1
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Borm KJ, Behzadi ST, Hörner-Rieber J, Krug D, Baumann R, Corradini S, Duma MN, Dunst J, Fastner G, Feyer P, Fietkau R, Haase W, Harms W, Hehr T, Matuschek C, Piroth MD, Schmeel LC, Souchon R, Strnad V, Budach W, Combs SE. DEGRO guideline for personalized radiotherapy of brain metastases and leptomeningeal carcinomatosis in patients with breast cancer. Strahlenther Onkol 2024; 200:259-275. [PMID: 38488902 DOI: 10.1007/s00066-024-02202-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 01/07/2024] [Indexed: 03/17/2024]
Abstract
PURPOSE The aim of this review was to evaluate the existing evidence for radiotherapy for brain metastases in breast cancer patients and provide recommendations for the use of radiotherapy for brain metastases and leptomeningeal carcinomatosis. MATERIALS AND METHODS For the current review, a PubMed search was conducted including articles from 01/1985 to 05/2023. The search was performed using the following terms: (brain metastases OR leptomeningeal carcinomatosis) AND (breast cancer OR breast) AND (radiotherapy OR ablative radiotherapy OR radiosurgery OR stereotactic OR radiation). CONCLUSION AND RECOMMENDATIONS Despite the fact that the biological subtype of breast cancer influences both the occurrence and relapse patterns of breast cancer brain metastases (BCBM), for most scenarios, no specific recommendations regarding radiotherapy can be made based on the existing evidence. For a limited number of BCBM (1-4), stereotactic radiosurgery (SRS) or fractionated stereotactic radiotherapy (SRT) is generally recommended irrespective of molecular subtype and concurrent/planned systemic therapy. In patients with 5-10 oligo-brain metastases, these techniques can also be conditionally recommended. For multiple, especially symptomatic BCBM, whole-brain radiotherapy (WBRT), if possible with hippocampal sparing, is recommended. In cases of multiple asymptomatic BCBM (≥ 5), if SRS/SRT is not feasible or in disseminated brain metastases (> 10), postponing WBRT with early reassessment and reevaluation of local treatment options (8-12 weeks) may be discussed if a HER2/Neu-targeting systemic therapy with significant response rates in the central nervous system (CNS) is being used. In symptomatic leptomeningeal carcinomatosis, local radiotherapy (WBRT or local spinal irradiation) should be performed in addition to systemic therapy. In patients with disseminated leptomeningeal carcinomatosis in good clinical condition and with only limited or stable extra-CNS disease, craniospinal irradiation (CSI) may be considered. Data regarding the toxicity of combining systemic therapies with cranial and spinal radiotherapy are sparse. Therefore, no clear recommendations can be given, and each case should be discussed individually in an interdisciplinary setting.
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Affiliation(s)
- Kai J Borm
- TUM School of Medicine, Department of Radiation Oncology, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Sophie T Behzadi
- TUM School of Medicine, Department of Radiation Oncology, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Rene Baumann
- Department of Radiation Oncology, St. Marien-Krankenhaus, Siegen, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Marciana Nona Duma
- Department of Radiation Oncology, Helios Clinics of Schwerin-University Campus of MSH Medical School Hamburg, Schwerin, Germany
- Department for Human Medicine, MSH Medical School Hamburg, Hamburg, Germany
| | - Jürgen Dunst
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Gerd Fastner
- Department of Radiotherapy and Radio-Oncology, University Hospital Salzburg, Landeskrankenhaus, Paracelsus Medical University, Salzburg, Austria
| | - Petra Feyer
- Formerly Department of Radiation Oncology, Vivantes Hospital Neukölln, Berlin, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany
| | - Wulf Haase
- Formerly Department of Radiation Oncology, St.-Vincentius-Hospital Karlsruhe, Karlsruhe, Germany
| | - Wolfgang Harms
- Department of Radiation Oncology, St. Claraspital, Basel, Switzerland
| | - Thomas Hehr
- Department of Radiation Oncology, Marienhospital Stuttgart, Stuttgart, Germany
| | - Christiane Matuschek
- Department of Radiation Oncology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Marc D Piroth
- Department of Radiation Oncology, HELIOS University Hospital Wuppertal, Witten/Herdecke University, Wuppertal, Germany
| | | | - Rainer Souchon
- Formerly Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
| | - Vratislav Strnad
- Department of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany
| | - Wilfried Budach
- Department of Radiation Oncology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Stephanie E Combs
- TUM School of Medicine, Department of Radiation Oncology, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany.
- Partner Site Munich, Deutsches Konsortium für Translationale Krebsforschung (DKTK), Munich, Germany.
- Department of Radiation Medicine (IRM), Helmholtz Zentrum München (HMGU), Neuherberg, Germany.
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2
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de Bernardi A, Bachelot T, Larrouquère L. Long-term response to sequential anti-HER2 therapies including trastuzumab-deruxtecan in a patient with HER2-positive metastatic breast cancer with leptomeningeal metastases: a case report and review of the literature. Front Oncol 2024; 13:1210873. [PMID: 38269026 PMCID: PMC10806069 DOI: 10.3389/fonc.2023.1210873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 12/13/2023] [Indexed: 01/26/2024] Open
Abstract
The incidence of leptomeningeal metastases (LM) is increasing among breast cancer patients, but their prognosis remains dismal. Many therapeutic options are now available to treat HER2-positive (HER2+) metastatic breast cancer (MBC) involving the central nervous system (CNS). This case report illustrates a long-lasting response of more than 2 years in a patient with HER2+ MBC with LM after sequential administration of systemic and intrathecal (IT) anti-HER2 therapies and highlights that an appropriate treatment of HER2+ LM can result in durable survival.
