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Takeda K, Umezawa R, Yamamoto T, Takahashi N, Jingu K. Craniospinal irradiation for leptomeningeal metastasis of solid tumors: survival analysis and prognostic factors. JOURNAL OF RADIATION RESEARCH 2024:rrae059. [PMID: 39154378 DOI: 10.1093/jrr/rrae059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 05/16/2024] [Indexed: 08/20/2024]
Abstract
We conducted a study to examine the treatment outcomes and prognostic factors for patients who underwent craniospinal irradiation (CSI) for leptomeningeal metastasis of solid tumors. This retrospective study included patients who received CSI for leptomeningeal metastasis at a single institute between 2010 and 2021. Data from clinical records and the radiation information system were obtained and analyzed. A total of 25 patients were included in the study. Eighteen patients (72%) completed the scheduled CSI. The median overall survival (OS) period was 4.8 months (95% confidence interval (CI): 3.2-10.0 months). Symptom relief was achieved in four out of 23 symptomatic patients (17%). Non-hematological adverse events occurred in 12 patients (48%), with 1 patient (4%) developing Grade 3 bacterial meningitis and the other patients having Grade 1-2 events. Twenty patients (80%) had hematological adverse events of Grade 3 or higher. Grade 4 hematologic toxicities occurred in 3 patients (12%) due to neutropenia and in 11 patients (44%) due to lymphopenia. In multivariate Cox regression analysis, the systemic immune-inflammation index (SII) was identified as the only significant parameter for predicting OS. The median OS periods for patients with SII < 607 and SII ≥ 607 were 6.1 and 2.1 months, respectively (P = 0.003). In conclusion, this study showed the treatment outcomes of CSI for leptomeningeal metastasis of solid tumors. It was shown that a high baseline SII was associated with shorter OS after CSI. The findings will contribute to the evaluation of prognosis after CSI.
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Affiliation(s)
- Kazuya Takeda
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8574, Japan
- Department of Radiation Oncology, South Miyagi Medical Center, 38-1 Nishi, Ogawara, Shibata, Miyagi 989-1253, Japan
| | - Rei Umezawa
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8574, Japan
| | - Takaya Yamamoto
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8574, Japan
| | - Noriyoshi Takahashi
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8574, Japan
| | - Keiichi Jingu
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8574, Japan
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Jia G, Bashir S, Ye M, Li Y, Lai M, Cai L, Xu M. Furmonertinib and intrathecal pemetrexed chemotherapy rechallenges osimertinib-refractory leptomeningeal metastasis in a non-small cell lung cancer patient harboring EGFR20 R776S, C797S, and EGFR21 L858R compound EGFR mutations: a case report. Anticancer Drugs 2024; 35:542-547. [PMID: 38513197 DOI: 10.1097/cad.0000000000001593] [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: 03/23/2024]
Abstract
Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) are considered the first-line treatment for advanced or metastatic non-small cell lung cancer (NSCLC) patients harboring EGFR mutations. However, due to the rarity of cases, the response of EGFR-TKIs in patients harboring uncommon compound EGFR mutations still needs to be determined. Here, we demonstrated the case of a 47-year-old smoker diagnosed with leptomeningeal metastasis from NSCLC and had EGFR20 R776S, C797S, and EGFR21 L858R compound mutations. He was treated with furmonertinib combined with intrathecal pemetrexed chemotherapy following progression on osimertinib, which led to clinical improvement and successfully prolonged his survival by 3 months. Regrettably, the patient eventually died from heart disease. This report provides the first reported evidence for the use of furmonertinib and intrathecal pemetrexed chemotherapy in NSCLC patients harboring EGFR R776S/C797S/L858R mutations who progressed on previous EGFR-TKIs.
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Affiliation(s)
- Guoxia Jia
- Oncology Department, First Affiliated Hospital of Jinan University
| | - Shoaib Bashir
- Oncology Department, Guangdong Sanjiu Brain Hospital, Guangzhou, China
| | - Minting Ye
- Oncology Department, Guangdong Sanjiu Brain Hospital, Guangzhou, China
| | - Yin Li
- Oncology Department, First Affiliated Hospital of Jinan University
| | - Mingyao Lai
- Oncology Department, Guangdong Sanjiu Brain Hospital, Guangzhou, China
| | - Linbo Cai
- Oncology Department, Guangdong Sanjiu Brain Hospital, Guangzhou, China
| | - Meng Xu
- Oncology Department, First Affiliated Hospital of Jinan University
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Maciel CB, Busl KM. Neuro-oncologic Emergencies. Continuum (Minneap Minn) 2024; 30:845-877. [PMID: 38830073 DOI: 10.1212/con.0000000000001435] [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: 06/05/2024]
Abstract
OBJECTIVE Neuro-oncologic emergencies have become more frequent as cancer remains one of the leading causes of death in the United States, second only to heart disease. This article highlights key aspects of epidemiology, diagnosis, and management of acute neurologic complications in primary central nervous system malignancies and systemic cancer, following three thematic classifications: (1) complications that are anatomically or intrinsically tumor-related, (2) complications that are tumor-mediated, and (3) complications that are treatment-related. LATEST DEVELOPMENTS The main driver of mortality in patients with brain metastasis is systemic disease progression; however, intracranial hypertension, treatment-resistant seizures, and overall decline due to increased intracranial burden of disease are the main factors underlying neurologic-related deaths. Advances in the understanding of tumor-specific characteristics can better inform risk stratification of neurologic complications. Following standardized grading and management algorithms for neurotoxic syndromes related to newer immunologic therapies is paramount to achieving favorable outcomes. ESSENTIAL POINTS Neuro-oncologic emergencies span the boundaries of subspecialties in neurology and require a broad understanding of neuroimmunology, neuronal hyperexcitability, CSF flow dynamics, intracranial compliance, and neuroanatomy.
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Goyal G, Singh A, Avaronnan M, Raut NV, Talreja V, Chandrasekharan A, Gupta K, Bhosale B, Kothari RK, Parekh D, Poladia BP, Ghosh J, Talele A, Shrirangwar S, Karpe A. Treatment pattern and outcomes of leptomeningeal carcinomatosis in India - a retrospective study. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2024; 24:100331. [PMID: 38756165 PMCID: PMC11096680 DOI: 10.1016/j.lansea.2023.100331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 12/06/2022] [Accepted: 11/14/2023] [Indexed: 05/18/2024]
Abstract
Background Leptomeningeal carcinomatosis (LMC), the metastatic spread of cancer to the leptomeninges, is a rare complication and has a dismal prognosis. Due to limited data available on LMC from India, we conducted a country-wise audit of LMC across 15 centres in India. Methods The current study conducted in 2020, was a retrospective, multicentric audit of adult patients (aged ≥18 years) with diagnosis of LMC and who received treatment during 2010-2020. Baseline characteristics, details related to previous treatments, cancer sites, LMC diagnosis, treatment pattern and overall survival (OS) were collected. Descriptive statistics were performed, and Kaplan Meier analysis was performed for the estimation of OS. Findings Among the patients diagnosed with LMC (n = 84), diagnosis was confirmed in 52 patients (61.9%) and 'probable' in 32 (38.1%) patients. The three most common cause of malignancy were non-small cell lung cancer (NSCLC), breast cancer and gastrointestinal cancer with 45 (53.6%), 22 (26.1%) and 9 (10.7%) patients respectively. Intrathecal therapy was offered in 33 patients (39.3%). The most common intrathecal agent was methotrexate in 23 patients (27.4%). The median OS was 90 days (95% CI 48-128). Among tested variables, intrathecal therapy administration (hazard ratio [HR] = 0.36, 95% CI 0.19-0.68) and primary in lung (HR = 0.43, 95% CI 0.23-0.83) had a favourable impact on OS. Interpretation Prognosis with leptomeningeal carcinomatosis is poor with a significant burden of morbidity and mortality in India. This data aims to highlight the current outcomes and facilitate further research on LMC. Funding None.
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Affiliation(s)
- Gautam Goyal
- Max Super Speciality Hospital, Mohali, Punjab, India
- Cancer Research and Statistic Foundation (CRSF), Indravati River Park, Rawal Pada SN Dube Road, Dahisar East, Mumbai, India
| | - Ashish Singh
- CMC Vellore, Vellore, Tamil Nadu, India
- Cancer Research and Statistic Foundation (CRSF), Indravati River Park, Rawal Pada SN Dube Road, Dahisar East, Mumbai, India
| | - Manuprasad Avaronnan
- Malabar Cancer Centre, Thalassery, Kerala, India
- Cancer Research and Statistic Foundation (CRSF), Indravati River Park, Rawal Pada SN Dube Road, Dahisar East, Mumbai, India
| | - Nirmal Vivek Raut
- Bhaktivedanta Hospital and Research Institute, Mumbai, Maharashtra, India
- Cancer Research and Statistic Foundation (CRSF), Indravati River Park, Rawal Pada SN Dube Road, Dahisar East, Mumbai, India
| | - Vikas Talreja
- Regency Hospital, Kanpur, Uttar Pradesh, India
- Cancer Research and Statistic Foundation (CRSF), Indravati River Park, Rawal Pada SN Dube Road, Dahisar East, Mumbai, India
| | - Arun Chandrasekharan
- Aster Malabar Institute of Medical Sciences (Aster MIMS), Kozhikode, Kerala, India
- Cancer Research and Statistic Foundation (CRSF), Indravati River Park, Rawal Pada SN Dube Road, Dahisar East, Mumbai, India
| | - Kushal Gupta
- Manipal Hospital, Bengaluru, Karnataka, India
- Cancer Research and Statistic Foundation (CRSF), Indravati River Park, Rawal Pada SN Dube Road, Dahisar East, Mumbai, India
| | - Bharat Bhosale
- Bombay Hospital, Mumbai, Maharashtra, India
- Cancer Research and Statistic Foundation (CRSF), Indravati River Park, Rawal Pada SN Dube Road, Dahisar East, Mumbai, India
| | - Rushabh Kiran Kothari
- Narayana Multispeciality Hospital, Ahmedabad, Gujarat, India
- Cancer Research and Statistic Foundation (CRSF), Indravati River Park, Rawal Pada SN Dube Road, Dahisar East, Mumbai, India
| | | | - Bhavesh Pradip Poladia
- Thangam Cancer Center, Namakkal, Tamil Nadu, India
- Cancer Research and Statistic Foundation (CRSF), Indravati River Park, Rawal Pada SN Dube Road, Dahisar East, Mumbai, India
| | - Joydeep Ghosh
- Tata Medical Center, Kolkata, West Bengal, India
- Cancer Research and Statistic Foundation (CRSF), Indravati River Park, Rawal Pada SN Dube Road, Dahisar East, Mumbai, India
| | - Avinash Talele
- Asian Cancer Institute, Mumbai, Maharashtra, India
- Cancer Research and Statistic Foundation (CRSF), Indravati River Park, Rawal Pada SN Dube Road, Dahisar East, Mumbai, India
| | - Sameer Shrirangwar
- National Cancer Institute, Nagpur, Maharashtra, India
- Cancer Research and Statistic Foundation (CRSF), Indravati River Park, Rawal Pada SN Dube Road, Dahisar East, Mumbai, India
| | - Akshay Karpe
- Cardinal Gracias Memorial Hospital, Vasai, Maharashtra, India
- Cancer Research and Statistic Foundation (CRSF), Indravati River Park, Rawal Pada SN Dube Road, Dahisar East, Mumbai, India
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Huang S, Kang X, Wang C, Zhang W, Jiang J, Kang Z, Yang S, Chen J, Chen F, Li W. Outcomes, responses, and prognostic analyses of intrathecal combined treatment for leptomeningeal metastasis from lung adenocarcinoma. J Cancer Res Ther 2024; 20:658-664. [PMID: 38687937 DOI: 10.4103/jcrt.jcrt_2071_23] [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: 09/13/2023] [Accepted: 12/12/2023] [Indexed: 05/02/2024]
Abstract
BACKGROUND Leptomeningeal metastasis (LM) is a severe lung cancer complication, with potentially fatal consequences. The use of intrathecal therapy (IT) combined with systemic therapy has shown promise as a treatment approach for LM. Thus, this study aimed to evaluate the features and responses to IT combined therapy and identify determinants affecting patients with leptomeningeal metastasis resulting from lung adenocarcinoma (LM-LA). METHODS A retrospective analysis of medical records from our hospital database was performed, covering from April 2018 to August 2022, for 37 patients diagnosed with LM-LA and treated with IT combined therapy. Patients who received IT combined therapy for LM-LA were evaluated for demographic characteristics, treatment efficacy, survival, and variables that impacted them. RESULTS The median overall survival (mOS) of 37 patients was 16.0 months, and the survival rates at 6 and 12 months were 75.7% and 35.1%, respectively. Among the 21 patients with LM-LA who received IT combined with tyrosine kinase inhibitors (TKIs), the mOS was 17.0 months, which was significantly longer than that of patients treated with IT combined with chemotherapy (7.0 months, P = 0.010) and the best supportive care (6.0 months, P = 0.001). However, no significant survival benefit was observed in patients treated with IT combined with TKIs when compared with those treated with IT combined with PD-1 (5.0 months, P = 0.249). Multivariate analysis indicated that the combination of TKIs was an independent favorable prognostic factor for patients with LM-LA. CONCLUSION Combination treatment is regarded as an additional option for patients with LM-LA. Compared with other combination therapies in our study, IT combined with TKI therapy provided a better survival outcome for patients with LM-LA.
