1
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Wilcox JA, Chukwueke UN, Ahn MJ, Aizer AA, Bale TA, Brandsma D, Brastianos PK, Chang S, Daras M, Forsyth P, Garzia L, Glantz M, Oliva ICG, Kumthekar P, Le Rhun E, Nagpal S, O'Brien B, Pentsova E, Lee EQ, Remsik J, Rudà R, Smalley I, Taylor MD, Weller M, Wefel J, Yang JT, Young RJ, Wen PY, Boire AA. Leptomeningeal metastases from solid tumors: A SNO and ASCO consensus review on clinical management and future directions. Neuro Oncol 2024:noae103. [PMID: 38902944 DOI: 10.1093/neuonc/noae103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Indexed: 06/22/2024] Open
Abstract
Leptomeningeal metastases are increasingly becoming recognized as a treatable, yet generally incurable, complication of advanced cancer. As modern cancer therapeutics have prolonged the lives of patients with metastatic cancer, specifically in patients with parenchymal brain metastases, treatment options and clinical research protocols for patients with leptomeningeal metastases from solid tumors have similarly evolved to improve survival within specific populations. Recent expansion in clinical investigation, early diagnosis, and drug development have given rise to new unanswered questions. These include leptomeningeal metastasis biology and preferred animal modeling, epidemiology in the modern cancer population, ensuring validation and accessibility of newer leptomeningeal metastasis diagnostics, best clinical practices with multi-modality treatment options, clinical trial design and standardization of response assessments, and avenues worthy of further research. An international group of multi-disciplinary experts in the research and management of leptomeningeal metastases, supported by the Society for Neuro-Oncology and American Society of Clinical Oncology, were assembled to reach a consensus opinion on these pressing topics and provide a roadmap for future directions. Our hope is that these recommendations will accelerate collaboration and progress in the field of leptomeningeal metastases and serve as a platform for further discussion and patient advocacy.
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Affiliation(s)
- Jessica A Wilcox
- Department of Neurology, Brain Tumor Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ugonma N Chukwueke
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Myung-Ju Ahn
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ayal A Aizer
- Department of Radiation Oncology, Brigham and Women's Hospital / Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Tejus A Bale
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Dieta Brandsma
- Department of Neuro-Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Priscilla K Brastianos
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Susan Chang
- Division of Neuro-Oncology, Department of Neurosurgery, University of San Francisco California, San Francisco, CA, USA
| | - Mariza Daras
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | - Peter Forsyth
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Livia Garzia
- Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Toronto, ON, Canada
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - Michael Glantz
- Department of Neurosurgery, Penn State College of Medicine, Hershey, PA, USA
| | - Isabella C Glitza Oliva
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Priya Kumthekar
- The Lou and Jean Malnati Brain Tumor Institute, Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, USA
| | - Emilie Le Rhun
- Departments of Neurology and Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Seema Nagpal
- Division of Neuro-Oncology, Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Barbara O'Brien
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elena Pentsova
- Department of Neurology, Brain Tumor Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Eudocia Quant Lee
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jan Remsik
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Laboratory for Immunology of Metastatic Ecosystems, Center for Cancer Biology, VIB, Leuven, Belgium
- Department of Oncology, KU Leuven, Leuven, Belgium
| | - Roberta Rudà
- Division of Neuro-Oncology, Department of Neuroscience, University and City of Health and Science Hospital, Turin, Italy
- Department of Neurology, Castelfranco Veneto and Treviso Hospitals, Castelfranco Veneto, Italy
| | - Inna Smalley
- Department of Tumor Biology, The Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Michael D Taylor
- Division of Neurosurgery, Department of Surgery, Texas Children's Hospital, Houston, TX, USA Neuro-oncology Research Program, Department of Pediatrics, Section of Hematology-Oncology, Baylor College of Medicine
| | - Michael Weller
- Department of Neurology, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Jeffrey Wefel
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jonathan T Yang
- Department of Radiation Oncology, Department of Radiation Oncology, New York University School of Medicine, New York, NY, USA
| | - Robert J Young
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Patrick Y Wen
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Adrienne A Boire
- Department of Neurology, Brain Tumor Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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2
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Le Rhun E, Weller M, van den Bent M, Brandsma D, Furtner J, Rudà R, Schadendorf D, Seoane J, Tonn JC, Wesseling P, Wick W, Minniti G, Peters S, Curigliano G, Preusser M. Leptomeningeal metastasis from solid tumours: EANO-ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up. ESMO Open 2023; 8:101624. [PMID: 37863528 PMCID: PMC10619142 DOI: 10.1016/j.esmoop.2023.101624] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 07/03/2023] [Accepted: 07/28/2023] [Indexed: 10/22/2023] Open
Abstract
•This Clinical Practice Guideline provides recommendations for managing leptomeningeal metastases from solid tumours. •The guideline covers clinical, imaging and cytological diagnosis, staging and risk assessment, treatment and follow-up. •A treatment and management algorithm is provided. •The author panel encompasses a multidisciplinary group of experts from different institutions and countries in Europe. •Recommendations are based on available scientific data and the authors’ collective expert opinion.
