1
|
Gaietto A, Panetta JC, Pauley JL, Relling MV, Ribeiro R, Ehrhardt MJ, Pui CH, Inaba H, Swanson HD. Ommaya reservoir use in pediatric ALL and NHL: a review at St. Jude Children's Research Hospital. Cancer Chemother Pharmacol 2024; 93:617-625. [PMID: 38416167 DOI: 10.1007/s00280-024-04653-9] [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: 10/26/2023] [Accepted: 02/11/2024] [Indexed: 02/29/2024]
Abstract
PURPOSE The intraventricular route of chemotherapy administration, via an Ommaya Reservoir (OmR) improves drug distribution in the central nervous system (CNS) compared to the more commonly used intrathecal administration. We retrospectively reviewed our experience with intraventricular chemotherapy, focused on methotrexate, in patients with Acute Lymphoblastic Leukemia (ALL) and Non-Hodgkin Lymphoma (NHL). METHODS Twenty-four patients (aged 7 days - 22.2 years) with 26 OmR placements were identified for a total of 25,009 OmR days between 1990 and 2019. Methotrexate cerebrospinal fluid (CSF) concentrations (n = 124) were analyzed from 59 courses of OmR therapy in 15 patients. Twenty-one courses involved methotrexate dosing on day 0 only, whereas 38 courses involved booster dosing on days 1, 2, or both. We simulated the time CSF methotrexate concentrations remained > 1 µM for 3 days given various dosing regimens. RESULTS CSF methotrexate exposure was higher in those who concurrently received systemic methotrexate than via OmR alone (p < 10- 7). Our simulations showed that current intraventricular methotrexate boosting strategy for patients ≥ 3 years of age maintained CSF methotrexate concentrations ≥ 1 µM for 72 h 40% of the time. Alternatively, other boosting strategies were predicted to achieve CSF methotrexate concentrations ≥ 1 µM for 72 h between 46 and 72% of the time. CONCLUSIONS OmR were able to be safely placed and administer intraventricular methotrexate with and without boost doses in patients from 7 days to 22 years old. Boosting strategies are predicted to increase CSF methotrexate concentrations ≥ 1 µM for 72 h.
Collapse
Affiliation(s)
- Alyssa Gaietto
- Department of Pharmacy Services, University of Kentucky Healthcare, Lexington, KY, USA
| | - John C Panetta
- Department of Pharmacy and Pharmaceutical Services, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Mail stop 150, Memphis, TN, 38105, USA
| | - Jennifer L Pauley
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Mary V Relling
- Department of Pharmacy and Pharmaceutical Services, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Mail stop 150, Memphis, TN, 38105, USA
| | - Raul Ribeiro
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Matthew J Ehrhardt
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Hiroto Inaba
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Hope D Swanson
- Department of Pharmacy and Pharmaceutical Services, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Mail stop 150, Memphis, TN, 38105, USA.
| |
Collapse
|
2
|
Central Nervous System Involvement in Adults with Acute Leukemia: Diagnosis, Prevention, and Management. Curr Oncol Rep 2022; 24:427-436. [PMID: 35141858 DOI: 10.1007/s11912-022-01220-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Recent treatment advances in both acute myeloid leukemia and acute lymphoblastic leukemia have drastically improved outcomes for these diseases, but central nervous system (CNS) relapses still occur. Treatment of CNS disease can be challenging due to the impermeability of the blood-brain barrier to many systemic therapies. RECENT FINDINGS The diagnosis of CNS leukemia relies on assessment of clinical symptoms, cerebrospinal fluid sampling for conventional cytology and/or flow cytometry, and neuroimaging. While treatment of CNS leukemia with systemic or intrathecal chemotherapy and/or radiation can be curative in some patients, these modalities can also lead to serious toxicities. In the modern era, prophylaxis with intrathecal chemotherapy is the most important strategy to prevent CNS relapses in high risk patients. Accurate risk stratification tools and the use of risk-adapted prophylactic therapy are imperative to improving the outcomes of patients with acute leukemias and preventing the development of CNS leukemia.