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Affiliation(s)
- Sijie Huang
- Department of Neuro-Oncology, Cancer Center, Beijing Tiantan Hospital, Capital Medical University, Fengtai District, Beijing, China
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Oka K, Futamura S, Harada T. Intrathecal Trastuzumab for HER2-Positive Cancer of Unknown Primary Leptomeningeal Metastasis: A Case Report. Cureus 2024; 16:e57322. [PMID: 38690464 PMCID: PMC11060115 DOI: 10.7759/cureus.57322] [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: 03/27/2024] [Indexed: 05/02/2024] Open
Abstract
Cancer of unknown primary (CUP) and leptomeningeal metastasis are difficult conditions with limited treatment options. We report a case of CUP leptomeningeal metastasis that was refractory to empirical chemotherapy but achieved a favorable response to intrathecal trastuzumab after the identification of human epidermal growth factor receptor-2 (HER2) amplification. A 59-year-old woman was diagnosed with CUP with metastasis of a poorly differentiated carcinoma to the left axillary, anterior mediastinal, peritoneal, and bilateral supraclavicular lymph nodes. Leptomeningeal metastasis was confirmed shortly after she started empiric chemotherapy; empiric therapy with intrathecal methotrexate failed to relieve her symptoms. Meanwhile, the lymph node specimen tested positive for HER2 amplification. She underwent intrathecal trastuzumab, then her neurological symptoms resolved the following day. We suggest that intrathecal trastuzumab is an effective treatment for HER2-positive CUP leptomeningeal metastasis.
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Affiliation(s)
- Kohei Oka
- Department of Medical Oncology, Fukuchiyama City Hospital, Fukuchiyama, JPN
| | - Shun Futamura
- Department of Medical Oncology, Fukuchiyama City Hospital, Fukuchiyama, JPN
| | - Taishi Harada
- Department of Medical Oncology, Fukuchiyama City Hospital, Fukuchiyama, JPN
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Cooper CG, Kafetzis KN, Patabendige A, Tagalakis AD. Blood-brain barrier disruption in dementia: Nano-solutions as new treatment options. Eur J Neurosci 2024; 59:1359-1385. [PMID: 38154805 DOI: 10.1111/ejn.16229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 11/28/2023] [Accepted: 12/02/2023] [Indexed: 12/30/2023]
Abstract
Candidate drugs targeting the central nervous system (CNS) demonstrate extremely low clinical success rates, with more than 98% of potential treatments being discontinued due to poor blood-brain barrier (BBB) permeability. Neurological conditions were shown to be the second leading cause of death globally in 2016, with the number of people currently affected by neurological disorders increasing rapidly. This increasing trend, along with an inability to develop BBB permeating drugs, is presenting a major hurdle in the treatment of CNS-related disorders, like dementia. To overcome this, it is necessary to understand the structure and function of the BBB, including the transport of molecules across its interface in both healthy and pathological conditions. The use of CNS drug carriers is rapidly gaining popularity in CNS research due to their ability to target BBB transport systems. Further research and development of drug delivery vehicles could provide essential information that can be used to develop novel treatments for neurological conditions. This review discusses the BBB and its transport systems and evaluates the potential of using nanoparticle-based delivery systems as drug carriers for CNS disease with a focus on dementia.
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Affiliation(s)
| | | | - Adjanie Patabendige
- Department of Biology, Edge Hill University, Ormskirk, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
| | - Aristides D Tagalakis
- Department of Biology, Edge Hill University, Ormskirk, UK
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK
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Barbour AB, Kotecha R, Lazarev S, Palmer JD, Robinson T, Yerramilli D, Yang JT. Radiation Therapy in the Management of Leptomeningeal Disease From Solid Tumors. Adv Radiat Oncol 2024; 9:101377. [PMID: 38405313 PMCID: PMC10885590 DOI: 10.1016/j.adro.2023.101377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 09/03/2023] [Indexed: 02/27/2024] Open
Abstract
Purpose Leptomeningeal disease (LMD) is clinically detected in 5% to 10% of patients with solid tumors and is a source of substantial morbidity and mortality. Prognosis for this entity remains poor and treatments are palliative. Radiation therapy (RT) is an essential tool in the management of LMD, and a recent randomized trial demonstrated a survival benefit for proton craniospinal irradiation (CSI) in select patients. In the setting of this recent advance, we conducted a review of the role of RT in LMD from solid tumors to evaluate the evidence basis for RT recommendations. Methods and Materials In November 2022, we conducted a comprehensive literature search in PubMed, as well as a review of ongoing clinical trials listed on ClinicalTrials.gov, to inform a discussion on the role of RT in solid tumor LMD. Because of the paucity of high-quality published evidence, discussion was informed more by expert consensus and opinion, including a review of societal guidelines, than evidence from clinical trials. Results Only 1 prospective randomized trial has evaluated RT for LMD, demonstrating improved central nervous system progression-free survival for patients with breast and lung cancer treated with proton CSI compared with involved-field RT. Modern photon CSI techniques have improved upon historical rates of acute hematologic toxicity, but the overall benefit of this modality has not been prospectively evaluated. Multiple retrospective studies have explored the use of involved-field RT or the combination of RT with chemotherapy, but clear evidence of survival benefit is lacking. Conclusions Optimal management of LMD with RT remains reliant upon expert opinion, with proton CSI indicated in patients with good performance status and extra-central nervous system disease that is either well-controlled or for which effective treatment options are available. Photon-based CSI traditionally has been associated with increased marrow and gastrointestinal toxicities, though intensity modulated RT/volumetric-modulated arc therapy based photon CSI may have reduced the toxicity profile. Further work is needed to understand the role of radioisotopes as well as combined modality treatment with intrathecal or central nervous system penetrating systemic therapies.
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Affiliation(s)
- Andrew B. Barbour
- Department of Radiation Oncology, University of Washington – Fred Hutchinson Cancer Center, Seattle, Washington
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | - Stanislav Lazarev
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Joshua D. Palmer
- Department of Radiation Oncology, The James Cancer Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Timothy Robinson
- Department of Therapeutic Radiology, Yale University, New Haven, Connecticut
| | - Divya Yerramilli
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonathan T. Yang
- Department of Radiation Oncology, University of Washington – Fred Hutchinson Cancer Center, Seattle, Washington
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Goldberg M, Mondragon-Soto MG, Altawalbeh G, Meyer B, Aftahy AK. New Breakthroughs in the Diagnosis of Leptomeningeal Carcinomatosis: A Review of Liquid Biopsies of Cerebrospinal Fluid. Cureus 2024; 16:e55187. [PMID: 38558729 PMCID: PMC10980855 DOI: 10.7759/cureus.55187] [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: 02/28/2024] [Indexed: 04/04/2024] Open
Abstract
Leptomeningeal carcinomatosis represents a terminal stage and is a devastating complication of cancer. Despite its high incidence, current diagnostic methods fail to accurately detect this condition in a timely manner. This failure to diagnose leads to the refusal of treatment and the absence of clinical trials, hampering the development of new therapy strategies. The use of liquid biopsy is revolutionizing the field of diagnostic oncology. The dynamic and non-invasive detection of tumor markers has enormous potential in cancer diagnostics and treatment. Leptomeningeal carcinomatosis is a condition where invasive tissue biopsy is not part of the routine diagnostic analysis, making liquid biopsy an essential diagnostic tool. Several elements in cerebrospinal fluid (CSF) have been investigated as potential targets of liquid biopsy, including free circulating tumor cells, free circulating nucleic acids, proteins, exosomes, and even non-tumor cells as part of the dynamic tumor microenvironment. This review aims to summarize current breakthroughs in the research on liquid biopsy, including the latest breakthroughs in the identification of tumor cells and nucleic acids, and give an overview of future directions in the diagnosis of leptomeningeal carcinomatosis.
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Affiliation(s)
- Maria Goldberg
- Department of Neurosurgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, DEU
| | | | - Ghaith Altawalbeh
- Department of Neurosurgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, DEU
| | - Bernhard Meyer
- Department of Neurosurgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, DEU
| | - Amir Kaywan Aftahy
- Department of Neurosurgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, DEU
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Pinkiewicz M, Pinkiewicz M, Walecki J, Zaczyński A, Zawadzki M. Breaking Barriers in Neuro-Oncology: A Scoping Literature Review on Invasive and Non-Invasive Techniques for Blood-Brain Barrier Disruption. Cancers (Basel) 2024; 16:236. [PMID: 38201663 PMCID: PMC10778052 DOI: 10.3390/cancers16010236] [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: 12/05/2023] [Revised: 12/22/2023] [Accepted: 12/27/2023] [Indexed: 01/12/2024] Open
Abstract
The blood-brain barrier (BBB) poses a significant challenge to drug delivery for brain tumors, with most chemotherapeutics having limited permeability into non-malignant brain tissue and only restricted access to primary and metastatic brain cancers. Consequently, due to the drug's inability to effectively penetrate the BBB, outcomes following brain chemotherapy continue to be suboptimal. Several methods to open the BBB and obtain higher drug concentrations in tumors have been proposed, with the selection of the optimal method depending on the size of the targeted tumor volume, the chosen therapeutic agent, and individual patient characteristics. Herein, we aim to comprehensively describe osmotic disruption with intra-arterial drug administration, intrathecal/intraventricular administration, laser interstitial thermal therapy, convection-enhanced delivery, and ultrasound methods, including high-intensity focused and low-intensity ultrasound as well as tumor-treating fields. We explain the scientific concept behind each method, preclinical/clinical research, advantages and disadvantages, indications, and potential avenues for improvement. Given that each method has its limitations, it is unlikely that the future of BBB disruption will rely on a single method but rather on a synergistic effect of a combined approach. Disruption of the BBB with osmotic infusion or high-intensity focused ultrasound, followed by the intra-arterial delivery of drugs, is a promising approach. Real-time monitoring of drug delivery will be necessary for optimal results.
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Affiliation(s)
- Miłosz Pinkiewicz
- Faculty of Medicine, Wroclaw Medical University, 50-367 Wrocław, Poland
| | - Mateusz Pinkiewicz
- Department of Diagnostic Imaging, Mazowiecki Regional Hospital in Siedlce, 08-110 Siedlce, Poland
| | - Jerzy Walecki
- Division of Interventional Neuroradiology, Department of Radiology, The National Medical Institute of the Ministry of the Interior and Administration, 02-507 Warsaw, Poland
| | - Artur Zaczyński
- Department of Neurosurgery, The National Medical Institute of the Ministry of the Interior and Administration, 02-507 Warsaw, Poland
| | - Michał Zawadzki
- Division of Interventional Neuroradiology, Department of Radiology, The National Medical Institute of the Ministry of the Interior and Administration, 02-507 Warsaw, Poland
- Department of Radiology, Centre of Postgraduate Medical Education, 01-813 Warsaw, Poland
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Shelly S, Dubey D, Mills JR, Klein CJ. Paraneoplastic neuropathies and peripheral nerve hyperexcitability disorders. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:239-273. [PMID: 38494281 DOI: 10.1016/b978-0-12-823912-4.00020-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Peripheral neuropathy is a common referral for patients to the neurologic clinics. Paraneoplastic neuropathies account for a small but high morbidity and mortality subgroup. Symptoms include weakness, sensory loss, sweating irregularity, blood pressure instability, severe constipation, and neuropathic pain. Neuropathy is the first presenting symptom of malignancy among many patients. The molecular and cellular oncogenic immune targets reside within cell bodies, axons, cytoplasms, or surface membranes of neural tissues. A more favorable immune treatment outcome occurs in those where the targets reside on the cell surface. Patients with antibodies binding cell surface antigens commonly have neural hyperexcitability with pain, cramps, fasciculations, and hyperhidrotic attacks (CASPR2, LGI1, and others). The antigenic targets are also commonly expressed in the central nervous system, with presenting symptoms being myelopathy, encephalopathy, and seizures with neuropathy, often masked. Pain and autonomic components typically relate to small nerve fiber involvement (nociceptive, adrenergic, enteric, and sudomotor), sometimes without nerve fiber loss but rather hyperexcitability. The specific antibodies discovered help direct cancer investigations. Among the primary axonal paraneoplastic neuropathies, pathognomonic clinical features do not exist, and testing for multiple antibodies simultaneously provides the best sensitivity in testing (AGNA1-SOX1; amphiphysin; ANNA-1-HU; ANNA-3-DACH1; CASPR2; CRMP5; LGI1; PCA2-MAP1B, and others). Performing confirmatory antibody testing using adjunct methods improves specificity. Antibody-mediated demyelinating paraneoplastic neuropathies are limited to MAG-IgM (IgM-MGUS, Waldenström's, and myeloma), with the others associated with cytokine elevations (VEGF, IL6) caused by osteosclerotic myeloma, plasmacytoma (POEMS), and rarely angiofollicular lymphoma (Castleman's). Paraneoplastic disorders have clinical overlap with other idiopathic antibody disorders, including IgG4 demyelinating nodopathies (NF155 and Contactin-1). This review summarizes the paraneoplastic neuropathies, including those with peripheral nerve hyperexcitability.