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Affiliation(s)
- E Le Rhun
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland; Department of Neurology, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - M Weller
- Department of Neurology, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - M van den Bent
- Department of The Brain Tumour Center at the Erasmus MC Cancer Institute, Rotterdam
| | - D Brandsma
- Department of Neuro-Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - J Furtner
- Research Center for Medical Image Analysis and Artificial Intelligence (MIAAI), Faculty of Medicine and Dentistry, Danube Private University, Krems, Austria
| | - R Rudà
- Division of Neuro-Oncology, Department of Neuroscience, University of Turin, Turin, Italy
| | - D Schadendorf
- Department of Dermatology, University Hospital Essen, Essen; University of Duisburg-Essen, Essen; German Cancer Consortium (DKTK), Partner Site Essen, Essen, Germany
| | - J Seoane
- Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron University Hospital (HUVH), Universitat Autònoma de Barcelona, Institució Catalana de Recerca i Estudis Avançats (ICREA), CIBERONC, Barcelona, Spain
| | - J-C Tonn
- Department of Neurosurgery, Ludwig-Maximilians-University School of Medicine, Munich; German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - P Wesseling
- Department of Pathology, Amsterdam University Medical Centers/VUmc and Brain Tumour Center, Amsterdam; Princess Máxima Center for Paediatric Oncology, Utrecht, The Netherlands
| | - W Wick
- Neurology Clinic, Heidelberg University Hospital, Heidelberg; Clinical Cooperation Unit Neuro-Oncology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Centre (DKFZ), Heidelberg, Germany
| | - G Minniti
- Department of Radiological Sciences, Oncology and Anatomical Pathology, Sapienza University of Rome, Policlinico Umberto I, Rome; IRCCS Neuromed, Pozzilli IS, Italy
| | - S Peters
- Department of Oncology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne University, Lausanne, Switzerland
| | - G Curigliano
- European Institute of Oncology, IRCCS, Milan; Department of Oncology and Hemato-Oncology, University of Milano, Milan, Italy
| | - M Preusser
- Division of Oncology, Department of Medicine 1, Medical University, Vienna, Austria
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3
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Ozcan G, Singh M, Vredenburgh JJ. Leptomeningeal Metastasis from Non-Small Cell Lung Cancer and Current Landscape of Treatments. Clin Cancer Res 2023; 29:11-29. [PMID: 35972437 DOI: 10.1158/1078-0432.ccr-22-1585] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/06/2022] [Accepted: 08/11/2022] [Indexed: 02/06/2023]
Abstract
Leptomeningeal metastasis (LM), also known as leptomeningeal carcinomatosis (LC), is a devastating complication of metastatic cancer that occurs when neoplastic cells invade the meningeal space. Diagnosis of LM remains challenging given the heterogeneous signs and symptoms at presentation and requires thorough neurological examination, cerebrospinal fluid (CSF) analysis, and MRI of the brain and spine with gadolinium. Detecting neoplastic cells in the CSF is the gold standard for diagnosing leptomeningeal metastases; however, it has low sensitivity and may require multiple CSF samples. New emerging technologies, such as liquid biopsy of CSF, have increased sensitivity and specificity for detecting circulating tumor cells in CSF. The management of LM in patients with NSCLC requires an individualized multidisciplinary approach. Treatment options include surgery for ventricular shunt placement, radiation therapy to bulky or symptomatic disease sites, systemic or intrathecal chemotherapy, molecularly targeted agents, and, more recently, immunotherapy. Targeting actionable mutations in LM from NSCLC, such as EGFR tyrosine kinase inhibitors or anaplastic lymphoma kinase gene rearrangement inhibitors, has shown encouraging results in terms of disease control and survival. Although there are limited data regarding the use of immunotherapy in LM, immunotherapy has produced promising results in several case reports. In this review, we focused on the epidemiology, pathophysiology, clinical presentation, diagnosis, and current treatment strategies, with a special emphasis on novel agents, including targeted therapies and immunotherapy of LM in patients with NSCLC.
