Leptomeningeal carcinomatosis associated with gastric cancer

Malignant transformation and subsequent leptomeningeal carcinomatosis of a gastric polyp in a dog

Progressive carcinogenesis of a gastric polyp with transformation to gastric adenocarcinoma and subsequent development of leptomeningeal carcinomatosis is described in an adult male Scottish terrier. Presenting clinical signs consisted of vomiting with intermittent hematemesis. Surgical biopsies over the course of 14 months documented the progression from gastric polyp to minimally invasive gastric carcinoma to invasive gastric adenocarcinoma, a pathogenesis not previously documented in veterinary oncology. The patient ultimately developed neurologic pathology and was euthanized, and necropsy evaluation identified widespread carcinomatosis with accompanying leptomeningeal metastasis. As in humans, gastric polyps in dogs rarely have malignant potential.

Incidence, clinicopathological characteristics, and therapeutic strategy for gastric cancer patients with metastasis to the central nervous system

AIM

This study aimed to analyze the clinicopathologic features and treatment outcomes of central nervous system (CNS) metastasis from gastric cancer.

METHODS

A total of 419 patients diagnosed with unresectable advanced or recurrent gastric cancer at Kochi Medical School between January 2007 and December 2021 were evaluated. Data of patients were reviewed, and clinicopathological information and survival outcomes of those with CNS metastases were compared to patients without CNS metastases.

RESULTS

In total, 12/419 (2.9%) patients (median age: 66.5 years [range, 41-82 years]) were diagnosed with CNS metastasis from gastric cancer. Eleven had diffuse-type gastric cancer which was significantly more common than in those without CNS metastasis (91% vs. 61%, p = .034). Human epidermal growth factor receptor 2 status was positive in one of the 12 patients. The median survival time was significantly lower for patients with CNS metastasis than for those without CNS metastasis (1.8 months vs. 11.4 months, p < .001). The median survival time for patients who underwent surgical resection, radiation, or chemotherapy for CNS metastasis was significantly higher than those who received only best supportive care (3.5 months vs. .6 months; p = .007).

CONCLUSIONS

CNS metastasis was found in 2.9% (12/419) of patients with unresectable advanced or recurrent gastric cancer. Diffuse-type histology was a risk factor for CNS metastasis. Multidisciplinary treatment, including surgical resection, radiation treatment, or chemotherapy, for CNS metastasis from gastric cancer may benefit selected patients.

Radiotherapy in Leptomeningeal Disease: A Systematic Review of Randomized and Non-randomized Trials

Background: Leptomeningeal disease (LMD), also known as neoplastic meningitis, leptomeningeal carcinomatosis, or carcinomatous meningitis, is a rare cancer complication occurring in ~5% of cases and ultimately leads to significant morbidity and mortality. In the modern era, incidence of this condition continues to rise with longer survival of patients with advanced and even metastatic disease due to continued improvements in systemic therapies that are providing prolonged control of distant disease, but with limited effect in the central nervous system (CNS). Typical treatment strategies include optimal systemic therapy for the primary disease, as well as neuroaxis directed therapies, which may include intrathecal chemotherapy (ITC) or radiotherapy (RT). Methods: A systematic review of radiotherapy for LMD was performed. Medline, EMBASE, and Cochrane databases were searched from 1946 to 2018 for clinical trials, retrospective/prospective reviews, and case series with ≥2 human subjects that used radiation therapy techniques in the treatment of LMD. The outcome measures of interest included: characteristics of trial participants, inclusion/exclusion criteria, study type, number of participants, primary cancer histology, type of intervention for LMD, survival results if reported, length of follow up, and study conclusion. Results: Of 547 unique citations, 62 studies met the pre-specified eligibility criteria. These studies included 36 retrospective cohorts, 11 prospective series, 12 case series, and a single citation of guidelines, NCDB analysis, and a randomized control trial. Owing to study heterogeneity, meta-analyses of the endpoint data could not be performed. Conclusions: LMD is a devastating complication of cancer with reported survivals ranging from 2 to 4 months. Based on this systematic review, the recommendation for the treatment of LMD is for multimodality discussion of cases and treatment, including the use of radiotherapy, for LMD. However, with continued advances in systemic therapy as well as imaging advances, the landscape of LMD is evolving rapidly and the role of RT will likely also continue to evolve and advance. There is limited high-quality evidence to guide the optimal use of RT for the treatment of LMD, and there is a great need for prospective, histology specific investigation of the role of radiotherapy for LMD in the era of modern systemic therapies.

