CSF CA 15-3 in breast cancer-related leptomeningeal metastases

Leptomeningeal metastatic disease: new frontiers and future directions

Leptomeningeal metastatic disease (LMD), encompassing entities of 'meningeal carcinomatosis', neoplastic meningitis' and 'leukaemic/lymphomatous meningitis', arises secondary to the metastatic dissemination of cancer cells from extracranial and certain intracranial malignancies into the leptomeninges and cerebrospinal fluid. The clinical burden of LMD has been increasing secondary to more sensitive diagnostics, aggressive local therapies for discrete brain metastases, and improved management of extracranial disease with targeted and immunotherapeutic agents, resulting in improved survival. However, owing to drug delivery challenges and the unique microenvironment of LMD, novel therapies against systemic disease have not yet translated into improved outcomes for these patients. Underdiagnosis and misdiagnosis are common, response assessment remains challenging, and the prognosis associated with this disease of whole neuroaxis remains extremely poor. The dearth of effective therapies is further challenged by the difficulties in studying this dynamic disease state. In this Review, a multidisciplinary group of experts describe the emerging evidence and areas of active investigation in LMD and provide directed recommendations for future research. Drawing upon paradigm-changing advances in mechanistic science, computational approaches, and trial design, the authors discuss domain-specific and cross-disciplinary strategies for optimizing the clinical and translational research landscape for LMD. Advances in diagnostics, multi-agent intrathecal therapies, cell-based therapies, immunotherapies, proton craniospinal irradiation and ongoing clinical trials offer hope for improving outcomes for patients with LMD.

Long-term response to sequential anti-HER2 therapies including trastuzumab-deruxtecan in a patient with HER2-positive metastatic breast cancer with leptomeningeal metastases: a case report and review of the literature

The incidence of leptomeningeal metastases (LM) is increasing among breast cancer patients, but their prognosis remains dismal. Many therapeutic options are now available to treat HER2-positive (HER2+) metastatic breast cancer (MBC) involving the central nervous system (CNS). This case report illustrates a long-lasting response of more than 2 years in a patient with HER2+ MBC with LM after sequential administration of systemic and intrathecal (IT) anti-HER2 therapies and highlights that an appropriate treatment of HER2+ LM can result in durable survival.

Evolving management of HER2+ breast cancer brain metastases and leptomeningeal disease

Patients with human epidermal growth factor receptor 2 (HER2)-positive breast cancer are at a particularly high risk of breast cancer brain metastasis (BCBM) and leptomeningeal disease (LMD). Improvements in systemic therapy have translated to improved survival for patients with HER2-positive BCBM and LMD. However, the optimal management of these cases is rapidly evolving and requires a multidisciplinary approach. Herein, a team of radiation oncologists, medical oncologists, neuro-oncologists, and breast surgeon created a review of the evolving management of HER2-positive BCBM and LMD. We assess the epidemiology, diagnosis, and evolving treatment options for patients with HER2-positive BCBM and LMD, as well as the ongoing prospective clinical trials enrolling these patients. The management of HER2-positive BCBM and LMD represents an increasingly common challenge that involves the coordination of local and systemic therapy. Advances in systemic therapy have resulted in an improved prognosis, and promising targeted therapies currently under prospective investigation have the potential to further benefit these patients.

The impact of different preanalytical methods related to CA 15-3 determination in frozen human blood samples: a systematic review

BACKGROUND

The determination of CA 15-3 is useful for monitoring breast cancer patients. Several retrospective studies determined CA 15-3 levels in frozen samples to evaluate the sensitivity and specificity of novel biomarkers in relation to breast cancer; however, freeze-thaw cycles, as well as preanalytical variables before sample storage, are not always reported. Here, we analyzed the current scientific literature to identify possible critical aspects related to CA 15-3 determination in frozen-stored human serum/plasma samples.

METHODS

We obtained data from 4 different bibliographic databases: Web of Science, Embase, PubMed, and Cochrane Library. We followed the PRISMA guidelines to screen and select the eligible articles discussed in the final revision.

RESULTS

Initially, 674 scientific papers were evaluated, and after the application of the screening and eligibility criteria, 18 studies were included in the qualitative synthesis. The analysis reported an important level of heterogeneity concerning the preanalytical phase before sample storage.

