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Chen J, Staibano P, Zhou K, Gupta M. Bilateral Vocal Cord Paralysis Secondary to Leptomeningeal Metastases With Unknown Primary Malignancy: A Case Report and Review of the Literature. Cureus 2022; 14:e27425. [PMID: 36051729 PMCID: PMC9420173 DOI: 10.7759/cureus.27425] [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: 07/28/2022] [Indexed: 12/02/2022] Open
Abstract
Bilateral vocal cord paralysis (BVCP) most commonly occurs secondary to iatrogenic injury and/or malignancy, but can also be a consequence of central nervous system (CNS) pathology. We report a case of BVCP secondary to leptomeningeal consequence in the context of unknown primary malignancy. The aim of this report is to promote awareness for BVCP caused by rare CNS pathology and highlight the importance of complete neoplastic and paraneoplastic workups in new-onset BVCP with unclear etiology. Here, we present a case report and review of the literature. A 68-year-old female presented with new-onset BVCP in the context of progressive dysphagia in addition to rectal and urinary incontinence. She underwent an awake tracheostomy. Her infectious and paraneoplastic workups did not identify a cause for her BVCP. Her brain MRI demonstrated enhancement of multiple cranial nerves, spine MRI demonstrated leptomeningeal enhancement, and cerebrospinal fluid (CSF) cytology was positive for metastatic adenocarcinoma. Her functional status was poor and she was deemed ineligible for chemotherapy and transitioned to palliative care. She died three months following her hospital admission. Leptomeningeal metastasis is a rare cause of new-onset BVCP. Airway management remains a critical component in BVCP. The sudden onset of BVCP in the context of generalized neurologic symptoms or cranial nerve deficits should prompt complete neoplastic and paraneoplastic investigation.
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2
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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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3
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Holroyd KB, Rubin DB, Vaitkevicius H. Neurologic Complications in Patients with Cancer. Semin Neurol 2021; 41:588-605. [PMID: 34619783 DOI: 10.1055/s-0041-1733788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Neurologic symptoms are commonly seen in patients with cancer and can be among the most challenging to diagnose and manage. It is often difficult to determine if new neurologic symptoms are secondary to direct effects of a malignant lesion, systemic complications of disease, paraneoplastic disorders, or side effects of cancer treatment itself. However, early diagnosis and treatment of each of these conditions can improve patients' quality of life and long-term functional outcomes. In this review, we describe a systematic approach to the diagnosis of new neurologic symptoms in patients with known malignancy. We have categorized the neurologic complications of cancer through a mechanistic approach, with an emphasis on ascertaining underlying pathophysiology to guide treatment choice. This review focuses on the acute neurologic complications of cancer that require hospital admission.
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Affiliation(s)
| | - Daniel B Rubin
- Department of Neurology, Massachusetts General Hospital, Brigham and Women's Hospital, Boston, Massachusetts
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4
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Andugulapati SS, Chheda A, Desai K, Ravat SH. Diagnostic challenges in neoplastic meningitis presenting as intracranial hypertension. BMJ Case Rep 2021; 14:14/3/e238808. [PMID: 33692049 PMCID: PMC7949390 DOI: 10.1136/bcr-2020-238808] [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: 11/04/2022] Open
Abstract
A diagnosis of idiopathic intracranial hypertension should be considered only after careful exclusion of all possible aetiologies. We report a case of neoplastic meningitis presenting as intracranial hypertension with inconclusive repeated cerebrospinal fluid (CSF) cytology and MRI of brain, emphasising the importance of meticulous CSF analysis and role of early whole-body PET-CT scan for diagnosis of systemic malignancy.