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Affiliation(s)
- Shahar Shelly
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States; Department of Neurology, Rambam Health Care Campus, Haifa, Israel; Faculty of Medicine, Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Divyanshu Dubey
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - John R Mills
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Christopher J Klein
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States.
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12
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Meneguetti RT, Cruz FJSM, del Giglio A. Role of intrathecal chemotherapy in the management of meningeal carcinomatosis in patients with breast cancer. EINSTEIN-SAO PAULO 2023; 21:eAO0481. [PMID: 38126659 PMCID: PMC10730263 DOI: 10.31744/einstein_journal/2023ao0481] [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: 02/06/2023] [Accepted: 06/12/2023] [Indexed: 12/23/2023] Open
Abstract
OBJECTIVE To evaluate whether intrathecal chemotherapy improves clinical outcomes in patients with meningeal carcinomatosis. METHODS This retrospective cohort study included consecutive patients with breast cancer diagnosed with meningeal carcinomatosis. Clinical and treatment data were collected from the patients' medical charts. The primary outcome was overall survival, and the secondary outcomes were time to neurological deterioration and reporting of clinical benefit. Logistic regression and Cox proportional hazard models adjusted for potential confounders were used to evaluate the clinical response and overall survival, respectively. RESULTS Overall, 109 female patients were included, 50 (45.9%) of whom received intrathecal chemotherapy with methotrexate and dexamethasone. The median treatment duration was 3 weeks (range, 1-13 weeks). Patients treated with intrathecal chemotherapy were more likely to report clinical benefit (74% versus 57.7%, adjusted odds ratio [OR] = 9.0, 95%CI=2.6-30.9, p<0.001). However, there was no difference in the time to neurologic deterioration (hazard ratio [HR] = 0.96, 95%CI= 0.57-1.59, p=0.86). Patients who received intrathecal chemotherapy did not show an increase in overall survival compared with that of patients who did not receive intrathecal chemotherapy (median overall survival = 1.8 months, 95%CI= 1.27-3.0 versus 2.5, 95%CI= 1.9-3.9, adjusted HR = 0.71, 95%CI= 0.41-1.22, p=0.21). There was a significant interaction between intrathecal chemotherapy and systemic treatment, and patients who received systemic therapy without intrathecal chemotherapy had better overall survival than that of the no-treatment group (adjusted HR = 0.38, 95%CI= 0.20-0.70, p=0.002). CONCLUSION Intrathecal chemotherapy did not increase overall survival or time to neurological deterioration and should not preclude or postpone systemic treatments.
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Affiliation(s)
- Renata Tortato Meneguetti
- Instituto Brasileiro de Controle do CâncerSão PauloSPBrazil Instituto Brasileiro de Controle do Câncer
,
São Paulo
,
SP
,
Brazil
.
- Centro Universitário FMABCSanto AndréSPBrazil Centro Universitário FMABC
,
Santo André
,
SP
,
Brazil
.
| | - Felipe José Silva Melo Cruz
- Instituto Brasileiro de Controle do CâncerSão PauloSPBrazil Instituto Brasileiro de Controle do Câncer
,
São Paulo
,
SP
,
Brazil
.
- Centro Universitário FMABCSanto AndréSPBrazil Centro Universitário FMABC
,
Santo André
,
SP
,
Brazil
.
| | - Auro del Giglio
- Centro Universitário FMABCSanto AndréSPBrazil Centro Universitário FMABC
,
Santo André
,
SP
,
Brazil
.
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13
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Shi M, Sun D, Ma X, Liu J, Zhang Y, Liu T, Chen X, Mo S, Zhao Y, Zhang L. Case report: Leptomeningeal metastasis of advanced nasopharyngeal carcinoma treated with chemoimmunotherapy. Hum Vaccin Immunother 2023; 19:2294579. [PMID: 38111107 PMCID: PMC10732638 DOI: 10.1080/21645515.2023.2294579] [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: 08/11/2023] [Accepted: 12/11/2023] [Indexed: 12/20/2023] Open
Abstract
Leptomeningeal metastasis (LM) of nasopharyngeal carcinoma (NPC) is rare and associated with a poor prognosis. Immune checkpoint inhibitors (ICIs) have been the standard first-line treatment for metastatic NPC, but their effect on meningeal metastasis of NPC needs further investigation. A 38-year-old man complained of bilateral neck masses and sought medical care. He was diagnosed with nasopharyngeal undifferentiated non-keratinizing carcinoma with bilateral cervical lymph node metastasis and multiple bone metastasis, stage cT4N2M1 IVb. Then, the patient received first-line anti-PD-1 antibody tislelizumab combined with gemcitabine and cisplatin and achieved partial response. After seven cycles of first-line chemoimmunotherapy, the patient subsequently developed neurological symptoms, including unsteady walking, slurred speech, coughing on drinking, and unconsciousness. MRI showed leptomeningeal linear enhancement, and cerebrospinal fluid (CSF) analysis indicated Epstein-Barr virus (EBV) infection and squamous cell carcinoma cytology, suggesting the diagnosis of leptomeningeal metastasis. After the definite diagnosis of LM, the patient's condition deteriorated rapidly, leading to his death from brain herniation. We reported the first case of advanced NPC with pathologically confirmed leptomeningeal metastasis after receiving first-line chemoimmunotherapy. Considering the poor prognosis of LM, it is suggested to perform MRI and CSF examination when patients have neurological symptoms. Although immunotherapy significantly improved survival outcomes of advanced NPC patients, it seemed not effective in the setting of LM. The effect of other treatment options, such as radiation therapy and intrathecal therapy, requires further verification.
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Affiliation(s)
- Mengting Shi
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in South China, Guangzhou, China
- Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Dongchen Sun
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in South China, Guangzhou, China
- Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Xilun Ma
- Department of Radiology, The First Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Jiaqing Liu
- State Key Laboratory of Oncology in South China, Guangzhou, China
- Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
- Department of Intensive Care Unit, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Yaxiong Zhang
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in South China, Guangzhou, China
- Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Tingting Liu
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in South China, Guangzhou, China
- Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Xueyuan Chen
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in South China, Guangzhou, China
- Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Silang Mo
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in South China, Guangzhou, China
- Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Yuanyuan Zhao
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in South China, Guangzhou, China
- Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Li Zhang
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in South China, Guangzhou, China
- Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
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14
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Primdahl D, Cohen-Nowak A, Kumthekar P. Novel approaches to treatment of leptomeningeal metastases. Curr Opin Neurol 2023; 36:592-602. [PMID: 37865856 DOI: 10.1097/wco.0000000000001218] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
PURPOSE OF REVIEW The incidence of leptomeningeal metastases is increasing in the setting of improved survival from systemic cancers. In more recent years, our understanding of leptomeningeal metastasis pathogenesis, how to diagnose and treat has been evolving. RECENT FINDINGS Diagnosing leptomeningeal metastasis has been challenging due to the limitations of cytology and neuroimaging; However, newer techniques detecting circulating tumor cells (CTCs) or circulating tumor DNA (ctDNA) have shown potential advantage with diagnosis, quantification and detection of oncogenic mutations. The use of small molecule inhibitors and immunotherapy has shown some promise in specific leptomeningeal metastasis subtypes. SUMMARY These new discoveries have improved clinical trials' ability to assess treatment response and thereby more optimally compare different treatments. Furthermore, they have helped the individual clinician better diagnose, monitor the disease and provide novel therapies.
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Affiliation(s)
- Ditte Primdahl
- Department of Neurology at The Feinberg School of Medicine at Northwestern University and The Malnati Brain Tumor Institute at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | - Adam Cohen-Nowak
- Department of Internal Medicine, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Priya Kumthekar
- Department of Neurology at The Feinberg School of Medicine at Northwestern University and The Malnati Brain Tumor Institute at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University
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15
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Schwarzova K, Li X, Adekunle F, Gupta A. Leptomeningeal Carcinomatosis: A Rare Presentation of Perforated Gastric Cancer. Cureus 2023; 15:e48775. [PMID: 38098918 PMCID: PMC10719753 DOI: 10.7759/cureus.48775] [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: 11/13/2023] [Indexed: 12/17/2023] Open
Abstract
Leptomeningeal carcinomatosis (LMC) or leptomeningeal metastasis is defined as metastasis to the pia mater, arachnoid, and subarachnoid space. Only very few patients with cancer have LMC. In the practice of general surgeons, this diagnosis is rarely, if ever, encountered. We present a rare case of a patient presenting to ED with worsening headaches over several months that developed acute-onset abdominal pain while being evaluated. Further workup showed free air, and the patient was taken emergently to the OR, where a perforated gastric ulcer was identified and biopsied. Pathology revealed gastric adenocarcinoma and subsequent MRI pointed to suspected LMC. Unfortunately, till today there is no effective treatment for advanced-stage gastric cancer, and aggressive intrathecal chemotherapy is only available to mitigate leptomeningeal involvement.
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Affiliation(s)
| | - Xiaolong Li
- Surgery, Ascension Saint Agnes Hospital, Baltimore, USA
| | - Faith Adekunle
- School of Medicine, American University of the Carribbean, Cupecoy, SXM
| | - Alok Gupta
- General Surgery, Ascension Saint Agnes Hospital, Baltimore, USA
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16
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Fujiwara M, Tada H. Perihippocampal Meningeal Carcinomatosis Following Hippocampal Avoidance Prophylactic Cranial Irradiation in Small Cell Lung Cancer: A Case Report. Cureus 2023; 15:e46499. [PMID: 37927701 PMCID: PMC10624598 DOI: 10.7759/cureus.46499] [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: 10/04/2023] [Indexed: 11/07/2023] Open
Abstract
Prophylactic cranial irradiation (PCI) for limited disease small cell lung cancer is the standard of care for curative treatment of this disease. However, neurocognitive dysfunction is one of the late adverse events of PCI and is often problematic. Recently, hippocampal avoidance prophylactic cranial irradiation (HA-PCI) is sometimes performed to prevent neurocognitive dysfunction after PCI. In HA-PCI, the question is whether or not metastases appear around the hippocampus that were not irradiated. We have experienced a case of perihippocampal meningeal carcinomatosis after HA-PCI. We also draw attention to the potential risks of performing HA-PCI based on this experience.
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Affiliation(s)
- Masateru Fujiwara
- Radiation Oncology, Osaka University Graduate School of Medicine, Suita, JPN
- Radiation Oncology, Suita Tokushukai Hospital, Suita, JPN
| | - Hirohito Tada
- Thoracic Surgery, Suita Tokushukai Hospital, Suita, JPN
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17
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Saeed L, Khalil SK, Khalil SK, Madani OA, Al Refai F, Musa M, Adam E, Abu-Obieda H. A Case of Leptomeningeal Carcinomatosis Manifesting With Vertigo in the Setting of Intracranial Hypertension. Cureus 2023; 15:e47431. [PMID: 38021693 PMCID: PMC10659059 DOI: 10.7759/cureus.47431] [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: 10/19/2023] [Indexed: 12/01/2023] Open
Abstract
Leptomeningeal carcinomatosis (LMC) is a rare condition where malignant cells infiltrate the leptomeninges of the central nervous system. We present a case of a 51-year-old male with stage IV adenocarcinoma of the lung who developed recurrent vertigo. The patient initially received a diagnosis of peripheral vertigo, but his symptoms worsened over time and were associated with headache, vomiting, and one episode of seizure. Upon readmission, based on his normal neuroimaging results, normal CSF examination with elevated opening pressure, and papilledema on fundoscopic examination, a diagnosis of pseudotumor cerebri was made. The result of CSF cytology revealed the presence of malignant cells confirming the presence of LMC. This case highlights the importance of considering LMC as a potential cause for unusual neurological symptoms in patients with advanced malignancy, particularly when other conditions like pseudotumor cerebri could obscure its presentation. It is crucial to rule out malignancy through CSF cytology in patients presenting with vertigo and/or other vestibulocochlear symptoms before making an alternative diagnosis that could present similarly.
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Affiliation(s)
- Leena Saeed
- Internal Medicine, Hamad Medical Corporation, Doha, QAT
| | | | | | - Omar A Madani
- Internal Medicine, Hamad Medical Corporation, Doha, QAT
| | | | - Muzamil Musa
- Internal Medicine, Hamad Medical Corporation, Doha, QAT
| | - Ehab Adam
- Internal Medicine, Hamad Medical Corporation, Doha, QAT
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18
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Baskaran AB, Bhatia A, Kumthekar P, Boire A, Lukas RV. Cerebrospinal fluid-administered therapies for leptomeningeal metastases from solid tumors. Future Oncol 2023; 19:1801-1807. [PMID: 37737023 DOI: 10.2217/fon-2022-0926] [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] [Indexed: 09/23/2023] Open
Abstract
Aims/purpose: Leptomeningeal metastases (LM) are associated with substantial morbidity and mortality. Several approaches are used to treat LM, including intrathecally administered therapies. We consolidated current studies exploring intrathecal therapies for LM treatment. Patients & methods: A review of clinical trials using intrathecal agents was conducted with outcomes tabulated and trends described. 48 trials met the inclusion criteria. Initial investigations began with cytotoxic agents; following this were formulations with longer cerebrospinal fluid half-lives, targeted antibodies and radionucleotides. Results & conclusion: Outcomes were not reported consistently. Survival, when reported, remained poor. Intrathecal therapies for LM remain a viable option. Their use can be informed by an understanding of efficacy, safety and toxicity. They may be an important component of future LM treatments.
