Meningeal dissemination from an ovarian carcinoma with effective response to intrathecal chemotherapy

The clinicopathologic significance of psammoma bodies in cytology specimens: A series of 78 cases

BACKGROUND

Currently the clinicopathologic significance of psammoma bodies in cytology specimens are not completely understood, including types of cytology specimens and pathologic conditions frequently associated with this unique cytologic feature. In this study, we undertook a retrospective approach to review the specimen types, cytology preparations, patient characteristics, organs or tissues involved and differential diagnoses in cytology specimens with the finding of psammoma bodies.

METHODS

Cytology cases with the finding of psammoma bodies from January 2004 to December 2022 were retrieved from our institution's pathology databases, and their clinicopathological features were reviewed.

RESULTS

A total of 78 cytology specimens with the finding of psammoma bodies were recorded in our CoPath system. The mean age at diagnosis was 59 years. The patient group showed female gender predominancy (90%). FNA specimens comprised about 38.5% of total cases. Other common specimen types were body cavity fluids (38.5%), including pleural effusion and peritoneal fluid, and about 20.5% of the cases were pelvic washing performed during gynecologic surgeries. Most cytology cases with psammoma bodies had a malignant diagnosis (69%). About 18% of the cases were in the indeterminate diagnostic categories, with 12% suspicious for malignancy and 6% of the cases with atypical cells. About 5% of cases were placed in the neoplastic category, while 8% of cases were negative for malignancy. About 79% of peritoneal cytology with psammoma bodies were neoplastic and mostly gynecologic tumors. Pleural fluids with psammoma bodies were very likely to be malignant and involved by serous carcinoma (15 of 16 cases, 94%). Papillary thyroid carcinoma was the second most common malignancy in our series, present in about 53% of thyroid cytologies with the finding of psammoma bodies.

CONCLUSION

Our study showed that psammoma bodies in cytology preparations were more often associated with malignancies in our study of 78 cytology specimens (69%). The most sampled location in our study was peritoneal cavity, followed by pleural cavity, thyroid, lymph nodes, neck masses, and omentum. The clinicopathologic value of psammoma bodies in predicting malignancy varies depending on locations and specimen types.

A Review on the Efficacy and Safety of Intrathecal Administration of Novel Medications for Leptomeningeal Metastases in Solid Cancers

Leptomeningeal disease (LMD) is a rare and lethal manifestation that may occur in the advanced stages of solid tumors and hematological malignancies. With advances in diagnostic techniques, the detection and confirmation of the presence of LMD have increased. Although its optimal treatment remains a challenge, the use of the intrathecal route for the delivery of novel therapeutics is now considered a promising drug delivery strategy to complement radiation and systemic-based therapies. Although methotrexate, cytarabine, and thiotepa have a long history in the treatment of LMD, other medications have also been shown to be beneficial. In this article, we have reviewed the effects of novel medications administered via the intrathecal route for the treatment of solid tumors. We have searched PubMed, Scopus, and Google Scholar databases till the end of September 2021 using the following keywords: "leptomeningeal disease", "leptomeningeal carcinomatosis", "leptomeningeal metastases", "solid tumors", "solid cancers", and "intrathecal". Our literature findings have uncovered that most studies on LMD, which occurs secondary to solid cancers, are available as 'case reports', and few clinical trials have been conducted to date. Single-drug (monotherapy) or combination drug therapy, administered via the intrathecal route, especially in metastatic breast and lung cancer, has been shown to improve patients' symptoms and overall lifespan, while exhibiting a low and acceptable prevalence of side effects. However, judgments/conclusions about the effectiveness and safety of these drugs still require further clinical evaluation.

