanism contributing to psychopathology in ALL survivors.
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Affiliation(s)
- Ellen van der Plas
- Psychiatry Department, The Hospital for Sick Children, Toronto, Ontario
- Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, Ontario
| | - Brian J. Nieman
- Mouse Imaging Centre, The Hospital for Sick Children, Toronto, Ontario
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario
| | - Darci T. Butcher
- Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Ontario
| | - Johann K. Hitzler
- Division of Haematology/Oncology and Cancer and Blood, Department of Pediatrics, the Hospital for Sick Children, Toronto, Ontario
| | - Rosanna Weksberg
- Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Ontario
- Division of Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, Toronto, Ontario
- Institute of Medical Science, The University of Toronto, Toronto, Ontario
| | - Shinya Ito
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, the Hospital for Sick Children, Toronto, Ontario
| | - Russell Schachar
- Psychiatry Department, The Hospital for Sick Children, Toronto, Ontario
- Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, Ontario
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Liu YG, Dai QL, Wang SB, Deng QJ, Wu WG, Chen AZ. Preparation and in vitro antitumor effects of cytosine arabinoside-loaded genipin-poly-l-glutamic acid-modified bacterial magnetosomes. Int J Nanomedicine 2015; 10:1387-97. [PMID: 25733831 PMCID: PMC4337507 DOI: 10.2147/ijn.s76123] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
To solve the problem of synthesized magnetic nanoparticles in cancer therapy, a new drug delivery system synthesized from bacteria was used to load cytosine arabinoside (Ara-C). Genipin (GP) and poly-l-glutamic acid (PLGA) were selected as dual cross-linkers. The preparation and characterization of Ara-C-loaded GP-PLGA-modified bacterial magnetosomes (BMs) (ABMs-P), as well as their in vitro antitumor effects, were all investigated. Transmission electron micrographs (TEM) and Fourier transform infrared (FTIR) spectroscopy suggested that Ara-C could be bound to the membrane of BMs modified by GP-PLGA. The diameters of the BMs and ABMs-P were 42.0±8.6 nm and 74.9±8.2 nm, respectively. The zeta potential revealed that the nanoparticles were stable. Moreover, this system exhibited optimal drug-loading properties and long-term release behavior. The optimal encapsulation efficiency and drug-loading were 64.1%±6.6% and 38.9%±2.4%, respectively, and ABMs-P could effectively release 90% Ara-C within 40 days, without the release of an initial burst. In addition, in vitro antitumor experiments elucidated that ABMs-P is cytotoxic to HL-60 cell lines, with an inhibition rate of 95%. The method of coupling drugs on BMs using dual cross-linkers is effective, and our results reveal that this new system has potential applications for drug delivery in the future.
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Affiliation(s)
- Yuan-Gang Liu
- College of Chemical Engineering, Huaqiao University, Xiamen, People's Republic of China ; Institute of Pharmaceutical Engineering, Huaqiao University, Xiamen, People's Republic of China
| | - Qing-Lei Dai
- College of Chemical Engineering, Huaqiao University, Xiamen, People's Republic of China
| | - Shi-Bin Wang
- College of Chemical Engineering, Huaqiao University, Xiamen, People's Republic of China ; Institute of Pharmaceutical Engineering, Huaqiao University, Xiamen, People's Republic of China
| | - Qiong-Jia Deng
- College of Chemical Engineering, Huaqiao University, Xiamen, People's Republic of China
| | - Wen-Guo Wu
- College of Chemical Engineering, Huaqiao University, Xiamen, People's Republic of China ; Institute of Pharmaceutical Engineering, Huaqiao University, Xiamen, People's Republic of China
| | - Ai-Zheng Chen
- College of Chemical Engineering, Huaqiao University, Xiamen, People's Republic of China ; Institute of Pharmaceutical Engineering, Huaqiao University, Xiamen, People's Republic of China
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Alsdorf WH, Schmitz M, Schieferdecker A, Dierlamm J, Bokemeyer C, Binder M. Severe and irreversible myelopathy after concurrent systemic and intrathecal nucleoside analogue treatment for refractory diffuse large B-cell lymphoma: A case report and review of the literature. J Oncol Pharm Pract 2015; 22:523-7. [PMID: 25655468 DOI: 10.1177/1078155214562268] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We report a patient with refractory diffuse large B-cell lymphoma who developed irreversible, severe spinal neurotoxicity after concurrent treatment with intrathecal and systemic cytarabine. Shortly after concomitant administration of intrathecal triple therapy (MTX, dexamethasone and cytarabine) and high-dose systemic cytarabin (R-DHAP protocol) the patient lost control of bowel and bladder function and developed an ascending, irreversible paraplegia. Infectious or neoplastic diseases of the spinal cord were ruled out. A magnetic resonance imaging scan of the spine resulted in a diagnosis of toxic myelitis. Previously observed cases of spinal neurotoxicity after cytarabine treatment are reviewed as well as current guidelines for the use of intrathecal chemotherapy in high-grade non-Hodgkin lymphoma. In summary, severe spinal neurotoxicity of intrathecal chemotherapy is a rare side-effect, however several studies suggest that the neurotoxicity of cytarabine is significantly enhanced by concurrent intrathecal and high-dose systemic administration. Simultaneous high-dose systemic and intrathecal chemotherapy with cytarabine should therefore be avoided.