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Affiliation(s)
- Gonca Ozcan
- Department of Medicine, University of Connecticut Health Center, Farmington, Connecticut
| | - Meghana Singh
- Department of Medicine, University of Connecticut Health Center, Farmington, Connecticut
| | - James J Vredenburgh
- Department of Medicine, Division of Hematology-Oncology, Saint Francis Hospital, Hartford, Connecticut
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Neratinib and Capecitabine for the Treatment of Leptomeningeal Metastases from HER2-Positive Breast Cancer: A Series in the Setting of a Compassionate Program. Cancers (Basel) 2022; 14:cancers14051192. [PMID: 35267501 PMCID: PMC8909342 DOI: 10.3390/cancers14051192] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 02/15/2022] [Accepted: 02/24/2022] [Indexed: 02/05/2023] Open
Abstract
Simple Summary Leptomeningeal metastases represent an unmet need due to the lack of effective therapy and poor survival. The tyrosine kinase inhibitor, neratinib, has demonstrated promising activity against brain metastases from HER2-positive breast cancer, as reported by the TBCRC and NALA trials, thus suggesting a potential activity also in leptomeningeal metastases when associated with capecitabine. The aim of the study was to investigate the efficacy and tolerability of neratinib in association with capecitabine in leptomeningeal metastases from heavily-pretreated breast cancer patients who failed multiple lines of treatment. Primary endpoints were 6-month overall survival and intracranial progression-free survival. Secondary endpoints were the responses assessed by whole CNS MRI performed every 8 weeks, neurological improvement, and safety. We obtained a median overall survival of 10 months, an intracranial progression-free survival of 4 months, neurological improvement and stable disease on an MRI lasting 6.5 months in six patients (60%). These preliminary findings suggest a potential activity of this treatment in LM from HER2-positive breast cancer that needs to be further investigated in larger datasets. Abstract Background: Leptomeningeal metastasis is a neurological complication from HER2-positive breast cancer with a poor prognosis and limited treatment options. This study has evaluated the activity of neratinib in association with capecitabine in 10 patients with LM from HER2-positive BC after the failure of multiple lines of treatment, including trastuzumab-based therapy, within a compassionate program, and a comparison was made with a historical control group of 10 patients. Methods: Patients aged ≥ 18 years with histological diagnosis of primary HER2-positive BC, either amplified or mutated, and newly-diagnosed LM were enrolled. Coexistence of BM that has or has not received radiotherapy, as well as prior chemotherapy, hormone therapy, or monoclonal HER2-targeting antibodies or antibody–drug conjugates, were allowed, with the exclusion of lapatinib. Results: Six-months OS was 60% with a median OS of 10 months (95% CI: 2.00–17.0). Three-month intracranial PFS was 60% with a median intracranial PFS of 4.0 months (95% CI: 2.00–6.0). The neurological benefit was observed in 70% of patients with a median duration of neurological response of 6.5 months. The best radiological response was stable disease in 60% of patients. Conclusions: This small series shows that the combination of neratinib and capecitabine is a safe treatment in LM from heavily pretreated HER2-positive BC with clinical efficacy in some patients and is worth investigating in a larger study.
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Comlek S, Saglam S. A new approach for leptomeningeal metastases: chemotherapy administered through lumbar intrathecal port. ARQUIVOS DE NEURO-PSIQUIATRIA 2021; 79:816-823. [PMID: 34669821 DOI: 10.1590/0004-282x-anp-2020-0554] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 02/28/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Intrathecal chemotherapy is a local therapeutic modality used for treatment of leptomeningeal metastases. However, the techniques currently used, i.e. repeated lumbar puncture and Ommaya reservoir, have certain disadvantages. Lumbar intrathecal port (LIP) placement is a relatively novel technique, which has been used for pain management in cancer patients. OBJECTIVE To investigate the use of LIP for intrathecal administration of chemotherapeutic agents in patients with leptomeningeal metastases. METHODS Retrospective study of 13 patients treated with intrathecal chemotherapy for secondary leptomeningeal involvement of a primary solid tumor were included in this retrospective study. The patients received intrathecal chemotherapy through a LIP. RESULTS The patients received a total of 123 intrathecal chemotherapy doses. No grade 3-4 toxicity, technical problem or severe complication developed. During a median of 136 days of follow-up (range, 67-376 days), 12 patients died (92.3%). The treatment resulted in symptom improvement in all patients and self-rated overall health and quality of life improved, compared with baseline. CONCLUSIONS The LIP system, which has been used for intrathecal pain management for decades, appears to offer a safe alternative for intrathecal chemotherapy in patients with leptomeningeal metastases. Further studies are warranted to clarify its potential use in this setting.
