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Romero IO, Simiele EA, Lozko Y, Severyn Y, Skinner LB, Yang Y, Wang JY, Xing L, Gibbs I, Hiniker SM, Kovalchuk N. Automating the Treatment Planning Process for Volumetric Modulated Arc Therapy Craniospinal Irradiation. Pract Radiat Oncol 2024; 14:e165-e172. [PMID: 38048988 DOI: 10.1016/j.prro.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 10/19/2023] [Accepted: 11/14/2023] [Indexed: 12/06/2023]
Abstract
PURPOSE The purpose of this work is to develop a method to automate the treatment planning process of craniospinal irradiation (CSI) using volumetric modulated arc therapy. METHODS AND MATERIALS Two scripts were developed using the Eclipse Scripting Application Programming Interface to perform auto-plan preparation and optimization. Ten patients (age, 5-44 years) previously treated at our institution with low dose volumetric modulated arc therapy CSI (prescription of 12 Gy) before total body irradiation were selected to evaluate the efficacy of the proposed auto-planning process. Paired t tests compared the dosimetric indices of the auto-plans to the manually generated clinical plans. All plans were normalized to 95% of planning target volume (PTV) coverage with the prescription dose. Two physicians and one physicist were asked to evaluate the manual plans and auto-plans of each patient in a blinded retrospective review and to indicate clinical acceptability and which plans were preferred for treatment. RESULTS Compared with the manual CSI plans, the auto plans obtained significant reductions in Dmean to the parotids, submandibular glands, larynx, thyroid, and significant reduction in the plan PTV Dmax and D0.03 cc. The standard deviation range of the dosimetric parameters was greatly reduced for auto plans (range, 0.1-1.3 Gy) relative to manual plans (range, 0.4-5.9 Gy) indicating better plan consistency. Among the 10 patients, the auto-plans were preferred over the manual plans 90% of the time by the reviewing experts. The required time for auto-planning was approximately 1 hour compared with estimated 4 or more hours for manual planning. CONCLUSIONS Reductions in planning time without sacrifices in plan quality were obtained using the auto-planning process compared with manual planning. Variation in plan quality was also reduced. The auto-planning scripts will be made freely available to other institutions and clinics.
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Affiliation(s)
- Ignacio O Romero
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Eric A Simiele
- Department of Radiation Oncology, University of Alabama, Birmingham, Alabama
| | - Yuliia Lozko
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Yuliia Severyn
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Lawrie B Skinner
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Yong Yang
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Jen-Yeu Wang
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Lei Xing
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Iris Gibbs
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Susan M Hiniker
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Nataliya Kovalchuk
- Department of Radiation Oncology, Stanford University, Stanford, California.
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Ebadi M, Morse M, Gooley T, Ermoian R, Halasz LM, Lo SS, Yang JT, Blau MH, Percival ME, Cassaday RD, Graber J, Taylor LP, Venur V, Tseng YD. Craniospinal irradiation for CNS leukemia: rates of response and durability of CNS control. J Neurooncol 2024; 166:351-357. [PMID: 38244173 DOI: 10.1007/s11060-023-04501-5] [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: 10/01/2023] [Accepted: 11/03/2023] [Indexed: 01/22/2024]
Abstract
PURPOSE Management of CNS involvement in leukemia may include craniospinal irradiation (CSI), though data on CSI efficacy are limited. METHODS We retrospectively reviewed leukemia patients who underwent CSI at our institution between 2009 and 2021 for CNS involvement. CNS local recurrence (CNS-LR), any recurrence, progression-free survival (PFS), CNS PFS, and overall survival (OS) were estimated. RESULTS Of thirty-nine eligible patients treated with CSI, most were male (59%) and treated as young adults (median 31 years). The median dose was 18 Gy to the brain and 12 Gy to the spine. Twenty-five (64%) patients received CSI immediately prior to allogeneic hematopoietic cell transplant, of which 21 (84%) underwent total body irradiation conditioning (median 12 Gy). Among 15 patients with CSF-positive disease immediately prior to CSI, all 14 assessed patients had pathologic clearance of blasts (CNS-response rate 100%) at a median of 23 days from CSI start. With a median follow-up of 48 months among survivors, 2-year PFS and OS were 32% (95% CI 18-48%) and 43% (95% CI 27-58%), respectively. Only 5 CNS relapses were noted (2-year CNS-LR 14% (95% CI 5-28%)), which occurred either concurrently or after a systemic relapse. Only systemic relapse after CSI was associated with higher risk of CNS-LR on univariate analysis. No grade 3 or higher acute toxicity was seen during CSI. CONCLUSION CSI is a well-tolerated and effective treatment option for patients with CNS leukemia. Control of systemic disease after CSI may be important for CNS local control. CNS recurrence may reflect reseeding from the systemic space.
