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Khaled ML, Ren Y, Kundalia R, Alhaddad H, Chen Z, Wallace GC, Evernden B, Ospina OE, Hall M, Liu M, Darville LN, Izumi V, Chen YA, Pilon-Thomas S, Stewart PA, Koomen JM, Corallo SA, Jain MD, Robinson TJ, Locke FL, Forsyth PA, Smalley I. Branched-chain keto acids promote an immune-suppressive and neurodegenerative microenvironment in leptomeningeal disease. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.12.18.572239. [PMID: 38187773 PMCID: PMC10769272 DOI: 10.1101/2023.12.18.572239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
Leptomeningeal disease (LMD) occurs when tumors seed into the leptomeningeal space and cerebrospinal fluid (CSF), leading to severe neurological deterioration and poor survival outcomes. We utilized comprehensive multi-omics analyses of CSF from patients with lymphoma LMD to demonstrate an immunosuppressive cellular microenvironment and identified dysregulations in proteins and lipids indicating neurodegenerative processes. Strikingly, we found a significant accumulation of toxic branched-chain keto acids (BCKA) in the CSF of patients with LMD. The BCKA accumulation was found to be a pan-cancer occurrence, evident in lymphoma, breast cancer, and melanoma LMD patients. Functionally, BCKA disrupted the viability and function of endogenous T lymphocytes, chimeric antigen receptor (CAR) T cells, neurons, and meningeal cells. Treatment of LMD mice with BCKA-reducing sodium phenylbutyrate significantly improved neurological function, survival outcomes, and efficacy of anti-CD19 CAR T cell therapy. This is the first report of BCKA accumulation in LMD and provides preclinical evidence that targeting these toxic metabolites improves outcomes.
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Affiliation(s)
- Mariam Lotfy Khaled
- The Department of Metabolism and Physiology, The Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL, USA
- Department of Biochemistry, Faculty of Pharmacy, Cairo University, Egypt
| | - Yuan Ren
- The Department of Metabolism and Physiology, The Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL, USA
| | - Ronak Kundalia
- The Department of Metabolism and Physiology, The Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL, USA
| | - Hasan Alhaddad
- The Department of Metabolism and Physiology, The Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL, USA
| | - Zhihua Chen
- Department of Biostatistics and Bioinformatics, The Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL, USA
| | - Gerald C. Wallace
- Department of Hematology/Oncology, Georgia Cancer Center at Medical College of Georgia, Augusta, GA, USA
| | - Brittany Evernden
- Department of Neuro Oncology, The Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL, USA
| | - Oscar E. Ospina
- Department of Biostatistics and Bioinformatics, The Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL, USA
| | - MacLean Hall
- Department of Immunology, The Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL, USA
| | - Min Liu
- The Proteomics and Metabolomics Core, The Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL, USA
| | - Lancia N.F. Darville
- The Proteomics and Metabolomics Core, The Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL, USA
| | - Victoria Izumi
- The Proteomics and Metabolomics Core, The Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL, USA
| | - Y. Ann Chen
- Department of Biostatistics and Bioinformatics, The Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL, USA
| | - Shari Pilon-Thomas
- Department of Immunology, The Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL, USA
| | - Paul A. Stewart
- Department of Biostatistics and Bioinformatics, The Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL, USA
| | - John M. Koomen
- The Proteomics and Metabolomics Core, The Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL, USA
- Department of Molecular Oncology, The Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL, USA
| | - Salvatore A. Corallo
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, The Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL, USA
| | - Michael D. Jain
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, The Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL, USA
| | - Timothy J. Robinson
- Therapeutic Radiology, Smilow Cancer Hospital at Yale New Haven, 35 Park Street, New Haven, CT, USA
| | - Fredrick L. Locke
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, The Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL, USA
| | - Peter A. Forsyth
- Department of Neuro Oncology, The Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL, USA
- The Department of Tumor Biology, The Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL, USA
| | - Inna Smalley
- The Department of Metabolism and Physiology, The Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL, USA
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Omori M, Ogawa T, Oyama K, Tagaya H, Fukasawa H, Hirata S. Leptomeningeal metastasis from cervical cancer: Report of two cases and a review of the literature. J Obstet Gynaecol Res 2021; 47:2782-2789. [PMID: 34002430 DOI: 10.1111/jog.14825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 04/02/2021] [Accepted: 04/30/2021] [Indexed: 12/01/2022]
Abstract
Leptomeningeal metastases from cervical cancer are extremely rare, with only 24 cases reported in the English-language literature. Leptomeningeal metastasis (LM) is usually a late event, but it can develop at any stage. A 44-year-old woman presented with vertigo, tinnitus, diminution of hearing, and a cervical tumor at the initial visit. She underwent whole brain radiotherapy and systemic chemotherapy. Five months after the initial visit, her condition deteriorated rapidly and she died. A 49-year-old woman underwent surgery and pelvic radiotherapy for cervical cancer. She underwent resection of lung metastases 2 years later and received systemic chemotherapy for lymph node metastases 4 years later. Five years after the initial visit, the patient suddenly presented with diplopia, headache, and vomiting; her clinical course was fulminant and she died. Most patients with LM present with diverse clinical manifestations and deteriorate rapidly despite multiple treatment modalities. Gynecologic oncologists should be aware of this rare complication.