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Affiliation(s)
- Savas Comlek
- Gayrettepe Florence Nightingale Hastanesi, Department of Anesthesiology and Reanimation, Istanbul, Turkey
| | - Sezer Saglam
- Demiroglu Bilim Üniversitesi, Department of Medical Oncology, Istanbul, Turkey
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6
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Sondhi D, Kaminsky SM, Hackett NR, Pagovich OE, Rosenberg JB, De BP, Chen A, Van de Graaf B, Mezey JG, Mammen GW, Mancenido D, Xu F, Kosofsky B, Yohay K, Worgall S, Kaner RJ, Souwedaine M, Greenwald BM, Kaplitt M, Dyke JP, Ballon DJ, Heier LA, Kiss S, Crystal RG. Slowing late infantile Batten disease by direct brain parenchymal administration of a rh.10 adeno-associated virus expressing CLN2. Sci Transl Med 2021; 12:12/572/eabb5413. [PMID: 33268510 DOI: 10.1126/scitranslmed.abb5413] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 11/11/2020] [Indexed: 12/11/2022]
Abstract
Late infantile Batten disease (CLN2 disease) is an autosomal recessive, neurodegenerative lysosomal storage disease caused by mutations in the CLN2 gene encoding tripeptidyl peptidase 1 (TPP1). We tested intraparenchymal delivery of AAVrh.10hCLN2, a nonhuman serotype rh.10 adeno-associated virus vector encoding human CLN2, in a nonrandomized trial consisting of two arms assessed over 18 months: AAVrh.10hCLN2-treated cohort of 8 children with mild to moderate disease and an untreated, Weill Cornell natural history cohort consisting of 12 children. The treated cohort was also compared to an untreated European natural history cohort of CLN2 disease. The vector was administered through six burr holes directly to 12 sites in the brain without immunosuppression. In an additional safety assessment under a separate protocol, five children with severe CLN2 disease were treated with AAVrh.10hCLN2. The therapy was associated with a variety of expected adverse events, none causing long-term disability. Induction of systemic anti-AAVrh.10 immunity was mild. After therapy, the treated cohort had a 1.3- to 2.6-fold increase in cerebral spinal fluid TPP1. There was a slower loss of gray matter volume in four of seven children by MRI and a 42.4 and 47.5% reduction in the rate of decline of motor and language function, compared to Weill Cornell natural history cohort (P < 0.04) and European natural history cohort (P < 0.0001), respectively. Intraparenchymal brain administration of AAVrh.10hCLN2 slowed the progression of disease in children with CLN2 disease. However, improvements in vector design and delivery strategies will be necessary to halt disease progression using gene therapy.
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Affiliation(s)
- Dolan Sondhi
- Department of Genetic Medicine, Weill Cornell Medical College, New York, NY 10065, USA
| | - Stephen M Kaminsky
- Department of Genetic Medicine, Weill Cornell Medical College, New York, NY 10065, USA
| | - Neil R Hackett
- Department of Genetic Medicine, Weill Cornell Medical College, New York, NY 10065, USA
| | - Odelya E Pagovich
- Department of Genetic Medicine, Weill Cornell Medical College, New York, NY 10065, USA
| | - Jonathan B Rosenberg
- Department of Genetic Medicine, Weill Cornell Medical College, New York, NY 10065, USA
| | - Bishnu P De
- Department of Genetic Medicine, Weill Cornell Medical College, New York, NY 10065, USA
| | - Alvin Chen
- Department of Genetic Medicine, Weill Cornell Medical College, New York, NY 10065, USA
| | - Benjamin Van de Graaf
- Department of Genetic Medicine, Weill Cornell Medical College, New York, NY 10065, USA
| | - Jason G Mezey
- Department of Genetic Medicine, Weill Cornell Medical College, New York, NY 10065, USA.,Department of Biological Statistics and Computational Biology, Cornell University, Ithaca, NY 14853, USA
| | - Grace W Mammen
- Department of Genetic Medicine, Weill Cornell Medical College, New York, NY 10065, USA
| | - Denesy Mancenido
- Department of Genetic Medicine, Weill Cornell Medical College, New York, NY 10065, USA
| | - Fang Xu
- Department of Genetic Medicine, Weill Cornell Medical College, New York, NY 10065, USA
| | - Barry Kosofsky
- Department of Pediatrics, Weill Cornell Medical College, New York, NY 10065, USA
| | - Kaleb Yohay
- Department of Pediatrics, Weill Cornell Medical College, New York, NY 10065, USA
| | - Stefan Worgall
- Department of Genetic Medicine, Weill Cornell Medical College, New York, NY 10065, USA.,Department of Pediatrics, Weill Cornell Medical College, New York, NY 10065, USA
| | - Robert J Kaner
- Department of Genetic Medicine, Weill Cornell Medical College, New York, NY 10065, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY 10065, USA
| | - Mark Souwedaine
- Department of Neurological Surgery, Weill Cornell Medical College, New York, NY 10065, USA
| | - Bruce M Greenwald
- Department of Pediatrics, Weill Cornell Medical College, New York, NY 10065, USA
| | - Michael Kaplitt
- Department of Neurological Surgery, Weill Cornell Medical College, New York, NY 10065, USA
| | - Jonathan P Dyke
- Department of Radiology, Weill Cornell Medical College, New York, NY 10065, USA