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Affiliation(s)
| | - Akash Chheda
- Department of Neurology, Seth GS Medical College and KEM Hospital, Mumbai, Maharastra, India
| | - Karan Desai
- Department of Neurology, Seth GS Medical College and KEM Hospital, Mumbai, Maharastra, India
| | - Sangeeta Hasmukh Ravat
- Department of Neurology, Seth GS Medical College and KEM Hospital, Mumbai, Maharastra, India
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5
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Kumthekar P, Tang SC, Brenner AJ, Kesari S, Piccioni DE, Anders C, Carrillo J, Chalasani P, Kabos P, Puhalla S, Tkaczuk K, Garcia AA, Ahluwalia MS, Wefel JS, Lakhani N, Ibrahim N. ANG1005, a Brain-Penetrating Peptide-Drug Conjugate, Shows Activity in Patients with Breast Cancer with Leptomeningeal Carcinomatosis and Recurrent Brain Metastases. Clin Cancer Res 2020; 26:2789-2799. [PMID: 31969331 DOI: 10.1158/1078-0432.ccr-19-3258] [Citation(s) in RCA: 124] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 12/12/2019] [Accepted: 01/17/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE ANG1005, a novel taxane derivative, consists of three paclitaxel molecules covalently linked to Angiopep-2, designed to cross the blood-brain and blood-cerebrospinal barriers and to penetrate malignant cells via LRP1 transport system. Preclinical and clinical evidence of efficacy with ANG1005 has been previously shown. PATIENTS AND METHODS A multicenter, open-label phase II study in adult patients with measurable recurrent brain metastases from breast cancer (BCBM), with or without leptomeningeal carcinomatosis was conducted (n = 72 BCBM; n = 28 leptomeningeal carcinomatosis subset). ANG1005 was administered intravenously at 600 mg/m2 every 3 weeks. Tumor assessment was based on central nervous system (CNS) RECIST 1.1 for intracranial, and RECIST 1.1 for extracranial response. The primary endpoint was determination of intracranial objective response rate (iORR). RESULTS Median age was 47.5 years. Safety profile was similar to that of paclitaxel with myelosuppression as the predominating toxicity. Average number of prior CNS-directed therapies was 2.8 and 94% of the patients had prior taxane treatment. Patient benefit (stable disease or better) was seen in 77% (intracranial) and 86% (extracranial) of the evaluable patients, with iORR of 15% (investigator) or 8% (independent radiology facility [IRF] review). In the leptomeningeal carcinomatosis subset, 79% of the patients had intracranial disease control and estimated median overall survival of 8.0 months (95% CI, 5.4-9.4). CONCLUSIONS Even though the study preset rule for iORR per IRF was not met in this heavily pretreated population, a notable CNS and systemic treatment effect was seen in all patients including symptom improvement and prolonged overall survival compared to historical control for the subset of patients with leptomeningeal carcinomatosis (n = 28).
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Affiliation(s)
- Priya Kumthekar
- Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | - Shou-Ching Tang
- Cancer Center and Research Institute, University of Mississippi Medical Center, Jackson, Mississippi
| | | | - Santosh Kesari
- John Wayne Cancer Institute and Pacific Neuroscience Institute, Santa Monica, California
| | - David E Piccioni
- Department of Neurosciences, UC San Diego Moores Cancer Center, La Jolla, California
| | | | - Jose Carrillo
- John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, California
| | | | - Peter Kabos
- University of Colorado, Anschutz Medical Campus, Greenwood Village, Colorado
| | - Shannon Puhalla
- University of Pittsburgh Magee Women's Cancer Program, Pittsburgh, Pennsylvania
| | - Katherine Tkaczuk
- University Maryland Greenebaum Comprehensive Cancer Center, Baltimore, Maryland
| | | | - Manmeet S Ahluwalia
- Miller Family Endowed Chair in NeuroOncology; Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Jeffrey S Wefel
- Departments of Neuro-Oncology and Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Nehal Lakhani
- Cancer and Hematology Centers of Western Michigan, Grand Rapids, Michigan
| | - Nuhad Ibrahim
- Department of Breast Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center; Houston, Texas
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6
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Bernstock JD, Ostby S, Fox B, Sotoudeh H, Janssen A, Kang YJ, Chen J, Prattipati V, Elsayed G, Chagoya G, Yamashita D, Friedman GK, Nabors B, Huh WK, Lobbous M. Cauda equina syndrome in an ovarian malignant-mixed müllerian tumor with leptomeningeal spread. Clin Case Rep 2019; 7:2341-2345. [PMID: 31893054 PMCID: PMC6935635 DOI: 10.1002/ccr3.2472] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 08/18/2019] [Accepted: 09/06/2019] [Indexed: 12/27/2022] Open
Abstract
Leptomeningeal metastasis is extremely rare in patients with ovarian cancer, but should be considered in patients presenting with neurologic deficits such as cauda equine syndrome. Given its poor prognosis and lack of data currently on management, additional studies are needed to optimize treatment regimens and improve outcomes.