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Affiliation(s)
- Makiko Omori
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Tatsuyuki Ogawa
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Keisuke Oyama
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Hikaru Tagaya
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Hiroko Fukasawa
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Shuji Hirata
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
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Mitsuya K, Nakasu Y, Hayashi N, Deguchi S, Takahashi T, Murakami H, Naito T, Kenmotsu H, Ono A, Wakuda K, Harada H. Palliative cerebrospinal fluid shunting for leptomeningeal metastasis-related hydrocephalus in patients with lung adenocarcinoma: A single-center retrospective study. PLoS One 2019; 14:e0210074. [PMID: 30629621 PMCID: PMC6328154 DOI: 10.1371/journal.pone.0210074] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 12/17/2018] [Indexed: 11/18/2022] Open
Abstract
PURPOSE Management of leptomeningeal metastasis-related hydrocephalus (LM-H) is particularly challenging regarding the control of severe headache, nausea, and vomiting due to intracranial hypertension. To investigate the improvements of performance status and outcome with cerebrospinal fluid (CSF) shunt surgery for LM-H in patients with lung adenocarcinoma. METHODS Data on patients with leptomeningeal metastasis-related hydrocephalus from lung adenocarcinoma diagnosed by MR imaging and/or cytological examination were retrospectively analyzed. Between August 2008 and July 2017, the authors reviewed 31 patients requiring CSF shunt, who underwent ventriculo-peritoneal or lumbo-peritoneal shunt. RESULTS The patients consisted of 11 men and 20 women with a median age of 59 years. Twenty-six patients received EGFR-tyrosine kinase inhibitors (TKIs). CSF shunt surgery yielded rapid improvement in the performance status of 90.3% of patients. Median overall survival from the diagnosis of LM in patients with ECOG performance status less than 2 was 7.7 months, and this was significantly longer than those in patients with PS 3 or 4 (4.4 or 1.5 months; p<0.001). Multivariate analysis by Cox regression revealed survival differences according to PS at diagnosis of LM [PS 1-3 vs. PS4, hazard ratio (HR) 0.201, p = 0.034], controlled extracranial disease (HR 0.248, p = 0.005), and post-shunt EGFR-TKI for LM treatment (HR 0.193, p = 0.008). Postoperative symptomatic peritoneal carcinomatosis was observed in one patient (3.2%). CONCLUSION CSF shunting may be a safe and effective strategy in patients with LM-H from lung adenocarcinoma. A prospective study is needed to establish the effectiveness and safety of palliative CSF shunt for LM-H.
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Affiliation(s)
- Koichi Mitsuya
- Division of Neurosurgery, Shizuoka Cancer Center, Shizuoka, Japan
- * E-mail:
| | - Yoko Nakasu
- Division of Neurosurgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Nakamasa Hayashi
- Division of Neurosurgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Shoichi Deguchi
- Division of Neurosurgery, Shizuoka Cancer Center, Shizuoka, Japan
| | | | - Haruyasu Murakami
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Tateaki Naito
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | | | - Akira Ono
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kazushige Wakuda
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Hideyuki Harada
- Division of Radiation Oncology, Shizuoka Cancer Center, Shizuoka, Japan
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Abstract
Metastatic cancer to the central nervous system is primarily deposited by hematogenous spread in various anatomically distinct regions: calvarial, pachymeningeal, leptomeningeal, and brain parenchyma. A patient's overall clinical status and the information needed to make treatment decisions are the primary considerations in initial imaging modality selection. Contrast-enhanced MR imaging is the preferred imaging modality. Morphologic MR imaging is limited to delineating anatomic deraignment of tissues. Dynamic susceptibility contrast-enhanced perfusion and diffusion-weighted physiology-based MR imaging sequences have been developed that complement morphologic MR imaging by providing additional diagnostic information.