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Affiliation(s)
- Archit B Baskaran
- Resident, Department of Neurology, The University of Chicago Medicine, Chicago, IL 60637, USA
| | - Ankush Bhatia
- Section Head of Neuro-Oncology, Department of Neurology, Medicine, & Human Oncology, University of Wisconsin School of Medicine & Public Health, Madison, WI 53705, USA
| | - Priya Kumthekar
- Department of Neurology, Lou & Jean Malnati Brain Tumor Institute, Northwestern University, Chicago, IL 60611, USA
| | - Adrienne Boire
- Geoffrey Beene Junior Faculty Chair, Department of Neurology, Human Oncology & Pathogenesis Program, Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Rimas V Lukas
- Neuro-Oncology Division, Associate Professor, Regional Ambulatory Medical Director, Neurology, Department of Neurology, Lou & Jean Malnati Brain Tumor Institute, Northwestern University, Chicago, IL 60611, USA
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19
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Roy-O'Reilly MA, Lanman T, Ruiz A, Rogawski D, Stocksdale B, Nagpal S. Diagnostic and Therapeutic Updates in Leptomeningeal Disease. Curr Oncol Rep 2023; 25:937-950. [PMID: 37256537 PMCID: PMC10326117 DOI: 10.1007/s11912-023-01432-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2023] [Indexed: 06/01/2023]
Abstract
PURPOSE OF REVIEW Leptomeningeal disease (LMD) is a devastating complication of advanced metastatic cancer associated with a poor prognosis and limited treatment options. This study reviews the current understanding of the clinical presentation, pathogenesis, diagnosis, and treatment of LMD. We highlight opportunities for advances in this disease. RECENT FINDINGS In recent years, the use of soluble CSF biomarkers has expanded, suggesting improved sensitivity over traditional cytology, identification of targetable mutations, and potential utility for monitoring disease burden. Recent studies of targeted small molecules and intrathecal based therapies have demonstrated an increase in overall and progression-free survival. In addition, there are several ongoing trials evaluating immunotherapy in LMD. Though overall prognosis of LMD remains poor, studies suggest a potential role for soluble CSF biomarkers in diagnosis and management and demonstrate promising findings in patient outcomes with targeted therapies for specific solid tumors. Despite these advances, there continues to be a gap of knowledge in this disease, emphasizing the importance of inclusion of LMD patients in clinical trials.
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Affiliation(s)
| | - Tyler Lanman
- Department of Neurology, Stanford Medicine, Palo Alto, CA, 94305, USA
| | - Amber Ruiz
- Department of Neurology, Stanford Medicine, Palo Alto, CA, 94305, USA
| | - David Rogawski
- Department of Neurology, Stanford Medicine, Palo Alto, CA, 94305, USA
| | - Brian Stocksdale
- Department of Neurology, Stanford Medicine, Palo Alto, CA, 94305, USA
| | - Seema Nagpal
- Department of Neurology, Stanford Medicine, Palo Alto, CA, 94305, USA.
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20
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Pan E. Potential Molecular Targets in the Treatment of Patients with CNS Tumors. Cancers (Basel) 2023; 15:3807. [PMID: 37568623 PMCID: PMC10417102 DOI: 10.3390/cancers15153807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
The challenges in identifying effective therapies for CNS tumors continue to be daunting [...].
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Affiliation(s)
- Edward Pan
- Daiichi-Sankyo, Inc., 211 Mt. Airy Road, Basking Ridge, NJ 07920, USA
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21
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Ahmad A, Khan P, Rehman AU, Batra SK, Nasser MW. Immunotherapy: an emerging modality to checkmate brain metastasis. Mol Cancer 2023; 22:111. [PMID: 37454123 PMCID: PMC10349473 DOI: 10.1186/s12943-023-01818-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 07/06/2023] [Indexed: 07/18/2023] Open
Abstract
The diagnosis of brain metastasis (BrM) has historically been a dooming diagnosis that is nothing less than a death sentence, with few treatment options for palliation or prolonging life. Among the few treatment options available, brain radiotherapy (RT) and surgical resection have been the backbone of therapy. Within the past couple of years, immunotherapy (IT), alone and in combination with traditional treatments, has emerged as a reckoning force to combat the spread of BrM and shrink tumor burden. This review compiles recent reports describing the potential role of IT in the treatment of BrM in various cancers. It also examines the impact of the tumor microenvironment of BrM on regulating the spread of cancer and the role IT can play in mitigating that spread. Lastly, this review also focuses on the future of IT and new clinical trials pushing the boundaries of IT in BrM.
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Affiliation(s)
- Aatiya Ahmad
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE-68198, USA
| | - Parvez Khan
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE-68198, USA
| | - Asad Ur Rehman
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE-68198, USA
| | - Surinder Kumar Batra
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE-68198, USA
- Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE, 68198, USA
- Eppley Institute for Research in Cancer and Allied Diseases, University of Nebraska Medical Center, Omaha, NE-68198, USA
| | - Mohd Wasim Nasser
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE-68198, USA.
- Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE, 68198, USA.
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22
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Baskaran AB, Buerki RA, Khan OH, Gondi V, Stupp R, Lukas RV, Villaflor VM. Building Team Medicine in the Management of CNS Metastases. J Clin Med 2023; 12:3901. [PMID: 37373596 DOI: 10.3390/jcm12123901] [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: 04/13/2023] [Revised: 05/30/2023] [Accepted: 06/03/2023] [Indexed: 06/29/2023] Open
Abstract
CNS metastases are often terminal for cancer patients and occur at an approximately 10-fold higher rate than primary CNS tumors. The incidence of these tumors is approximately 70,000-400,000 cases annually in the US. Advances that have occurred over the past two decades have led to more personalized treatment approaches. Newer surgical and radiation techniques, as well as targeted and immune therapies, have enanled patient to live longer, thus increasing the risk for the development of CNS, brain, and leptomeningeal metastases (BM and LM). Patients who develop CNS metastases have often been heavily treated, and options for future treatment could best be addressed by multidisciplinary teams. Studies have indicated that patients with brain metastases have improved survival outcomes when cared for in high-volume academic institutions using multidisciplinary teams. This manuscript discusses a multidisciplinary approach for both parenchymal brain metastases as well as leptomeningeal metastases implemented in three academic institutions. Additionally, with the increasing development of healthcare systems, we discuss optimizing the management of CNS metastases across healthcare systems and integrating basic and translational science into our clinical care to further improve outcomes. This paper summarizes the existing therapeutic approaches to the treatment of BM and LM and discusses novel and emerging approaches to optimizing access to neuro-oncologic care while simultaneously integrating multidisciplinary teams in the care of patients with BM and LM.
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Affiliation(s)
- Archit B Baskaran
- Department of Neurology, The University of Chicago, Chicago, IL 60637, USA
| | - Robin A Buerki
- Health System Clinician of Neurology (Neuro-Oncology), Northwestern Medicine Regional Medical Group, Warrenville, IL 60555, USA
| | - Osaama H Khan
- Surgical Neuro-Oncology, Northwestern Medicine Central DuPage Hospital, Winfield, IL 60190, USA
| | - Vinai Gondi
- Department of Radiation Oncology, Nothwestern Medicine West Region, Lou & Jean Malnati Brain Tumor Institute, Northwestern University, Warrenville, IL 60555, USA
| | - Roger Stupp
- Neuro-Oncology Division, Neurological Surgery, Medicine (Hematology and Oncology), Neurology, Department of Neurology, Lou & Jean Malnati Brain Tumor Institute Northwestern University, Chicago, IL 60611, USA
| | - Rimas V Lukas
- Neuro-Oncology Division, Department of Neurology, Lou & Jean Malnati Brain Tumor Institute, Northwestern University, Chicago, IL 60611, USA
| | - Victoria M Villaflor
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA
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23
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Alimonti P, Gonzalez Castro LN. The Current Landscape of Immune Checkpoint Inhibitor Immunotherapy for Primary and Metastatic Brain Tumors. Antibodies (Basel) 2023; 12:antib12020027. [PMID: 37092448 PMCID: PMC10123751 DOI: 10.3390/antib12020027] [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: 12/24/2022] [Revised: 02/14/2023] [Accepted: 03/27/2023] [Indexed: 04/25/2023] Open
Abstract
Antibodies against immune checkpoint inhibitors (ICIs) have revolutionized the treatment of multiple aggressive malignancies, including melanoma and non-small cell lung cancer. ICIs for the treatment of primary and metastatic brain tumors have been used with varying degrees of success. Here, we discuss the available evidence for the use of ICIs in the treatment of primary and metastatic brain tumors, highlighting challenges and opportunities for furthering this type of cancer immunotherapy in neuro-oncology.
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Affiliation(s)
- Paolo Alimonti
- Department of Medicine, Vita-Salute San Raffaele University, Via Olgettina, 58, 20132 Milano, Italy
| | - L Nicolas Gonzalez Castro
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
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24
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Ozcan G, Singh M, Vredenburgh JJ. Leptomeningeal Metastasis from Non-Small Cell Lung Cancer and Current Landscape of Treatments. Clin Cancer Res 2023; 29:11-29. [PMID: 35972437 DOI: 10.1158/1078-0432.ccr-22-1585] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/06/2022] [Accepted: 08/11/2022] [Indexed: 02/06/2023]
Abstract
Leptomeningeal metastasis (LM), also known as leptomeningeal carcinomatosis (LC), is a devastating complication of metastatic cancer that occurs when neoplastic cells invade the meningeal space. Diagnosis of LM remains challenging given the heterogeneous signs and symptoms at presentation and requires thorough neurological examination, cerebrospinal fluid (CSF) analysis, and MRI of the brain and spine with gadolinium. Detecting neoplastic cells in the CSF is the gold standard for diagnosing leptomeningeal metastases; however, it has low sensitivity and may require multiple CSF samples. New emerging technologies, such as liquid biopsy of CSF, have increased sensitivity and specificity for detecting circulating tumor cells in CSF. The management of LM in patients with NSCLC requires an individualized multidisciplinary approach. Treatment options include surgery for ventricular shunt placement, radiation therapy to bulky or symptomatic disease sites, systemic or intrathecal chemotherapy, molecularly targeted agents, and, more recently, immunotherapy. Targeting actionable mutations in LM from NSCLC, such as EGFR tyrosine kinase inhibitors or anaplastic lymphoma kinase gene rearrangement inhibitors, has shown encouraging results in terms of disease control and survival. Although there are limited data regarding the use of immunotherapy in LM, immunotherapy has produced promising results in several case reports. In this review, we focused on the epidemiology, pathophysiology, clinical presentation, diagnosis, and current treatment strategies, with a special emphasis on novel agents, including targeted therapies and immunotherapy of LM in patients with NSCLC.
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Affiliation(s)
- Gonca Ozcan
- Department of Medicine, University of Connecticut Health Center, Farmington, Connecticut
| | - Meghana Singh
- Department of Medicine, University of Connecticut Health Center, Farmington, Connecticut
| | - James J Vredenburgh
- Department of Medicine, Division of Hematology-Oncology, Saint Francis Hospital, Hartford, Connecticut
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25
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Paisana E, Cascão R, Custódia C, Qin N, Picard D, Pauck D, Carvalho T, Ruivo P, Barreto C, Doutel D, Cabeçadas J, Roque R, Pimentel J, Miguéns J, Remke M, Barata JT, Faria CC. UBE2C promotes leptomeningeal dissemination and is a therapeutic target in brain metastatic disease. Neurooncol Adv 2023; 5:vdad048. [PMID: 37215954 PMCID: PMC10195208 DOI: 10.1093/noajnl/vdad048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023] Open
Abstract
Background Despite current improvements in systemic cancer treatment, brain metastases (BM) remain incurable, and there is an unmet clinical need for effective targeted therapies. Methods Here, we sought common molecular events in brain metastatic disease. RNA sequencing of thirty human BM identified the upregulation of UBE2C, a gene that ensures the correct transition from metaphase to anaphase, across different primary tumor origins. Results Tissue microarray analysis of an independent BM patient cohort revealed that high expression of UBE2C was associated with decreased survival. UBE2C-driven orthotopic mouse models developed extensive leptomeningeal dissemination, likely due to increased migration and invasion. Early cancer treatment with dactolisib (dual PI3K/mTOR inhibitor) prevented the development of UBE2C-induced leptomeningeal metastases. Conclusions Our findings reveal UBE2C as a key player in the development of metastatic brain disease and highlight PI3K/mTOR inhibition as a promising anticancer therapy to prevent late-stage metastatic brain cancer.