A case of leptomeningeal carcinomatosis in advanced gastric adenocarcinoma with controlled peritoneal dissemination

A 48-year-old man with unresectable gastric cancer and widespread peritoneal dissemination received concentrated ascites reinfusion therapy, followed by systemic chemotherapy. However, leptomeningeal carcinomatosis (LMC) was diagnosed 1 year later. Spinal drainage and ventriculoperitoneal shunting improved the patient's neurological functions for approximately 2 weeks. The patient died 2 months after LMC diagnosis, but these treatments temporarily improved the quality of life during end-of-life care.

Exclusive Cerebellar and Leptomeningeal Metastases from Early Gastric Cancer 14 Months after Proximal Gastrectomy: An Autopsy Case Report

We report a rare autopsy case in which the patient received gastrectomy after an endoscopic diagnosis of early gastric cancer, and had deteriorated due to exclusive metastatic cerebellar tumors identified 14 months after surgery. A 65-year-old male was diagnosed as having a 0-IIc-type early gastric cancer on the posterior wall of the upper stomach by gastrointestinal endoscopy in search of a cause of epigastralgia, and thus received proximal gastrectomy and pyloroplasty. Although the tumor was in the early stages and limited within the mucosal layer, adjuvant chemotherapy was started by using S-1 80 mg daily due to evidence of metastasis into lymph node #3 at the lesser curvature. Evidence of both recurrence and metastases was not detected by CT scans of the chest, abdomen, and pelvis, and the chemotherapy was completed 12 months after surgery. However, the patient was admitted to hospital 14 months postoperatively due to dizziness and gait disturbance. Cranial MRI (Magnetic Resonance Imaging) revealed multiple tumors in the bilateral cerebellar hemispheres with additional leptomeningeal involvement. The patient died 2 weeks after admission. An autopsy revealed metastatic cerebellar tumors and leptomeningeal lesions from the early gastric cancer, and obstructive hydrocephalus due to metastatic cerebellar tumors. To our knowledge, this case is the first report of metastasis exclusive to the cerebellum and leptomeninges from early gastric cancer limited to the mucosal layer.

[A Case of Isolated Leptomeningeal Carcinomatosis from Advanced Gastric Cancer]

Leptomeningeal carcinomatosis (LMC) is rare metastatic form of gastric cancer. Most cases are diagnosed in the final stage after multiple distant metastasis. An 84-year-old woman was admitted with melena, headache and vomiting. Esophagogastroduodenoscopy showed an ulceroinfiltrating lesion at the stomach (Borrmann class III), and biopsy revealed a signet ring cell carcinoma. The abdominal-pelvic CT showed no evidence of metastasis. A sudden decrease of consciousness was noted, but the brain CT showed no active lesion while the brain MRI revealed enhancement of leptomeninges. A lumbar puncture was performed and the cerebrospinal fluid study revealed malignant neoplastic cells. With family consent, no further evaluation and treatment were administered and she died six weeks after the diagnosis of gastric cancer. We report an extremely rare case of a patient who initially presented with neurologic symptoms, and was diagnosed LMC from advanced gastric cancer without any evidence of metastasis in abdomen and pelvis.

Clinicopathological significance of N-cadherin and VEGF in advanced gastric cancer brain metastasis and the effects of metformin in preclinical models

Gastric cancer is the second most common cause of cancer-related death worldwide. Although brain metastasis is a rare complication of gastric cancer, no standard therapy for gastric cancer brain metastasis has been established. We attempted to identify biological markers that predict brain metastasis, and investigated how to modulate such markers. A case-control study of patients newly diagnosed with gastric cancer who had developed brain metastasis during follow-up, was conducted. These patients were compared with patients who had advanced gastric cancer but no evidence of brain metastasis. Immunohistochemistry was used to analyze the expression of E-cadherin, N-cadherin, MSS1, claudin-3, claudin-4, Glut1, clusterin, ITGB4, vascular endothelial growth factor (VEGF), epidermal growth factor receptor (EGFR) and p53. The expression of VEGF tended to be higher in the case group (33.3 vs. 0%, p=0.055). Median survival was significantly correlated with vascular invasion (12 vs. 33 months, p=0.008) and N-cadherin expression (36 vs. 12 months, p=0.027). We also investigated the effects of metformin in tumor-bearing mouse models. VEGF expression was decreased and E-cadherin increased in the metformin‑treated group when compared with the control group. The expression of the mesenchymal marker MMP9 was decreased in the metformin-treated group. Brain metastasis of advanced gastric cancer was associated with the expression of VEGF. Metformin treatment may be useful for modulating the metastatic capacity by reducing VEGF expression and blocking epithelial-to-mesenchymal transition.