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Affiliation(s)
- Ramon Francisco Barajas
- Departments of Radiology and Advanced Imaging Research Center, Oregon Health and Science University, 3181 South West Sam Jackson Park Road, Portland, OR 97239, USA
| | - Soonmee Cha
- Departments of Neurological Surgery, Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus Avenue, Long L200B, Box 0628, San Francisco, CA 94143, USA.
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Perillyl Alcohol and Its Drug-Conjugated Derivatives as Potential Novel Methods of Treating Brain Metastases. Int J Mol Sci 2016; 17:ijms17091463. [PMID: 27598140 PMCID: PMC5037741 DOI: 10.3390/ijms17091463] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 08/22/2016] [Accepted: 08/26/2016] [Indexed: 12/02/2022] Open
Abstract
Metastasis to the central nervous system remains difficult to treat, and such patients are faced with a dismal prognosis. The blood-brain barrier (BBB), despite being partially compromised within malignant lesions in the brain, still retains much of its barrier function and prevents most chemotherapeutic agents from effectively reaching the tumor cells. Here, we review some of the recent developments aimed at overcoming this obstacle in order to more effectively deliver chemotherapeutic agents to the intracranial tumor site. These advances include intranasal delivery to achieve direct nose-to-brain transport of anticancer agents and covalent modification of existing drugs to support enhanced penetration of the BBB. In both of these areas, use of the natural product perillyl alcohol, a monoterpene with anticancer properties, contributed to promising new results, which will be discussed here.
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Le Rhun E, Kramar A, Salingue S, Girot M, Rodrigues I, Mailliez A, Zairi F, Bakhache E, Robin YM, Taillibert S, Dubois F, Bonneterre J, Chamberlain MC. CSF CA 15-3 in breast cancer-related leptomeningeal metastases. J Neurooncol 2014; 117:117-24. [PMID: 24469852 DOI: 10.1007/s11060-014-1361-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 01/06/2014] [Indexed: 12/27/2022]
Abstract
UNLABELLED The sensitivity of CSF cytology, the standard method for diagnosis of leptomeningeal metastases (LM), is low. Serum cancer antigen 15-3 (CA 15-3) is frequently used for the monitoring of patients with breast cancer (BC) and is a laboratory test available in most centers. The aim of the current study was to determine the feasibility of measuring CSF CA 15-3 and CA 15-3 CSF/serum ratio in patients with BC-related LM. Serum and CSF CA 15-3 values were evaluated in 20 BC patients with LM (Group 1), 20 patients with LM from other primary cancers (Group 2), 20 BC patients with parenchymal brain metastases only (Group 3) and 20 controls (Group 4). CSF and serum were collected on the same day. Serum and CSF CA 15-3 were assessed by an automatized immuno-enzymatic technology (TRACE(®) technology, KRYPTOR Automate, Brahms Society, France). In univariate analysis, BC patients with LM (Group 1) compared to other groups, a significantly elevated serum CA 15-3 (median 51 U/ml, range 12-2819) and CSF CA 15-3 (median 8.7 U/ml, range 0.1-251) was observed. Additionally, the CSF/serum ratio of CA 15-3 was significantly higher in this group of patients (median 0.18, range 0.002-4.40). Multivariate analysis identified a cut-off for CSF CA15-3 with 80 % sensitivity and 70 % specificity. CONCLUSIONS The current study confirms the feasibility of determining CSF CA 15-3 using a widely available technology. Evaluation of the CSF CA 15-3 may be useful in the diagnosis and management of BC-related LM but further studies are needed.
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Affiliation(s)
- Emilie Le Rhun
- Breast Unit, Department of Medical Oncology, Oscar Lambret Center, 59 020, Lille Cedex, France,
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Shahideh M, Fallah A, Munoz DG, Loch Macdonald R. Systematic review of primary intracranial glioblastoma multiforme with symptomatic spinal metastases, with two illustrative patients. J Clin Neurosci 2012; 19:1080-6. [PMID: 22704945 DOI: 10.1016/j.jocn.2011.09.024] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Revised: 09/25/2011] [Accepted: 09/30/2011] [Indexed: 11/18/2022]
Abstract
Glioblastoma multiforme is a malignant tumour with a universally fatal diagnosis. We report two patients with glioblastoma with symptomatic metastasis to the spinal cord and perform a systematic review all 35 reports of symptomatic glioblastoma dissemination to the spinal leptomeninges and/or intramedullary spinal axis. Our analysis of the data shows a median time to spinal metastasis of 10 months and a median time of three months from spinal metastasis to death. Treatments described include palliative laminectomies, radiotherapy and chemotherapy. No treatment strategy offered a therapeutic advantage as patients deteriorated rapidly regardless of intervention. Patients who underwent only a biopsy for intracranial glioblastoma had a shorter time to development of spinal metastasis. In addition, there may be an association between intramedullary metastasis and shorter survival. This paper highlights the importance of considering symptomatic spinal dissemination in glioblastoma multiforme. We also review the incidence and postulate mechanisms of tumour dissemination in the central nervous system. Clearly, further research into radiotherapeutic and chemotherapeutic options in this clinical setting is required.