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Affiliation(s)
- Maryam Ebadi
- Department of Radiation Oncology, University of Washington, 1959 NE Pacific Street, 98195, Seattle, WA, USA
| | - Margaret Morse
- University of Washington School of Medicine, Seattle, WA, USA
| | - Ted Gooley
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Ralph Ermoian
- Department of Radiation Oncology, University of Washington, 1959 NE Pacific Street, 98195, Seattle, WA, USA
| | - Lia M Halasz
- Department of Radiation Oncology, University of Washington, 1959 NE Pacific Street, 98195, Seattle, WA, USA
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington, 1959 NE Pacific Street, 98195, Seattle, WA, USA
| | - Jonathan T Yang
- Department of Radiation Oncology, University of Washington, 1959 NE Pacific Street, 98195, Seattle, WA, USA
| | - Molly H Blau
- Department of Radiation Oncology, University of Washington, 1959 NE Pacific Street, 98195, Seattle, WA, USA
| | - Mary-Elizabeth Percival
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Division of Hematology and Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Ryan D Cassaday
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Division of Hematology and Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Jerome Graber
- Department of Neurology, Division of Medical Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Lynne P Taylor
- Department of Neurology, Division of Medical Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Vyshak Venur
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Division of Hematology and Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Yolanda D Tseng
- Department of Radiation Oncology, University of Washington, 1959 NE Pacific Street, 98195, Seattle, WA, USA.
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA.
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Liu S, Wang Y. Diagnosis and management of adult central nervous system leukemia. BLOOD SCIENCE 2023; 5:141-149. [PMID: 37546706 PMCID: PMC10400053 DOI: 10.1097/bs9.0000000000000162] [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] [Received: 12/23/2022] [Accepted: 05/09/2023] [Indexed: 08/08/2023] Open
Abstract
Central nervous system leukemia (CNSL) is a prominent infiltration reason for therapy failing in acute leukemia. Recurrence rates and the prognosis have alleviated with current prophylactic regimens. However, the accurate stratification of relapse risk and treatment regimens for relapsed or refractory patients remain clinical challenges yet to be solved. Recently, with hematopoietic stem cell transplantation (HSCT) and chimeric antigen receptor-T (CAR-T) cellular therapy showing encouraging effects in some CNSL patients, advances in treating CNSL have already been reported. The development of molecular targeted agents as well as antibody-based drugs will provide patients with more personalized treatment. This article summarized recent research developments about risk factors, diagnosis, prevention, and treatment in adults with CNSL.
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Affiliation(s)
- Siyu Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
| | - Ying Wang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
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4
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Nguyen A, Nguyen A, Dada OT, Desai PD, Ricci JC, Godbole NB, Pierre K, Lucke-Wold B. Leptomeningeal Metastasis: A Review of the Pathophysiology, Diagnostic Methodology, and Therapeutic Landscape. Curr Oncol 2023; 30:5906-5931. [PMID: 37366925 DOI: 10.3390/curroncol30060442] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 06/14/2023] [Accepted: 06/16/2023] [Indexed: 06/28/2023] Open
Abstract
The present review aimed to establish an understanding of the pathophysiology of leptomeningeal disease as it relates to late-stage development among different cancer types. For our purposes, the focused metastatic malignancies include breast cancer, lung cancer, melanoma, primary central nervous system tumors, and hematologic cancers (lymphoma, leukemia, and multiple myeloma). Of note, our discussion was limited to cancer-specific leptomeningeal metastases secondary to the aforementioned primary cancers. LMD mechanisms secondary to non-cancerous pathologies, such as infection or inflammation of the leptomeningeal layer, were excluded from our scope of review. Furthermore, we intended to characterize general leptomeningeal disease, including the specific anatomical infiltration process/area, CSF dissemination, manifesting clinical symptoms in patients afflicted with the disease, detection mechanisms, imaging modalities, and treatment therapies (both preclinical and clinical). Of these parameters, leptomeningeal disease across different primary cancers shares several features. Pathophysiology regarding the development of CNS involvement within the mentioned cancer subtypes is similar in nature and progression of disease. Consequently, detection of leptomeningeal disease, regardless of cancer type, employs several of the same techniques. Cerebrospinal fluid analysis in combination with varied imaging (CT, MRI, and PET-CT) has been noted in the current literature as the gold standard in the diagnosis of leptomeningeal metastasis. Treatment options for the disease are both varied and currently in development, given the rarity of these cases. Our review details the differences in leptomeningeal disease as they pertain through the lens of several different cancer subtypes in an effort to highlight the current state of targeted therapy, the potential shortcomings in treatment, and the direction of preclinical and clinical treatments in the future. As there is a lack of comprehensive reviews that seek to characterize leptomeningeal metastasis from various solid and hematologic cancers altogether, the authors intended to highlight not only the overlapping mechanisms but also the distinct patterning of disease detection and progression as a means to uniquely treat each metastasis type. The scarcity of LMD cases poses a barrier to more robust evaluations of this pathology. However, as treatments for primary cancers have improved over time, so has the incidence of LMD. The increase in diagnosed cases only represents a small fraction of LMD-afflicted patients. More often than not, LMD is determined upon autopsy. The motivation behind this review stems from the increased capacity to study LMD in spite of scarcity or poor patient prognosis. In vitro analysis of leptomeningeal cancer cells has allowed researchers to approach this disease at the level of cancer subtypes and markers. We ultimately hope to facilitate the clinical translation of LMD research through our discourse.