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Affiliation(s)
- Eunice Paisana
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina da Universidade de Lisboa; Av. Prof. Egas Moniz, 1649-028, Lisboa, Portugal
| | - Rita Cascão
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina da Universidade de Lisboa; Av. Prof. Egas Moniz, 1649-028, Lisboa, Portugal
| | - Carlos Custódia
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina da Universidade de Lisboa; Av. Prof. Egas Moniz, 1649-028, Lisboa, Portugal
| | - Nan Qin
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Heinrich Heine University Düsseldorf, Medical Faculty, and University Hospital Düsseldorf; Moorenstraße 5, 40225 Düsseldorf, Germany
- German Cancer Consortium (DKTK), Partner Site Essen/Düsseldorf, Düsseldorf, Germany
- Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Daniel Picard
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Heinrich Heine University Düsseldorf, Medical Faculty, and University Hospital Düsseldorf; Moorenstraße 5, 40225 Düsseldorf, Germany
- German Cancer Consortium (DKTK), Partner Site Essen/Düsseldorf, Düsseldorf, Germany
- Moorenstraße 5, 40225 Düsseldorf, Germany
| | - David Pauck
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Heinrich Heine University Düsseldorf, Medical Faculty, and University Hospital Düsseldorf; Moorenstraße 5, 40225 Düsseldorf, Germany
- German Cancer Consortium (DKTK), Partner Site Essen/Düsseldorf, Düsseldorf, Germany
- Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Tânia Carvalho
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina da Universidade de Lisboa; Av. Prof. Egas Moniz, 1649-028, Lisboa, Portugal
| | - Pedro Ruivo
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina da Universidade de Lisboa; Av. Prof. Egas Moniz, 1649-028, Lisboa, Portugal
| | - Clara Barreto
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina da Universidade de Lisboa; Av. Prof. Egas Moniz, 1649-028, Lisboa, Portugal
| | - Delfim Doutel
- Anatomic Pathology Department, Instituto Português de Oncologia Francisco Gentil, R. Prof. Lima Basto, 1099-023, Lisboa, Portugal
| | - José Cabeçadas
- Anatomic Pathology Department, Instituto Português de Oncologia Francisco Gentil, R. Prof. Lima Basto, 1099-023, Lisboa, Portugal
| | - Rafael Roque
- Neurology Department, Laboratory of Neuropathology, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte (CHULN), Av. Prof. Egas Moniz, 1649-028, Lisboa, Portugal
| | - José Pimentel
- Neurology Department, Laboratory of Neuropathology, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte (CHULN), Av. Prof. Egas Moniz, 1649-028, Lisboa, Portugal
| | - José Miguéns
- Department of Neurosurgery, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte (CHULN), Av. Prof. Egas Moniz, 1649-028, Lisboa, Portugal
| | - Marc Remke
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Heinrich Heine University Düsseldorf, Medical Faculty, and University Hospital Düsseldorf; Moorenstraße 5, 40225 Düsseldorf, Germany
- German Cancer Consortium (DKTK), Partner Site Essen/Düsseldorf, Düsseldorf, Germany
- Moorenstraße 5, 40225 Düsseldorf, Germany
| | | | - Claudia C Faria
- Corresponding Author: Claudia C. Faria, Instituto de Medicina Molecular João Lobo Antunes, Edifício Egas Moniz, Faculdade de Medicina da Universidade de Lisboa, Av. Professor Egas Moniz, Lisboa, 1649-028, Portugal ()
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Novel Therapeutic Approaches in Neoplastic Meningitis. Cancers (Basel) 2022; 15:cancers15010119. [PMID: 36612116 PMCID: PMC9817816 DOI: 10.3390/cancers15010119] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 12/18/2022] [Accepted: 12/23/2022] [Indexed: 12/28/2022] Open
Abstract
Central nervous system (CNS) metastasis from systemic cancers can involve the brain parenchyma, leptomeninges, or the dura. Neoplastic meningitis (NM), also known by different terms, including leptomeningeal carcinomatosis and carcinomatous meningitis, occurs due to solid tumors and hematologic malignancies and is associated with a poor prognosis. The current management paradigm entails a multimodal approach focused on palliation with surgery, radiation, and chemotherapy, which may be administered systemically or directly into the cerebrospinal fluid (CSF). This review focuses on novel therapeutic approaches, including targeted and immunotherapeutic agents under investigation, that have shown promise in NM arising from solid tumors.
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Uchikura E, Fukuda T, Imai K, Yamauchi M, Kasai M, Ichimura T, Yasui T, Kuwae Y, Sumi T. Carcinomatous meningitis from ovarian serous carcinoma: A case report. Oncol Lett 2022; 25:66. [PMID: 36644158 PMCID: PMC9827457 DOI: 10.3892/ol.2022.13652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 11/30/2022] [Indexed: 01/17/2023] Open
Abstract
Multifocal dissemination of cancer cells from the primary tumor sites to the subarachnoid, pia mater and cerebrospinal fluid (CSF) of the brain and spinal cord causes carcinomatous meningitis (CM). CM is rarely observed in patients with gynecological cancer. The present study described a 59-year-old woman who was diagnosed with CM as a recurrence of stage IIIC ovarian cancer, after presenting with headache and decreased level of consciousness. During adjuvant therapy following surgical debulking, she developed nausea and vomiting. The post-contrast fluid-attenuated inversion-recovery magnetic resonance imaging showed leptomeningeal enhancement on all sulci, particularly around the falx cerebri and cerebellar hemisphere. CM was suspected and CSF cytology revealed adenocarcinoma cells, thus confirming the diagnosis. Overall, although CM is rare, clinicians should be aware of this complication when patients with malignancies experience neurological symptoms, including headache, nausea and vomiting. Knowledge of this clinical entity should assist clinicians in ascertaining accurate diagnoses.
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Affiliation(s)
- Eijiro Uchikura
- Department of Obstetrics and Gynecology, Osaka City University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Takeshi Fukuda
- Department of Obstetrics and Gynecology, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8585, Japan,Correspondence to: Dr Takeshi Fukuda, Department of Obstetrics and Gynecology, Osaka Metropolitan University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan, E-mail:
| | - Kenji Imai
- Department of Obstetrics and Gynecology, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Makoto Yamauchi
- Department of Obstetrics and Gynecology, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Mari Kasai
- Department of Obstetrics and Gynecology, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Tomoyuki Ichimura
- Department of Obstetrics and Gynecology, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Tomoyo Yasui
- Department of Obstetrics and Gynecology, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Yuko Kuwae
- Department of Diagnostic Pathology, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Toshiyuki Sumi
- Department of Obstetrics and Gynecology, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8585, Japan
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Seidel S, Kowalski T, Nilius-Eliliwi V, Schroers R, Schlegel U. Outcome and prognostic factors of very old patients with primary CNS lymphoma: a retrospective analysis of patients ≥80 years treated with high-dose methotrexate-based chemotherapy. Leuk Lymphoma 2022; 63:2905-2911. [PMID: 35856480 DOI: 10.1080/10428194.2022.2100371] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Although >10% of primary CNS lymphoma (PCNSL) patients are ≥80 years, data on this population are limited. We analyzed 19 consecutive octogenarians with PCNSL treated with high-dose methotrexate (HD-MTX)-based chemotherapy at our institution concerning outcome, prognostic factors and living conditions at six-month follow-up for 11 patients alive and in remission. Seven patients received intracerebroventricular (ICV) treatment additional to systemic therapy. Median follow-up was 27.3 months. Median overall survival was 16.3 months. Positive prognosticators of survival were application of ICV treatment (p = 0.033) and female gender (p = 0.015). All 11 patients alive and in remission at 6-month follow-up were living at home with a median Karnofsky performance score of 60 (range 50-90) and a median instrumental activities of daily living score of 3 (range 1-8). HD-MTX-based polychemotherapy including ICV treatment was feasible in this population, patients in remission needed moderate support in everyday live.
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Affiliation(s)
- Sabine Seidel
- Department of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, Bochum, Germany
| | - Thomas Kowalski
- Department of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, Bochum, Germany
| | - Verena Nilius-Eliliwi
- Department of Hematology and Oncology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, Bochum, Germany
| | - Roland Schroers
- Department of Hematology and Oncology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, Bochum, Germany
| | - Uwe Schlegel
- Department of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, Bochum, Germany
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Yang JT, Wijetunga NA, Pentsova E, Wolden S, Young RJ, Correa D, Zhang Z, Zheng J, Steckler A, Bucwinska W, Bernstein A, Betof Warner A, Yu H, Kris MG, Seidman AD, Wilcox JA, Malani R, Lin A, DeAngelis LM, Lee NY, Powell SN, Boire A. Randomized Phase II Trial of Proton Craniospinal Irradiation Versus Photon Involved-Field Radiotherapy for Patients With Solid Tumor Leptomeningeal Metastasis. J Clin Oncol 2022; 40:3858-3867. [PMID: 35802849 PMCID: PMC9671756 DOI: 10.1200/jco.22.01148] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 05/26/2022] [Accepted: 06/14/2022] [Indexed: 01/12/2023] Open
Abstract
PURPOSE Photon involved-field radiotherapy (IFRT) is the standard-of-care radiotherapy for patients with leptomeningeal metastasis (LM) from solid tumors. We tested whether proton craniospinal irradiation (pCSI) encompassing the entire CNS would result in superior CNS progression-free survival (PFS) compared with IFRT. PATIENTS AND METHODS We conducted a randomized, phase II trial of pCSI versus IFRT in patients with non-small-cell lung cancer and breast cancers with LM. We enrolled patients with other solid tumors to an exploratory pCSI group. For the randomized groups, patients were assigned (2:1), stratified by histology and systemic disease status, to pCSI or IFRT. The primary end point was CNS PFS. Secondary end points included overall survival (OS) and treatment-related adverse events (TAEs). RESULTS Between April 16, 2020, and October 11, 2021, 42 and 21 patients were randomly assigned to pCSI and IFRT, respectively. At planned interim analysis, a significant benefit in CNS PFS was observed with pCSI (median 7.5 months; 95% CI, 6.6 months to not reached) compared with IFRT (2.3 months; 95% CI, 1.2 to 5.8 months; P < .001). We also observed OS benefit with pCSI (9.9 months; 95% CI, 7.5 months to not reached) versus IFRT (6.0 months; 95% CI, 3.9 months to not reached; P = .029). There was no difference in the rate of grade 3 and 4 TAEs (P = .19). In the exploratory pCSI group, 35 patients enrolled, the median CNS PFS was 5.8 months (95% CI, 4.4 to 9.1 months) and OS was 6.6 months (95% CI, 5.4 to 11 months). CONCLUSION Compared with photon IFRT, we found pCSI improved CNS PFS and OS for patients with non-small-cell lung cancer and breast cancer with LM with no increase in serious TAEs.
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Affiliation(s)
- Jonathan T. Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - N. Ari Wijetunga
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Elena Pentsova
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Suzanne Wolden
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Robert J. Young
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Denise Correa
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Junting Zheng
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Alexa Steckler
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Weronika Bucwinska
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ashley Bernstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Allison Betof Warner
- Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, Melanoma and Immunotherapeutics Service, New York, NY
| | - Helena Yu
- Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, Thoracic Oncology Service, New York, NY
| | - Mark G. Kris
- Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, Thoracic Oncology Service, New York, NY
| | - Andrew D. Seidman
- Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, Breast Medicine Service, New York, NY
| | - Jessica A. Wilcox
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Rachna Malani
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andrew Lin
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Lisa M. DeAngelis
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nancy Y. Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Simon N. Powell
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Adrienne Boire
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, Brain Tumor Center, New York, NY
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[Investigation of Methods and Influencing Factors to Increase the Positive Rate of
Cytological Pathology of Cerebrospinal Fluid from Lung Cancer Leptomeningeal Metastases]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2022; 25:789-796. [PMID: 36419392 PMCID: PMC9720682 DOI: 10.3779/j.issn.1009-3419.2022.102.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND In advanced non-small cell lung cancer (NSCLC), leptomeningeal metastases (LM) is a common consequence with rapid progression and a poor prognosis. LM affects roughly 3% to 5% of NSCLC patients, and it affects as many as 9.4% of individuals with epidermal growth factor receptor (EGFR) mutations. Cerebrospinal fluid cytology is the gold standard for diagnosing LM, while conventional cytopathology has a positive detection rate of less than 50%, resulting in a delay in diagnosis and treatment of LM. The fixation treatment of cerebrospinal fluid samples has a significant impact on the positive cytology detection rate, and how to improve the positive cytopathology detection rate of cerebrospinal fluid is a hot topic in clinical research. METHODS From June 2019 to November 2021, 105 cases diagnosed with LM based on clinical symptoms and positive imaging were collected and retrospectively evaluated in the second ward of the Department of Oncology of The Second Affiliated Hospital of Harbin Medical University. The effect of different fixation methods on the positive rate of cerebrospinal fluid cytopathology was investigated, and specimens of cerebrospinal fluid were collected and sent for examination using different delivery methods, including the application of the TIB cell preservation solution kit (experimental group) and the routine application of sterile plastic tubes in lumbar puncture bags (control group). Biochemical assays (glucose and total protein) were performed on the cerebrospinal fluid fluid, and Logistic regression analysis and receiver operating characteristic (ROC) curve were used to evaluate the supplementary diagnostic value for LM patients with lung cancer. The relevance of chemical indexes in the assessment of therapeutic efficacy was examined, and biochemical (glucose, total protein) indices and cytological changes in cerebrospinal fluid fluid after pemetrexed intrathecal injection therapy were dynamically monitored. RESULTS In the control group, 24 (45.28%) patients were positive for the first time, while 42 (80.77%) patients were positive for the first time and 10 (19.23%) patients were negative for the first time in the experimental group. Significant differences existed between the two groups (P<0.001). The results of Logistic regression analysis of patients with the first cerebrospinal fluid biochemical test showed that the risk of positive cerebrospinal fluid biochemical pathology with less than 2.5 mmol/L was 2.456 times greater than 2.5 mmol/L of cerebrospinal fluid glucose (OR=2.456, P<0.05), and total cerebrospinal fluid biochemical protein greater than 430 mg/L was 2.647 times less than 430 mg/L (OR=2.647, P>0.05). The ROC curve showed glucose sensitivity of 76.9% in cerebrospinal fluid, the specificity of 54.5%, Youden index of 0.315 and area under the curve (AUC) of 0.620, total protein sensitivity in cerebrospinal fluid of 44.4%, 90.6%, Youden index of 0.350 and AUC of 0.671. After 2 cycles of pemetrexed intrathecal treatment with complete cerebrospinal fluid cytology and cerebrospinal fluid biochemical (glucose, total protein) tests in 73 and 50 patients, respectively, the rate of cerebrospinal fluid cytology turning negative was gradually increased. Cerebrospinal fluid glucose levels increased after 2 cycles of treatment compared with the first time, with a statistically significant difference (P<0.001). CONCLUSIONS The use of a cell preservation solution kit to immediately fix cerebrospinal fluid samples following isolation in patients with clinical symptoms and positive imaging greatly enhances the rate of positive cerebrospinal fluid cytology detection. The effect of treatment can be assessed and predicted by continuous dynamic monitoring of cerebrospinal fluid biochemistry and cytology.