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Affiliation(s)
- Mehdi Shahideh
- Division of Neurosurgery, St. Michael's Hospital, Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael's Hospital and Department of Surgery, University of Toronto, 30 Bond Street, Toronto, Ontario, Canada M5B 1W8
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Fakhry C, Bajaj G, Aygun N, Westra W, Gillison M. Long-term survival of a patient with leptomeningeal involvement by nasopharyngeal carcinoma after treatment with high-dose intravenous methotrexate. Head Neck 2012; 34:296-300. [PMID: 20737501 PMCID: PMC3715067 DOI: 10.1002/hed.21516] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Revised: 04/30/2010] [Accepted: 05/13/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Nasopharyngeal carcinoma with leptomeningeal involvement is rare and typically has poor prognosis. METHODS AND RESULTS We present a case report of a patient with nasopharyngeal carcinoma who was treated with high-dose intravenous methotrexate and remains asymptomatic and without clinical evidence of disease 6 years later. CONCLUSIONS Systemic high-dose methotrexate should be evaluated in the treatment of advanced nasopharyngeal carcinoma with central nervous involvement.
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Affiliation(s)
- Carole Fakhry
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Gopal Bajaj
- Department of Radiation Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nafi Aygun
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - William Westra
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Maura Gillison
- Department of Medicine, Division of Hematology and Oncology, Ohio State University, Columbus, Ohio
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Heiss JD, Taha S, Oldfield EH, Ram Z. Intrathecal gene therapy for treatment of leptomeningeal carcinomatosis. J Neurooncol 2010; 104:365-9. [PMID: 21110219 DOI: 10.1007/s11060-010-0458-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2010] [Accepted: 11/08/2010] [Indexed: 01/11/2023]
Abstract
Leptomeningeal carcinomatosis occurs occasionally in patients with solid malignancies and carries a poor prognosis despite treatment with systemic chemotherapy and/or radiotherapy. We describe the case of a 43 year old man who presented with leptomeningeal carcinomatosis secondary to malignant melanoma. The patient received intraventricular delivery of NIH3T3 producer cells expressing the thymidine kinase (HSV-Tk1) gene via a retroviral vector followed by intravenous ganciclovir. He experienced abrupt and severe meningeal irritation and hyperpyrexia immediately after injection of the producer cells into the ventricular CSF. Vector producer cells (VPC) survived and were detected by NeoR marker gene expression in the CSF for a week, until a single dose of ganciclovir (GCV) was followed by a decline in the copy number of the NeoR marker gene to undetectable levels over 24 h. This decline upon introduction of ganciclovir suggests effective distribution of ganciclovir to producer cells bearing the HSV-Tk gene. The patient survived 9 months after treatment. Side-effects from the treatment included acute hyperpyrexia which was short-lived and medically manageable.
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Affiliation(s)
- John D Heiss
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, 10 Center Drive, 10-3D20, MSC-1414, Bethesda, MD 20892-1414, USA.
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Porto L, Kieslich M, Bartels M, Schwabe D, Zanella FE, Du Mesnil R. Leptomeningeal metastases in pediatrics: magnetic resonance image manifestations and correlation with cerebral spinal fluid cytology. Pediatr Int 2010; 52:541-6. [PMID: 20534022 DOI: 10.1111/j.1442-200x.2010.03171.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Detection of leptomeningeal metastases is fundamental to a complete evaluation of central nervous system (CNS) or non-CNS tumor with suspected involvement of the neuroaxis. Our purpose was to assess the appearances of different magnetic resonance (MR) sequences in the diagnosis of leptomeningeal metastases and correlate those positive findings with the cerebral spinal fluid (CSF) cytology results. METHODS The authors reviewed the medical records and MR image manifestations of leptomeningeal metastases from 18 children who had positive MR findings and retrospectively correlated them with CSF cytologic results. There was a uniform MR protocol and the patients were examined with the same sequences. RESULTS The abnormalities included pial-arachnoid disease (n = 16), disease coating the nerves (n = 12), hydrocephalus (n = 3) and subependymal metastases (n = 2). Enhanced T1 images were better than unenhanced fluid attenuated inversion recovery (FLAIR) and T2 to delineate cranial and spinal leptomeningeal metastases. In our sample, seven out of 18 cases were cytologically negative on a single lumbar puncture. CONCLUSIONS Contrast-enhanced MR imaging can be invaluable, detecting the false-negative lumbar punctures. FLAIR and diffusion images can be helpful in diagnosing leptomeningeal metastases of non-enhancing primary tumors. Prognosis was more related to the primary tumor type than to the leptomeningeal enhancement MR pattern.