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Affiliation(s)
- Joshua D. Bernstock
- Department of NeurosurgeryBrigham and Women's HospitalHarvard UniversityBostonMAUSA
| | - Stuart Ostby
- Division of Gynecologic OncologyUniversity of Alabama at BirminghamBirminghamALUSA
| | - Brandon Fox
- School of MedicineUniversity of Alabama at BirminghamBirminghamALUSA
| | - Houman Sotoudeh
- Department of Radiology, Neuroradiology SectionUniversity of Alabama at BirminghamBirminghamALUSA
| | - Andrew Janssen
- School of MedicineUniversity of Alabama at BirminghamBirminghamALUSA
| | | | - Jason Chen
- Medical Scientist Training ProgramUniversity of CaliforniaLos AngelesCAUSA
| | | | - Galal Elsayed
- Department of NeurosurgeryUniversity of Alabama at BirminghamBirminghamALUSA
| | - Gustavo Chagoya
- Department of NeurosurgeryUniversity of Alabama at BirminghamBirminghamALUSA
| | - Daisuke Yamashita
- Department of NeurosurgeryBrigham and Women's HospitalHarvard UniversityBostonMAUSA
| | - Gregory K. Friedman
- Division of Pediatric Hematology and OncologyDepartment of PediatricsUniversity of Alabama at BirminghamBirminghamALUSA
| | - Burt Nabors
- Department of NeurologyUniversity of Alabama at BirminghamBirminghamALUSA
| | - Warner K. Huh
- Division of Gynecologic OncologyUniversity of Alabama at BirminghamBirminghamALUSA
| | - Mina Lobbous
- Department of NeurologyUniversity of Alabama at BirminghamBirminghamALUSA
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7
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Montes de Oca Delgado M, Cacho Díaz B, Santos Zambrano J, Guerrero Juárez V, López Martínez MS, Castro Martínez E, Avendaño Méndez-Padilla J, Mejía Pérez S, Reyes Moreno I, Gutiérrez Aceves A, González Aguilar A. The Comparative Treatment of Intraventricular Chemotherapy by Ommaya Reservoir vs. Lumbar Puncture in Patients With Leptomeningeal Carcinomatosis. Front Oncol 2018; 8:509. [PMID: 30524956 PMCID: PMC6256195 DOI: 10.3389/fonc.2018.00509] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 10/17/2018] [Indexed: 12/05/2022] Open
Abstract
Object: Leptomeningeal Carcinomatosis (LCM) represents a state of systemic malignant disease with poor prognosis. The purpose of this study is to compare overall survival (OS) between intraventricular chemotherapy through Ommaya reservoir (OR) and chemotherapy through lumbar puncture (LP) in LCM. Patients and Methods: Forty adult patients with LCM were included. All patients underwent lumbar puncture and Magnetic resonance imaging (MRI). Thirty patients received chemotherapy through LP and 10 undergone colocation of Ommaya reservoir for intraventricular chemotherapy. Results: The most common symptom was headache (Present in 50%). The cranial nerves most affected were VI and VII. Leptomeningeal enhancement was the most frequent finding in MRI. The OS in the LP group was 4 months and Ommaya group was 9.2 months (p = 0.0006; CI:1.8-3), with statistical differences in favor to Intraventricular treatment. Proportional hazard regression showed that receiving chemotherapy through Ommaya reservoir was a protective factor (Hazard ratio = 0.258, Standard Error = 0.112, p = 0.002 and 95% CI 0.110-0.606). Using KPS as a factor did not affect the hazard ratio of Ommaya reservoir itself. Conclusions: OS was significantly higher in patients with Ommaya reservoir in spite of Karnofsky Performance Status (KPS) previous to chemotherapy. Therefore, intraventricular chemotherapy should be preferred over lumbar puncture chemotherapy administration if there are resources available.