CONCLUSION

Although advances in healthcare have been achieved using certified workflows in medical diagnostics, standardized preanalytical processes are not always applied when referring to frozen-stored biosamples. Biobanks will guarantee the best possible conditions for the storage of human biological samples to be used in clinical research. The use of certified bioresources will favor the optimal development and introduction of new disease biomarkers.

Novel methods to diagnose leptomeningeal metastases in breast cancer

Leptomeningeal metastases (LM) in breast cancer patients are rare but often accompanied by devastating neurological symptoms and carry a very poor prognosis, even if treated. To date, two diagnostic methods are clinically used to diagnose LM: gadolinium MRI of the brain and/or spinal cord and cytological examination of cerebrospinal fluid (CSF). Both techniques are, however, hampered by limited sensitivities, often leading to a long diagnostic process requiring repeated lumbar punctures and MRI examinations. To improve the detection rate of LM, numerous studies have assessed new techniques. In this review, we present the current workup to diagnose LM, set out an overview of novel techniques to diagnose LM, and give recommendations for future research.

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.

Breast leptomeningeal disease: a review of current practices and updates on management

PURPOSE

Leptomeningeal disease (LMD) is an advanced metastatic disease presentation portending a poor prognosis with minimal treatment options. The advent and widespread use of new systemic therapies for metastatic breast cancer has improved systemic disease control and extended survival; however, as patients live longer, the rates of breast cancer LMD are increasing.

METHODS

In this review, a group of medical oncologists, radiation oncologists, radiologists, breast surgeons, and neurosurgeons specializing in treatment of breast cancer reviewed the available published literature and compiled a comprehensive review on the current state of breast cancer LMD.

RESULTS

We discuss the pathogenesis, epidemiology, diagnosis, treatment options (including systemic, intrathecal, surgical, and radiotherapy treatment modalities), and treatment response evaluation specific to breast cancer patients. Furthermore, we discuss the controversies within this unique clinical setting and identify potential clinical opportunities to improve upon the diagnosis, treatment, and treatment response evaluation in the management of breast LMD.

CONCLUSIONS

We recognize the shortcomings in our current understanding of the disease and explore the future role of genomic/molecular disease characterization, technological innovations, and ongoing clinical trials attempting to improve the prognosis for this advanced disease state.

Baseline serum/cerebrospinal fluid ratio of carcinoembryonic antigen and carbohydrate antigen series biomarkers in non-neoplastic diseases: a cross-sectional study on 224 patients

BACKGROUND

The measurement of carcinoembryonic antigen, carbohydrate antigen series biomarkers in cerebrospinal fluid (CSF), is useful for the diagnosis of brain metastasis and leptomeningeal metastases to a certain extent. Their serum/CSF ratios may be of benefit to earlier diagnosis and treatment. However, the normal reference values of the ratios were not available. Accordingly, in this study we analyzed the serum/CSF ratios of tumor markers levels in non-neoplastic diseases patients for possible normal values.

MATERIAL AND METHODS

We screened our database for paired CSF and serum samples which have been collected by lumbar puncture. 224 pairs of CSF and serum samples were obtained and compared. The 97.5th percentile, maximum value, and their serum/CSF ratios were obtained.

RESULTS

The 97.5th percentile and maximum value of CSF CEA, CA125, CA19-9, CA15-3, CA724, and CYFRA21-1 concentration for overall participants were 0.572 μ/mL, 4.343 μ/mL, 2.872 μ/mL, 2.108 μ/mL, 1.62 μ/mL, and 1.997 μ/mL, respectively. Gender had no significant difference in these CSF biomarkers except CA15-3. The 97.5th percentile serum/CSF ratio of CEA, CA125, CA19-9, CA15-3, CA724, and CYFRA21-1 level were 34.554, 44.772, 51.232, 20.941, 20.737, and 5.389 respectively. The serum/CSF ratios in different age groups were also described.

CONCLUSIONS

Here, serum/CSF ratios of six tumor markers were determined in non-neoplastic diseases. The usefulness of this index for diagnosis, management, and prognostic utility of leptomeningeal metastases must be validated in larger cohort studies over the long term.