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Affiliation(s)
- Axel de Bernardi
- Department of Medical Oncology, Centre Léon Bérard, Lyon, France
| | - Thomas Bachelot
- Department of Medical Oncology, Centre Léon Bérard, Lyon, France
- Cancer Reseach Center of Lyon, Lyon, France
| | - Louis Larrouquère
- Department of Medical Oncology, Centre Léon Bérard, Lyon, France
- Cancer Reseach Center of Lyon, Lyon, France
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3
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Bardhan M, Dey D, Suresh V, Javed B, Venur VA, Joe N, Kalidindi R, Ozair A, Khan M, Mahtani R, Lo S, Odia Y, Ahluwalia MS. An overview of the therapeutic strategies for neoplastic meningitis due to breast cancer: when and why? Expert Rev Neurother 2024; 24:77-103. [PMID: 38145503 DOI: 10.1080/14737175.2023.2293223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 12/06/2023] [Indexed: 12/27/2023]
Abstract
INTRODUCTION Neoplastic meningitis (NM), also known as leptomeningeal carcinomatosis, is characterized by the infiltration of tumor cells into the meninges, and poses a significant therapeutic challenge owing to its aggressive nature and limited treatment options. Breast cancer is a common cause of NM among solid tumors, further highlighting the urgent need to explore effective therapeutic strategies. This review aims to provide insights into the evolving landscape of NM therapy in breast cancer by collating existing research, evaluating current treatments, and identifying potential emerging therapeutic options. AREAS COVERED This review explores the clinical features, therapeutic strategies, recent advances, and challenges of managing NM in patients with breast cancer. Its management includes multimodal strategies, including systemic and intrathecal chemotherapy, radiation therapy, and supportive care. This review also emphasizes targeted drug options and optimal drug concentrations, and discusses emerging therapies. Additionally, it highlights the variability in treatment outcomes and the potential of combination regimens to effectively manage NM in breast cancer. EXPERT OPINION Challenges in treating NM include debates over clinical trial end points and the management of adverse effects. Drug resistance and low response rates are significant hurdles, particularly inHER2-negative breast cancer. The development of more precise and cost-effective medications with improved selectivity is crucial. Additionally, global efforts are needed for infrastructure development and cancer control considering the diverse nature of the disease.
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Affiliation(s)
- Mainak Bardhan
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | | | - Vinay Suresh
- King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Binish Javed
- Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Vyshak Alva Venur
- Seattle Cancer Care Alliance, Fred Hutchinson Cancer Center, University of Washington, Seattle, WA, USA
| | - Neha Joe
- St John's Medical College Hospital, Bengaluru, India
| | | | - Ahmad Ozair
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Reshma Mahtani
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Simon Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Yazmin Odia
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Manmeet S Ahluwalia
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
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4
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Malani R, Bhatia A, Warner AB, Yang JT. Leptomeningeal Carcinomatosis from Solid Tumor Malignancies: Treatment Strategies and Biomarkers. Semin Neurol 2023; 43:859-866. [PMID: 37989214 DOI: 10.1055/s-0043-1776996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Abstract
Leptomeningeal metastases/diseases (LMDs) are a late-stage complication of solid tumor or hematologic malignancies. LMD is spread of cancer cells to the layers of the leptomeninges (pia and arachnoid maters) and subarachnoid space seen in 3 to 5% of cancer patients. It is a disseminated disease which carries with it significant neurologic morbidity and mortality. Our understanding of disease pathophysiology is currently lacking; however, advances are being made. As our knowledge of disease pathogenesis has improved, treatment strategies have evolved. Mainstays of treatment such as radiotherapy have changed from involved-field radiotherapy strategies to proton craniospinal irradiation which has demonstrated promising results in recent clinical trials. Systemic treatment strategies have also improved from more traditional chemotherapeutics with limited central nervous system (CNS) penetration to more targeted therapies with better CNS tumor response. Many challenges remain from earlier clinical detection of disease through improvement of active treatment options, but we are getting closer to meaningful treatment.
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Affiliation(s)
- Rachna Malani
- Department of Neurosurgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Ankush Bhatia
- Department of Neurology, Carbone Cancer Center, University of Wisconsin, Madison, Wisconsin
| | - Allison Betof Warner
- Division of Oncology, Department of Medicine, Stanford Cancer Institute, Stanford University, Stanford, California
| | - Jonathan T Yang
- Department of Radiation Oncology, Fred Hutchinson Cancer Center, University of Washington, Seattle, Washington
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5
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Integrating Systematic Reviews into Supportive Care Trial Design: The Rethinking Clinical Trials (REaCT) Program. Curr Oncol 2022; 29:9550-9559. [PMID: 36547164 PMCID: PMC9776426 DOI: 10.3390/curroncol29120750] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 11/28/2022] [Accepted: 11/30/2022] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To review the successes and challenges of integrating systematic reviews (SRs) into the Rethinking Clinical Trials (REaCT) Program. METHODS All REaCT program SRs were evaluated and descriptive summaries presented. RESULTS Twenty-two SRs have been performed evaluating standard of care interventions for the management of: breast cancer (n = 15), all tumour sites (n = 4), breast and prostate cancers (n = 2), and prostate cancer (n = 1). The majority of SRs were related to supportive care (n = 14) and survivorship (n = 5) interventions and most (19/22, 86%) confirmed the existence of uncertainty relating to the clinical question addressed in the SR. Most SRs (15/22, 68%) provided specific recommendations for future studies and results were incorporated into peer-reviewed grant applications (n = 6) and clinical trial design (n = 12). In 12/22 of the SRs, the first author was a trainee. All SRs followed PRISMA guidelines. CONCLUSION SRs are important for identifying and confirming clinical equipoise and designing trials. SRs provide an excellent opportunity for trainees to participate in research.