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Sakai M, Kashiwagi N, Nakanishi K, Maeda N, Nakaya Y, Tanaka J, Watanabe S, Hongyo H, Tanaka Y, Yamada S, Kawata A, Toda S, Takano K, Arita H, Tomiyama N. Nonbrain metastases seen on magnetic resonance imaging during metastatic brain tumor screening. Jpn J Radiol 2022; 41:367-381. [PMID: 36374473 PMCID: PMC10066091 DOI: 10.1007/s11604-022-01362-2] [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: 08/11/2022] [Accepted: 11/04/2022] [Indexed: 11/16/2022]
Abstract
AbstractAlthough metastases found during head magnetic resonance imaging (MRI) are not limited to metastatic brain tumors, the MRI is a very common method for “brain metastasis screening,” a modality that is being increasingly performed. In this review, we describe MRI findings of nonbrain metastases and discuss ways to avoid missing these lesions. Metastatic cranial bone tumors are among the most common nonbrain metastatic lesions found on head MRI, followed by leptomeningeal carcinomatosis. The other less-frequent metastatic lesions include those in the ventricle/choroid plexus, the pituitary gland and stalk, and the pineal gland. Metastases in the head and neck area, as well as cranial and intracranial lesions, should be carefully evaluated. Furthermore, direct geographical invasion, perineural spread, and double cancers should also be considered. While it is important to recognize these metastatic lesions on MRI, because they may necessitate a change in treatment strategy that could lead to an improvement in prognosis due to early introduction of therapy, nonbrain lesions should also be given greater attention, given the increasing survival of patients with cancer and advances in MRI technology, such as contrast-enhanced-3D T1-weighted imaging.
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Affiliation(s)
- Mio Sakai
- Department of Diagnostic and Interventional Radiology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-Ku, Osaka-Shi, Osaka, 541-8567, Japan.
| | - Nobuo Kashiwagi
- Department of Diagnostic and Interventional Radiology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-Ku, Osaka-Shi, Osaka, 541-8567, Japan
| | - Katsuyuki Nakanishi
- Department of Diagnostic and Interventional Radiology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-Ku, Osaka-Shi, Osaka, 541-8567, Japan
| | - Noboru Maeda
- Department of Diagnostic and Interventional Radiology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-Ku, Osaka-Shi, Osaka, 541-8567, Japan
| | - Yasuhiro Nakaya
- Department of Diagnostic and Interventional Radiology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-Ku, Osaka-Shi, Osaka, 541-8567, Japan
| | - Junichiro Tanaka
- Department of Diagnostic and Interventional Radiology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-Ku, Osaka-Shi, Osaka, 541-8567, Japan
| | - Shinichiro Watanabe
- Department of Diagnostic and Interventional Radiology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-Ku, Osaka-Shi, Osaka, 541-8567, Japan
| | - Hidenari Hongyo
- Department of Diagnostic and Interventional Radiology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-Ku, Osaka-Shi, Osaka, 541-8567, Japan
| | - Yu Tanaka
- Department of Diagnostic and Interventional Radiology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-Ku, Osaka-Shi, Osaka, 541-8567, Japan
| | - Sawaka Yamada
- Department of Diagnostic and Interventional Radiology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-Ku, Osaka-Shi, Osaka, 541-8567, Japan
| | - Atsushi Kawata
- Department of Diagnostic and Interventional Radiology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-Ku, Osaka-Shi, Osaka, 541-8567, Japan
| | - Sou Toda
- Department of Diagnostic and Interventional Radiology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-Ku, Osaka-Shi, Osaka, 541-8567, Japan
| | - Koji Takano
- Department of Neurosurgery, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-Ku, Osaka-Shi, Osaka, 541-8567, Japan
| | - Hideyuki Arita
- Department of Neurosurgery, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-Ku, Osaka-Shi, Osaka, 541-8567, Japan
| | - Noriyuki Tomiyama
- Department of Radiology, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan
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Intrathecal therapy for the management of leptomeningeal metastatic disease: a scoping review of the current literature and ongoing clinical trials. J Neurooncol 2022; 160:79-100. [PMID: 35999434 DOI: 10.1007/s11060-022-04118-0] [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: 07/29/2022] [Accepted: 08/16/2022] [Indexed: 02/01/2023]
Abstract
PURPOSE Leptomeningeal metastatic disease (LMD) from advanced malignancies has poor prognoses and limited treatments. Intrathecal therapy (ITT) protocols are available, showing variable outcomes. We reviewed the therapeutic and toxicity profiles of ITT in LMD. METHODS PubMed, EMBASE, Web-of-Science, and Scopus were searched following the PRISMA-ScR guidelines to include studies reporting ITT for LMD. CLINICALTRIAL gov and Cochrane were searched to identify ongoing clinical trials. RESULTS We included 27 published studies encompassing 2161 patients and 4 ongoing trials. LMD originated from brain metastases (85.5%), lymphomas (5.4%), high-grade gliomas (4.6%), medulloblastomas (2.3%), and leukemias (2.1%). LMD was mostly diagnosed with the co-presence of neurological-related symptoms and positive imaging and/or cerebrospinal fluid cytology (60.8%). The most common ITT agents were methotrexate (35.9%), cytarabine (21.9%), and thiotepa (8.2%), standalone or combined. Patients received a median of 6.5 ITT cycles (range, 1.0-71.0) via intraventricular (58.8%) or lumbar intrathecal (41.2%) routes. The Ommaya reservoir was implanted in 38.5% cases. Concurrent systemic chemotherapy (45.2%) and/or radiotherapy (30.6%) were used. After 1-3 cycles, 44.7% patients had improved clinical status and 29.9% converted into negative cerebrospinal fluid cytology. The most common ITT-related severe adverse events were neutropenia (6.5%), meningitis (5.2%) and encephalopathy (4.5%). Median freedom from progression was 2.4 months (range, 0.1-59.5) and median overall survival 5.5 months (range, 0.1-148.0). CONCLUSION Current ITT protocols are variable but effective and well-tolerated in LMD. Ongoing trials are investigating dose-limiting toxicity profiles and long-term overall survival. Future studies should analyze the therapeutic and safety profiles of ITT compared to newer systemic therapies.
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Falk Z, Bou Nasif M, Fallouh N. Ophthalmoplegia in a Her2+ and β-hCG+ Patient With Leptomeningeal Carcinomatosis Secondary to Gastric Adenocarcinoma. Cureus 2022; 14:e26658. [PMID: 35815304 PMCID: PMC9266915 DOI: 10.7759/cureus.26658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2022] [Indexed: 11/30/2022] Open
Abstract
Leptomeningeal carcinomatosis (LMC) is an uncommon and devastating late complication of metastatic malignancy that carries a poor prognosis, typically faring worse when secondary to solid tumors. Diagnosis of LMC can be challenging, especially if the underlying cancer is undiagnosed, as presenting symptoms can be nonspecific or involve focal deficits such as cranial nerve palsies. Typically, LMC can be recognized due to new central neurological findings with concomitant peripheral nerve involvement, but there has not been a case of LMC with isolated peripheral nerve findings to our knowledge. In this report, we present a case of LMC secondary to metastatic gastric adenocarcinoma in a patient whose only manifestation was cranial nerve palsies, and whose cancer was also found to be Her2+ and β-hCG positive, two markers not widely recognized in gastric cancer.
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Khang M, Bindra RS, Mark Saltzman W. Intrathecal delivery and its applications in leptomeningeal disease. Adv Drug Deliv Rev 2022; 186:114338. [PMID: 35561835 DOI: 10.1016/j.addr.2022.114338] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 04/26/2022] [Accepted: 05/06/2022] [Indexed: 12/22/2022]
Abstract
Intrathecal delivery (IT) of opiates into the cerebrospinal fluid (CSF) for anesthesia and pain relief has been used clinically for decades, but this relatively straightforward approach of bypassing the blood-brain barrier has been underutilized for other indications because of its lack of utility in delivering small lipid-soluble drugs. However, emerging evidence suggests that IT drug delivery be an efficacious strategy for the treatment of cancers in which there is leptomeningeal spread of disease. In this review, we discuss CSF flow dynamics and CSF clearance pathways in the context of intrathecal delivery. We discuss human and animal studies of several new classes of therapeutic agents-cellular, protein, nucleic acid, and nanoparticle-based small molecules-that may benefit from IT delivery. The complexity of the CSF compartment presents several key challenges in predicting biodistribution of IT-delivered drugs. New approaches and strategies are needed that can overcome the high rates of turnover in the CSF to reach specific tissues or cellular targets.
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35
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Christidis P, Kantas T, Kalitsis C. Total hip arthroplasty for an intracapsular femoral neck fracture of high-femoral amputee. Arch Clin Cases 2022; 9:50-55. [PMID: 35813498 PMCID: PMC9262082 DOI: 10.22551/2022.35.0902.10203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Femoral neck fractures in transfemoral amputees are not common and management is associated with surgical technique and post-operative rehabilitation challenges. A 61-year-old Caucasian, male, above-knee amputee (following mangled extremity trauma 8 months before) who mobilized with a prosthesis presented to the emergency department with a right femoral neck fracture (Garden III). The patient underwent cementless total hip replacement (THR), using the lateral (Hardinge’s) approach. No additional instrument was used to manipulate the residual femoral stump. The absence of the distal limb required careful preparation of the femoral canal, taking into consideration the position of the lesser trochanter, in order to appropriately align the femoral prosthesis regarding anteversion. Postoperative recovery was uneventful. Six months later, the patient was ambulating using his prothesis and had almost returned to his pre-injury activity status. Satisfactory results can be obtained after THR in trans-femoral amputees.
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Yim E, Leung D. Leptomeningeal disease in BRIP1-mutated pancreatic adenocarcinoma. BMJ Case Rep 2022; 15:e249837. [PMID: 35675963 PMCID: PMC9185485 DOI: 10.1136/bcr-2022-249837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2022] [Indexed: 12/29/2022] Open
Abstract
Leptomeningeal disease is rare in pancreatic cancer and prognosis remains poor. Mutation profiles are now directing therapy to improve survival. We describe a case of leptomeningeal and brain metastasis in BRCA1 interacting protein 1, or BRIP1-mutated pancreatic adenocarcinoma with progression through several lines of chemotherapy and immunotherapy. A woman in her late 50s presented with metastatic pancreatic adenocarcinoma on liver biopsy. She achieved complete response after modified FOLFIRINOX and started a poly (ADP-ribose) polymerase (PARP) inhibitor for a BRIP1 mutation. She had recurrence at 9 months and started pembrolizumab (programmed cell death protein 1, or PD-1receptor antibody) for tumour mutational burden of 10 muts/Mb. At 10 months, she presented with lower extremity weakness and back pain. MRI revealed leptomeningeal metastases from T11 to cauda equina roots and right occipital metastasis. Cerebrospinal fluid studies revealed elevated pressure (290 mm H2O) and protein (73 mg/dL) with negative cytology. Leptomeningeal carcinomatosis was diagnosed. She began palliative radiation but died at 11 months from initial diagnosis.
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Affiliation(s)
- Eunji Yim
- Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - Denise Leung
- Neurology, University of Michigan, Ann Arbor, Michigan, USA
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37
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Alajangi HK, Kaur M, Sharma A, Rana S, Thakur S, Chatterjee M, Singla N, Jaiswal PK, Singh G, Barnwal RP. Blood-brain barrier: emerging trends on transport models and new-age strategies for therapeutics intervention against neurological disorders. Mol Brain 2022; 15:49. [PMID: 35650613 PMCID: PMC9158215 DOI: 10.1186/s13041-022-00937-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 05/24/2022] [Indexed: 12/12/2022] Open
Abstract
The integrity of the blood–brain barrier (BBB) is essential for normal central nervous system (CNS) functioning. Considering the significance of BBB in maintaining homeostasis and the neural environment, we aim to provide an overview of significant aspects of BBB. Worldwide, the treatment of neurological diseases caused by BBB disruption has been a major challenge. BBB also restricts entry of neuro-therapeutic drugs and hinders treatment modalities. Hence, currently nanotechnology-based approaches are being explored on large scale as alternatives to conventional methodologies. It is necessary to investigate the in-depth characteristic features of BBB to facilitate the discovery of novel drugs that can successfully cross the barrier and target the disease effectively. It is imperative to discover novel strategies to treat life-threatening CNS diseases in humans. Therefore, insights regarding building blocks of BBB, activation of immune response on breach of this barrier, and various autoimmune neurological disorders caused due to BBB dysfunction are discussed. Further, special emphasis is given on delineating BBB disruption leading to CNS disorders. Moreover, various mechanisms of transport pathways across BBB, several novel strategies, and alternative routes by which drugs can be properly delivered into CNS are also discussed.