Leptomeningeal metastasis

Leptomeningeal metastasis (LM) results from dissemination of cancer cells to both the leptomeninges (pia and arachnoid) and cerebrospinal fluid (CSF) compartment. Breast cancer, lung cancer, and melanoma are the most common solid tumors that cause LM. Recent approval of more active anticancer therapies has resulted in improvement in survival that is partly responsible for an increased incidence of LM. Neurologic deficits, once manifest, are mostly irreversible, and often have a significant impact on patient quality of life. LM-directed therapy is based on symptom palliation, circumscribed use of neurosurgery, limited field radiotherapy, intra-CSF and systemic therapies. Novel methods of detecting LM include detection of CSF circulating tumor cells and tumor cell-free DNA. A recent international guideline for a standardization of response assessment in LM may improve cross-trial comparisons as well as within-trial evaluation of treatment. An increasing number of retrospective studies suggest that molecular-targeted therapy, such as EGFR and ALK inhibitors in lung cancer, trastuzumab in HER2+ breast cancer, and BRAF inhibitors in melanoma, may be effective as part of the multidisciplinary management of LM. Prospective randomized trials with standardized response assessment are needed to further validate these preliminary findings.

Management of leptomeningeal metastasis in breast cancer

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.

Comparing the performance of CA 15-3 CSF to cytology in a cohort of patients with breast cancer leptomeningeal metastasis

BACKGROUND AND OBJECTIVE

Leptomeningeal metastasis (LM) can occur as a late manifestation of breast cancer and has traditionally been diagnosed by CSF cytology; however, cytology suffers from low sensitivity and it is believed that many cases of LM go undiagnosed. Some studies have suggested the use of CA 15-3 in CSF (CA 15-3 CSF) to aid in the detection of LM. The purpose of this study was to compare the performance of CA 15-3 CSF to cytology for the detection and treatment monitoring of breast cancer LM.

METHODS

CA 15-3 CSF requests between 2014 and 2016 were retrospectively reviewed. Fifty-two measurements from nine patients were from our health system and had corresponding CSF cytology measurements. Concordance between CA 15-3 CSF and CSF cytology was calculated. For patients with quantifiable CA 15-3 CSF, sequential determinations of CA 15-3 and cytology were compared over time to assess correlation of CA 15-3 CSF concentration and cytology with disease status.

RESULTS

At the time of initial testing, seven of the nine patients (78%) had positive cytology. Two samples (22%) had quantifiable CA 15-3, both of which were also positive by cytology. The positive concordance between all cytology and CA 15-3 measurements was 9% (2/22), while negative concordance was 100% (30/30). Sequential CA 15-3 and cytology measurements showed a decrease in CA 15-3 that paralleled changes observed with cytology.

CONCLUSIONS

In this cohort of patients, CA 15-3 CSF performance was neither superior nor complementary to cytology for the detection of LM, nor did the combination of CA 15-3 CSF and cytology improve performance over cytology alone.

Treatment and prognosis of leptomeningeal disease secondary to metastatic breast cancer: A single-centre experience

PURPOSE

Leptomeningeal disease (LMD) is an uncommon complication of advanced breast cancer. The prognosis is poor, and although radiotherapy (RT), systemic and intra-thecal (IT) chemotherapy are accepted treatment modalities, efficacy data are limited. This study was designed to evaluate potential predictors of survival in this patient group.

METHODS

Breast cancer patients with LMD diagnosed by MRI in a 10-year period (2004-2014) were identified from electronic patient records. PFS and OS estimates were calculated using Kaplan-Meier method, with planned sub-group analysis by treatment modality. Cox regression was employed to identify significant prognostic variables.