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6
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Local and systemic therapy in breast cancer patients with central nervous system metastases. Breast Cancer Res Treat 2022; 194:365-384. [PMID: 35680734 DOI: 10.1007/s10549-022-06605-4] [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: 12/09/2021] [Accepted: 04/06/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE As survival of patients with central nervous system (CNS) metastases from breast cancer is poor and incidence rates are increasing, there is a growing need for better treatment strategies. In the current study, the efficacy of local and systemic therapies was analyzed in breast cancer patients with CNS metastases. METHODS Medical records from breast cancer patients with brain and/or leptomeningeal metastases (LM) treated at a tertiary referral center and a teaching hospital between 2010 and 2020 were retrospectively studied. Main outcomes of interest were overall survival (OS) and CNS progression free survival. Analyses were performed among patients with brain metastases (BM) and patients with LM, for the different systemic and local therapies for CNS metastases, and for subgroups based on breast cancer subtypes. RESULTS We identified 155 patients, 97 with BM and 58 with LM. Median OS was 15.9 months for patients with BM and 1.5 months for patients with LM. Median OS was significantly longer for HER2-positive patients with BM (22.8 months) vs triple negative (8.4 months) and hormone receptor positive/HER2-negative (5.9 months) (P < 0.001). Patients with BM receiving both local and systemic therapy also had a longer median OS (21.8 months), compared to the other three subgroups (local therapy only: 9.9 months, systemic therapy only: 4.3 months, no therapy: 0.5 months, P < 0.001). No significant difference in OS was observed between different systemic treatment regimens. CONCLUSION Breast cancer patients with BM show longest median OS when the subtype is HER2-positive and when they are treated with both local and systemic therapy.
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7
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Mampre D, Mehkri Y, Rajkumar S, Sriram S, Hernandez J, Lucke-Wold B, Chandra V. Treatment of breast cancer brain metastases: radiotherapy and emerging preclinical approaches. DIAGNOSTICS AND THERAPEUTICS 2022; 1:25-38. [PMID: 35782783 PMCID: PMC9249118 DOI: 10.55976/dt.1202216523-36] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
The breast is one of the common primary sites of brain metastases (BM). Radiotherapy for BM from breast cancer may include whole brain radiation therapy (WBRT), stereotactic radiosurgery (SRS), and stereotactic radiotherapy (SRT), but a consensus is difficult to reach because of the wide and varied protocols, indications, and outcomes of these interventions. Overall, dissemination of disease, patient functional status, and tumor size are all important factors in the decision of treatment with WBRT or SRS. Thus far, previous studies indicate that WBRT can improve tumor control compared to SRS, but increase side effects, however no randomized trials have compared the efficacy of these therapies in BM from breast cancer. Therapies targeting long non-coding RNAs and transcription factors, such as MALAT1, HOTAIR, lnc-BM, TGL1, and ATF3, have the potential to both prevent metastatic spread and treat BM with improved radiosensitivity. Given the propensity for HER2+ breast cancer to develop BM, the above-mentioned cell lines may represent an important target for future investigations, and the development of everolimus and pyrotinib are equally important.
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Affiliation(s)
- David Mampre
- Department of Neurosurgery, University of Florida, Gainesville, FL
| | - Yusuf Mehkri
- Department of Neurosurgery, University of Florida, Gainesville, FL
| | | | - Sai Sriram
- Department of Neurosurgery, University of Florida, Gainesville, FL
| | - Jairo Hernandez
- Department of Neurosurgery, University of Florida, Gainesville, FL
| | | | - Vyshak Chandra
- Department of Neurosurgery, University of Florida, Gainesville, FL
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8
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Mollica L, Leli C, Puglisi S, Sardi S, Sottotetti F. Leptomeningeal carcinomatosis and breast cancer: a systematic review of current evidence on diagnosis, treatment and prognosis. Drugs Context 2021; 10:dic-2021-6-6. [PMID: 34745272 PMCID: PMC8552906 DOI: 10.7573/dic.2021-6-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/14/2021] [Indexed: 02/02/2023] Open
Abstract
Leptomeningeal carcinomatosis (LC) is a rare but challenging manifestation of advanced breast cancer with a severe impact on morbidity and mortality. We performed a systematic review of the evidence published over the last two decades, focusing on recent advances in the diagnostic and therapeutic options of LC. Lobular histology and a triple-negative intrinsic subtype are well-known risk factors for LC. Clinical manifestations are diverse and often aspecific. There is no gold standard for LC diagnosis: MRI and cerebrospinal fluid cytology are the most frequently used modalities despite the low accuracy. Current standard of care involves a multimodal strategy including systemic and intrathecal chemotherapy in combination with brain radiotherapy. Intrathecal chemotherapy has been widely used through the years despite the lack of data from randomized controlled trials and conflicting evidence on patient outcomes. No specific chemotherapeutic agent has shown superiority over others for both intrathecal and systemic treatment. Although endocrine therapy was heuristically considered unable to exert significant control on central nervous system metastatic disease, retrospective data suggest a favourable toxicity profile and even a possible positive impact on survival. In recent years, encouraging data on the use of targeted agents has emerged but further research in this field is required. Palliative treatment in the form of whole brain or stereotactic radiotherapy is associated with improvement in clinical manifestations and quality of life, with no proven impact on survival. The most investigated prognostic factors include performance status, non-triple-negative disease and multimodal treatment. Validation of prognostic scores is necessary to aid clinicians in the identification of patient subgroups that are most likely to benefit from an intensive therapeutic approach.