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Affiliation(s)
- Hema Kumari Alajangi
- Department of Biophysics, Panjab University, Chandigarh, 160014, India.,University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh, 160014, India
| | - Mandeep Kaur
- Department of Biophysics, Panjab University, Chandigarh, 160014, India
| | - Akanksha Sharma
- Department of Biophysics, Panjab University, Chandigarh, 160014, India.,University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh, 160014, India
| | - Sumedh Rana
- Department of Biophysics, Panjab University, Chandigarh, 160014, India
| | - Shipali Thakur
- Department of Biophysics, Panjab University, Chandigarh, 160014, India
| | - Mary Chatterjee
- Department of Biotechnology, UIET, Panjab University, Chandigarh, 160014, India
| | - Neha Singla
- Department of Biophysics, Panjab University, Chandigarh, 160014, India
| | - Pradeep Kumar Jaiswal
- Department of Biochemistry and Biophysics, Texas A&M University, College Station, TX, 77843, USA.
| | - Gurpal Singh
- University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh, 160014, India.
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Kundu R, Singh B, Dey P. Cytology coupled with immunocytochemistry nails Merkel cell carcinoma: a rare intruder in the cerebrospinal fluid. Cytopathology 2022; 33:530-533. [PMID: 35416339 DOI: 10.1111/cyt.13127] [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: 03/14/2022] [Revised: 03/31/2022] [Accepted: 04/08/2022] [Indexed: 11/28/2022]
Abstract
Merkel cell carcinoma is an uncommon aggressive skin tumor which is well known for its recurrence and metastasis. Leptomeningeal metastasis involving the cerebrospinal fluid is extremely rare. The diagnosis may easily be missed as it simulates other much common small round blue cell tumors. A history of primary diagnosis may not always be available. Awareness and cytomorphological vigilance with judicious employment of appropriate immunomarkers on limited cerebrospinal fluid samples is indispensable for nailing the diagnosis. The tumor cells are usually monotonous small round cells, singly scattered or as loosely cohesive clusters. Cells have round to elongated nuclei with coarsely granular chromatin, nuclear molding at places and scanty basophilic cytoplasm. A limited immunocytochemistry panel employing CK20 and CD56 for which the tumor is positive is confirmatory. We herein present a case of infiltration of cerebrospinal fluid by Merkel cell carcinoma.
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Affiliation(s)
- Reetu Kundu
- Department of Cytology & Gynecological Pathology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh-160012, India
| | - Brijdeep Singh
- Department of Cytology & Gynecological Pathology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh-160012, India
| | - Pranab Dey
- Department of Cytology & Gynecological Pathology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh-160012, India
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Ferguson SD, Fomchenko EI, Guerrieri RA, Glitza Oliva IC. Challenges and Advances in Diagnosis and Treatment of Leptomeningeal Disease (LMD). Front Oncol 2022; 11:800053. [PMID: 35096602 PMCID: PMC8789647 DOI: 10.3389/fonc.2021.800053] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 12/06/2021] [Indexed: 12/11/2022] Open
Abstract
Leptomeningeal disease (LMD) is a devastating category of CNS metastasis with a very poor prognosis and limited treatment options. With maximal aggressive therapy, survival times remain short and, without treatment, prognosis is measured in weeks. Both LMD diagnosis and treatment are challenging topics within neuro-oncology. In this review, we discuss the advances in LMD diagnosis with a focus on the role of circulating tumor DNA (ctDNA) and discuss the role of targeted and immunotherapy in LMD treatment.
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Affiliation(s)
- Sherise D Ferguson
- Department of Neurosurgery, University of Texas, MD Anderson Cancer Center, Houston, TX, United States
| | - Elena I Fomchenko
- Department of Neurosurgery, University of Texas, MD Anderson Cancer Center, Houston, TX, United States
| | - Renato A Guerrieri
- Department of Melanoma Medical Oncology, University of Texas, MD Anderson Cancer Center, Houston, TX, United States
| | - Isabella C Glitza Oliva
- Department of Melanoma Medical Oncology, University of Texas, MD Anderson Cancer Center, Houston, TX, United States
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40
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Deciphering Biomarkers for Leptomeningeal Metastasis in Malignant Hemopathies (Lymphoma/Leukemia) Patients by Comprehensive Multipronged Proteomics Characterization of Cerebrospinal Fluid. Cancers (Basel) 2022; 14:cancers14020449. [PMID: 35053611 PMCID: PMC8773653 DOI: 10.3390/cancers14020449] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/04/2022] [Accepted: 01/06/2022] [Indexed: 11/16/2022] Open
Abstract
Simple Summary The early diagnosis of leptomeningeal disease is a challenge because it is asymptomatic in the early stages. Consequently, it is important to identify a panel of biomarkers to help in its diagnosis and/or prognosis. For this purpose, we explored a multipronged proteomics approach in cerebrospinal fluid (CSF) to determine a potential panel of biomarkers. Thus, a systematic and exhaustive characterization of more than 300 CSF samples was performed by an integrated approach by Liquid Chromatography-Tandem Mass Spectrometry (LC-MS/MS) and functional proteomics analysis to establish protein profiles, which were useful for developing a panel of biomarkers validated by in silico approaches. Abstract In the present work, leptomeningeal disease, a very destructive form of systemic cancer, was characterized from several proteomics points of view. This pathology involves the invasion of the leptomeninges by malignant tumor cells. The tumor spreads to the central nervous system through the cerebrospinal fluid (CSF) and has a very grim prognosis; the average life expectancy of patients who suffer it does not exceed 3 months. The early diagnosis of leptomeningeal disease is a challenge because, in most of the cases, it is an asymptomatic pathology. When the symptoms are clear, the disease is already in the very advanced stages and life expectancy is low. Consequently, there is a pressing need to determine useful CSF proteins to help in the diagnosis and/or prognosis of this disease. For this purpose, a systematic and exhaustive proteomics characterization of CSF by multipronged proteomics approaches was performed to determine different protein profiles as potential biomarkers. Proteins such as PTPRC, SERPINC1, sCD44, sCD14, ANPEP, SPP1, FCGR1A, C9, sCD19, and sCD34, among others, and their functional analysis, reveals that most of them are linked to the pathology and are not detected on normal CSF. Finally, a panel of biomarkers was verified by a prediction model for leptomeningeal disease, showing new insights into the research for potential biomarkers that are easy to translate into the clinic for the diagnosis of this devastating disease.
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Baleiras MM, Graça J, Fernandes L. Leptomeningeal carcinomatosis in gastric cancer: a case report of a rare yet aggressive entity. Arch Clin Cases 2022; 9:6-11. [PMID: 35529092 PMCID: PMC9066584 DOI: 10.22551/2022.34.0901.10196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Leptomeningeal carcinomatosis (LMC) is exceedingly rare in gastric cancer. It is most commonly seen in breast, lung cancer and melanoma, and is associated with an extremely poor prognosis. If untreated, median overall survival is four to six weeks. No standard treatment for LMC exists and published data are scarce. We present two cases of gastric carcinoma diagnosed with LMC that exemplify how aggressive this condition is and how short the time lapse is to perform any targeted therapy. This report aims to raise awareness of this rare metastatic possibility in gastric cancer and its diagnostic and therapeutic challenges.
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Geng D, Guo Q, Huang S, Zhang H, Guo S, Li X. A Retrospective Study of Intrathecal Pemetrexed Combined With Systemic Therapy for Leptomeningeal Metastasis of Lung Cancer. Technol Cancer Res Treat 2022; 21:15330338221078429. [PMID: 35289201 PMCID: PMC8928347 DOI: 10.1177/15330338221078429] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Objective This retrospective study aimed to investigate the clinical features of lung cancer patients with leptomeningeal metastasis (LM) and explore the clinical efficacy and tolerance of intrathecal pemetrexed (IP) combined with systemic antitumor therapy. Methods Thirty-four lung cancer patients (11 men, 23 women) with LM receiving IP at our hospital were retrospectively reviewed between August 2018 and December 2019. Identified cases showed either positive cerebrospinal fluid cytology or typical findings (leptomeningeal enhancement or ventricle broadening) upon imaging examination. Results Before the diagnosis of LM, 24 (70.6%) patients received EGFR-TKI therapy with or without other agents (antivascular therapy, or chemotherapy), 5 (14.7%) patients received chemotherapy, 1 (2.9%) patient received antivascular therapy, and 3 (8.8%) patients received ALK inhibitors. Fourteen (41.2%) patients did not change the systematic regimen at the beginning of IP, while 20 (58.8%) patients changed to antitumor agents. IP was administered for a median of 3 times (range, 1-12 times). The IP dose was 15, 20, 25, 30, and 40 mg in 8 (23.5%), 21 (58.8%), 2 (5.9%), 2 (5.9%), and 1 (5.9%) patient, respectively. In all IP dose levels, the major adverse events were myelosuppression and elevation of hepatic aminotransferases (EHA). Grade 1/2 myelosuppression occurred in 4 (11.8%) patients. Grade 1/2 EHA also occurred in 4 (11.8%) patients. Grades 3/4 adverse events were not observed. After IP and systematic therapy, the clinical manifestations related to LM in 26 (76.5%) patients improved. In the whole cohort, the median overall survival was 20 months. The median time from the initial IP administration until death or the last follow-up was 3.5 months. Conclusions IP showed controllable toxicity and good efficacy, prolonged the survival time, and improved the quality of life when combined with tailored systemic antitumor therapy in lung cancer patients.
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Affiliation(s)
- Di Geng
- 191599Department of Medical Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Qianqian Guo
- 191599Department of Medical Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Siyuan Huang
- 191599Department of Medical Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Huixian Zhang
- 191599Department of Medical Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Sanxing Guo
- 191599Department of Medical Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Xingya Li
- 191599Department of Medical Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
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Hou L, Han W, Jin J, Chen X, Zou Y, Yan L, He J, Bu H. Clinical efficacy and safety of different doses of intrathecal methotrexate in the treatment of leptomeningeal carcinomatosis: a prospective and single-arm study. Jpn J Clin Oncol 2021; 51:1715-1722. [PMID: 34585252 DOI: 10.1093/jjco/hyab155] [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] [Received: 04/16/2021] [Accepted: 09/14/2021] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To investigate the clinical efficacy and safety of different doses of intrathecal methotrexate in the treatment of leptomeningeal carcinomatosis. METHODS 53 patients admitted to the Second Hospital of Hebei Medical University with leptomeningeal carcinomatosis were recruited. They were divided into two groups: 15-mg-group received 15 mg methotrexate intrathecally, while the other received 10 mg methotrexate. All patients were followed up to 31 December 2020 or until death. Primary endpoint was the response rate. Secondary endpoints were survival and safety. Treatment-related adverse events were recorded. RESULTS The intrathecal chemotherapy was regularly maintained in 42 cases. Most primary cancers were lung (60.4%), stomach (18.9%) or breast (5.7%). The clinical response rate was higher in the 15 mg group than the 10 mg group (62.5 vs. 34.5%, P = 0.042). In the 15 mg group, two cases showed myelosuppression and one case showed seizures. In the 10 mg group, one patient appeared fever, three patients appeared myelosuppression and one showed leukoencephalopathy. However, there were no serious irreversible adverse reactions in neither of the two groups. In terms of survival, the median survival was 15.7 weeks in the 15 mg group and 27.1 weeks in the 10 mg group (P = 0.116). Multivariate analysis showed that only targeted therapy improved the survival (P < 0.0001, HR = 5.386). CONCLUSION Increased dose of methotrexate did not prolong the overall survival, but it was more effective in relieving clinical symptoms with no increased adverse reactions. Targeted therapy might improve the survival.