Collapse
|
3
|
Hosoda T, Katayama M. Epidemiology and prognosis of ommaya reservoir-related bacterial meningitis in adult patients with leptomeningeal metastases from solid tumors: A 10-year retrospective single-center study in Japan. J Infect Chemother 2020; 27:486-491. [PMID: 33214071 DOI: 10.1016/j.jiac.2020.10.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 10/20/2020] [Accepted: 10/22/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Leptomeningeal metastases (LM) from solid tumors have poor prognosis. Intrathecal chemotherapy through the Ommaya reservoir (OR) is one of the options for treating LM; however, OR-related bacterial meningitis (ORRBM) is a severe complication in patients who underwent OR placement. Little is known about the incidence rate and prognosis of ORRBM among patients with LM from solid tumors. METHODS We retrospectively reviewed the records of patients who underwent OR placement to treat LM from solid tumors at Kawasaki Municipal Kawasaki Hospital between January 2009, and December 2018. RESULTS Among 136 patients with OR placement (median age of 64.5 years) including 30,320 Ommaya-days, 18 (13.2%) developed ORRBM (5.9 infections per 10,000 Ommaya-days). The major primary diseases were lung cancer (65.4%). The median times from OR placement and from last OR puncture to ORRBM onset were 20 days and 4.5 days, respectively. Major clinical symptoms were fever (83.3%), headache (50.0%), disturbance of consciousness (50.0%), and nausea (38.9%). Seventeen of 18 patients underwent an OR removal operation. One patient died from ORRBM, and another patient died from heart failure during ORRBM treatment. The median duration of treatment with antibiotics was 16.5 days. The median survival period from the day of OR placement was 146.5 days among patients who developed ORRBM and 142.5 days among patients who did not develop ORRBM. CONCLUSIONS The rate of ORRBM among patients with LM from solid tumors in our hospital was 13.2%. ORRBM may not shorten the patients' survival period with adequate management including removal of the device.
Collapse
Affiliation(s)
- Tomohiro Hosoda
- Department of Infectious Disease, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Japan.
| | - Makoto Katayama
- Department of Neurosurgery, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Japan
| |
Collapse
|
4
|
Operative Complications with and without Image Guidance: A Systematic Review and Meta-Analysis of the Ommaya Reservoir Literature. World Neurosurg 2019; 122:404-414. [DOI: 10.1016/j.wneu.2018.11.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 11/02/2018] [Accepted: 11/04/2018] [Indexed: 11/24/2022]
|
5
|
Cohen-Pfeffer JL, Gururangan S, Lester T, Lim DA, Shaywitz AJ, Westphal M, Slavc I. Intracerebroventricular Delivery as a Safe, Long-Term Route of Drug Administration. Pediatr Neurol 2017; 67:23-35. [PMID: 28089765 DOI: 10.1016/j.pediatrneurol.2016.10.022] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 09/07/2016] [Accepted: 10/30/2016] [Indexed: 01/19/2023]
Abstract
Intrathecal delivery methods have been used for many decades to treat a broad range of central nervous system disorders. A literature review demonstrated that intracerebroventricular route is an established and well-tolerated method for prolonged central nervous system drug delivery in pediatric and adult populations. Intracerebroventricular devices were present in patients from one to 7156 days. The number of punctures per device ranged from 2 to 280. Noninfectious complication rates per patient (range, 1.0% to 33.0%) were similar to infectious complication rates (0.0% to 27.0%). Clinician experience and training and the use of strict aseptic techniques have been shown to reduce the frequency of complications.
Collapse
Affiliation(s)
| | | | | | - Daniel A Lim
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | | | - Manfred Westphal
- Department of Neurosurgery, University Clinic Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Irene Slavc
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria.
| |
Collapse
|
6
|
Inserra A, Narciso A, Paolantonio G, Messina R, Crocoli A. Palliative care and pediatric surgical oncology. Semin Pediatr Surg 2016; 25:323-332. [PMID: 27955737 DOI: 10.1053/j.sempedsurg.2016.08.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Survival rate for childhood cancer has increased in recent years, reaching as high as 70% in developed countries compared with 54% for all cancers diagnosed in the 1980s. In the remaining 30%, progression or metastatic disease leads to death and in this framework palliative care has an outstanding role though not well settled in all its facets. In this landscape, surgery has a supportive actor role integrated with other welfare aspects from which are not severable. The definition of surgical palliation has moved from the ancient definition of noncurative surgery to a group of practices performed not to cure but to alleviate an organ dysfunction offering the best quality of life possible in all the aspects of life (pain, dysfunctions, caregivers, psychosocial, etc.). To emphasize this aspect a more modern definition has been introduced: palliative therapy in whose context is comprised not only the care assistance but also the plans of care since the onset of illness, teaching the matter to surgeons in training and share paths. Literature is very poor regarding surgical aspects specifically dedicated and all researches (PubMed, Google Scholar, and Cochrane) with various meshing terms result in a more oncologic and psychosocial effort.