Leptomeningeal Carcinomatosis From Primary Mucinous Carcinoma of the Ovary

Leptomeningeal carcinomatosis (LMC) is an extremely rare site for metastasis from a primary ovarian cancer. LMC occurs when the thin layers of tissue that surround the brain and spinal cord are infiltrated by ovarian cancer metastasis. We present a case of a 63-year-old female with recurrent metastatic mucinous adenocarcinoma of the ovary who was diagnosed with LMC. While undergoing sixth-line chemotherapy, she presented with debilitating headaches and gait instability. Brain MRI revealed subarachnoid enhancement and other findings diagnostic of LMC. Given the rarity of this disease, treatment protocols have yet to be established. In patients with primary ovarian cancer that present with new onset neurological complaints, LMC should be suspected and appropriate imaging obtained.

Prolonged Survival and Restored Useful Life by Early Induction of Intrathecal Chemotherapy in a Patient with Leptomeningeal Carcinomatosis from Ovarian Cancer

Leptomeningeal carcinomatosis (LMC) is a rare but devastating complication of advanced cancer. Breast cancer, lung cancer, and melanoma are the three most common causes of LMC, whereas it is rare in ovarian cancer. Here, we report the case of a 59-year-old woman who was diagnosed with LMC from ovarian cancer and was successfully treated with intrathecal chemotherapy via Ommaya reservoir and radiation therapy. The patient had an amelioration of symptoms and prolonged survival. Though LMC from ovarian cancer is thought to be rare, it is not going to remain a rare entity because the incidence of LMC in general is thought to be increasing, which is also the case with ovarian cancer. According to 31 cases whose treatment course is reported in literature, despite the absence of an established treatment for LMC, intrathecal (IT) chemotherapy whose survival benefit has been suggested in past studies might also prolong survival in patients with LMC from ovarian cancer. IT chemotherapy via Ommaya reservoir may be preferred to the lumbar puncture route. The presentation of non-specific symptoms of LMC in patients may hinder its diagnosis; however, early diagnosis and treatment induction is the key for patients' prolonged survival and restored useful life.

Iatrogenic Leptomeningeal Carcinomatosis Following Craniotomy for Resection of Metastatic Serous Ovarian Carcinoma: A Systematic Literature Review and Case Report

Metastasis of ovarian carcinoma to the central nervous system occurs in <2% of cases and classically localizes within the brain parenchyma. Moreover, leptomeningeal spread of these tumors is an exceedingly rare phenomenon. Here, we conduct a systematic review of the current literature on the natural history, treatment options, and proposed pathogenic mechanisms of leptomeningeal carcinomatosis in ovarian carcinoma. We also report a case of a 67-year-old female with stage IV metastatic ovarian serous carcinoma initially confined to the peritoneal cavity with a stable disease burden over the course of three years. Follow-up imaging demonstrated an intracranial lesion, which was resected via craniotomy, and pathology was consistent with the original diagnosis. Three months after surgery, she developed rapidly progressive dizziness, generalized weakness, fatigue, and ataxia. Repeat MRI demonstrated interval development of extensive and diffusely enhancing dural nodularity, numerous avidly enhancing supratentorial and infratentorial lesions, enhancement of the bilateral trigeminal nerves, internal auditory canals, and exit wound from the surgical site into the posterior aspect of the right-sided neck musculature consistent with diffuse leptomeningeal dissemination. The present case highlights that leptomeningeal dissemination of ovarian carcinoma is a potential yet rare consequence following surgical resection of an ovarian parenchymal metastasis. Progressive clinical symptomatology that develops postoperatively in this patient population should prompt urgent workup to rule out leptomeningeal disease and an expedited radiation oncology consultation if identified.