| | - Douglas J Ballon
- Department of Genetic Medicine, Weill Cornell Medical College, New York, NY 10065, USA.,Department of Radiology, Weill Cornell Medical College, New York, NY 10065, USA
| | - Linda A Heier
- Department of Radiology, Weill Cornell Medical College, New York, NY 10065, USA
| | - Szilard Kiss
- Department of Ophthalmology, Retina Service, Weill Cornell Medical College, New York, NY 10065, USA
| | - Ronald G Crystal
- Department of Genetic Medicine, Weill Cornell Medical College, New York, NY 10065, USA. .,Department of Medicine, Weill Cornell Medical College, New York, NY 10065, USA
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7
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Ganau M, Magdum SA, Calisto A. Pre-operative imaging and post-operative appearance of standard paediatric neurosurgical approaches: a training guide for neuroradiologists. Transl Pediatr 2021; 10:1231-1243. [PMID: 34012863 PMCID: PMC8107881 DOI: 10.21037/tp-20-484] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
A short-cut narrative review was conducted according to the SANRA guidelines to identify studies describing normal and abnormal postoperative radiological features of the most common paediatric neurosurgical procedures. Rather than focusing on the original pathology addressed by neurosurgical means, this review explored three main areas of operative neurosurgery: ventricular access, supratentorial & infratentorial craniotomies, and posterior fossa/craniocervical junction decompression. A total of twenty-three landmark papers were included for review based on their relevance to address the research question and serve as a practical guide for paediatric neuroradiology trainees and fellows. Accurate in text referencing of the ClinicalTrials.gov identifier, and weblink, has also been provided for all trials discussed in the results section. All the above is complemented by relevant iconography meant to describe a wide range of postoperative changes and early complications. Finally, the review is enriched by a discussion touching upon haemostatic agents, intentionally retained foreign bodies and the future of machine learning for neuroradiology reporting. Overall, the information presented in a systematic fashion will not only help trainees and fellows to deepen these topics and expand their knowledge in preparation for written and oral boards, but will also represent a useful resource for everyone including trained neuroradiologists and neurosurgeons themselves.
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Affiliation(s)
- Mario Ganau
- Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Shailendra A Magdum
- Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Amedeo Calisto
- Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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8
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Anton S, Margold M, Kowalski T, Miller D, Schmieder K, Schlegel U, Seidel S. Complications of intracerebroventricular chemotherapy via subgaleal reservoir in primary central nervous system lymphoma: A single-institution experience on 1247 installations in 94 consecutive patients. Hematol Oncol 2021; 39:176-184. [PMID: 33316084 DOI: 10.1002/hon.2833] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 11/09/2020] [Accepted: 12/09/2020] [Indexed: 11/09/2022]
Abstract
The implantation of a subgaleal reservoir intracerebroventricular (ICV port) in order to apply ICV chemotherapy in patients with leptomeningeal cancer may be complicated by misplacement of the device, pericatheter leucencephalopathy, hemorrhage and iatrogenic ventriculitis/meningitis. Here we analyzed the occurrence of such complications in patients with primary central nervous system lymphoma (PCNSL) treated with systemic and ICV methotrexate- and cytarabine-based chemotherapy. We retrospectively reviewed the medical records of 94 consecutive patients (1247 installations), who had received an ICV port for intraventricular chemotherapy for treatment of histologically confirmed PCNSL at our institution between September 2005 and October 2018. Infectious and noninfectious complications were systematically recorded including clinical, laboratory, and imaging data. In 9/94 patients (9.6%), a misplacement of the ICV port seen on the postoperative computed tomography scan was corrected immediately and chemotherapy was then continued as planned. In 5/94 patients (5.3%), symptomatic noninfectious complications were observed (four patients with symptomatic pericatheter leucencephalopathy and one patient with surgical scar dehiscence with CSF leak). In 8/94 patients (8.5%), asymptomatic white matter lesions around the catheter were visible on cerebral magnetic resonance imaging after completion of therapy. The rate of infectious complications was 6/94 patients (6.4%). No complication was lethal or required intensive care monitoring. This retrospective study shows that complications of ICV treatment have to be expected in a fraction of patients, however, in this series these complications were manageable and did not result in long-term deficits.
