Intra-CSF administration of chemotherapy medications

Application and Safety of Externally Controlled Metronomic Drug Delivery to the Brain by an Implantable Smart Pump in a Sheep Model

BACKGROUND AND OBJECTIVES

Intraventricular drug delivery enables the delivery of therapeutics to the central nervous system, while minimizing peripheral drug exposure and toxicity. However, currently used delivery devices cannot be controlled externally to adjust their output during delivery. Here, the authors investigated the performance of a conceptually novel device designed to metronomically deliver a drug to the cerebrospinal fluid in a manner that can be adjusted wirelessly from an external controller.

METHODS

Six sheep were subcutaneously implanted in the shoulder region with a drug delivery pump and a catheter connecting to the brain ventricles. Three groups of 2 sheep received low, medium, and high dosages of metronomic methotrexate (MTX) over several weeks, while kept mobile outdoors in a pen. MTX dosages were adjusted from a wireless external controller, and intraventricular MTX concentrations were measured in regular intervals with an Ommaya reservoir.

RESULTS

Over the course of this 12-week study, sheep showed no signs of toxicity. MTX measurements in the cerebrospinal fluid confirmed that the pump remained responsive to external control and able to deliver drug in an adjustable, metronomic fashion.

CONCLUSION

This implantable pump system enables external control of drug output, so that the resulting intraventricular drug concentrations can continuously be maintained within the therapeutic range.

Intrathecal Trastuzumab for HER2-Positive Cancer of Unknown Primary Leptomeningeal Metastasis: A Case Report

Cancer of unknown primary (CUP) and leptomeningeal metastasis are difficult conditions with limited treatment options. We report a case of CUP leptomeningeal metastasis that was refractory to empirical chemotherapy but achieved a favorable response to intrathecal trastuzumab after the identification of human epidermal growth factor receptor-2 (HER2) amplification. A 59-year-old woman was diagnosed with CUP with metastasis of a poorly differentiated carcinoma to the left axillary, anterior mediastinal, peritoneal, and bilateral supraclavicular lymph nodes. Leptomeningeal metastasis was confirmed shortly after she started empiric chemotherapy; empiric therapy with intrathecal methotrexate failed to relieve her symptoms. Meanwhile, the lymph node specimen tested positive for HER2 amplification. She underwent intrathecal trastuzumab, then her neurological symptoms resolved the following day. We suggest that intrathecal trastuzumab is an effective treatment for HER2-positive CUP leptomeningeal metastasis.

Etoposide-Bound Magnetic Nanoparticles Designed for Remote Targeting of Cancer Cells Disseminated Within Cerebrospinal Fluid Pathways

Magnetic nanoparticles (MNPs) have potential for enhancing drug delivery in selected cancer patients, including those which have cells that have disseminated within cerebrospinal fluid (CSF) pathways. Here, we present data related to the creation and in vitro use of new two-part MNPs consisting of magnetic gold-iron alloy cores which have streptavidin binding sites, and are coated with biotinylated etoposide. Etoposide was chosen due to its previous use in the CSF and ease of biotinylation. Etoposide magnetic nanoparticles (“Etop-MNPs”) were characterized by several different methods, and moved at a distance by surface-walking of MNP clusters, which occurs in response to a rotating permanent magnet. Human cell lines including D283 (medulloblastoma), U138 (glioblastoma), and H2122 (lung adenocarcinoma) were treated with direct application of Etop-MNPs (and control particles), and after remote particle movement. Cell viability was determined by MTT assay and trypan blue exclusion. Results indicated that the biotinylated etoposide was successfully bound to the base MNPs, with the hybrid particle attaining a maximum velocity of 0.13 ± 0.018 cm/sec. Etop-MNPs killed cancer cells in a dose-dependent fashion, with 50 ± 6.8% cell killing of D283 cells (for example) with 24 h of treatment after remote targeting. U138 and H2122 cells were found to be even more susceptible to the killing effect of Etop-MNPs than D283 cells. These findings indicate that the novel Etop-MNPs have a cytotoxic effect, and can be moved relatively rapidly at physiologic distances, using a rotating magnet. While further testing is needed, intrathecal administration of Etop-MNPs holds promise for magnetically-enhanced eradication of cancer cells distributed within CSF pathways, particularly if given early in the course of the disease.