Collapse
Affiliation(s)
- Alessandro Inserra
- General Pediatric and Thoracic Surgery, Bambino Gesù Children׳s Hospital-Research Institute, Rome, Italy.
| | - Alessandra Narciso
- General Pediatric and Thoracic Surgery, Bambino Gesù Children׳s Hospital-Research Institute, Rome, Italy
| | - Guglielmo Paolantonio
- Interventional Radiology Unit, Bambino Gesù Children׳s Hospital-Research Institute, Rome, Italy
| | - Raffaella Messina
- Neurosurgery Unit, Bambino Gesù Children׳s Hospital-Research Institute, Rome, Italy
| | - Alessandro Crocoli
- General Pediatric and Thoracic Surgery, Bambino Gesù Children׳s Hospital-Research Institute, Rome, Italy
| |
Collapse
|
7
|
Morgenstern PF, Connors S, Reiner AS, Greenfield JP. Image Guidance for Placement of Ommaya Reservoirs: Comparison of Fluoroscopy and Frameless Stereotactic Navigation in 145 Patients. World Neurosurg 2016; 93:154-8. [PMID: 27292205 DOI: 10.1016/j.wneu.2016.04.090] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 04/22/2016] [Accepted: 04/25/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Ommaya reservoirs are used for administration of intrathecal chemotherapy and cerebrospinal fluid sampling. Ventricular catheter placement for these purposes requires a high degree of accuracy. Various options exist to optimize catheter placement. We analyze a cohort of patients receiving catheters using 2 different technologies. METHODS Retrospective chart review was performed on patients undergoing Ommaya reservoir placement between 2011 and 2014. Most procedures were assisted by either frameless stereotactic neuronavigation or fluoroscopic guidance with pneumoencephalogram. Catheter accuracy, revision rates, perioperative complications, and operative time were measured. Preoperative similarities and differences in diagnosis, demographics, and ventricular size were also recorded to avoid a biased assessment of our results. RESULTS One-hundred and forty-five patients were included, 57 using fluoroscopic guidance and 88 using frameless stereotaxy. Common diagnoses in both groups were lymphoma and leptomeningeal disease. Qualitative measures of catheter placement accuracy showed no significant difference between the 2 groups. Proximity to the foramen of Monro favored fluoroscopy by a small margin (8.6 mm vs. 10.2 mm, P = 0.03). Overall revision rates were not significantly different between the groups (3.5% vs. 4.5%, P = 1.00). Early surgical complications occurred in 6.8% of the frameless stereotaxy group and 1.8% of the fluoroscopy group (P = 0.25). CONCLUSIONS Ommaya reservoirs can be placed accurately using different methods. Although there are slight differences between fluoroscopy and frameless stereotaxy in quantitative accuracy and procedure time, there is no significant advantage of 1 method over the other when evaluating revision or complication rates. Technique familiarity and surgeon preference may dictate the preferred procedure.
Collapse
Affiliation(s)
- Peter F Morgenstern
- Department of Neurological Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York, USA; Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA.
| | - Scott Connors
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Anne S Reiner
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jeffrey P Greenfield
- Department of Neurological Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York, USA; Weill Cornell Medical College, New York, New York, USA; Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| |
Collapse
|
8
|
Zoghi B, Elledge R. Endocrine Therapy for Leptomeningeal Metastases from ER-Positive Breast Cancer: Case Report and a Review of the Literature. Breast J 2016; 22:218-23. [PMID: 26748605 DOI: 10.1111/tbj.12554] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Leptomeningeal disease is an uncommon complication of estrogen receptor positive breast cancer. While there is little consensus on the standard of care, recommendations from current clinical practice guidelines are to treat with intrathecal chemotherapy, necessitating invasive procedures and potentially resulting in a substantial incidence of serious complications and side effects. Here, we review all published evidence of the effectiveness of systemic hormonal therapy alone in treating this condition, with the advantage of requiring no invasive procedures and having virtually no serious complications or side effects. Evidence indicates that most hormonal therapies can penetrate the central nervous system and can be an effective treatment of endocrine sensitive breast cancer that is widely metastatic to the leptomeninges.