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Affiliation(s)
- Luciana Porto
- Department of Neuroradiology, Institut fur Neuroradiologie, Klinikum der Johann Wolfgang Goethe-Universitat, Schleusenweg, Frankfurt am Main, Germany.
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Walbert T, Groves MD. Known and emerging biomarkers of leptomeningeal metastasis and its response to treatment. Future Oncol 2010; 6:287-97. [DOI: 10.2217/fon.09.167] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Leptomeningeal metastasis (LM) is the metastatic dissemination of malignant cells to the leptomeninges and the subarachnoid space of the CNS, affecting approximately 8% of all cancer patients. Cerebrospinal fluid cytology is currently the gold standard for diagnosis of LM and assessment of treatment response, but it has relatively low sensitivity. Thus, specific biomarkers of LM may allow for earlier diagnosis and treatment. This article reviews known tumor markers for LM and describes recent work to find LM-specific markers, such as angiogenesis-related proteins. Novel methods of protein profiling that may aid this search are also described; these methods still need to be standardized and validated to gain widespread acceptance. Nevertheless, we anticipate that future biomarkers will have not only the potential to detect LM, but to predict its progression and response to treatment.
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Affiliation(s)
- Tobias Walbert
- Department of Neuro-Oncology, Unit 431, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030-4009, USA
| | - Morris D Groves
- Department of Neuro-Oncology, Unit 431, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030-4009, USA
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Yamakawa H, Ariga H, Enomoto A, Netsu S, Suzuki Y, Konno R. Meningeal dissemination from an ovarian carcinoma with effective response to intrathecal chemotherapy. Int J Clin Oncol 2009; 14:447-51. [PMID: 19856055 DOI: 10.1007/s10147-008-0846-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2007] [Accepted: 10/06/2008] [Indexed: 11/30/2022]
Abstract
Meningeal dissemination is rare in the clinical course of ovarian carcinoma, and its prognosis is poor. Although it is treated by the intrathecal administration of methotrexate (MTX) and/or total brain irradiation, these treatments are usually ineffective. We report a 58-year-old woman with stage IIIc ovarian cancer who had received nine courses of adjuvant chemotherapy after surgery. But her carbohydrate antigen (CA) 125 serum level had increased further (38.9 U/ml) after five courses of biweekly paclitaxel (Taxol; Bristol-Myers Squibb, Tokyo, Japan; BT) maintenance therapy. Fainting occurred, with a few seconds of unconsciousness, as did severe headaches. However, results of head computed tomography (CT), head magnetic resonance imaging, and electroencephalogram were normal. Lumbar puncture (LP) was performed. The opening pressure was 30 cmH2O or greater. Meningeal dissemination of the ovarian cancer was diagnosed, as adenocarcinoma cells were found by cerebrospinal fluid (CSF) cytology. We started chemotherapy with intrathecal injections of MTX and hydrocortisone acetate. Establishing a diagnosis of carcinomatous meningitis may be difficult. Clinical signs and biological data are not conclusive. In this patient, CSF cytology was very effective in establishing the diagnosis, and the intrathecal administration of MTX and hydrocortisone was very effective.
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Affiliation(s)
- Hiromitsu Yamakawa
- Department of Gynecology, Jichi Medical University Saitama Medical Center, Omiya-ku, Saitama, Japan
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Balaji R, Ramachandran K, Kusumakumari P. Neuroimaging patterns of central nervous system metastases in neuroblastoma: report of 2 recent cases and literature review. J Child Neurol 2009; 24:1290-3. [PMID: 19564645 DOI: 10.1177/0883073809333532] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The authors describe imaging patterns of intracranial metastases in 2 children with grade 4 neuroblastoma. Central nervous system metastases from neuroblastoma are extremely rare and may involve the cerebral parenchyma, leptomeninges, or dura. Cerebral parenchymal metastases can be cystic with mural nodules or solid with hemorrhagic elements. The first patient in our study had multiple cystic parenchymal metastases with calcific mural nodules, while the second patient developed solid hemorrhagic parenchymal metastatic lesions along with extensive leptomeningeal and dural deposits. Central nervous system involvement in both patients occurred within a time span ranging from 12 to 14 months from the time of initial diagnosis.