Epithelial Ovarian Carcinoma Associated with Metastases to Central Nervous System: Two Case Reports

We experienced two rare cases of metastases to the central nervous system (cerebral and leptomeningeal metastases) from primary epithelial ovarian carcinoma. The first case was a 55-year-old woman who developed carcinomatous meningitis while on chemotherapy for ovarian cancer stage IIIC. Cytological analysis confirmed carcinomatous cells of ovarian origin in the cerebrospinal fluid. Magnetic resonance imaging demonstrated abnormal hyperintensity in the cerebral sulci on fluid attenuated inversion recovery (FLAIR) sequence with enhanced gadolinium indicating leptomeningeal metastases. Her consciousness rapidly declined and she died 42 days after diagnosis. The second case was a 63-year-old woman who underwent surgery for ovarian cancer and who was diagnosed as stage IA. Thirty-eight months after surgery, she developed weakness of the left hand and headaches. A CT scan revealed metastases to the right cerebrum and she was treated with surgical resection followed by radiotherapy. Five months after resection, she developed ileus caused by multiple relapses in the pelvis. Despite chemotherapy, her performance status declined and she died nine months after the resection. Both cases were rare because the first case was isolated leptomeningeal metastases, and the second case was confirmed relapse site in the cerebrum due to neurological symptoms despite her early clinical stage.

Modeling the Accumulation of Degradable Polymer Drug Carriers in the Brain

The blood-brain barrier (BBB) limits the access of drugs to the brain. Intensive research is being conducted on the development of nanoparticulate drug carriers that mediate transfer across the BBB. A question that has been neglected so far is the potential accumulation of the carrier in the brain upon long-term exposure. Here, we address this question by implementing a kinetic model to relate drug loading, required concentration of drug in the brain, and drug clearance to the degradation half-life of the carrier. As a test case with clinical relevance we chose poly-lactic-co-glycolic-acid (PLGA) as a carrier material and a chemotherapeutic for which the required parameters could be recovered from the literature. For methotrexate with a drug load of 8.5 %, a required concentration of free drug of 1 μm, a release from PLGA of 6 hours, a drug clearance from the brain of 3 hours and a half-life of polymer degradation of 28 days, a steady-state accumulation of 1.3 g polymer would be reached in the brain (1.5 L) after seven months. While this number is surprisingly small, further physiological research is warranted to assess to which degree this will be in a tolerable range.

Ovarian small cell carcinoma complicated by carcinomatous meningitis

Meningeal metastasis is rare in the clinical course of ovarian carcinoma and its prognosis is extremely poor. We experienced a case of carcinomatous meningitis from metastatic ovarian small cell carcinoma. A 33-year-old woman with atypical genital bleeding, was diagnosed with a right ovarian tumor and referred to our department. She underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and lymphadenectomy. It was an optimal debulking surgery. She was diagnosed with ovarian carcinoma classified as Stage IIIc according to the Féderation Internationale de Gynécologie et d'Obstétrique classification system. Histological findings showed small cell carcinoma of the pulmonary type. The tumor was bilateral with paraaortic lymph node involvement. The patient was treated with irinotecan and cisplatin (CPT-P therapy). After 4 courses of CPT-P therapy, multiple liver metastases and Virchow's lymph node metastases were found. She was treated with amrubicin as a second-line chemotherapy, but the treatment was ineffective. Five months after surgery, the patient complained of severe headache and nausea. Lumbar puncture was performed and cytology was positive. Magnetic resonance brain imaging indicated meningeal thickening. The patient was diagnosed with meningeal metastasis and received 19-Gy whole cranial irradiation. In spite of these treatments, her disease progressed rapidly and she was often drowsy. She died of aspiration pneumonia 6 months after surgery.

Leptomeningeal carcinomatosis from ovarian cancer

Ovarian cancer is the most common cause of mortality among women with gynecologic malignancies and the fifth leading cause of death in all women. It usually spreads locally; hematogenous dissemination is rare, most often involving the liver and lungs. Cerebral metastases are reported in less than 2% of cases and tend to localize to the parenchyma, usually in the cerebrum. Leptomeningeal involvement is exceptionally rare. We report a case of a woman with metastatic ovarian cancer who developed leptomeningeal carcinomatosis while receiving systemic chemotherapy. We also provide an extensive review of the existing literature on neoplastic meningitis from ovarian cancer.