Collapse
Affiliation(s)
- Behyar Zoghi
- University of Texas Health Science Center, Cancer Therapy and Research Center at San Antonio, San Antonio, Texas
| | - Richard Elledge
- University of Texas Health Science Center, Cancer Therapy and Research Center at San Antonio, San Antonio, Texas
| |
Collapse
|
9
|
Safety of Ommaya reservoirs in children with brain tumors: a 20-year experience with 5472 intraventricular drug administrations in 98 patients. J Neurooncol 2014; 120:139-45. [DOI: 10.1007/s11060-014-1531-1] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 06/28/2014] [Indexed: 11/26/2022]
|
10
|
Szvalb AD, Raad II, Weinberg JS, Suki D, Mayer R, Viola GM. Ommaya reservoir-related infections: clinical manifestations and treatment outcomes. J Infect 2013; 68:216-24. [PMID: 24360921 DOI: 10.1016/j.jinf.2013.12.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 12/07/2013] [Accepted: 12/11/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVES As infection is a severe complication of Ommaya reservoirs (OR), and existing data is limited, herein we describe the largest study of the clinical manifestations and treatment outcomes of Ommaya reservoir-related infections (ORRI). METHODS We retrospectively reviewed the records of all patients at our institution who had an OR placed, and developed a definite device-related infection between 2001 and 2011. RESULTS Among 501 OR placements, 40 patients (8%) developed an ORRI. These presented with meningitis and/or meningoencephalitis (60%), cellulitis (20%), or a combination thereof (20%). Approximately 40% occurred ≤30 days of OR placement, while 60% occurred ≤10 days after the device was last accessed. Only 20% presented with leukocytosis, while another 18% had a normal cerebrospinal fluid (CSF). Gram-positive skin flora accounted >80% of the pathogens. The median hospital stay and duration of antibiotics were 13 and 24 days, respectively. Although mortality rates (≈10%) were similar among all treatment groups (p > 0.99), shorter hospitalization and antimicrobial treatment durations were obtained with early versus late device removal (p < 0.038). CONCLUSIONS As clinical symptoms can be non-specific and CSF parameters may be within normal limits, a high suspicion for infection is required. The shortest hospitalization and treatment course was achieved with early device removal.
Collapse
Affiliation(s)
- Ariel D Szvalb
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Infectious Diseases, Baylor College of Medicine, Houston, TX, USA.
| | - Issam I Raad
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Infectious Diseases, Baylor College of Medicine, Houston, TX, USA
| | - Jeffrey S Weinberg
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Dima Suki
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rory Mayer
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - George M Viola
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Infectious Diseases, Baylor College of Medicine, Houston, TX, USA
| |
Collapse
|
11
|
Zairi F, Le Rhun E, Tetard MC, Kotecki N, Assaker R. Complications related to the placement of an intraventricular chemotherapy device. J Neurooncol 2010; 104:247-52. [DOI: 10.1007/s11060-010-0474-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2010] [Accepted: 11/12/2010] [Indexed: 11/25/2022]
|
12
|
Jabbour E, Thomas D, Cortes J, Kantarjian HM, O'Brien S. Central nervous system prophylaxis in adults with acute lymphoblastic leukemia: current and emerging therapies. Cancer 2010; 116:2290-300. [PMID: 20209620 DOI: 10.1002/cncr.25008] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Central nervous system (CNS) recurrence continues to be a significant complication in the treatment of adult patients with acute lymphoblastic leukemia (ALL). Preventing CNS recurrence has been a therapeutic challenge and has not been addressed critically in many clinical trials. Adult studies modeled on childhood ALL studies have used multiple treatment modalities, including radiation therapy, systemic therapy, intrathecal therapy, and combinations thereof. Cranial irradiation is effective but is offset by substantial toxicity, including neurologic sequelae. Systemic chemotherapy, especially with cytarabine (AraC) and methotrexate, has demonstrated promise in decreasing CNS recurrence, but therapeutic levels of drugs in the cerebrospinal fluid (CSF) are not maintained. Intrathecal chemotherapy with or without high-dose systemic therapy is the most common approach to CNS prophylaxis. Liposomal AraC recently has become available and confers prolonged levels of free AraC in the CSF, a critical requirement for CNS prophylactic therapy. This review discusses the various modalities used for CNS prophylaxis in patients with ALL and the emerging trends, with specific emphasis on the outcome in terms of event-free survival and toxicity.