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Affiliation(s)
- Winfried H Alsdorf
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section Pneumology, Hubertus Wald-Tumor Zentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Schmitz
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section Pneumology, Hubertus Wald-Tumor Zentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Aneta Schieferdecker
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section Pneumology, Hubertus Wald-Tumor Zentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Judith Dierlamm
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section Pneumology, Hubertus Wald-Tumor Zentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Carsten Bokemeyer
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section Pneumology, Hubertus Wald-Tumor Zentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mascha Binder
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section Pneumology, Hubertus Wald-Tumor Zentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Yoon JH, Yoon JY, Park HJ, Son MH, Kim SH, Kim W, Kim HJ, Lee SH, Park BK. Diffuse cerebral vasospasm with infarct after intrathecal cytarabine in childhood leukemia. Pediatr Int 2014; 56:921-924. [PMID: 25521979 DOI: 10.1111/ped.12394] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Revised: 03/18/2014] [Accepted: 04/01/2014] [Indexed: 11/28/2022]
Abstract
Although the varied neurotoxicity of intrathecal (IT) chemotherapy for treatment of childhood acute leukemia is well known, most are related to transient post-puncture headache, drug-induced arachnoiditis, or leukoencephalopathy after methotrexate or cytarabine. Cerebral vasospasm leading to acute infarct after IT chemotherapy is very uncommon in children. Reported herein is a rare case of diffuse cerebral vasospasm with subsequent cerebral infarct after IT cytarabine in a 7-year-old boy with acute lymphoblastic leukemia, who successfully recovered with supportive management, and a review of the literature.
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Affiliation(s)
- Jong Hyung Yoon
- Center for Pediatric Oncology, National Cancer Center, Goyang, South Korea
| | - Ju Young Yoon
- Center for Pediatric Oncology, National Cancer Center, Goyang, South Korea
| | - Hyeon Jin Park
- Center for Pediatric Oncology, National Cancer Center, Goyang, South Korea
| | - Meong Hi Son
- Center for Pediatric Oncology, National Cancer Center, Goyang, South Korea
| | - Su-Hyun Kim
- Department of Neurology, National Cancer Center, Goyang, South Korea
| | - Woojun Kim
- Department of Neurology, National Cancer Center, Goyang, South Korea
| | - Ho Jin Kim
- Department of Neurology, National Cancer Center, Goyang, South Korea
| | - Sang Hyun Lee
- Department of Radiology, National Cancer Center, Goyang, South Korea
| | - Byung-Kiu Park
- Center for Pediatric Oncology, National Cancer Center, Goyang, South Korea
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50
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Al Omar S, Amayiri N, Madanat F. Safety of inadvertent administration of overdose of intrathecal Cytarabine in a pediatric patient. J Oncol Pharm Pract 2014; 21:384-7. [PMID: 24781453 DOI: 10.1177/1078155214534104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To describe a medication error of intrathecal Cytarabine overdose that was managed conservatively with no apparent toxicities. SUMMARY An 11-year-old girl was diagnosed with bone marrow relapsed precursor B-cell acute lymphoblastic leukemia. According to her chemotherapy protocol, she was started on triple intrathecal chemotherapy consisting of Methotrexate, Cytarabine and Hydrocortisone on day 1 of the protocol. After the intrathecal therapy being administered to the patient, the pharmacist who checked the medication realized that the wrong formulation of Cytarabine was used to prepare the intrathecal therapy; this error resulted in five times overdose of Cytarabine. The patient was then managed conservatively without cerebrospinal fluid exchange. Our patient remained clinically and neurologically stable without apparent toxicities and was discharged safely from hospital. CONCLUSION Supportive care without the need for invasive procedures such as cerebrospinal fluid exchange may be adequate for managing intrathecal Cytarabine overdose.
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Affiliation(s)
- Suha Al Omar
- Department of Pharmacy, King Hussein Cancer Center, Amman, Jordan
| | - Nisreen Amayiri
- Department of Pediatrics, King Hussein Cancer Center, Amman, Jordan
| | - Faris Madanat
- Department of Pediatrics, King Hussein Cancer Center, Amman, Jordan
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