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Affiliation(s)
- Andrew Nguyen
- College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Alexander Nguyen
- College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | | | - Persis D Desai
- College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Jacob C Ricci
- College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Nikhil B Godbole
- School of Medicine, Tulane University, New Orleans, LA 70112, USA
| | - Kevin Pierre
- Department of Radiology, University of Florida, Gainesville, FL 32610, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL 32610, USA
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Chen Z, Dominello MM, Joiner MC, Burmeister JW. Proton versus photon radiation therapy: A clinical review. Front Oncol 2023; 13:1133909. [PMID: 37064131 PMCID: PMC10091462 DOI: 10.3389/fonc.2023.1133909] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 03/13/2023] [Indexed: 03/31/2023] Open
Abstract
While proton radiation therapy offers substantially better dose distribution characteristics than photon radiation therapy in certain clinical applications, data demonstrating a quantifiable clinical advantage is still needed for many treatment sites. Unfortunately, the number of patients treated with proton radiation therapy is still comparatively small, in some part due to the lack of evidence of clear benefits over lower-cost photon-based treatments. This review is designed to present the comparative clinical outcomes between proton and photon therapies, and to provide an overview of the current state of knowledge regarding the effectiveness of proton radiation therapy.
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Affiliation(s)
- Zhe Chen
- School of Medicine, Wayne State University, Detroit, MI, United States
- *Correspondence: Zhe Chen,
| | - Michael M. Dominello
- Karmanos Cancer Institute, Department of Oncology, Wayne State University School of Medicine, Detroit, MI, United States
| | - Michael C. Joiner
- Karmanos Cancer Institute, Department of Oncology, Wayne State University School of Medicine, Detroit, MI, United States
| | - Jay W. Burmeister
- Karmanos Cancer Institute, Department of Oncology, Wayne State University School of Medicine, Detroit, MI, United States
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6
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Central Nervous System Prophylaxis and Treatment in Acute Leukemias. Curr Treat Options Oncol 2022; 23:1829-1844. [PMID: 36510037 PMCID: PMC9767998 DOI: 10.1007/s11864-022-01032-5] [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] [Accepted: 10/21/2022] [Indexed: 12/15/2022]
Abstract
OPINION STATEMENT Improvements in systemic therapy in the treatment of acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML) have improved patient outcomes and reduced the incidence of CNS relapse. However, management of patients with CNS disease remains challenging, and relapses in the CNS can be difficult to salvage. In addition to treatment with CNS-penetrant systemic therapy (high-dose methotrexate and cytarabine), intrathecal prophylaxis is indicated in all patients with ALL, however is not uniformly administered in patients with AML without high-risk features. There is a limited role for radiation treatment in CNS prophylaxis; however, radiation should be considered for consolidative treatment in patients with CNS disease, or as an option for palliation of symptoms. Re-examining the role of established treatment paradigms and investigating the role of radiation as bridging therapy in the era of cellular therapy, particularly in chemotherapy refractory patients, is warranted.