Collapse
Affiliation(s)
- Elias Jabbour
- Department of Leukemia, The University of Texas M.D. Anderson Cancer Center, Houston, Texas 77030, USA.
| | | | | | | | | |
Collapse
|
13
|
Herrlinger U, Glantz M, Schlegel U, Gisselbrecht C, Cavalli F. Should Intra-cerebrospinal Fluid Prophylaxis Be Part of Initial Therapy for Patients With Non-Hodgkin Lymphoma: What We Know, and How We Can Find Out More. Semin Oncol 2009; 36:S25-34. [DOI: 10.1053/j.seminoncol.2009.05.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
14
|
Abstract
Long-term survival is occasionally observed in patients with neoplastic meningitis (NM) accompanying breast cancer (13% one-year and 6% 2-year survival), melanoma, and lymphoma, but in general the survival of most patients is short and averages only 3 to 4 months. The incidence of NM appears to be increasing, in part due to earlier detection by magnetic resonance imaging (MRI), and in part due to development of more effective therapies for systemic cancer, which has resulted in a larger subset at risk for late-stage development of this complication. Survival of NM patients is negatively affected by concomitant progression of systemic disease despite multiple prior therapies. However, there are certain prognostic factors that have been identified as "favorable" in retrospective series, including age less than 60 years, long symptom duration, controlled systemic disease, Karnofsky performance status (KPS) > or =70, lack of encephalopathy or cranial nerve deficits, low initial cerebrospinal fluid (CSF) protein level, history of breast primary tumor, and lack of evidence of CSF compartmentalization or bulky meningeal disease as determined by CSF flow studies. Standard treatment has traditionally involved radiotherapy (RT) to sites of symptomatic or bulky disease, as detected by neuroimaging, and in selected patients, the administration of intrathecal, intraventricular, or systemic chemotherapy. However, treatment remains palliative and many patients and physicians choose supportive care only. Future hope is provided by studies that have improved our understanding of the disease pathogenesis, have identified prognostic variables associated with outcome, and have provided new therapeutic approaches, such as administration of high-dose systemic chemotherapy and investigations of novel therapeutic agents.
Collapse
Affiliation(s)
- Kurt A Jaeckle
- Department of Neurology and Oncology, Mayo Clinic Jacksonville, Jacksonsville, FL 32224, USA.
| |
Collapse
|
15
|
McDermott MW, Ciricillo SF, Gutin PH, Edwards MS. Stereotactic insertion of an ommaya reservoir: technical note. Neurol Sci 1995; 22:235-8. [PMID: 8529178 DOI: 10.1017/s0317167100039913] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Stereotactic insertion of catheters into deep-seated tumors or developmental cysts is easily accomplished, but connecting the catheter to an Ommaya reservoir while maintaining catheter position can be difficult. We describe a technique for easy placement of a catheter-Ommaya reservoir construct with one pass. METHODS Standard stereotactic imaging is performed. The distance from the outer table of the skull to the target point is measured. A catheter-Ommaya reservoir construct is assembled to this length and directed to the target position with a standard Cosman-Robert-Wells (CRW) stereotactic frame. RESULTS Use of this technique placed catheters into tumor or developmental cysts accurately and with no surgical complications in 12 patients. CONCLUSIONS This technique is simple, safe, reliable, and requires no special equipment. It avoids the risk of dislodging the catheter when it is being connected to the Ommaya reservoir, reducing the chances of cyst leakage and collapse.