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Affiliation(s)
| | - Claudia Leli
- Division of Medical Oncology, IRCCS-ICS Maugeri, Pavia, Italy
| | - Silvia Puglisi
- Division of Medical Oncology, Ospedale Policlinico San Martino, Genova, Italy
| | - Silvia Sardi
- Department of Anaesthesia and Intensive Care Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Federico Sottotetti
- Division of Medical Oncology, IRCCS-ICS Maugeri, Pavia, Italy.,Department of Molecular Medicine, University of Pavia, Pavia, Italy
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9
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Liu C, Zhang Y, Li Y, Bu H, Meng Z, Ji Y, Wu J, Zou Y, Chen X, He J, Hong K. A rare magnetic resonance imaging pattern of leptomeningeal carcinomatosis: a case description. Quant Imaging Med Surg 2021; 11:3367-3370. [PMID: 34249661 DOI: 10.21037/qims-20-45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 09/24/2020] [Indexed: 11/06/2022]
Affiliation(s)
- Chang Liu
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China.,Institute of Cardiocerebrovascular Disease, Shijiazhuang, China.,Neurological Laboratory of Hebei Province, Shijiazhuang, China
| | - Yu Zhang
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China.,Institute of Cardiocerebrovascular Disease, Shijiazhuang, China.,Neurological Laboratory of Hebei Province, Shijiazhuang, China
| | - Yi Li
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China.,Institute of Cardiocerebrovascular Disease, Shijiazhuang, China.,Neurological Laboratory of Hebei Province, Shijiazhuang, China
| | - Hui Bu
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China.,Institute of Cardiocerebrovascular Disease, Shijiazhuang, China.,Neurological Laboratory of Hebei Province, Shijiazhuang, China
| | - Zhaohua Meng
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China.,Institute of Cardiocerebrovascular Disease, Shijiazhuang, China.,Neurological Laboratory of Hebei Province, Shijiazhuang, China
| | - Yingxiao Ji
- Department of Neurology, Hebei General Hospital, Shijiazhuang, China
| | - Jiang Wu
- Department of Neurosurgery, Hebei General Hospital, Shijiazhuang, China
| | - Yueli Zou
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China.,Institute of Cardiocerebrovascular Disease, Shijiazhuang, China.,Neurological Laboratory of Hebei Province, Shijiazhuang, China
| | - Xinxin Chen
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China.,Institute of Cardiocerebrovascular Disease, Shijiazhuang, China.,Neurological Laboratory of Hebei Province, Shijiazhuang, China
| | - Junying He
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China.,Institute of Cardiocerebrovascular Disease, Shijiazhuang, China.,Neurological Laboratory of Hebei Province, Shijiazhuang, China
| | - Kun Hong
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China.,Institute of Cardiocerebrovascular Disease, Shijiazhuang, China.,Neurological Laboratory of Hebei Province, Shijiazhuang, China
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10
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ctDNA-Based Liquid Biopsy of Cerebrospinal Fluid in Brain Cancer. Cancers (Basel) 2021; 13:cancers13091989. [PMID: 33919036 PMCID: PMC8122255 DOI: 10.3390/cancers13091989] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/15/2021] [Accepted: 04/19/2021] [Indexed: 12/18/2022] Open
Abstract
The correct characterisation of central nervous system (CNS) malignancies is crucial for accurate diagnosis and prognosis and also the identification of actionable genomic alterations that can guide the therapeutic strategy. Surgical biopsies are performed to characterise the tumour; however, these procedures are invasive and are not always feasible for all patients. Moreover, they only provide a static snapshot and can miss tumour heterogeneity. Currently, monitoring of CNS cancer is performed by conventional imaging techniques and, in some cases, cytology analysis of the cerebrospinal fluid (CSF); however, these techniques have limited sensitivity. To overcome these limitations, a liquid biopsy of the CSF can be used to obtain information about the tumour in a less invasive manner. The CSF is a source of cell-free circulating tumour DNA (ctDNA), and the analysis of this biomarker can characterise and monitor brain cancer. Recent studies have shown that ctDNA is more abundant in the CSF than plasma for CNS malignancies and that it can be sequenced to reveal tumour heterogeneity and provide diagnostic and prognostic information. Furthermore, analysis of longitudinal samples can aid patient monitoring by detecting residual disease or even tracking tumour evolution at relapse and, therefore, tailoring the therapeutic strategy. In this review, we provide an overview of the potential clinical applications of the analysis of CSF ctDNA and the challenges that need to be overcome in order to translate research findings into a tool for clinical practice.
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11
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Damaske M, Panarese V, Casey S, Feeney M, Liuzzi FJ. Leptomeningeal Carcinomatosis Secondary to Adenocarcinoma of the Breast: A Cadaveric Case Report. Cureus 2021; 13:e12693. [PMID: 33604223 PMCID: PMC7881351 DOI: 10.7759/cureus.12693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
A rare complication of metastatic breast cancer, leptomeningeal carcinomatosis (LC) was discovered during routine cadaveric dissection of a 57-year-old Caucasian female who died from breast cancer metastasis to the brain. This pathology develops in only 5% of patients with metastatic breast cancer and presents with a number of neurological deficits. Progressive neurologic dysfunction is fatal, with a median survival of 10 to 15 weeks. In this case study, we examine the gross and microscopic features of LC and document the infiltration of metastatic cells into the brain parenchyma along the Virchow-Robin spaces.