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Affiliation(s)
- Mariano Montes de Oca Delgado
- Emergency Department, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez" (INNN), Mexico City, Mexico
| | | | - José Santos Zambrano
- Emergency Department, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez" (INNN), Mexico City, Mexico
| | - Vicente Guerrero Juárez
- Emergency Department, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez" (INNN), Mexico City, Mexico
| | - Manuel Salvador López Martínez
- Emergency Department, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez" (INNN), Mexico City, Mexico
| | - Elvira Castro Martínez
- Emergency Department, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez" (INNN), Mexico City, Mexico
| | - Javier Avendaño Méndez-Padilla
- Neurosurgery Department, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez" (INNN), Mexico City, Mexico.,Neurooncology Department, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez" (INNN), Mexico City, Mexico
| | - Sonia Mejía Pérez
- Neurosurgery Department, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez" (INNN), Mexico City, Mexico.,Neurooncology Department, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez" (INNN), Mexico City, Mexico
| | - Ignacio Reyes Moreno
- Neurological Service, The American British Cowdray Medical Center, Mexico City, Mexico
| | - Axayacatl Gutiérrez Aceves
- Neurological Service, The American British Cowdray Medical Center, Mexico City, Mexico.,Radioneurosurgery Department, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez" (INNN), Mexico City, Mexico
| | - Alberto González Aguilar
- Emergency Department, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez" (INNN), Mexico City, Mexico.,Neurosurgery Department, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez" (INNN), Mexico City, Mexico.,Neurooncology Department, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez" (INNN), Mexico City, Mexico.,Neurological Service, The American British Cowdray Medical Center, Mexico City, Mexico
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8
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Burger MC, Wagner M, Franz K, Harter PN, Bähr O, Steinbach JP, Senft C. Ventriculoperitoneal Shunts Equipped with On-Off Valves for Intraventricular Therapies in Patients with Communicating Hydrocephalus due to Leptomeningeal Metastases. J Clin Med 2018; 7:jcm7080216. [PMID: 30110924 PMCID: PMC6111529 DOI: 10.3390/jcm7080216] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 07/28/2018] [Accepted: 08/10/2018] [Indexed: 11/23/2022] Open
Abstract
Ventriculoperitoneal shunts equipped with a reservoir and a valve to manually switch off the shunt function can be used for intraventricular injections of therapeutics in patients suffering from a communicating hydrocephalus caused by leptomeningeal metastases. These shunt devices avoid the risk of injecting therapeutics through the distal leg of the shunt system into the intraperitoneal space, which may cause toxicity. Furthermore, regular intraventricular injections of chemotherapeutics help to maintain sufficient concentrations in the ventricular space. Therefore, ventriculoperitoneal shunts equipped with an on-off valve are a useful tool to reliably inject chemotherapeutics into the ventricles. In order to systematically assess feasibility, safety, and efficacy of this procedure, we performed a retrospective analysis of all patients with leptomeningeal metastases who had received a shunt system at our institution. In total, six adult patients had a ventriculoperitoneal shunt equipped with an on-off valve implanted. Out of these six patients, two patients subsequently received intraventricular injections of chemotherapeutics. The configuration of the valve setting and the intraventricular injections were easily feasible in the setting of a neuro-oncology department. The complication of a shunt leakage occurred in one patient following the first intraventricular injection. No extra-central nervous system (CNS) toxicities were observed. In summary, ventriculoperitoneal shunts with on-off valves are useful tools for reliable intraventricular administration of therapeutics.
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Affiliation(s)
- Michael C Burger
- Dr. Senckenberg Institute of Neurooncology, Goethe University Hospital, 60528 Frankfurt, Germany.
- University Cancer Center Frankfurt (UCT), 60590 Frankfurt, Germany.
| | - Marlies Wagner
- University Cancer Center Frankfurt (UCT), 60590 Frankfurt, Germany.
- Institute of Neuroradiology, Goethe University Hospital, 60528 Frankfurt, Germany.
| | - Kea Franz
- University Cancer Center Frankfurt (UCT), 60590 Frankfurt, Germany.
- Department of Neurosurgery, Goethe University Hospital, 60528 Frankfurt, Germany.
| | - Patrick N Harter
- University Cancer Center Frankfurt (UCT), 60590 Frankfurt, Germany.
- Institute of Neurology (Edinger Institute), Goethe University Hospital, 60528 Frankfurt, Germany.
- German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz, 60590 Frankfurt, Germany.
| | - Oliver Bähr
- Dr. Senckenberg Institute of Neurooncology, Goethe University Hospital, 60528 Frankfurt, Germany.
- University Cancer Center Frankfurt (UCT), 60590 Frankfurt, Germany.
- German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz, 60590 Frankfurt, Germany.
| | - Joachim P Steinbach
- Dr. Senckenberg Institute of Neurooncology, Goethe University Hospital, 60528 Frankfurt, Germany.