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Affiliation(s)
- Ravikanth Balaji
- Imageology Division, Regional Cancer Centre, Medical College PO, Trivandrum, Kerala, India.
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Narita Y, Shibui S. Strategy of surgery and radiation therapy for brain metastases. Int J Clin Oncol 2009; 14:275-80. [PMID: 19705236 DOI: 10.1007/s10147-009-0917-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2009] [Indexed: 11/30/2022]
Abstract
Cancer patients with brain metastases have poor prognoses and their median survival time is about 1 year. Surgery with whole-brain radiation therapy (WBRT) has been used in the treatment of single brain metastasis measuring 3 cm or more. Stereotactic radiosurgery (SRS) including the use of the Gamma knife and Cyberknife is widely used for the treatment of small and multiple brain metastases; however, recent clinical studies have revealed that SRS + WBRT is superior to WBRT or SRS alone in terms of survival time and local tumor control rates. Here, surgical indications and the strategy of surgery and radiation therapy are discussed, based on many clinical trials of treatments for brain metastases. To improve the survival rate and quality of life for these cancer patients with brain metastases, it is necessary to choose the most suitable mode of surgery and radiotherapy with the close cooperation of physicians, surgeons, radiologists, and neurosurgeons, based on accumulated evidence.
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Affiliation(s)
- Yoshitaka Narita
- Neurosurgery Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan.
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Breivik KL, Laurini R, Steen R, Alstadhaug KB. [A 61-year-old man with sciatica]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2009; 129:1000-2. [PMID: 19448754 DOI: 10.4045/tidsskr.09.33160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
A 61-year-old man was admitted to our department with radicular back-pain and progressive gait-difficulties. On examination he had flaccid paraparesis and bladder-retention. He subsequently developed palsy of n. oculomotorius, dysarthria, right-sided Bells palsy and weakness of his right arm over a 4-week period. He became disoriented and died without a diagnosis. MRI of the brain and columna were negative. Extensive search for malignancies yielded negative results. Cytology specimens were inconclusive and repeated liquor-examinations showed very low glucose levels, mild pleocytosis, elevated protein. Autopsy revealed a small adenocarcinoma of the lung and meningeal carcinomatosis originating from the adenocarcinoma.
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Ramenofsky DH, Weissman DE. Cardiopulmonary Resuscitation Survival in the Hospital Setting # 179. J Palliat Med 2009; 12:89-90. [DOI: 10.1089/jpm.2009.9652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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20
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Corsini E, Bernardi G, Gaviani P, Silvani A, de Grazia U, Ciusani E, Croci D, Salmaggi A. Intrathecal synthesis of tumor markers is a highly sensitive test in the diagnosis of leptomeningeal metastasis from solid cancers. Clin Chem Lab Med 2009; 47:874-9. [DOI: 10.1515/cclm.2009.183] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Hsieh PC, Wu CT, Lin KL, Jaing TH, Tseng CK, Lui TN, Jung SM. The clinical experience of medulloblastoma treatment and the significance of time sequence for development of leptomeningeal metastasis. Childs Nerv Syst 2008; 24:1463-7. [PMID: 18802711 DOI: 10.1007/s00381-008-0697-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2008] [Indexed: 10/21/2022]
Abstract
OBJECTS Among patients with medulloblastoma, an unrare aggressive central nervous system (CNS) tumor found mostly in the posterior fossa, drop metastasis from primary location to anatomically lower sites including whole spinal cord is known as a potential way for tumor to spread. There were already lots of extensive discussions regarding diagnosis and treatment for such common neurologic complication in systemic cancer; however, fewer were found about medulloblastoma. This study aimed to reexamine the possible known prognostic factors, especially drop metastasis, and defined the influence of them. MATERIALS AND METHODS We retrospectively review a series of 36 patients who suffered from posterior fossa medulloblastoma and found leptomeningeal metastasis in 12 of them. Incidence, diagnosis, prognostic factors, and treatments for this common complication are discussed. The magnetic resonance images (MRI) of these patients were reviewed. The time sequence between primary surgical procedure and development of MRI evidences of drop metastasis was used for subgrouping. Log-rank test was used for survival analysis. CONCLUSIONS By survival analysis, patients with late drop metastasis, defined as new radiologic evidence of leptomeningeal involvement after primary CNS procedures, were found to have significant survival difference to those with early metastasis defined as drop metastasis found at the time of diagnosis (log-rank test, p = 0.0047). Further stratification of patients within this group may help in evaluation of prognosis and development of different treatment strategies.