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Affiliation(s)
- Melissa Damaske
- Anatomy, Lake Erie College of Osteopathic Medicine, Bradenton, USA
| | | | - Sean Casey
- Anatomy, Lake Erie College of Osteopathic Medicine, Bradenton, USA
| | - Madeline Feeney
- Anatomy, Lake Erie College of Osteopathic Medicine, Bradenton, USA
| | - Francis J Liuzzi
- Anatomy, Lake Erie College of Osteopathic Medicine, Bradenton, USA
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12
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Fernandes L, de Matos LV, Cardoso D, Saraiva M, Medeiros-Mirra R, Coelho A, Miranda H, Martins A. Endocrine therapy for the treatment of leptomeningeal carcinomatosis in luminal breast cancer: a comprehensive review. CNS Oncol 2020; 9:CNS65. [PMID: 33078616 PMCID: PMC7737195 DOI: 10.2217/cns-2020-0023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Leptomeningeal disease (LMD) represents a devastating complication of advanced breast cancer (ABC), with survival of <5 months with multimodal treatment. The role of endocrine therapy (ET), due to its favorable toxicity profile and first-line indication in luminal ABC, appears promising in the setting of LMD, where symptom stabilization and quality-of-life preservation are the main goals; however, evidenced-based data are lacking. We conducted a thorough review of published evidence, aiming to investigate the role of ET in LMD treatment in luminal ABC. Twenty-one of 342 articles, evaluating 1302 patients, met inclusion criteria. ET use was rarely reported. New targeted agents show CNS activity. Research is lacking on the role of ET and targeted agents in BC-LMD treatment.
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Affiliation(s)
- Leonor Fernandes
- Department of Medical Oncology, Hospital São Francisco Xavier, Centro Hospitalar Lisboa Ocidental, 1449-005 Lisboa, Portugal
| | - Leonor Vasconcelos de Matos
- Department of Medical Oncology, Hospital São Francisco Xavier, Centro Hospitalar Lisboa Ocidental, 1449-005 Lisboa, Portugal
| | - Débora Cardoso
- Department of Medical Oncology, Hospital São Francisco Xavier, Centro Hospitalar Lisboa Ocidental, 1449-005 Lisboa, Portugal
| | - Marlene Saraiva
- Department of Neurology, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, 1349-019 Lisboa, Portugal
| | - Renata Medeiros-Mirra
- Cardiff School of Dentistry, College of Biomedical & Life Sciences, Cardiff University, Cardiff CF10 3AT, Wales, UK
| | - Andreia Coelho
- Department of Medical Oncology, Hospital São Francisco Xavier, Centro Hospitalar Lisboa Ocidental, 1449-005 Lisboa, Portugal
| | - Helena Miranda
- Department of Medical Oncology, Hospital São Francisco Xavier, Centro Hospitalar Lisboa Ocidental, 1449-005 Lisboa, Portugal
| | - Ana Martins
- Department of Medical Oncology, Hospital São Francisco Xavier, Centro Hospitalar Lisboa Ocidental, 1449-005 Lisboa, Portugal
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Cerebrospinal fluid circulating tumour DNA as a liquid biopsy for central nervous system malignancies. Curr Opin Neurol 2020; 33:736-741. [DOI: 10.1097/wco.0000000000000869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Brizzi K, Zupanc SN, Udelsman BV, Tulsky JA, Wright AA, Poort H, Lindvall C. Natural Language Processing to Assess Palliative Care and End-of-Life Process Measures in Patients With Breast Cancer With Leptomeningeal Disease. Am J Hosp Palliat Care 2020; 37:371-376. [PMID: 31698921 DOI: 10.1177/1049909119885585] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024] Open
Abstract
BACKGROUND Palliative care consultation during serious life-limiting illness can reduce symptom burden and improve quality of care. However, quantifying the impact of palliative care is hindered by the limitations of manual chart review and administrative coding. OBJECTIVES Using novel natural language process (NLP) techniques, we examined associations between palliative care consultations and performance on nationally endorsed metrics for high-quality end-of-life (EOL) care in patients with leptomeningeal disease (LMD) secondary to metastatic breast cancer. METHODS Patients with breast cancer with LMD were identified using administrative billing codes and NLP review of magnetic resonance imaging reports at 2 tertiary care centers between 2010 and 2016. Next, NLP was used to review clinical notes to (1) determine the presence of palliative care consultations and (2) determine the performance of process measures associated with high-quality EOL care, including discussions of goals of care, code status limitations, and hospice. Associations between palliative care consultation and documentation of EOL process measures were assessed using logistic regression. RESULTS We identified 183 cases of LMD. Median age was 56 (interquartile range [IQR]: 46-64) years and median survival was 150 days (IQR: 67-350). Within 6 months of diagnosis, 88.5% of patients had documentation of ≥1 process measure, including discussions of goals of care (63.4%), code status limitations (62.8%), or hospice (72.1%). Palliative care consultation was a predictor of subsequent documentation of goals of care (odds ratio [OR], 3.15; 95% confidence interval [CI], 1.58-6.27) and hospice discussions (OR, 4.61; 95% CI, 2.12-10.03). CONCLUSION Palliative care involvement is associated with increased performance of EOL process measures in patients with breast cancer with LMD.
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Affiliation(s)
- Kate Brizzi
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
- Division of Palliative Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Sophia N Zupanc
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Brooks V Udelsman
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Alexi A Wright
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Hanneke Poort
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Charlotta Lindvall
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, USA
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Figura NB, Rizk VT, Armaghani AJ, Arrington JA, Etame AB, Han HS, Czerniecki BJ, Forsyth PA, Ahmed KA. Breast leptomeningeal disease: a review of current practices and updates on management. Breast Cancer Res Treat 2019; 177:277-294. [PMID: 31209686 DOI: 10.1007/s10549-019-05317-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 06/07/2019] [Indexed: 01/23/2023]
Abstract
PURPOSE Leptomeningeal disease (LMD) is an advanced metastatic disease presentation portending a poor prognosis with minimal treatment options. The advent and widespread use of new systemic therapies for metastatic breast cancer has improved systemic disease control and extended survival; however, as patients live longer, the rates of breast cancer LMD are increasing. METHODS In this review, a group of medical oncologists, radiation oncologists, radiologists, breast surgeons, and neurosurgeons specializing in treatment of breast cancer reviewed the available published literature and compiled a comprehensive review on the current state of breast cancer LMD. RESULTS We discuss the pathogenesis, epidemiology, diagnosis, treatment options (including systemic, intrathecal, surgical, and radiotherapy treatment modalities), and treatment response evaluation specific to breast cancer patients. Furthermore, we discuss the controversies within this unique clinical setting and identify potential clinical opportunities to improve upon the diagnosis, treatment, and treatment response evaluation in the management of breast LMD. CONCLUSIONS We recognize the shortcomings in our current understanding of the disease and explore the future role of genomic/molecular disease characterization, technological innovations, and ongoing clinical trials attempting to improve the prognosis for this advanced disease state.