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Kumar A, Sardhara JC, Singh G, Kanjilal S, Maurya VP, Behari S. Malignant Meningitis Associated with Hydrocephalus. Neurol India 2021; 69:S443-S455. [PMID: 35103001 DOI: 10.4103/0028-3886.332278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Malignant meningitis (MM) is the diffuse involvement of the leptomeninges by infiltrating cancer cells, most frequently from lung and breast cancers. This review is aimed to discuss the current advances in the diagnosis and management of MM, along with management of MM-associated hydrocephalus. We reviewed the literature using PubMed and Google Scholar search engines, focusing on various recent randomized controlled trials and clinical trials on MM. Given the hallmark multifocal involvement, the clinical symptoms and signs are also random and asymmetric. There are three important pillars for establishing a diagnosis of MM: clinical examination, neuroimaging, and CSF cytological findings. Several factors should be considered in decision-making, including performance status, neurological findings (clinical, MRI, and CSF flow dynamic), and evaluation of the primary tumor (nature and systemic dissemination). Response Assessment in Neuro-Oncology (RANO) working group recommended the objective assessment of disease for evaluating the progression and response to therapy. Pillars of current management are mainly focal irradiation and intrathecal or systemic chemotherapy. Symptomatic hydrocephalus is managed with a ventriculoperitoneal shunt, lumboperitoneal shunt, or endoscopic third ventriculostomy as palliative procedures, providing significant improvement in performance scores in the limited survival time of patients with MM. Studies using novel therapeutic approaches, such as new biological or cytotoxic compounds, are ongoing. Despite the use of all the combinations, the overall prognosis remains grim; therefore, decision-making for treatment should predominantly be based on attaining an optimal quality of life.
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Affiliation(s)
- Ashutosh Kumar
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Jayesh C Sardhara
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Guramritpal Singh
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Soumen Kanjilal
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ved P Maurya
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sanjay Behari
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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8
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Bhambhvani HP, Rodrigues AJ, Umeh-Garcia MC, Hayden Gephart M. Leptomeningeal Carcinomatosis: Molecular Landscape, Current Management, and Emerging Therapies. Neurosurg Clin N Am 2021; 31:613-625. [PMID: 32921356 DOI: 10.1016/j.nec.2020.06.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Leptomeningeal carcinomatosis is a devastating consequence of late-stage cancer, and despite multimodal treatment, remains rapidly fatal. Definitive diagnosis requires identification of malignant cells in the cerebrospinal fluid (CSF), or frank disease on MRI. Therapy is generally palliative and consists primarily of radiotherapy and/or chemotherapy, which is administered intrathecally or systemically. Immunotherapies and novel experimental therapies have emerged as promising options for decreasing patient morbidity and mortality. In this review, the authors discuss a refined view of the molecular pathophysiology of leptomeningeal carcinomatosis, current approaches to disease management, and emerging therapies.
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Affiliation(s)
- Hriday P Bhambhvani
- Department of Neurosurgery, Stanford University Medical Center, 300 Pasteur Drive, Palo Alto, CA, 94305 USA
| | - Adrian J Rodrigues
- Department of Neurosurgery, Stanford University Medical Center, 300 Pasteur Drive, Palo Alto, CA, 94305 USA
| | - Maxine C Umeh-Garcia
- Department of Neurosurgery, Stanford University Medical Center, 300 Pasteur Drive, Palo Alto, CA, 94305 USA
| | - Melanie Hayden Gephart
- Department of Neurosurgery, Stanford University Medical Center, 300 Pasteur Drive, Palo Alto, CA, 94305 USA; Department of Neurosurgery, Brain Tumor Center, Stanford University School of Medicine, 300 Pasteur Drive, Palo Alto, CA 94305, USA.
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9
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Maillie L, Salgado LR, Lazarev S. A systematic review of craniospinal irradiation for leptomeningeal disease: past, present, and future. Clin Transl Oncol 2021; 23:2109-2119. [PMID: 33881707 DOI: 10.1007/s12094-021-02615-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 03/30/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Leptomeningeal disease (LMD) is a rare but deadly complication of cancer in which the disease spreads to the cerebrospinal fluid and seeds the meninges of the central nervous system (CNS). Craniospinal irradiation (CSI) involves treatment of the entire CNS subarachnoid space and is occasionally used as a last-resort palliative therapy for LMD. METHODS This review examined literature describing the role of CSI for LMD from solid and hematologic malignancies in adults. A search for studies published until September 1, 2020 was conducted using PubMed database. RESULTS A total of 262 unique articles were identified. Thirteen studies were included for analysis in which a total of 275 patients were treated with CSI for LMD. Median age at time of irradiation was 43 years, and most patients had KPS score of 70 and higher. The most common cancers resulting in LMD were acute lymphocytic leukemia, breast cancer, and acute myelogenous leukemia. Median CSI dose was 30 Gy and 18% of patients were treated with proton radiation. 52% of patients had stable-to-improved neurologic symptoms. Median overall survival for the entire cohort was 5.3 months. Patients treated with marrow-sparing proton radiation had median OS of 8 months. The most common treatment toxicities were hematologic and gastrointestinal events. CONCLUSIONS Despite advances in systemic and radiation therapies, LMD remains a devastating end-stage complication of some malignancies. Treatment-related toxicities can be a significant barrier to CSI delivery. In select patients with LMD, marrow-sparing proton CSI may provide safer palliation of symptoms and prolong survival.