Intrathecal administration of anti-HER2 treatment for the treatment of meningeal carcinomatosis in breast cancer: A metanalysis with meta-regression

Leptomeningeal Metastases (LM) is a turning point in terms of prognosis and quality of life of patients with breast cancer (BC). Intrathecal therapy is largely used for the treatment of breast cancer LM. In this metanalysis with meta-regression, we gathered data on intrathecal (IT) trastuzumab administration in patients with HER2 positive breast cancer with LM. A total of 24 articles (58 patients) were included in the study and intrathecal trastuzumab was used in all patients. The mean age at IT administration was 50.7 years (SD 11.4, range 24-80) and the mean total dose of IT trastuzumab was 711.9 mg (SD 634.9, median 450). IT trastuzumab was used both alone (n = 20) and in combination with systemic pharmacotherapy (n = 37). No serious adverse events were reported in 87.9% of cases. In this selected population a significant clinical improvement was observed in 55.0% of cases while stabilization was reported in 14% of cases. CSF response was observed in 55.6% of the cases. MRI was improved or stable in 70.8% of the cases. Interestingly, the CNS-PFS was 5.2 months and the median OS was 13.2 months. A clinical improvement (HR 0.13, 95% CI 0.03-0.49) and CSF response (HR 0.13, 95% CI 0.03-0.58) were associated with a longer CNS-PFS. The association of longer CNS-PFS with radio- or neurosurgery prior to the administration of IT trastuzumab did not reach statistical significance. This metanalysis with meta-regression indicates that IT trastuzumab in patients with HER2 positive breast cancer LM might be a safe and effective treatment, but further prospective studies are needed to definitively prove such a point.

Efficient brain targeting and therapeutic intracranial activity of bortezomib through intranasal co-delivery with NEO100 in rodent glioblastoma models

OBJECTIVE

Many pharmaceutical agents are highly potent but are unable to exert therapeutic activity against disorders of the central nervous system (CNS), because the blood-brain barrier (BBB) impedes their brain entry. One such agent is bortezomib (BZM), a proteasome inhibitor that is approved for the treatment of multiple myeloma. Preclinical studies established that BZM can be effective against glioblastoma (GBM), but only when the drug is delivered via catheter directly into the brain lesion, not after intravenous systemic delivery. The authors therefore explored alternative options of BZM delivery to the brain that would avoid invasive procedures and minimize systemic exposure.

METHODS

Using mouse and rat GBM models, the authors applied intranasal drug delivery, where they co-administered BZM together with NEO100, a highly purified, GMP-manufactured version of perillyl alcohol that is used in clinical trials for intranasal therapy of GBM patients.

RESULTS

The authors found that intranasal delivery of BZM combined with NEO100 significantly prolonged survival of tumor-bearing animals over those that received vehicle alone and also over those that received BZM alone or NEO100 alone. Moreover, BZM concentrations in the brain were higher after intranasal co-delivery with NEO100 as compared to delivery in the absence of NEO100.

CONCLUSIONS

This study demonstrates that intranasal delivery with a NEO100-based formulation enables noninvasive, therapeutically effective brain delivery of a pharmaceutical agent that otherwise does not efficiently cross the BBB.

Leptomeningeal metastasis from solid tumors

Central nervous system (CNS) metastasis from systemic cancers can involve the brain parenchyma, leptomeninges (pia, subarachnoid space and arachnoid mater), and dura. Leptomeningeal metastases (LM), also known by different terms including neoplastic meningitis and carcinomatous meningitis, occur in both solid tumors and hematologic malignancies. This review will focus exclusively on LM arising from solid tumors with a goal of providing the reader an understanding of the epidemiology, pathophysiology, clinical presentation, prognostication, current management and future directions.

Phase I feasibility study for intrathecal administration of trastuzumab in patients with HER2 positive breast carcinomatous meningitis

PURPOSE

Leptomeningeal carcinomatosis (MC) is commonly associated with HER2-positive breast cancer (HER2-BC), with a poor prognosis and no standardised treatment. We conducted a phase I dose-escalation study of intrathecal (IT) administration of trastuzumab in HER2-BC patients with MC to determine the maximum tolerated dose (MTD), which was based on both the achievement of a trastuzumab intra-cerebrospinal fluid concentration close to a conventional therapeutic plasma concentration (30 mg/L) and/or dose-limiting toxicity (DLT).

METHODS

The protocol planned IT administration of trastuzumab (30 mg, 60 mg, 100 mg or 150 mg dose levels) once a week, over the course of at least 4 weeks. Sixteen patients with MC from HER2-BC received IT trastuzumab. Intra-cerebrospinal fluid samples were obtained before each injection for pharmacokinetics.