- University Cancer Center Frankfurt (UCT), 60590 Frankfurt, Germany.
- German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz, 60590 Frankfurt, Germany.
| | - Christian Senft
- University Cancer Center Frankfurt (UCT), 60590 Frankfurt, Germany.
- Department of Neurosurgery, Goethe University Hospital, 60528 Frankfurt, Germany.
- German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz, 60590 Frankfurt, Germany.
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9
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Abstract
Leptomeningeal metastasis (LM) results from dissemination of cancer cells to both the leptomeninges (pia and arachnoid) and cerebrospinal fluid (CSF) compartment. Breast cancer, lung cancer, and melanoma are the most common solid tumors that cause LM. Recent approval of more active anticancer therapies has resulted in improvement in survival that is partly responsible for an increased incidence of LM. Neurologic deficits, once manifest, are mostly irreversible, and often have a significant impact on patient quality of life. LM-directed therapy is based on symptom palliation, circumscribed use of neurosurgery, limited field radiotherapy, intra-CSF and systemic therapies. Novel methods of detecting LM include detection of CSF circulating tumor cells and tumor cell-free DNA. A recent international guideline for a standardization of response assessment in LM may improve cross-trial comparisons as well as within-trial evaluation of treatment. An increasing number of retrospective studies suggest that molecular-targeted therapy, such as EGFR and ALK inhibitors in lung cancer, trastuzumab in HER2+ breast cancer, and BRAF inhibitors in melanoma, may be effective as part of the multidisciplinary management of LM. Prospective randomized trials with standardized response assessment are needed to further validate these preliminary findings.
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10
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Lamba N, Fick T, Nandoe Tewarie R, Broekman ML. Management of hydrocephalus in patients with leptomeningeal metastases: an ethical approach to decision-making. J Neurooncol 2018; 140:5-13. [PMID: 30022283 PMCID: PMC6182391 DOI: 10.1007/s11060-018-2949-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Accepted: 07/07/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE Leptomeningeal metastases (LM) are a rare, but often debilitating complication of advanced cancer that can severely impact a patient's quality-of-life. LM can result in hydrocephalus (HC) and lead to a range of neurologic sequelae, including weakness, headaches, and altered mental status. Given that patients with LM generally have quite poor prognoses, the decision of how to manage this HC remains unclear and is not only a medical, but also an ethical one. METHODS We first provide a brief overview of management options for hydrocephalus secondary to LM. We then apply general ethical principles to decision making in LM-associated hydrocephalus that can help guide physicians and patients. RESULTS Management options for LM-associated hydrocephalus include shunt placement, repeated lumbar punctures, intraventricular reservoir placement, endoscopic third ventriculostomy, or pain management alone without intervention. While these options may offer symptomatic relief in the short-term, each is also associated with risks to the patient. Moreover, data on survival and quality-of-life following intervention is sparse. We propose that the pros and cons of each option should be evaluated not only from a clinical standpoint, but also within a larger framework that incorporates ethical principles and individual patient values. CONCLUSIONS The decision of how to manage LM-associated hydrocephalus is complex and requires close collaboration amongst the physician, patient, and/or patient's family/friends/community leaders. Ultimately, the decision should be rooted in the patients' values and should aim to optimize a patient's quality-of-life.
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Affiliation(s)
- Nayan Lamba
- Department of Neurosurgery, Computational Neurosciences Outcomes Center, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Tim Fick
- Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Marike L Broekman
- Department of Neurosurgery, Computational Neurosciences Outcomes Center, Brigham and Women's Hospital, Boston, MA, USA.
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands.
- Department of Neurosurgery, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands.