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Affiliation(s)
- L Maillie
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - L R Salgado
- Department of Radiation Oncology, Elmhurst Hospital, New York, NY, USA
| | - S Lazarev
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA. .,New York Proton Center, New York, NY, USA.
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10
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Yang TJ, Wijetunga NA, Yamada J, Wolden S, Mehallow M, Goldman DA, Zhang Z, Young RJ, Kris MG, Yu HA, Seidman AD, Gavrilovic IT, Lin A, Santomasso B, Grommes C, Piotrowski AF, Schaff L, Stone JB, DeAngelis LM, Boire A, Pentsova E. Clinical trial of proton craniospinal irradiation for leptomeningeal metastases. Neuro Oncol 2021; 23:134-143. [PMID: 32592583 PMCID: PMC7850116 DOI: 10.1093/neuonc/noaa152] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Leptomeningeal metastases (LM) are associated with limited survival and treatment options. While involved-field radiotherapy is effective for local palliation, it lacks durability. We evaluated the toxicities of proton craniospinal irradiation (CSI), a treatment encompassing the entire central nervous system (CNS) compartment, for patients with LM from solid tumors. METHODS We enrolled patients with LM to receive hypofractionated proton CSI in this phase I prospective trial. The primary endpoint was to describe treatment-related toxicity, with dose-limiting toxicity (DLT) defined as any radiation-related grade 3 non-hematologic toxicity or grade 4 hematologic toxicity according to the Common Terminology Criteria for Adverse Events that occurred during or within 4 weeks of completion of proton CSI. Secondary endpoints included CNS progression-free survival (PFS) and overall survival (OS). RESULTS We enrolled 24 patients between June 2018 and April 2019. Their median follow-up was 11 months. Twenty patients were evaluable for protocol treatment-related toxicities and 21 for CNS PFS and OS. Two patients in the dose expansion cohort experienced DLTs consisted of grade 4 lymphopenia, grade 4 thrombocytopenia, and/or grade 3 fatigue. All DLTs resolved without medical intervention. The median CNS PFS was 7 months (95% CI: 5-13) and the median OS was 8 months (95% CI: 6 to not reached). Four patients (19%) were progression-free in the CNS for more than 12 months. CONCLUSION Hypofractionated proton CSI using proton therapy is a safe treatment for patients with LM from solid tumors. We saw durable disease control in some patients.