Collapse
Affiliation(s)
- M W McDermott
- Department of Neurological Surgery, School of Medicine, University of California, San Francisco, USA
| | | | | | | |
Collapse
|
16
|
Glantz MJ, Hall WA, Cole BF, Chozick BS, Shannon CM, Wahlberg L, Akerley W, Marin L, Choy H. Diagnosis, management, and survival of patients with leptomeningeal cancer based on cerebrospinal fluid-flow status. Cancer 1995; 75:2919-31. [PMID: 7773943 DOI: 10.1002/1097-0142(19950615)75:12<2919::aid-cncr2820751220>3.0.co;2-9] [Citation(s) in RCA: 144] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND The authors assessed cerebrospinal fluid (CSF) flow in patients with carcinomatous meningitis using technetium-99m-DTPA (Tc-99) ventriculography to determine the frequency of flow abnormalities, their reversibility with treatment, and the implications for successful therapy and survival. METHODS Technetium-99m-DTPA flow studies were performed in 31 patients after placement of Ommaya reservoirs (Baxter, McGaw Park, IL). Two millicuries of Tc-99 were injected into the reservoir. Planar images of the head and entire spine were obtained after 10 and 30 minutes and after 1, 4, 6, and 24 hours. Follow-up studies were performed for 12 patients whose initial studies were abnormal or who developed complications of therapy. RESULTS In 19 of the 31 patients (61%), ventricular-outlet, spinal, or convexity blocks were identified. In 11 of these 19 patients, focal radiotherapy to the site of the block restored normal flow. Survival among patients with initially normal, abnormal but correctable, and abnormal but uncorrectable CSF flow differed significantly (6.9, 13.0, and 0.7 months respectively; P < 0.001). Some patients who were treated intrathecally despite abnormal CSF flow experienced drug-related toxicity. CONCLUSIONS Cerebrospinal fluid-flow blocks are common in patients with carcinomatous meningitis and may occur at the skull base, in the spinal canal, and over the convexities. These flow abnormalities often can be corrected with appropriately directed radiotherapy. If untreated, CSF tumor progression (protected site effect), neurotoxicity (high concentration effect), and systemic toxicity (reservoir effect) can occur, resulting in shortened survival and treatment-related morbidity. Therefore, intrathecal chemotherapy should be preceded by a radionuclide flow study and should be delayed if abnormal flow is documented until appropriate radiotherapy reestablishes normal flow.
Collapse
Affiliation(s)
- M J Glantz
- Department of Medicine, Brown University School of Medicine, Providence, Rhode Island, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Iacoangeli M, Roselli R, Pagano L, Leone G, Marra R, Pompucci A, Trignani R, Scerrati M. Intrathecal chemotherapy for treatment of overt meningeal leukemia: comparison between intraventricular and traditional intralumbar route. Ann Oncol 1995; 6:377-82. [PMID: 7619753 DOI: 10.1093/oxfordjournals.annonc.a059187] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Despite advances in the treatment of acute lymphoblastic leukemia (ALL), overt meningeal leukemia remains a dire condition. The role of intraventricular chemotherapy (IVC) in its treatment is still a matter for debate. Data suggesting benefit from it have been countered by statements of concern regarding the potential complications associated with its use. This report details our results from using IVC. PATIENTS AND METHODS We compared two groups of adult patients with ALL at their first meningeal involvement. Twelve of them were submitted to ILC and 9 to IVC. RESULTS Our data showed that IVC yielded a higher rate of complete response (88% vs. 33%) and a lower incidence of second CNS relapse than did ILC (none vs. 50%). Even though there were more long-term disease-free survivors (33% vs. 8%) among the IVC patients, the difference in median event-free survival was not significant (120 vs. 80 weeks; p = 0.66). IVC was associated with a longer overall survival (p = 0.005) and CNS remission time (p = 0.046). Two cases refractory to ILC were later fully responsive to IVC. There were 22% device-related and 11% drug-related complications. CONCLUSIONS The results are promising, but the small series does not allow for any definite conclusion. In our opinion, the hazards inherent in the placement and operation of the device do not outweight the benefits of IVC for the treatment of overt meningeal leukemia and should not preclude its use. Accurate neurosurgical technique, meticulous care in drug administration and experience with this form of therapy can all contribute to minimizing complications so that full advantage can be taken of IVC's potential.
Collapse
Affiliation(s)
- M Iacoangeli
- Institute of Neurosurgery, Catholic University School of Medicine, Rome, Italy
| | | | | | | | | | | | | | | |
Collapse
|