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Affiliation(s)
- Po-Chuan Hsieh
- Department of Neurosurgery, Chang Gung Memorial Hospital, No. 5, Fu-Shin Street, Kwei-Shan, Taoyuan, 333, Taiwan, Republic of China.
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Chuang TY, Yu CJ, Shih JY, Yang PC, Kuo SH. Cytologically Proven Meningeal Carcinomatosis in Patients with Lung Cancer: Clinical Observation of 34 Cases. J Formos Med Assoc 2008; 107:851-6. [DOI: 10.1016/s0929-6646(08)60201-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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23
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Taithe F, Dionet E, Durif F. Atteinte diffuse du deuxième motoneurone révélant une méningite carcinomateuse. Rev Neurol (Paris) 2006; 162:1002-6. [PMID: 17028569 DOI: 10.1016/s0035-3787(06)75111-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Between 4 and 15% of solid cancers are associated with carcinomatous meningitis ant its unfavorable prognosis. The clinical presentation of neoplastic meningitis typically associates cerebral signs, cranial nerve involvement, and medullary or radicular symptoms. OBSERVATION We report a case of a 58-year-old woman, with a history of breast cancer in remission since 8 years, who presented an acute paraparesia and a pure motor deficit of the left arm. This diffuse lower motor neuron disease was the inaugural sign of carcinomatous meningitis. CONCLUSION The diagnosis of cacinomatous meningitis is based on medullar MRI and lumbar puncture. In same cases, clinical signs are limited to a pure diffuse lower motor neuron disease.
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Affiliation(s)
- F Taithe
- Fédération de Neurologie, CHU Gabriel Montpied, 63000 Clermont-Ferrand, France.
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Brandsma D, Voest EE, de Jager W, Bonfrer H, Algra A, Boogerd W, Korse T, Reijneveld JC, Verbeek MM, Rijkers G, Taphoorn MJB. CSF protein profiling using Multiplex Immuno-assay. J Neurol 2006; 253:1177-84. [PMID: 16998648 DOI: 10.1007/s00415-006-0187-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2005] [Accepted: 12/13/2005] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The diagnosis of leptomeningeal metastases (LM) is based on clinical symptoms, magnetic resonance imaging (MRI) of brain and spine and cytological analysis of cerebrospinal fluid (CSF). The clinical picture of LM is highly variable and both cytological CSF analysis and contrast-enhanced MRI are limited in sensitivity. More sensitive tools are needed to diagnose LM. We measured a profile of proteins involved in adhesion and inflammation in the CSF of LM and control patients and determined their potential diagnostic value for LM. PATIENTS AND METHODS Using Multiplex Immuno-Assay (MIA), the CSF concentrations of nine soluble adhesion molecules, cyto- and chemokines were measured in patients with cytologically proven LM (n = 57) and control patients with a systemic malignancy (n = 20), aseptic/viral meningitis (n = 11) or other (non-)neurological diseases (n = 19). RESULTS We found high CSF levels of soluble Vascular Cell Adhesion Molecule-1 (sVCAM-1), soluble Intercellular Adhesion Molecule-1 (sICAM-1), Interleukin-8 (IL-8), Pulmonary and Activation Regulated Chemokine (PARC), Interleukin-18 (IL-18) and Interferon-gamma inducible protein (IP-10) in patients with LM. The CSF protein profile in LM patients differed significantly from the profile found in control patients. Multivariate logistic regression and ROC analysis showed that the MIA-measured CSF protein profile has an additive discriminating value for LM above standard CSF parameters. A combination of total protein, glucose, IL-8, PARC and IP-10 CSF levels proved to be most discriminative between LM and non-LM patients. CONCLUSION Our results warrant a prospective study to determine whether a CSF protein profile, including IL-8, PARC and IP-10 has diagnostic value compared with CSF cytology, the golden standard for LM.
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Affiliation(s)
- Dieta Brandsma
- Department of Neurology, G03.228, University Medical Center Utrecht, PO Box 85500, 3584 Utrecht, CX, The Netherlands.