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Affiliation(s)
- T Jonathan Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
- PROMISE (Precision Radiation for OligoMetastatIc and MetaStatic DiseasE) Program, Memorial Sloan Kettering Cancer Center, New York, New York
- Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Neil A Wijetunga
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Josh Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
- PROMISE (Precision Radiation for OligoMetastatIc and MetaStatic DiseasE) Program, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Suzanne Wolden
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michelle Mehallow
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Debra A Goldman
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Robert J Young
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mark G Kris
- Division of Solid Tumor Oncology, Thoracic Oncology Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Helena A Yu
- Division of Solid Tumor Oncology, Thoracic Oncology Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew D Seidman
- Division of Solid Tumor Oncology, Breast Medicine Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Igor T Gavrilovic
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
- Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew Lin
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
- Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Bianca Santomasso
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Christian Grommes
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
- Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anna F Piotrowski
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
- Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lauren Schaff
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
- Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jacqueline B Stone
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
- Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lisa M DeAngelis
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
- Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Adrienne Boire
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
- Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, New York
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Elena Pentsova
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
- Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, New York
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11
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Deak D, Gorcea-Andronic N, Sas V, Teodorescu P, Constantinescu C, Iluta S, Pasca S, Hotea I, Turcas C, Moisoiu V, Zimta AA, Galdean S, Steinheber J, Rus I, Rauch S, Richlitzki C, Munteanu R, Jurj A, Petrushev B, Selicean C, Marian M, Soritau O, Andries A, Roman A, Dima D, Tanase A, Sigurjonsson O, Tomuleasa C. A narrative review of central nervous system involvement in acute leukemias. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:68. [PMID: 33553361 PMCID: PMC7859772 DOI: 10.21037/atm-20-3140] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Acute leukemias (both myeloid and lymphoblastic) are a group of diseases for which each year more successful therapies are implemented. However, in a subset of cases the overall survival (OS) is still exceptionally low due to the infiltration of leukemic cells in the central nervous system (CNS) and the subsequent formation of brain tumors. The CNS involvement is more common in acute lymphocytic leukemia (ALL), than in adult acute myeloid leukemia (AML), although the rates for the second case might be underestimated. The main reasons for CNS invasion are related to the expression of specific adhesion molecules (VLA-4, ICAM-1, VCAM, L-selectin, PECAM-1, CD18, LFA-1, CD58, CD44, CXCL12) by a subpopulation of leukemic cells, called “sticky cells” which have the ability to interact and adhere to endothelial cells. Moreover, the microenvironment becomes hypoxic and together with secretion of VEGF-A by ALL or AML cells the permeability of vasculature in the bone marrow increases, coupled with the disruption of blood brain barrier. There is a single subpopulation of leukemia cells, called leukemia stem cells (LSCs) that is able to resist in the new microenvironment due to its high adaptability. The LCSs enter into the arachnoid, migrate, and intensively proliferate in cerebrospinal fluid (CSF) and consequently infiltrate perivascular spaces and brain parenchyma. Moreover, the CNS is an immune privileged site that also protects leukemic cells from chemotherapy. CD56/NCAM is the most important surface molecule often overexpressed by leukemic stem cells that offers them the ability to infiltrate in the CNS. Although asymptomatic or with unspecific symptoms, CNS leukemia should be assessed in both AML/ALL patients, through a combination of flow cytometry and cytological analysis of CSF. Intrathecal therapy (ITT) is a preventive measure for CNS involvement in AML and ALL, still much research is needed in finding the appropriate target that would dramatically lower CNS involvement in acute leukemia.
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Affiliation(s)
- Dalma Deak
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj-Napoca, Romania.,Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Nicolae Gorcea-Andronic
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Valentina Sas
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.,Department of Pediatrics, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Patric Teodorescu
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj-Napoca, Romania.,Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Catalin Constantinescu
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.,Intensive Care Unit, Ion Chiricuta Clinical Cancer Center, Cluj-Napoca, Romania
| | - Sabina Iluta
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj-Napoca, Romania.,Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Sergiu Pasca
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj-Napoca, Romania.,Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Ionut Hotea
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj-Napoca, Romania.,Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Cristina Turcas
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj-Napoca, Romania.,Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Vlad Moisoiu
- Department of Neurosurgery, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Alina-Andreea Zimta
- Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Simona Galdean
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj-Napoca, Romania
| | - Jakob Steinheber
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Ioana Rus
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj-Napoca, Romania
| | - Sebastian Rauch
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Cedric Richlitzki
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Raluca Munteanu
- Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Ancuta Jurj
- Research Center for Functional Genomics and Translational Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Bobe Petrushev
- Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Cristina Selicean
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj-Napoca, Romania
| | - Mirela Marian
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj-Napoca, Romania
| | - Olga Soritau
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj-Napoca, Romania
| | - Alexandra Andries
- Department of Radiology, Ion Chiricuta Clinical Cancer Center, Cluj-Napoca, Romania
| | - Andrei Roman
- Department of Radiology, Ion Chiricuta Clinical Cancer Center, Cluj-Napoca, Romania.,Department of Radiology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Delia Dima
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj-Napoca, Romania
| | - Alina Tanase
- Department of Stem Cell Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | | | - Ciprian Tomuleasa
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj-Napoca, Romania.,Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.,Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
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12
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Abstract
Radiation therapy plays a critical role in the management of a wide range of hematologic malignancies. The optimal radiation dose and target volume, and safe and effective ways of integrating radiation with systemic agents, vary depending on the histologic subtypes, stage at presentation, patient performance status, response to systemic therapy if given, treatment intent, and patient preferences. Limiting doses to surrounding organs without sacrificing disease control is of paramount importance. Reducing radiation doses and treatment volume in selected cases, and the use of advanced radiotherapy technology, can improve the therapeutic ratio of patients receiving radiation therapy for hematologic malignancies.