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Affiliation(s)
- Nicholas B Figura
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Dr., Tampa, FL, 33612, USA
| | - Victoria T Rizk
- Morsani College of Medicine, University of South Florida, Tampa, FL, 33612, USA
| | - Avan J Armaghani
- Department of Breast Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Dr., Tampa, FL, 33612, USA
| | - John A Arrington
- Department of Radiology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Dr., Tampa, FL, 33612, USA
| | - Arnold B Etame
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Dr., Tampa, FL, 33612, USA
| | - Hyo S Han
- Department of Breast Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Dr., Tampa, FL, 33612, USA
| | - Brian J Czerniecki
- Department of Breast Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Dr., Tampa, FL, 33612, USA
| | - Peter A Forsyth
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Dr., Tampa, FL, 33612, USA.
| | - Kamran A Ahmed
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Dr., Tampa, FL, 33612, USA.
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Koga M, Aoki T, Negoto T, Makizono T, Sugi K, Fujimori K, Kajiwara S, Komaki S, Yoshitomi M, Sugita Y, Morioka M. Leptomeningeal Carcinomatosis After Neoplastic Cerebral Aneurysm Rupture. World Neurosurg 2019; 126:281-284. [PMID: 30822576 DOI: 10.1016/j.wneu.2019.02.058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 02/08/2019] [Accepted: 02/09/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Several possible mechanisms exist for the spread of a primary tumor to the leptomeninges in leptomeningeal carcinomatosis. This report describes a case caused by direct bleeding in the subarachnoid space from a neoplastic cerebral aneurysm rupture. CASE DESCRIPTION A 48-year-old Japanese woman, who was diagnosed with breast carcinoma (pT3 pN2 M0) at the age of 45 years and underwent mastectomy and chemotherapy, was admitted in a coma following a sudden-onset severe headache. Computed tomography revealed diffuse hemorrhage in the subarachnoid space, and angiography revealed an aneurysm at the distal middle cerebral artery. Superficial temporal artery-middle cerebral artery bypass, aneurysmal trapping, and aneurysm resection were performed within 24 hours of admission. Staining for AE1/AE3 revealed accumulation of atypical cells with a high nuclear-cytoplasmic ratio in the aneurysmal wall. After showing initial improvement, she developed disturbed consciousness due to complicated ventricular enlargement on day 45. Although the cerebrospinal fluid in the acute phase had no atypical cells, subsequent testing revealed atypical cells, which supported a diagnosis of leptomeningeal carcinomatosis due to breast cancer dissemination. The patient died on day 78 after receiving standard endocrine therapy and radiation therapy. CONCLUSIONS Tumor cells reach the leptomeninges via hematogenous spread or direct extension from preexisting lesions and can undergo neuraxis dissemination via the cerebrospinal fluid. Subarachnoid hemorrhage and leptomeningeal carcinomatosis are both devastating conditions with extremely poor prognoses. This patient experienced delayed disturbed consciousness leptomeningeal carcinomatosis with decreased performance status, which made it difficult to justify aggressive treatment on the basis of her poor prognosis.
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Affiliation(s)
- Motohisa Koga
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Takachika Aoki
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Tetsuya Negoto
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan.
| | - Takehiro Makizono
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Keisuke Sugi
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Kana Fujimori
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Sosho Kajiwara
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Satoru Komaki
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Munetake Yoshitomi
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Yasuo Sugita
- Department of Pathology, Kurume University School of Medicine, Fukuoka, Japan
| | - Motohiro Morioka
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
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17
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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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18
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Seoane J, De Mattos-Arruda L, Le Rhun E, Bardelli A, Weller M. Cerebrospinal fluid cell-free tumour DNA as a liquid biopsy for primary brain tumours and central nervous system metastases. Ann Oncol 2019; 30:211-218. [PMID: 30576421 DOI: 10.1093/annonc/mdy544] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Challenges in obtaining tissue specimens from patients with brain tumours limit the diagnosis and molecular characterisation and impair the development of better therapeutic approaches. The analysis of cell-free tumour DNA in plasma (considered a liquid biopsy) has facilitated the characterisation of extra-cranial tumours. However, cell-free tumour DNA in plasma is limited in quantity and may not reliably capture the landscape of genomic alterations of brain tumours. Here, we review recent work assessing the relevance of cell-free tumour DNA from cerebrospinal fluid in the characterisation of brain cancer. We focus on the advances in the use of the cerebrospinal fluid as a source of cell-free tumour DNA to facilitate diagnosis, reveal actionable genomic alterations, monitor responses to therapy, and capture tumour heterogeneity in patients with primary brain tumours and brain and leptomeningeal metastases. Profiling cerebrospinal fluid cell-free tumour DNA provides the opportunity to precisely acquire and monitor genomic information in real time and guide precision therapies.