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Siddiqui F, Marr L, Weissman DE. Neoplastic Meningitis #135. J Palliat Med 2006; 9:481-2. [PMID: 16629577 DOI: 10.1089/jpm.2006.9.481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Guillot N, Auvin S, Vinchon M, Joriot S, Soto-Ares G, Cuvellier JC, Vallée L. [Radiological quiz of the month. Multiple neurological symptoms in a 14-year-old child]. Arch Pediatr 2005; 12:1641-3, 1627. [PMID: 16216480 DOI: 10.1016/j.arcped.2005.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2005] [Accepted: 06/30/2005] [Indexed: 11/25/2022]
Affiliation(s)
- N Guillot
- Service de neurologie pédiatrique, hôpital Roger-Salengro, CHRU de Lille, boulevard du Professeur-J.-Leclercq, 59037 Lille cedex, France
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Danova M, Invernizzi R. La Carcinomatosi Meningea nei Pazienti Neoplastici. TUMORI JOURNAL 2005; 91:10-21. [PMID: 16459648 DOI: 10.1177/030089160509100523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Marco Danova
- Unità di Citometria e Terapie Cellulari, Oncologia Medica, Università e IRCCS San Matteo, Pavia
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Abstract
Leptomeningeal carcinomatosis is defined as malignant infiltration of the pia matter and arachnoid membrane. Leukaemias and lymphomas, lung, breast cancer and melanoma are the primary tumours commonly associated with leptomeningeal carcinomatosis. Diagnosis is based on compatible symptoms and signs, cytological evidence of malignancy in the cerebrospinal fluid, and neuroimaging studies. Treatment is largely palliative (median survival 2-4 months). Patients with lympomatous or leukaemic meningitis, chemosensitive tumours such as breast cancer, low tumour burden, minimal neurological deficits, good performance status and controllable systemic disease survive longer with occasional long-term responses. Available treatment options include focal radiation therapy to CNS sites of bulky, symptomatic or obstructive meningeal deposits, intrathecal cytotoxic therapy and systemic chemotherapy. No evidence of superiority of intrathecal treatment compared with best palliative care (including radiation therapy and systemic treatment) is available from clinical trials. Novel treatment approaches include intrathecal liposomal Ara-C, the development of new cytotoxic compounds, signal transduction inhibitors and monoclonal antibodies for intrathecal or systemic use. Until data from multi-centre randomised trials are available, rationalisation of therapy should be done by stratifying patients to prognostic groups. High-risk patients will only survive for a few weeks and are better managed with supportive measures, whereas low-risk patients justify vigorous cerebrospinal fluid-directed treatment combined with radiation therapy and systemic chemotherapy.
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Affiliation(s)
- George Pentheroudakis
- Department of Medical Oncology, Ioannina University Hospital, Panepistimiou Avenue, 45110 Ioannina, Greece
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Maroldi R, Ambrosi C, Farina D. Metastatic disease of the brain: extra-axial metastases (skull, dura, leptomeningeal) and tumour spread. Eur Radiol 2004; 15:617-26. [PMID: 15627175 DOI: 10.1007/s00330-004-2617-5] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2004] [Accepted: 12/02/2004] [Indexed: 11/24/2022]
Abstract
Extra-axial intracranial metastases may arise through several situations. Hematogenous spread to the meninges is the most frequent cause. Direct extension from contiguous extra-cranial neoplasms, secondary invasion of the meninges by calvarium and skull base metastases, and migration along perineural or perivascular structures are less common. Leptomeningeal invasion gives rise to tumour cell dissemination by the cerebrospinal fluid (CSF), eventually leading to neoplastic coating of brain surfaces. Contrast-enhanced magnetic resonance (MR) imaging is complementary to CSF examinations and can be invaluable, detecting up to 50% of false-negative lumbar punctures. MR findings range from diffuse linear leptomeningeal enhancement to multiple enhancing extra-axial nodules, obstructive communicating and non-communicating hydrocephalus. Both calvarial and epidural metastases infrequently transgress the dura, which acts as a barrier against tumour spread. Radionuclide bone studies are still a valuable screening test to detect bone metastases. With computed tomography (CT) and MR, bone metastases extending intracranially and primary dural metastases show the characteristic biconvex shape, usually associated with brain displacement away from the inner table. Although CT is better in detecting skull base erosion, MR is more sensitive and provides more detailed information about dural involvement. Perineural and perivascular spread from head and neck neoplasms require thin-section contrast-enhanced MR.
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Affiliation(s)
- Roberto Maroldi
- Department of Radiology, University of Brescia, Piazzale Spedali Civili 1, Brescia, BS, 25123, Italy.
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