RESULTS

We did not observe DLT of IT trastuzumab. Eleven patients had no toxicity attributed to IT trastuzumab. For 60 mg or higher dose levels, minor toxicities attributed to IT trastuzumab included headache (2 patients), nausea (2 patients), vomiting (1 patient), cervical pain (1 patient) and peripheral neuropathy (1 patient). Two patients experienced immediate toxicity including headache or vomiting. The mean residual intra-cerebrospinal fluid concentration of trastuzumab was 27.9 mg/L for the 150 mg dose level. Three patients achieved a clinical response, seven patients had stable disease and four patients had progressive disease.

CONCLUSIONS

The MTD and recommended phase II weekly dose of IT trastuzumab in patients with HER2-BC and MC is 150 mg. A phase II trial using this dose regimen in MC from HER2-BC is ongoing.

REGISTRATION IDENTIFICATION

ClinicalTrials.gov Identifier: NCT01373710 (https://clinicaltrials.gov/ct2/show/NCT01373710?term=trastuzumab+intrathecal&rank=1).

Transependymal Cerebrospinal Fluid Flow: Opportunity for Drug Delivery?

Drug delivery to the central nervous system (CNS) is complicated by the blood-brain barrier. As a result, many agents that are found to be potentially effective at their site of action cannot be sufficiently or effectively delivered to the CNS and therefore have been discarded and not developed further for clinical use, leaving many CNS diseases untreated. One way to overcome this obstacle is intracerebroventricular (ICV) delivery of the therapeutics directly to cerebrospinal fluid (CSF). Recent experimental and clinical findings reveal that CSF flows from the ventricles throughout the parenchyma towards the subarachnoid space also named minor CSF pathway, while earlier, it was suggested that only in pathological conditions such as hydrocephalus this form of CSF flow occurs. This transependymal flow of CSF provides a route to distribute ICV-infused drugs throughout the brain. More insight on transependymal CSF flow will direct more rational to ICV drug delivery and broaden its clinical indications in managing CNS diseases.

Leptomeningeal Disease and the Evolving Role of Molecular Targeted Therapy and Immunotherapy

BACKGROUND

Leptomeningeal disease (LMD) is a complication that results from solid tumor metastasis. Prognosis is extremely poor. As therapeutic options for solid tumors improve, the rate of LMD continues to increase. Until recently, treatment has been limited to radiation therapy, intrathecal chemotherapy, and systemic chemotherapy, with an overall survival of 2-3 months. Targeted molecular therapy and immunotherapies are promising new options for increasing overall survival and clinical improvement; however, optimal clinical management remains unknown.

METHODS

In this review, we discuss targeted molecular therapy and immunotherapy treatment options for LMD resulting from primary lung, breast, and melanoma tumors. In addition, we summarize dosing strategies, overall survival, clinical outcomes, and novel approaches to treatment.

RESULTS

Our review indicates a deficiency in the current literature. Presently, intrathecal trastuzumab administration may be an effective option for patients with HER2-positive breast cancer. BRAF inhibitors and cytotoxic T lymphocyte-associated antigen-4 targets have shown promising results in LMD resulting from melanoma. Finally, tyrosine kinase inhibitors may increase overall survival in epidermal growth factor receptor (EGFR)-mutant non-small cell lung cancer. Pulsatile drug administration or dual therapy may be beneficial for patients who progress to LMD while being treated with EGFR targets for their primary malignancy.

CONCLUSION

Targeted molecular therapy and immunotherapy in LMD may provide favorable treatment options. Current literature is lacking in safety, efficacy, and overall response rates from the use of targeted therapy. Research is needed to draw significant conclusions about the most appropriate therapy for patients with LMD.

Safety of intra-cerebrospinal fluid chemotherapy in onco-haematological patients: a retrospective analysis of 627 interventions

Intra-cerebrospinal fluid chemotherapy (ICC) is used widely to treat or prevent neoplastic meningitis (NM), although its safety has not been thoroughly assessed. We aimed to analyse the incidence, severity and cause of the adverse reactions provoked by ICC in a cohort of onco-haematological patients. We retrospectively reviewed all the adverse reactions related to ICC procedures performed by the same researcher over a 5-year period. We classified them according to their severity and cause, and examined their association with certain characteristics of the patients and interventions. A total of 627 procedures were performed on 124 patients, in which 59 adverse reactions were documented (9.4 %). Thirty-two (54 %) of these were considered severe and 30 (51 %) were due to the drug itself. NM was associated with a higher incidence of adverse reactions (p = 0.002) and severe adverse reactions (p < 0.001). Adverse reactions were more common (p = 0.028) and more often severe (p = 0.008) when an Ommaya reservoir was used, as opposed to the lumbar puncture procedure. The use of liposomal cytarabine was also associated with a higher incidence of adverse reactions (p < 0.001) and serious adverse reactions (p < 0.001) than immediate-release drugs. Liposomal cytarabine provoked more adverse reactions attributable to the drug when administered by lumbar puncture (p = 0.192), whereas the remaining drugs had higher risk when administered via Ommaya reservoir (p = 0.015). ICC seems a relatively safe procedure. Adverse reactions appear to be more frequent when NM is already present. Lumbar puncture seems to be safer than the Ommaya reservoir, except when liposomal cytarabine is administered.