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Affiliation(s)
- Yolanda D Tseng
- Department of Radiation Oncology, Seattle Cancer Care Alliance Proton Therapy Center, University of Washington School of Medicine, 1570 North 115th Street, Seattle, WA 98133, USA
| | - Andrea K Ng
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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13
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Reproductive outcomes following a stem cell transplant for a haematological malignancy in female cancer survivors: a systematic review and meta-analysis. Support Care Cancer 2019; 27:4451-4460. [PMID: 31541306 DOI: 10.1007/s00520-019-05020-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 07/30/2019] [Indexed: 12/12/2022]
Abstract
PURPOSE The use of high-dose chemotherapy and radiotherapy combined with haematopoietic stem cell transplantation (HSCT) may negatively affect a woman's reproductive potential. Reproductive outcomes such as infertility are a major concern for women who undergo treatment for a haematological cancer diagnosis. OBJECTIVE This systematic review and meta-analysis explores reproductive outcomes following a haematological cancer requiring HSCT. METHODS Electronic databases were searched to identify studies that reported on reproductive outcomes after treatment for a haematological cancer diagnosis. Studies were included that reported on pregnancy and reproductive outcomes following HSCT for a haematological malignancy. RESULTS The meta-analysis included 14 studies, collectively involving 744 female patients. The subgroup analysis showed an overall pooled estimated pregnancy rate, for autologous or allogeneic HSCT recipients, of 22.7% (n = 438). There were 25% (n = 240) of women who became pregnant after autologous HSCT compared with 22% (n = 198) who subsequently became pregnant following allogeneic HSCT. CONCLUSIONS This meta-analysis reflects low pregnancy rates for cancer survivors desiring a family. However, live births are improving over time with new technology and novel therapies. Hence, female cancer patients should be offered timely discussions, counselling and education around fertility preservation options prior to starting treatment with gonadotoxic therapy.
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14
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Thorpe CS, Niska JR, Brunnhoelzl DC, McGee LA, Kesslering CM, Hartsell WF, Vargas CE. First report of proton beam therapy for breast angiosarcoma from the prospective PCG registry. Acta Oncol 2018; 57:992-994. [PMID: 29303019 DOI: 10.1080/0284186x.2017.1423179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
| | - Joshua R. Niska
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Daniel C. Brunnhoelzl
- Creighton University School of Medicine at St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Lisa A. McGee
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
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15
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Pinnix CC, Yahalom J, Specht L, Dabaja BS. Radiation in Central Nervous System Leukemia: Guidelines From the International Lymphoma Radiation Oncology Group. Int J Radiat Oncol Biol Phys 2018; 102:53-58. [PMID: 30102203 DOI: 10.1016/j.ijrobp.2018.05.067] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 05/08/2018] [Accepted: 05/20/2018] [Indexed: 10/14/2022]
Affiliation(s)
- Chelsea C Pinnix
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Joachim Yahalom
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lena Specht
- Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Bouthaina Shbib Dabaja
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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16
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Barisano G, Bergamaschi S, Acharya J, Rajamohan A, Gibbs W, Kim P, Zada G, Chang E, Law M. Complications of Radiotherapy and Radiosurgery in the Brain and Spine. NEUROGRAPHICS (2011) 2018; 8:167-187. [PMID: 35388375 PMCID: PMC8981962 DOI: 10.3174/ng.1700066] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Radiation therapy is an integral part of the standard of care for many patients with brain and spine tumors. Stereotactic radiation surgery is increasingly being used as an adjuvant therapy as well as a sole treatment. However, despite newer and more focused techniques, radiation therapy still causes significant neurotoxicity. In this article, we reviewed the scientific literature, presented cases of patients who had developed different complications related to conventional radiation therapy or radiosurgery (gamma knife), demonstrated the imaging findings, and discussed the relevant clinical information for the correct diagnoses. Radiation therapy can cause injury in different ways: directly damaging the structures included in the radiation portal, indirectly affecting the blood vessels, and increasing the chance of tumor development. We also divided radiation complications according to the time of occurrence: acute (0 to 4 weeks), early delayed (4 weeks to months), and late delayed (months to years). With the increasing application of radiation therapy for the treatment of CNS tumors, it is important for the neuroradiologist to recognize the many possible complications of radiation therapy. Although this may cause significant diagnostic challenges, understanding the pathophysiology, time course of onset, and imaging features may help institute early therapy and prevent possible deleterious outcomes. Learning Objectives To recognize the main complications of radiation therapy and stereotactic radiosurgery in the brain and spine, and to highlight the imaging findings to improve the diagnostic process and treatment planning.