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Affiliation(s)
- Seena Anton
- Department of Neurology, Knappschaftskrankenhaus University of Bochum, Bochum, Germany
| | - Michelle Margold
- Department of Neurology, Knappschaftskrankenhaus University of Bochum, Bochum, Germany
| | - Thomas Kowalski
- Department of Neurology, Knappschaftskrankenhaus University of Bochum, Bochum, Germany
| | - Dorothea Miller
- Department of Neurosurgery, Knappschaftskrankenhaus University of Bochum, Bochum, Germany
| | - Kirsten Schmieder
- Department of Neurosurgery, Knappschaftskrankenhaus University of Bochum, Bochum, Germany
| | - Uwe Schlegel
- Department of Neurology, Knappschaftskrankenhaus University of Bochum, Bochum, Germany
| | - Sabine Seidel
- Department of Neurology, Knappschaftskrankenhaus University of Bochum, Bochum, Germany
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9
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Lin Y, Li H, Huang M, Guo A, Yin Z. [Use of Ommaya Reservoirs to Deliver Pemetrexed in Leptomeningeal Metastasis from Non-small Cell Lung Cancer: A Case Report and Review of the Literature]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2020; 22:546-550. [PMID: 31451148 PMCID: PMC6717864 DOI: 10.3779/j.issn.1009-3419.2019.08.12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
软脑膜转移(leptomeningeal metastasis, LM)是非小细胞肺癌(non-small cell lung cancer, NSCLC)最严重的并发症之一。随着靶向药物的发展,LM发病率逐年上升,目前缺乏标准有效的治疗方案。鞘内化疗是治疗LM的一种重要方法,但对于NSCLC伴LM,现有的经鞘内途径给化疗药物治疗效果有限,最佳的药物、给药途径、给药模式和剂量仍不清楚。本文报道1例NSCLC伴LM患者,经奥希替尼治疗病情进展后,予培美曲塞经Ommaya囊脑室内化疗,颅内病灶得到较好控制,脑脊液(cerebrospinal fluid, CSF)细胞学转为阴性,同时患者耐受良好,生活质量明显改善,病情长时间内维持稳定,从确诊LM后随访至今已17个月。本文报道了国内外第一例关于经Ommaya囊鞘内注射培美曲塞治疗NSCLC患者LM的临床案例,并结合相关文献总结了鞘内化疗的安全性及有效性,为临床提供了一种LM局部治疗的新策略。
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Affiliation(s)
- Yongjuan Lin
- Department of Geriatric Oncology, Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School,
Nanjing 210008, China
| | - Huiying Li
- Department of Geriatric Oncology, Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School,
Nanjing 210008, China
| | - Mingmin Huang
- Department of Geriatric Oncology, Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School,
Nanjing 210008, China
| | - Aibin Guo
- Department of Geriatric Oncology, Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School,
Nanjing 210008, China
| | - Zhenyu Yin
- Department of Geriatric Oncology, Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School,
Nanjing 210008, China
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10
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Operative Complications with and without Image Guidance: A Systematic Review and Meta-Analysis of the Ommaya Reservoir Literature. World Neurosurg 2019; 122:404-414. [DOI: 10.1016/j.wneu.2018.11.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 11/02/2018] [Accepted: 11/04/2018] [Indexed: 11/24/2022]
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11
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Franzoi MA, Hortobagyi GN. Leptomeningeal carcinomatosis in patients with breast cancer. Crit Rev Oncol Hematol 2019; 135:85-94. [PMID: 30819451 DOI: 10.1016/j.critrevonc.2019.01.020] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 01/26/2019] [Accepted: 01/26/2019] [Indexed: 12/11/2022] Open
Abstract
Leptomeningeal carcinomatosis (LC) is defined as infiltration of the leptomeninges by metastatic carcinoma, a relatively uncommon but devastating complication of many malignancies. Although only 5% of patients with breast cancer develop leptomeningeal involvement, it remains the most common etiology of LC. It can occur as a late-stage complication of systemic progression or present as the first sign of metastatic disease, with or without parenchymal brain metastases. Lobular carcinomas have a higher propensity to metastasize into the meninges when compared to ductal carcinoma, especially the triple-negative subtype, which usually is associated with a shorter interval between metastatic breast cancer diagnosis and the development of LC. Prognosis remains poor, with median survival of 4 months for patients receiving state-of-the-art treatment. The main factors associated with survival are performance status at diagnosis, CSF protein level and triple-negative subtype. Headache is commonly the first clinical presentation of LC, and the diagnostic workup usually requires CSF-cytological analysis and or/MRI. The current management of LC consists of a combination of intra-CSF chemotherapy, systemic therapy, radiotherapy and/or best-supportive care. The standard intra-CSF chemotherapy regimen is methotrexate. Radiotherapy is used for relieving obstruction points on CSF-outflow channels due to ependymal nodules, tumor deposits or bulky disease. Objective responses have been reported with intrathecal administration of trastuzumab for HER2-positive disease, yet this strategy is still under investigation. Further prospective trials are needed to better address the impact of these treatment modalities on overall survival and quality of life.
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Affiliation(s)
| | - Gabriel N Hortobagyi
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Abstract
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.