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Affiliation(s)
- Lan Hou
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China.,Department of Neurology, Baoding No.1 Central Hospital, Baoding, China
| | - Weixin Han
- Department of Neurology, Hebei Chest Hospital, Shijiazhuang, China
| | - Jie Jin
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China.,Department of Neurology, Baoding No.1 Central Hospital, Baoding, China
| | - Xin Chen
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China.,Department of Neurology, Baoding No.1 Central Hospital, Baoding, China
| | - Yueli Zou
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China.,Department of Neurology, Baoding No.1 Central Hospital, Baoding, China
| | - Litian Yan
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China.,Department of Neurology, Baoding No.1 Central Hospital, Baoding, China
| | - Junying He
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China.,Department of Neurology, Baoding No.1 Central Hospital, Baoding, China
| | - Hui Bu
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China.,Department of Neurology, Baoding No.1 Central Hospital, Baoding, China
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44
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Yu Z, Tu Q, Wang Z, Ding Y, Yang X, Zhu L. Meningeal carcinomatosis following a curative endoscopic submucosal dissection of early gastric cancer: a case report. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2021; 60:593-597. [PMID: 34820804 DOI: 10.1055/a-1668-0625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Meningeal carcinomatosis (MC) is reported to occur in 4%-15% of patients with solid tumors. MC is not commonly associated with gastric carcinoma and is extremely rare in patients with early gastric cancer (EGC). MC derived from EGC after curative endoscopic submucosal dissection (ESD) has not been reported before. We present a rare case of a 49-year-old patient who developed MC after curative ESD of EGC. The cancer was an ulcerated lesion approximately 1.0 cm in diameter in endoscopic appearance in the minor curvature of the gastric antrum. The pathological examination after ESD indicated high-grade intraepithelial neoplasia (1.3 × 2.1 cm in size) with localized moderately differentiated adenocarcinoma (0-IIc in tumor stage, intestinal type in Lauren classification), which was confined to the mucosal layer with an intact submucosal layer and muscularis propria. The lesion was removed entirely by curative dissection without vertical and horizontal resection margins involvement in pathology. Two months after ESD, the patient was readmitted for severe headache and vomiting. Cytological examination of the cerebrospinal fluid found malignant tumor cells, which were considered by pathologists to have metastasized from the stomach, further confirming MC derived from EGC. The patient's condition deteriorated dramatically, which prevented him from receiving further therapies, such as chemotherapy, and he died 3 days after the diagnosis of MC. In conclusion, EGC can cause MC, even after curative ESD. New neurological manifestations in patients with EGC can alert physicians to a diagnosis of MC, and more attention needs to be paid to evaluating the nervous system and establishing diagnostic and therapeutic strategies as soon as possible.
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Affiliation(s)
- Zhengping Yu
- Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Qi Tu
- Neurology, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Zhenwen Wang
- Gastroenterology, Gaoxin Hospital of the First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Ying Ding
- Medical Cosmetology, Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xueping Yang
- Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Liang Zhu
- Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, China
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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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Sener U, Kumthekar P, Boire A. Advances in the diagnosis, evaluation, and management of leptomeningeal disease. Neurooncol Adv 2021; 3:v86-v95. [PMID: 34859236 PMCID: PMC8633748 DOI: 10.1093/noajnl/vdab108] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Leptomeningeal metastasis (LM) is a devastating complication of cancer with variable clinical presentation and limited benefit from existing treatment options. In this review, we discuss advances in LM diagnostics and therapeutics with the potential to reverse this grim course. Emerging cerebrospinal fluid circulating tumor cell and cell-free tumor DNA analysis technologies will improve diagnosis of LM, while providing crucial genetic information, capturing tumor heterogeneity, and quantifying disease burden. Circulating tumor cells and cell-free tumor DNA have utility as biomarkers to track disease progression and treatment response. Treatment options for LM include ventriculoperitoneal shunting for symptomatic relief, radiation therapy including whole-brain radiation and focal radiation for bulky leptomeningeal involvement, and systemic and intrathecal medical therapies, including targeted and immunotherapies based on tumor mutational profiling. While existing treatments for LM have limited efficacy, recent advances in liquid biopsy together with increasing availability of targeted treatments will lead to rational multimodal individualized treatments and improved patient outcomes.
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Affiliation(s)
- Ugur Sener
- Department of Neurology, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Priya Kumthekar
- Department of Neurology, Malnati Brain Tumor Institute at the Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Adrienne Boire
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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47
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Nieblas-Bedolla E, Zuccato J, Kluger H, Zadeh G, Brastianos PK. Central Nervous System Metastases. Hematol Oncol Clin North Am 2021; 36:161-188. [PMID: 34711458 DOI: 10.1016/j.hoc.2021.08.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The proportion of patients developing central nervous system (CNS) metastasis is increasing. Most are identified once symptomatic. Surgical resection is indicated for solitary or symptomatic brain metastases, separation surgery for compressive radioresistant spinal metastases, and instrumentation for unstable spinal lesions. Surgical biopsies are performed when histological diagnoses are required. Stereotactic radiosurgery is an option for limited small brain metastases and radioresistant spinal metastases. Whole-brain radiotherapy is reserved for extensive brain metastases and leptomeningeal disease with approaches to reduce cognitive side effects. Radiosensitive and inoperable spinal metastases typically receive external beam radiotherapy. Systemic therapy is increasingly being utilized for CNS metastases.
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Affiliation(s)
- Edwin Nieblas-Bedolla
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Jeffrey Zuccato
- MacFeeters-Hamilton Center for Neuro-Oncology Research, Princess Margaret Cancer Center, 14-701, Toronto Medical Discovery Tower (TMDT), 101 College Street, Toronto, Ontario M5G 1L7, Canada
| | - Harriet Kluger
- Section of Medical Oncology-WWW211, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520, USA
| | - Gelareh Zadeh
- MacFeeters-Hamilton Center for Neuro-Oncology Research, Princess Margaret Cancer Center, 14-701, Toronto Medical Discovery Tower (TMDT), 101 College Street, Toronto, Ontario M5G 1L7, Canada.
| | - Priscilla K Brastianos
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA.
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48
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Rinehardt H, Kassem M, Morgan E, Palettas M, Stephens JA, Suresh A, Ganju A, Lustberg M, Wesolowski R, Sardesai S, Stover D, Vandeusen J, Cherian M, Prieto Eibl MDPG, Miah A, Alnahhas I, Giglio P, Puduvalli VK, Ramaswamy B, Williams N, Noonan AM. Assessment of Leptomeningeal Carcinomatosis Diagnosis, Management and Outcomes in Patients with Solid Tumors Over a Decade of Experience. Eur J Breast Health 2021; 17:371-377. [PMID: 34651117 DOI: 10.4274/ejbh.galenos.2021.2021-4-10] [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] [Received: 04/27/2021] [Accepted: 07/18/2021] [Indexed: 12/01/2022]
Abstract
Objective Leptomeningeal carcinomatosis (LMC), a common complication of advanced malignancies, is associated with high morbidity and mortality, yet diagnosis and treatment decisions remain challenging. This study describes the diagnostic and treatment modalities for LMC and identifies factors associated with overall survival (OS). Materials and Methods We performed a single-institution retrospective study (registration #: OSU2016C0053) of 153 patients diagnosed with LMC treated at The Ohio State University, Comprehensive Cancer Center, (OSUCCC)-James between January 1, 2010 and December 31, 2015. Results Median age at diagnosis was 55.7 years, and 61% had Eastern Cooperative Oncology Group baseline performance status ≤1. Most common primary tumors were breast (43%), lung (26%), and cutaneous melanoma (10%). At presentation, most patients were stage III-IV (71%) with higher grade tumors (grade III: 46%). Metastases to bone (36%), brain (33%), and lung (12%) were the most common sites with a median of 0.5 years (range, 0-14.9 years) between the diagnosis of first metastasis and of LMC. 153 (100%) patients had MRI evidence of LMC. Of the 67 (44%) who underwent lumbar puncture (LP), 33 (22%) had positive cerebrospinal fluid (CSF) cytology. Most patients received radiotherapy for LMC (60%) and chemotherapy (93%) for either the primary disease or LMC. 28 patients received intrathecal chemotherapy, 22 of whom had a primary diagnosis of breast cancer. 98% died with median OS of all patients was 1.9 months (95% CI: 1.3-2.5 months). Conclusion Despite improved treatments and targeted therapies, outcomes of LMC remain extremely poor. Positive CSF cytology was associated with lower OS in patients who had cytology assessed and specifically in patients with breast cancer. CSF cytology serves as an important indicator for prognosis and helps aid in developing individualized therapeutic strategies for patients with LMC.
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Affiliation(s)
- Hannah Rinehardt
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Mahmoud Kassem
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, USA
| | - Evan Morgan
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, USA
| | - Marilly Palettas
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University College of Medicine Columbus, OH, USA
| | - Julie A Stephens
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University College of Medicine Columbus, OH, USA
| | - Anupama Suresh
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, USA
| | - Akansha Ganju
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, USA
| | - Maryam Lustberg
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, USA
| | - Robert Wesolowski
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, USA
| | - Sagar Sardesai
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, USA
| | - Daniel Stover
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, USA
| | - Jeffrey Vandeusen
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, USA
| | - Mathew Cherian
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, USA
| | | | - Abdul Miah
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Iyad Alnahhas
- Division of Neuro-oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Pierre Giglio
- Division of Neuro-oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Vinay K Puduvalli
- Division of Neuro-oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Bhuvaneswari Ramaswamy
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, USA
| | - Nicole Williams
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, USA
| | - Anne M Noonan
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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49
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García Molina E, Penas-Prado M. Neoplastic meningitis in solid tumours: updated review of diagnosis, prognosis, therapeutic management, and future directions. NEUROLOGÍA (ENGLISH EDITION) 2021; 37:794-805. [PMID: 34663545 DOI: 10.1016/j.nrleng.2019.10.009] [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: 07/22/2019] [Accepted: 10/14/2019] [Indexed: 10/20/2022] Open
Abstract
Neoplastic meningitis (NM) is a relatively frequent metastatic complication of cancer associated with high levels of neurological morbidity and generally poor prognosis. It appears in 5%-15% of patients with solid tumours, the most frequent being breast and lung cancer and melanoma. Symptoms are caused by involvement of the cerebral hemispheres, cranial nerves, spinal cord, and nerve roots, and are often multifocal or present with signs and symptoms of intracranial hypertension. The main diagnostic tools are the neurological examination, brain and spinal cord contrast-enhanced magnetic resonance imaging, and cerebrospinal fluid analysis including cytology, although studies have recently been conducted into the detection of tumour cells and DNA in the cerebrospinal fluid, which increases diagnostic sensitivity. With the currently available therapies, treatment aims not to cure the disease, but to delay and ameliorate the symptoms and to preserve quality of life. Treatment of NM involves a multimodal approach that may include radiotherapy, intrathecal and/or systemic chemotherapy, and surgery. Treatment should be individualised, and is based mainly on clinical practice guidelines and expert opinion. Promising clinical trials are currently being conducted to evaluate drugs with molecular and immunotherapeutic targets. This article is an updated review of NM epidemiology, clinical presentation, diagnosis, prognosis, management, and treatment; it is aimed at general neurologists and particularly at neurologists practicing in hospital settings with oncological patients.
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Affiliation(s)
- E García Molina
- Servicio de Neurología, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain.
| | - M Penas-Prado
- Neuro-Oncology Branch, National Cancer Institute, Bethesda, Maryland, United States
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50
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Brastianos PK, Strickland MR, Lee EQ, Wang N, Cohen JV, Chukwueke U, Forst DA, Eichler A, Overmoyer B, Lin NU, Chen WY, Bardia A, Juric D, Dagogo-Jack I, White MD, Dietrich J, Nayyar N, Kim AE, Alvarez-Breckenridge C, Mahar M, Mora JL, Nahed BV, Jones PS, Shih HA, Gerstner ER, Giobbie-Hurder A, Carter SL, Oh K, Cahill DP, Sullivan RJ. Phase II study of ipilimumab and nivolumab in leptomeningeal carcinomatosis. Nat Commun 2021; 12:5954. [PMID: 34642329 PMCID: PMC8511104 DOI: 10.1038/s41467-021-25859-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 08/25/2021] [Indexed: 11/09/2022] Open
Abstract
Leptomeningeal disease (LMD) is a common complication from solid tumor malignancies with a poor prognosis and limited treatment options. We present a single arm Phase II study of 18 patients with LMD receiving combined ipilimumab and nivolumab until progression or unacceptable toxicity (NCT02939300). The primary end point is overall survival at 3 months (OS3). Secondary end points include toxicity, cumulative time-to-progression at 3 months, and progression-free survival. A Simon two-stage design is used to compare a null hypothesis OS3 of 18% against an alternative of 44%. Median follow up based on patients still alive is 8.0 months (range: 0.5 to 15.9 months). The study has met its primary endpoint as 8 of 18 (OS3 0.44; 90% CI: 0.24 to 0.66) patients are alive at three months. One third of patients have experienced one (or more) grade-3 or higher adverse events. Two patients have discontinued protocol treatment due to unacceptable toxicity (hepatitis and colitis, respectively). The most frequent adverse events include fatigue (N = 7), nausea (N = 6), fever (N = 6), anorexia (N = 6) and rash (N = 6). Combined ipilimumab and nivolumab has an acceptable safety profile and demonstrates promising activity in LMD patients. Larger, multicenter clinical trials are needed to validate these results.
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Affiliation(s)
| | - Matthew R Strickland
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Eudocia Quant Lee
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Nancy Wang
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Justine V Cohen
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Ugonma Chukwueke
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | | | - April Eichler
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Beth Overmoyer
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Nancy U Lin
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Wendy Y Chen
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Aditya Bardia
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Dejan Juric
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | | | - Michael D White
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Jorg Dietrich
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Naema Nayyar
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Albert E Kim
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | | | - Maura Mahar
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Joana L Mora
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Brian V Nahed
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Pamela S Jones
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Helen A Shih
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | | | | | - Scott L Carter
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Kevin Oh
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Daniel P Cahill
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Ryan J Sullivan
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
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