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Affiliation(s)
- G Barisano
- Departments of Radiology (G.B., S.B., J.A., A.R., W.G., P.K., M.L.), Neurosurgery (G.Z.), Radiation Oncology (E.C.), and Stevens Institute of Neuroimaging and Informatics (M.L.), University of Southern California, Los Angeles, California
| | - S Bergamaschi
- Departments of Radiology (G.B., S.B., J.A., A.R., W.G., P.K., M.L.), Neurosurgery (G.Z.), Radiation Oncology (E.C.), and Stevens Institute of Neuroimaging and Informatics (M.L.), University of Southern California, Los Angeles, California
| | - J Acharya
- Departments of Radiology (G.B., S.B., J.A., A.R., W.G., P.K., M.L.), Neurosurgery (G.Z.), Radiation Oncology (E.C.), and Stevens Institute of Neuroimaging and Informatics (M.L.), University of Southern California, Los Angeles, California
| | - A Rajamohan
- Departments of Radiology (G.B., S.B., J.A., A.R., W.G., P.K., M.L.), Neurosurgery (G.Z.), Radiation Oncology (E.C.), and Stevens Institute of Neuroimaging and Informatics (M.L.), University of Southern California, Los Angeles, California
| | - W Gibbs
- Departments of Radiology (G.B., S.B., J.A., A.R., W.G., P.K., M.L.), Neurosurgery (G.Z.), Radiation Oncology (E.C.), and Stevens Institute of Neuroimaging and Informatics (M.L.), University of Southern California, Los Angeles, California
| | - P Kim
- Departments of Radiology (G.B., S.B., J.A., A.R., W.G., P.K., M.L.), Neurosurgery (G.Z.), Radiation Oncology (E.C.), and Stevens Institute of Neuroimaging and Informatics (M.L.), University of Southern California, Los Angeles, California
| | - G Zada
- Departments of Radiology (G.B., S.B., J.A., A.R., W.G., P.K., M.L.), Neurosurgery (G.Z.), Radiation Oncology (E.C.), and Stevens Institute of Neuroimaging and Informatics (M.L.), University of Southern California, Los Angeles, California
| | - E Chang
- Departments of Radiology (G.B., S.B., J.A., A.R., W.G., P.K., M.L.), Neurosurgery (G.Z.), Radiation Oncology (E.C.), and Stevens Institute of Neuroimaging and Informatics (M.L.), University of Southern California, Los Angeles, California
| | - M Law
- Departments of Radiology (G.B., S.B., J.A., A.R., W.G., P.K., M.L.), Neurosurgery (G.Z.), Radiation Oncology (E.C.), and Stevens Institute of Neuroimaging and Informatics (M.L.), University of Southern California, Los Angeles, California
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17
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Wang N, Bertalan MS, Brastianos PK. Leptomeningeal metastasis from systemic cancer: Review and update on management. Cancer 2018; 124:21-35. [PMID: 29165794 PMCID: PMC7418844 DOI: 10.1002/cncr.30911] [Citation(s) in RCA: 130] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 06/27/2017] [Accepted: 07/06/2017] [Indexed: 12/23/2022]
Abstract
Leptomeningeal metastasis is an uncommon and typically late complication of cancer with a poor prognosis and limited treatment options. Diagnosis is often challenging, with nonspecific presenting symptoms ranging from headache and confusion to focal neurologic deficits, such as cranial nerve palsies. Standard diagnostic evaluation involves a neurologic examination, magnetic resonance imaging of the brain and spine with gadolinium, and cytologic evaluation of the cerebral spinal fluid. Therapy entails a multimodal approach focused on palliation with surgery, radiation, and/or chemotherapy, which may be administered systemically or directly into the cerebral spinal fluid. Limited trial data exist to guide treatment, and current regimens are based primarily on expert opinion. Although newer targeted and immunotherapeutic agents are under investigation and have shown promise, an improved understanding of the biology of leptomeningeal metastasis and treatment resistance as well as additional randomized controlled studies are needed to guide the optimal treatment of this devastating disease. Cancer 2018;124:21-35. © 2017 American Cancer Society.
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Affiliation(s)
- Nancy Wang
- Division of Neuro-Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mia S Bertalan
- Division of Neuro-Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Division of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Priscilla K Brastianos
- Division of Neuro-Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Division of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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