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Le Rhun E, Taillibert S, Chamberlain MC. Neoplastic Meningitis Due to Lung, Breast, and Melanoma Metastases. Cancer Control 2018; 24:22-32. [DOI: 10.1177/107327481702400104] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Emilie Le Rhun
- Division of Neuro-Oncology, Departments of Neurology and
Neurological Surgery, University of Washington School of Medicine, Seattle,
Washington
- Department of Neurosurgery, University Hospital, the Breast
Unit, Departments of Neurology and Neurological Surgery, University of Washington School of
Medicine, Seattle, Washington
| | - Sophie Taillibert
- Department of Medical Oncology, Oscar Lambret Center, Lille
Cedex, France, the Division of Neuro-Oncology, Departments of Neurology and Neurological
Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Marc C. Chamberlain
- Departments of Neurology, and Radiation Oncology,
Pitié-Salpétrière Hospital, Assistance Publique des Hôpitaux de Paris, Université Pierre et
Marie Curie, Paris, France, and the Department of Neurology, Fred Hutchinson Cancer Research
Center, Seattle Cancer Care Alliance, and Division of Neuro-Oncology, Departments of
Neurology and Neurological Surgery, University of Washington School of Medicine, Seattle,
Washington
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Pellerino A, Bertero L, Rudà R, Soffietti R. Neoplastic meningitis in solid tumors: from diagnosis to personalized treatments. Ther Adv Neurol Disord 2018. [PMID: 29535794 PMCID: PMC5844521 DOI: 10.1177/1756286418759618] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Neoplastic meningitis (NM) is a devastating complication of solid tumors with poor outcome. Some randomized clinical trials have been conducted with heterogeneous inclusion criteria, diagnostic parameters, response evaluation and primary endpoints. Recently, the Leptomeningeal Assessment in Neuro-Oncology (LANO) Group and the European Society for Medical Oncology/European Association for Neuro-Oncology have proposed some recommendations in order to provide diagnostic criteria and response evaluation scores for NM. The aim of these guidelines is to integrate the neurological examination with magnetic resonance imaging and cerebrospinal fluid findings as well as to provide a framework for use in clinical trials. However, this composite assessment needs further validation. Since intrathecal therapy represents a treatment with limited efficacy in NM, many studies have been conducted on systemic therapies, including target therapies, with some encouraging results in terms of disease control. In this review, we have analyzed the clinical aspects and the most recent diagnostic tools and therapeutic options in NM.
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Affiliation(s)
- Alessia Pellerino
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Via Cherasco 15, Turin, 10126 Italy
| | - Luca Bertero
- Section of Pathology, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Roberta Rudà
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
| | - Riccardo Soffietti
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
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Durand B, Zairi F, Boulanger T, Bonneterre J, Mortier L, Le Rhun E. Chemical meningitis related to intra-CSF liposomal cytarabine. CNS Oncol 2017; 6:261-267. [PMID: 29057672 PMCID: PMC6004879 DOI: 10.2217/cns-2016-0046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 05/03/2017] [Indexed: 12/29/2022] Open
Abstract
Therapeutic options of leptomeningeal metastases include intra-cerebrospinal fluid (CSF) chemotherapy. Among intra-CSF agents, liposomal cytarabine has advantages but can induce specific toxicities. A BRAF-V600E-mutated melanoma leptomeningeal metastases patient, treated by dabrafenib and liposomal cytarabine, presented after the first injection of liposomal cytarabine with hyperthermia and headaches. Despite sterile CSF/blood analyses, extended intravenous antibiotics were given and the second injection was delayed. The diagnosis of chemical meningitis was finally made. Dose reduction and appropriate symptomatic treatment permitted the administration of 15 injections of liposomal cytarabine combined with dabrafenib. A confirmation of the diagnosis of chemical meningitis is essential in order (1) not to delay intra-CSF or systemic chemotherapy or (2) to limit the administration of unnecessary but potentially toxic antibiotics.
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Affiliation(s)
- Bénédicte Durand
- Lille University, F-59000 Lille, France
- Oscar Lambret Center, Medical Oncology Department, F-59000 Lille, France
| | - Fahed Zairi
- Lille University, F-59000 Lille, France
- Inserm, U-1192, F-59000 Lille, France
- CHU Lille, Neurosurgery Department, F-59000Lille, France
| | - Thomas Boulanger
- Oscar Lambret Center, Department of Radiology, F-59000 Lille, France
| | - Jacques Bonneterre
- Lille University, F-59000 Lille, France
- Oscar Lambret Center, Medical Oncology Department, F-59000 Lille, France
| | - Laurent Mortier
- Lille University, F-59000 Lille, France
- CHU Lille, Dermatology Department, F-59000Lille, France
| | - Emilie Le Rhun
- Lille University, F-59000 Lille, France
- Oscar Lambret Center, Medical Oncology Department, F-59000 Lille, France
- Inserm, U-1192, F-59000 Lille, France
- CHU Lille, Neurosurgery Department, F-59000Lille, France
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Abstract
Among the various routes of drug administration, perhaps the least studied is intracerebroventricular (ICV) administration. This route has been shown to be particularly useful in administering to the central nervous system (CNS) drugs that do not cross the blood-brain barrier readily. As such, the ICV route is a valuable option for providing therapeutic CNS drug concentrations to treat patients with CNS infectious and neoplastic diseases. This route of drug administration also has the advantage of minimizing systemic toxicity.