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Affiliation(s)
- J Seoane
- Vall d'Hebron Institute of Oncology, Vall d'Hebron University Hospital, Barcelona; Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona; CIBERONC, Barcelona; Universitat Autònoma de Barcelona, Cerdanyola del Vallès.
| | - L De Mattos-Arruda
- Vall d'Hebron Institute of Oncology, Vall d'Hebron University Hospital, Barcelona
| | - E Le Rhun
- Lille University, Inserm U1192 PRISM, Villeneuve d'Ascq; Neuro-oncology, Department of Neurosurgery, University Hospital, Lille; Neuro-oncology, Breast Unit, Department of Medical Oncology, Oscar Lambret Center, Lille, France
| | - A Bardelli
- Candiolo Cancer Institute-FPO, IRCCS, Candiolo (TO); Department of Oncology, University of Torino, Candiolo (TO), Italy
| | - M Weller
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
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19
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Griguolo G, Pouderoux S, Dieci MV, Jacot W, Bourgier C, Miglietta F, Firmin N, Conte P, Viala M, Guarneri V, Darlix A. Clinicopathological and Treatment-Associated Prognostic Factors in Patients with Breast Cancer Leptomeningeal Metastases in Relation to Tumor Biology. Oncologist 2018; 23:1289-1299. [PMID: 30120164 DOI: 10.1634/theoncologist.2018-0200] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 06/11/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Breast cancer (BC) is one of the solid tumors most commonly associated with leptomeningeal disease (LMD). LMD carries a devastating prognosis; however, disease presentation and prognostic factors are uncertain. SUBJECTS, MATERIALS, AND METHODS In order to describe patient characteristics, treatment patterns, and factors associated with survival in a contemporary multicentric cohort, 153 consecutive BC patients diagnosed with LMD at two European institutions (2002-2017) were included. Time to LMD and overall survival (OS) after LMD diagnosis were evaluated using the Kaplan-Meier method and Cox proportional hazards models. RESULTS Median age at LMD diagnosis was 58 years (25-84). Tumor phenotype distribution was as follows: hormone receptor (HR) positive (HR+)/human epidermal growth receptor 2 (HER2) negative 51.0%, triple-negative 15.0%, HR+/HER2 positive (HER2+) 13.1% and HR negative/HER2+ 7.2%. Most patients received active anticancer treatments (radiation therapy [RT] n = 42, systemic therapy n = 110, intrathecal treatment n = 103).Median OS was 3.9 months (95% confidence interval [CI] 2.4-5.5). Eastern Cooperative Oncology Group performance status (ECOG PS) >2, high white blood cells count, low glucose, and high protein in cerebrospinal fluid (CSF) were poor prognostic factors. Having received RT or systemic treatment was associated with better prognosis. In multivariate analysis, ECOG PS (hazard ratio 2.22, 95% CI 1.25-3.94), CSF glucose levels (hazard ratio 1.74, 95% CI 1.05-2.88), and having received systemic treatment (hazard ratio 0.17, 95% CI 0.09-0.32) were confirmed as independent prognostic factors. In HER2+ BC patients, having received systemic HER2-targeted therapy was the only factor maintaining independent prognostication (hazard ratio 0.12, 95% CI 0.02-0.67) in multivariate analysis. CONCLUSION Despite being limited by their retrospective nature, these results highlight the need for clinical trials in BC LMD, stratified on tumor biology. IMPLICATIONS FOR PRACTICE Leptomeningeal disease (LMD) is a devastating complication of breast cancer (BC), and its optimal therapy is still not defined. Here, patient characteristics, treatment patterns, and prognostic factors from a contemporary cohort of 153 BC-related LMD patients are reported. In multivariate analysis, Eastern Cooperative Oncology Group performance status, cerebrospinal fluid glucose levels, and having received systemic treatment were confirmed as independent prognostic factors in the overall population, whereas in human epidermal growth receptor 2 (HER2) positive BC patients, having received systemic HER2-targeted therapy was the only factor maintaining independent prognostication in multivariate analysis. These results highlight the need to consider stratification on tumor biology in the treatment of BC LMD.
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Affiliation(s)
- Gaia Griguolo
- Division of Medical Oncology 2, Istituto Oncologico Veneto IRCCS, Padova, Italy
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Stephane Pouderoux
- Departments of Medical Oncology, Institut Régional du Cancer de Montpellier (ICM), Montpellier, France
| | - Maria Vittoria Dieci
- Division of Medical Oncology 2, Istituto Oncologico Veneto IRCCS, Padova, Italy
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - William Jacot
- Departments of Medical Oncology, Institut Régional du Cancer de Montpellier (ICM), Montpellier, France
| | - Céline Bourgier
- Radiation Oncology, Institut Régional du Cancer de Montpellier (ICM), Montpellier, France
- Institut de Recherche en Cancérologie de Montpellier INSERM U1194, Université de Montpellier, ICM, Montpellier, France
| | - Federica Miglietta
- Division of Medical Oncology 2, Istituto Oncologico Veneto IRCCS, Padova, Italy
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Nelly Firmin
- Departments of Medical Oncology, Institut Régional du Cancer de Montpellier (ICM), Montpellier, France
| | - Pierfranco Conte
- Division of Medical Oncology 2, Istituto Oncologico Veneto IRCCS, Padova, Italy
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Marie Viala
- Departments of Medical Oncology, Institut Régional du Cancer de Montpellier (ICM), Montpellier, France
| | - Valentina Guarneri
- Division of Medical Oncology 2, Istituto Oncologico Veneto IRCCS, Padova, Italy
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Amélie Darlix
- Departments of Medical Oncology, Institut Régional du Cancer de Montpellier (ICM), Montpellier, France
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20
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Nuvoli S, Contu S, Pung BLJ, Solinas P, Madeddu G, Spanu A. Intracranial Leptomeningeal Carcinomatosis: A Diagnostic Study with 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography. Case Rep Neurol 2018. [PMID: 29515424 PMCID: PMC5836194 DOI: 10.1159/000486710] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Leptomeningeal carcinomatosis (LC) diagnosis is based on cerebrospinal fluid (CSF) cytological analysis and contrast-enhanced magnetic resonance imaging (MRI); however, low sensitivity was evidenced in some cases delaying prompt and adequate treatments. Brain 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) was also employed in doubtful cases. We retrospectively described 4 suspected LC cases with uncertain or undetectable MRI and initially negative CSF cytology. Whole-body (WB) and brain 18F-FDG PET/computed tomography (CT) were used, the latter showing intracranial tracer uptakes suspected for LC in 3/4 cases. In 2 of these 3 cases, WB scan also evidenced spinal cord lesion and pulmonary tumor, respectively, while both procedures were true negative in the fourth case. CSF cytology became positive after repeated exams in the 3 PET/CT-positive cases. In 1 of these 3 patients, it was also confirmed at MRI, while it stayed negative in the remaining PET/CT-negative case with uncertain MRI. 18F-FDG PET/CT could be a useful supportive diagnostic tool in doubtful intracranial and spinal LC.