RESULTS

We identified 182 eligible patients; all female, median age at LMD diagnosis 52.5 years (range 23-80). Ninety patients (49.5%) were ER positive/HER2 negative; 48 (26.4%) were HER2 positive, and 27 (14.8%) were triple negative. HER2 status was unknown in 17 (9.3%). Initial management of LMD was most commonly whole or partial brain RT in 62 (34.1%), systemic therapy in 45 (24.7%) or supportive care alone in 37 (20.3%). Fourteen patients (7.7%) underwent IT chemotherapy, of whom two also received IT trastuzumab. From diagnosis of LMD, the median PFS was 3.9 months (95%CI 3.2-5.0) and median OS was 5.4 months (95%CI 4.2-6.6). Patients treated with systemic therapy had the longest OS (median 8.8 months, 95%CI 5.5-11.1), compared to RT; 6.1 months (95%CI 4.2-7.9 months), IT therapy; 2.9 months (95%CI 1.2-5.8) and supportive care; 1.7 months (95%CI 0.9-3.0). On multivariable analysis, triple negative histology, concomitant brain metastases, and LMD involving both the brain and spinal cord were associated with poor OS.

CONCLUSIONS

Breast cancer patients with triple negative LMD, concomitant brain metastases or LMD affecting both the spine and brain have the poorest prognosis. Clinical trials to identify more effective treatments for these patients are urgently needed.

Leptomeningeal disease: current diagnostic and therapeutic strategies

Leptomeningeal disease has become increasingly prevalent as novel therapeutic interventions extend the survival of cancer patients. Although a majority of leptomeningeal spread occurs secondary to breast cancer, lung cancer, and melanoma, a wide variety of malignancies have been reported as primary sources. Symptoms on presentation are equally diverse, often involving a combination of neurological deficits with the possibility of obstructive hydrocephalus. Diagnosis is definitively made via cerebrospinal fluid cytology for malignant cells, but neuro-imaging with high quality T1-weighted magnetic resonance imaging can aid diagnosis and localization. While leptomeningeal disease is still a terminal, late-stage complication, a variety of treatment modalities, such as intrathecal chemotherapeutics and radiation therapy, have improved median survival from 4–6 weeks to 3–6 months. Positive prognosticative factors for survival include younger age, high performance scores, and controlled systemic disease. In looking to the future, diagnostics that improve early detection and chemotherapeutics tailored to the primary malignancy will likely be the most significant advances in improving survival.

Gadobutrol-enhanced magnetic resonance imaging of meningeal carcinomatosis: case report with emphasis on early diagnosis

Background

Timely diagnosis of meningeal carcinomatosis is often difficult even with the assistant of magnetic resonance imaging examination, cerebrospinal fluid analysis, or both. To the best of our knowledge, gadobutrol-enhanced MRI has not been reported in the diagnosis of meningeal carcinomatosis. Here we present two cases where meningeal carcinomatosis was identified on gadobutrol-enhanced magnetic resonance imaging.

Case presentation

We identified two cases of meningeal carcinomatosis who had been diagnosed with malignant tumors several years ago. Both patients presented with progressive headache and seizures. Gadopentetate dimeglumine-enhanced magnetic resonance imaging of the brain was performed and did not detect any abnormality of meninges. Lumbar puncture was performed repeatedly, but cerebrospinal fluid cytology showed no evidence of malignant cells. Finally the gadobutrol-enhanced magnetic resonance imaging detected the meningeal metastasis, and supported the diagnosis of meningeal carcinomatosis.

Conclusion

Gadobutrol provides higher lesion conspicuity and enhances lesion detection in meningeal metastasis compared with gadopentetate dimeglumine. Our observation is a cue to analyze the accuracy in the diagnosis of meningeal carcinomatosis, and presents a choice that may facilitate early diagnosis.

Treatment of leptomeningeal carcinomatosis: current challenges and future opportunities

Leptomeningeal metastasis (LM) in breast cancer patients confers a uniformly poor prognosis and decreased quality of life. Treatment options are limited and often ineffective, due in large part to limitations imposed by the blood-brain barrier and the very aggressive nature of this disease. The majority of studies investigating the treatment of LM are not specific to site of origin. Conducting randomized, disease-specific clinical trials in LM is challenging, and much clinical outcomes data are based on case reports or retrospective case series. Multiple studies have suggested that chemo-radiotherapy is superior to either chemotherapy or radiation therapy alone. Attempts to overcome current obstacles in the treatment of breast cancer LM hold promise for the future. We review the epidemiology, diagnosis, and prognosis of LM in breast cancer, and discuss the treatment options currently available as well as those under investigation.