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Affiliation(s)
- Arthur J Atkinson
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University Chicago, Illinois, USA
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Le Rhun E, Weller M, Brandsma D, Van den Bent M, de Azambuja E, Henriksson R, Boulanger T, Peters S, Watts C, Wick W, Wesseling P, Rudà R, Preusser M. EANO-ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up of patients with leptomeningeal metastasis from solid tumours. Ann Oncol 2017; 28:iv84-iv99. [PMID: 28881917 DOI: 10.1093/annonc/mdx221] [Citation(s) in RCA: 236] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Affiliation(s)
- E Le Rhun
- Neuro-Oncology, Department of Neurosurgery, Lille University Hospital, Lille
- Neurology, Medical Oncology Department, Oscar Lambret Center, Lille
- Lille University, Inserm U-1192, Villeneuve d'Ascq, France
| | - M Weller
- Department of Neurology and Brain Tumour Center, University Hospital, Zurich, Switzerland
| | - D Brandsma
- Department of Neuro-Oncology, Netherlands Cancer Institute, Amsterdam
| | - M Van den Bent
- The Brain Tumour Center at the Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - E de Azambuja
- Medical Oncology Department, Institut Jules Bordet and L'Université Libre de Bruxelles (U.L.B), Brussels, Belgium
| | - R Henriksson
- Regional Cancer Center, Stockholm
- Department of Radiation Sciences and Oncology, University, Umea, Sweden
| | - T Boulanger
- Neuroradiology, Imaging Department, Oscar Lambret Center, Lille, France
| | - S Peters
- Department of Oncology, University Hospital, Lausanne, Switzerland
| | - C Watts
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - W Wick
- Neurology Clinic, Heidelberg University Hospital, Heidelberg
- Clinical Cooperation Unit Neuro-Oncology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Centre (DKFZ), Heidelberg, Germany
| | - P Wesseling
- Department of Pathology, VU University Medical Centre and Brain Tumour Center, Amsterdam
- Department of Pathology, Princess Máxima Center for Paediatric Oncology and University Medical Centre Utrecht, Utrecht, The Netherlands
| | - R Rudà
- Department of Neuro-Oncology, City of Health and Science Hospital, University of Turin, Turin, Italy
| | - M Preusser
- Clinical Division of Oncology, Department of Medicine 1, CNS Unit Comprehensive Cancer Centre (CCC-CNS), Medical University, Vienna, Austria
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18
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Diagnosis and treatment patterns for patients with leptomeningeal metastasis from solid tumors across Europe. J Neurooncol 2017; 133:419-427. [PMID: 28455788 DOI: 10.1007/s11060-017-2452-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 04/24/2017] [Indexed: 10/19/2022]
Abstract
Leptomeningeal metastases are a late manifestation of systemic cancer which affects up to 10% of patients with solid tumors. Prognosis is poor, and overall survival at 1 year is only approximately 10%. Management depends mainly on general and neurological condition, primary tumor, and patterns of metastasis, notably absence or presence of concurrent systemic or solid brain metastases. Here we set out to characterize current practice patterns of diagnosis and treatment of patients with leptomeningeal metastasis in Europe. We prepared a web-based survey including 25 simple or multiple choices questions on best practice supplemented by eight case vignettes with various diagnosis and management options. The survey was sent to the membership of the European Association of Neuro-Oncology and the European Organisation for Research and Treatment of Cancer Brain Tumor Group. Between April 7, 2016 and August 8, 2016, 224 colleagues from 26 countries initiated the survey, 115 colleagues completed the whole survey. There were major differences both in the general diagnostic and therapeutic approach, e.g., regarding the use of cerebrospinal fluid (CSF) flow studies, intra-CSF chemotherapy, various types of radiotherapy, and even more so when selecting decisions on diagnostic and therapeutic measures for single case vignettes. Diagnosis and treatment decisions for patients with leptomeningeal metastasis from solid tumors vary widely across Europe. Standardization of diagnosis and evaluation tools as well as controlled studies to improve the level of evidence for all therapeutic approaches to LM are required.
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Pardo-Moreno J, Fernández C, Arroyo R, Ruiz-Ocaña C, Aláez C, Cuadrado ML. Safety of intra-cerebrospinal fluid chemotherapy in onco-haematological patients: a retrospective analysis of 627 interventions. J Neurooncol 2015; 125:351-8. [PMID: 26342710 DOI: 10.1007/s11060-015-1922-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 08/29/2015] [Indexed: 01/30/2023]
Abstract
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.
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Affiliation(s)
- Javier Pardo-Moreno
- Department of Neurology, Hospital Rey Juan Carlos, Universidad Rey Juan Carlos, C/Gladiolo s/n, Móstoles, 28933, Madrid, Spain.
| | - Cristina Fernández
- Department of Preventive Medicine, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria San Carlos, Universidad Complutense, Madrid, Spain
| | - Rafael Arroyo
- Department of Neurology, Hospital Quirón Madrid, Pozuelo de Alarcón, Madrid, Spain.,Department of Neurology, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria San Carlos, Universidad Complutense, Madrid, Spain
| | - Carlos Ruiz-Ocaña
- Department of Neurosurgery, Hospital Quirón Madrid, Pozuelo de Alarcón, Madrid, Spain
| | - Concepción Aláez
- Department of Haematology, Hospital Quirón Madrid, Pozuelo de Alarcón, Madrid, Spain
| | - María-Luz Cuadrado
- Department of Neurology, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria San Carlos, Universidad Complutense, Madrid, Spain
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