Leptomeningeal carcinomatosis of gastric cancer misdiagnosed as vestibular schwannoma

Gastric cancer is one of the most common causes of cancer-related death in Asian countries, including Korea. We experienced a case of leptomeningeal carcinomatosis (LC) from gastric cancer that was originally misdiagnosed as vestibular schwannoma based on the similar radiological characteristics. To our knowledge, LC from gastric cancer is very rare. In conclusion, our experience with this case suggests that clinicians should consider the possibility of delayed leptomeningeal metastasis when treating patients with gastric cancer.

MicroRNA-200 family members and ZEB2 are associated with brain metastasis in gastric adenocarcinoma

Although the incidence of brain metastasis in gastric cancer is relatively low, its prevalence may increase with improved therapy and longer survival tumors. The molecular mechanisms underlying brain metastases are not well understood. To gain insight into the mechanism of brain metastasis, we studied differences in microRNA (miRNA) expression levels in 8 cases of matched primary gastric adenocarcinoma and brain metastatic adenocarcinoma using the Illumina microRNA microarray chip. We identified 6 upregulated and 2 downregulated miRNAs in all 8 cases simultaneously. Interestingly, 2 out of 8 miRNAs (hsa-miR‑141-3p and hsa-miR-200b-3p) belonged to the miR-200 family. Online microRNA database searching revealed that ZEB2 is the top-ranked target gene for hsa-miR141-3p and hsa-miR-200b-3p, prompting us to focus ZEB2 expression in brain metastatic adenocarcinoma. We confirmed that ZEB2 expression was markedly downregulated in some brain metastatic samples. In addition, decreased ZEB2 expression was noted by western blot analysis of 2 metastatic gastric adenocarcinoma cell types that were derived by in vivo selection following intracardiac injection of gastric cancer cell lines. In conclusion, we demonstrate that expression of miRNA-200 family members and ZEB2 are associated with brain metastases of gastric adenocarcinoma, not only in matched patient samples, but also in metastatic cell lines that were derived by in vivo selection.

Leptomeningeal carcinomatosis from gastric cancer: single institute retrospective analysis of 9 cases

PURPOSE

The aim of this study is to investigate the clinical features and outcomes of 9 consecutive patients who suffered with leptomeningeal carcinomatosis (LMC) originating from gastric cancer.

METHODS

Between January 1995 and December 2010, we retrospectively reviewed the medical records of 9 patients with gastric LMC who had been treated at St. Vincent's Hospital, The Catholic University of Korea.

RESULTS

With the exception of 1 patient, the primary gastric cancer was Borrmann type III or IV, and 5 cases had poorly differentiated or signet ring cell histology. TNM stage of the primary gastric cancer was III in 6 patients. The median interval from diagnosis of the primary malignancy to the diagnosis of LMC was 9 months. Headache (6 cases), altered mental status (4 cases), and dysarthria (3 cases) were presenting symptoms of LMC. Computed tomography findings were abnormal in 4 of 7 cases, while magnetic resonance imaging revealed abnormality in 4 of 5 cases. Radiation therapy was administered to 5 patients and intrathecal chemotherapy was administered to only 1 patient. Median overall survival duration from the diagnosis of LMC was 3 months.

CONCLUSION

LMC originating from gastric cancer had a fatal clinical course and treatment strategies remain challenging.

A case of metastatic leptomeningeal carcinomatosis from early gastric carcinoma

Metastatic leptomeningeal carcinomatosis is estimated to occur in 3% to 8% of solid carcinomas. The most common causes of leptomeningeal carcinomatosis are breast cancer, lung cancer and malignant melanoma. Leptomeningeal carcinomatosis associated with gastric cancer, especially in its early stages, is exceedingly rare. Its presenting symptoms include headache, nauseaand seizures. In this report, we describe a case of leptomeningeal metastasis that presented with early-stage gastric cancer. A 67-year-old woman with a history of early-stage gastric cancer in remission was admitted to our hospital with 3 days of headache and nausea. Her gastric cancer had been treated 29 months prior to presentation by a radical subtotal gastrectomy with a Billroth I anastomosis. She had an uneventful recovery until she was diagnosed with metastases to the left axilla and neck 26 months after surgery. Her presenting symptoms of headache and nausea prompted cytologic examination of the cerebrospinal fluid and measurement of tumor markers, which revealed metastatic leptomeningeal carcinomatosis from her gastric cancer. This report aims to raise awareness of the possibility that even early-stage gastric cancer can lead to leptomeningeal carcinomatosis.