Development of the Metronomic Biofeedback Pump for leptomeningeal carcinomatosis: technical note

Patients with leptomeningeal carcinomatosis face a particularly grim prognosis. Current treatment consists of intrathecal delivery of methotrexate (MTX) or cytosine arabinoside (Ara-C) via Ommaya reservoir or lumbar puncture. Yet despite these interventions, the median survival after diagnosis is only 4–7 months. To address inherent shortcomings of current treatments and provide a more effective therapeutic approach, the Pharmaco-Kinesis Corporation has developed a novel type of implantable pump capable of delivering intrathecal chemotherapy (i.e., MTX) in a metronomic fashion with electronic feedback. The Metronomic Biofeedback Pump (MBP) consists of 3 components: 1) a 2-lumen catheter; 2) a microfluidic delivery pump with 2 reservoirs; and 3) a spectrophotometer monitoring MTX concentrations in the CSF. Using an animal model of intraventricular drug delivery, the authors demonstrate that the MBP can reliably deliver volumes of 500 μl/min, consistently measure real-time intrathecal MTX concentrations via CSF aspiration, and provide biofeedback with the possibility of instant control and delivery adjustments. Therefore, this novel approach to chemotherapy minimizes toxic drug levels and ensures continuous exposure at precisely adjusted, individualized therapeutic levels. Altogether, application of the MBP is expected to increase survival of patients with leptomeningeal carcinomatosis, and appropriate Phase I and II trials are pending.

Bevacizumab might potentiate the chemotherapeutic effect in breast cancer patients with leptomeningeal carcinomatosis

BACKGROUND/PURPOSE

Patients with leptomeningeal carcinomatosis (LC) from breast cancer is generally resistant to systemic chemotherapy. Bevacizumab may increase intratumor concentration of the chemotherapeutic agents through vascular normalization, although the overall clinical benefit of bevacizumab for metastatic breast cancer is under debate.

METHODS

Successful treatment of two breast cancer patients who developed LC after whole brain irradiation treatment for the brain metastases is reported here. Both patients have refractory disease to taxane and anthracycline, and both of them have disease progression under intrathecal methotrexate treatment for LC.

RESULTS

The two patients received systemic chemotherapy with bevacizumab (7.5 mg/kg infusion on Day 1), cisplatin (80 mg/m(2) infusion for 24 hours on Day 2), and etoposide (80 mg/m(2) infusion for 2 hours on Days 2-4) at 21-28 day intervals. Both patients achieved best response of negative cerebral spinal fluid cytology study and dramatic improvement of neurologic deficit after treatment. Their overall survival after development of LC was 8 months and 7.5 months respectively.

CONCLUSION

Bevacizumab plus etoposide and cisplatin might be a new option for breast cancer patients with LC. Further prospective study is warranted.

Meningeal and choroid plexus cells--novel drug targets for CNS disorders

The meninges and choroid plexus perform many functions in the developing and adult human central nervous system (CNS) and are composed of a number of different cell types. In this article I focus on meningeal and choroid plexus cells as targets for the development of drugs to treat a range of traumatic, ischemic and chronic brain disorders. Meningeal cells are involved in cortical development (and their dysfunction may be involved in cortical dysplasia), fibrotic scar formation after traumatic brain injuries (TBI), brain inflammation following infections, and neurodegenerative disorders such as Multiple Sclerosis (MS) and Alzheimer's disease (AD) and other brain disorders. The choroid plexus regulates the composition of the cerebrospinal fluid (CSF) as well as brain entry of inflammatory cells under basal conditions and after injuries. The meninges and choroid plexus also link peripheral inflammation (occurring in the metabolic syndrome and after infections) to CNS inflammation which may contribute to the development and progression of a range of CNS neurological and psychiatric disorders. They respond to cytokines generated systemically and secrete cytokines and chemokines that have powerful effects on the brain. The meninges may also provide a stem cell niche in the adult brain which could be harnessed for brain repair. Targeting meningeal and choroid plexus cells with therapeutic agents may provide novel therapies for a range of human brain disorders.