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Affiliation(s)
- Susanna Nuvoli
- Unit of Nuclear Medicine, Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy
| | - Silvia Contu
- Unit of Nuclear Medicine, Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy
| | - Bi Llie Joy Pung
- Unit of Nuclear Medicine, Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy
| | - Patrizia Solinas
- Unit of Nuclear Medicine, Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy
| | - Giuseppe Madeddu
- Unit of Nuclear Medicine, Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy
| | - Angela Spanu
- Unit of Nuclear Medicine, Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy
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Kingston B, Kayhanian H, Brooks C, Cox N, Chaabouni N, Redana S, Kalaitzaki E, Smith I, O'Brien M, Johnston S, Parton M, Noble J, Stanway S, Ring A, Turner N, Okines A. Treatment and prognosis of leptomeningeal disease secondary to metastatic breast cancer: A single-centre experience. Breast 2017; 36:54-59. [PMID: 28968585 DOI: 10.1016/j.breast.2017.07.015] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 07/18/2017] [Accepted: 07/19/2017] [Indexed: 02/05/2023] Open
Abstract
PURPOSE Leptomeningeal disease (LMD) is an uncommon complication of advanced breast cancer. The prognosis is poor, and although radiotherapy (RT), systemic and intra-thecal (IT) chemotherapy are accepted treatment modalities, efficacy data are limited. This study was designed to evaluate potential predictors of survival in this patient group. METHODS Breast cancer patients with LMD diagnosed by MRI in a 10-year period (2004-2014) were identified from electronic patient records. PFS and OS estimates were calculated using Kaplan-Meier method, with planned sub-group analysis by treatment modality. Cox regression was employed to identify significant prognostic variables. RESULTS We identified 182 eligible patients; all female, median age at LMD diagnosis 52.5 years (range 23-80). Ninety patients (49.5%) were ER positive/HER2 negative; 48 (26.4%) were HER2 positive, and 27 (14.8%) were triple negative. HER2 status was unknown in 17 (9.3%). Initial management of LMD was most commonly whole or partial brain RT in 62 (34.1%), systemic therapy in 45 (24.7%) or supportive care alone in 37 (20.3%). Fourteen patients (7.7%) underwent IT chemotherapy, of whom two also received IT trastuzumab. From diagnosis of LMD, the median PFS was 3.9 months (95%CI 3.2-5.0) and median OS was 5.4 months (95%CI 4.2-6.6). Patients treated with systemic therapy had the longest OS (median 8.8 months, 95%CI 5.5-11.1), compared to RT; 6.1 months (95%CI 4.2-7.9 months), IT therapy; 2.9 months (95%CI 1.2-5.8) and supportive care; 1.7 months (95%CI 0.9-3.0). On multivariable analysis, triple negative histology, concomitant brain metastases, and LMD involving both the brain and spinal cord were associated with poor OS. CONCLUSIONS Breast cancer patients with triple negative LMD, concomitant brain metastases or LMD affecting both the spine and brain have the poorest prognosis. Clinical trials to identify more effective treatments for these patients are urgently needed.
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Affiliation(s)
| | | | - Chloe Brooks
- The Royal Marsden NHS Foundation Trust, London and Surrey, UK
| | - Nicola Cox
- The Royal Marsden NHS Foundation Trust, London and Surrey, UK
| | - Narda Chaabouni
- The Royal Marsden NHS Foundation Trust, London and Surrey, UK
| | - Stefania Redana
- The Royal Marsden NHS Foundation Trust, London and Surrey, UK
| | | | - Ian Smith
- The Royal Marsden NHS Foundation Trust, London and Surrey, UK
| | - Mary O'Brien
- The Royal Marsden NHS Foundation Trust, London and Surrey, UK
| | | | - Marina Parton
- The Royal Marsden NHS Foundation Trust, London and Surrey, UK
| | - Jill Noble
- The Royal Marsden NHS Foundation Trust, London and Surrey, UK
| | - Susie Stanway
- The Royal Marsden NHS Foundation Trust, London and Surrey, UK
| | - Alistair Ring
- The Royal Marsden NHS Foundation Trust, London and Surrey, UK
| | - Nicholas Turner
- The Royal Marsden NHS Foundation Trust, London and Surrey, UK
| | - Alicia Okines
- The Royal Marsden NHS Foundation Trust, London and Surrey, UK.
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22
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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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23
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O’Sullivan CC, Davarpanah NN, Abraham J, Bates SE. Current challenges in the management of breast cancer brain metastases. Semin Oncol 2017; 44:85-100. [DOI: 10.1053/j.seminoncol.2017.06.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 06/29/2017] [Indexed: 02/06/2023]
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