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
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11
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Shim B, Koh J, Moon JH, Park IA, Ryu HS. Cytologic Diagnosis of Metastatic Alveolar Rhabdomyosarcoma in Cerebrospinal Fluid: A Case Report. J Pathol Transl Med 2018; 52:262-266. [PMID: 29902914 PMCID: PMC6056360 DOI: 10.4132/jptm.2018.05.15] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 05/15/2018] [Indexed: 01/15/2023] Open
Abstract
Rhabdomyosarcoma is a malignant soft tissue tumor which shows skeletal muscle differentiation. Leptomeningeal metastasis can occur as a late complication, but currently there are no reports that have documented the cytologic features in cerebrospinal fluid (CSF). We report a case of metastatic alveolar rhabdomyosarcoma diagnosed in the CSF of a 28-year-old male who was originally diagnosed with rhabdomyosarcoma on the neck, and that went through systemic therapy. The tumor was positive for anaplastic lymphoma kinase, but progressed despite additional therapy with crizotinib. The CSF specimen revealed small round cells, large atypical cells with abundant cytoplasm and eccentric nuclei, and cells with horseshoe-shaped nuclei. These cytologic findings were in agreement with previous literature and well-correlated with histopathology. This is the first report to document the cytologic feature of rhabdomyosarcoma in CSF. In many cases it is difficult to perform ancillary tests in a CSF specimen and cytopathologists should be aware of the cytomorphologic characteristics to avoid misdiagnosis.
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Affiliation(s)
- Bobae Shim
- Department of Pathology, Seoul National University Hospital, Seoul, Korea
| | - Jiwon Koh
- Department of Pathology, Seoul National University Hospital, Seoul, Korea
| | - Ji Hye Moon
- Department of Pathology, Seoul National University Hospital, Seoul, Korea
| | - In Ae Park
- Department of Pathology, Seoul National University Hospital, Seoul, Korea
| | - Han Suk Ryu
- Department of Pathology, Seoul National University Hospital, Seoul, Korea
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12
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Le Rhun E, Taillibert S, Chamberlain MC. Neoplastic Meningitis Due to Lung, Breast, and Melanoma Metastases. Cancer Control 2018; 24:22-32. [DOI: 10.1177/107327481702400104] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Emilie Le Rhun
- Division of Neuro-Oncology, Departments of Neurology and
Neurological Surgery, University of Washington School of Medicine, Seattle,
Washington
- Department of Neurosurgery, University Hospital, the Breast
Unit, Departments of Neurology and Neurological Surgery, University of Washington School of
Medicine, Seattle, Washington
| | - Sophie Taillibert
- Department of Medical Oncology, Oscar Lambret Center, Lille
Cedex, France, the Division of Neuro-Oncology, Departments of Neurology and Neurological
Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Marc C. Chamberlain
- Departments of Neurology, and Radiation Oncology,
Pitié-Salpétrière Hospital, Assistance Publique des Hôpitaux de Paris, Université Pierre et
Marie Curie, Paris, France, and the Department of Neurology, Fred Hutchinson Cancer Research
Center, Seattle Cancer Care Alliance, and Division of Neuro-Oncology, Departments of
Neurology and Neurological Surgery, University of Washington School of Medicine, Seattle,
Washington
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13
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Choi J, Vaidyanathan G, Koumarianou E, Kang CM, Zalutsky MR. Astatine-211 labeled anti-HER2 5F7 single domain antibody fragment conjugates: radiolabeling and preliminary evaluation. Nucl Med Biol 2018; 56:10-20. [PMID: 29031230 PMCID: PMC5732883 DOI: 10.1016/j.nucmedbio.2017.09.003] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 08/28/2017] [Accepted: 09/14/2017] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Derived from heavy chain only camelid antibodies, ~15-kDa single-domain antibody fragments (sdAbs) are an attractive platform for developing molecularly specific imaging probes and targeted radiotherapeutics. The rapid tumor accumulation and normal tissue clearance of sdAbs might be ideal for use with 211At, a 7.2-h half-life α-emitter, if appropriate labeling chemistry can be devised to trap 211At in cancer cells after sdAb binding. This study evaluated two reagents, [211At]SAGMB and iso-[211At]SAGMB, for this purpose. METHODS [211At]SAGMB and iso-[211At]SAGMB, and their radioiodinated analogues [131I]SGMIB and iso-[131I]SGMIB, were synthesized by halodestannylation and reacted with the anti-HER2 sdAb 5F7. Radiochemical purity, immunoreactivity and binding affinity were determined. Paired-label internalization assays on HER2-expressing BT474M1 breast carcinoma cells directly compared [131I]SGMIB-5F7/[211At]SAGMB-5F7 and iso-[131I]SGMIB-5F7/iso-[211At]SAGMB-5F7 tandems. The biodistribution of the two tandems was evaluated in SCID mice with subcutaneous BT474M1 xenografts. RESULTS Radiochemical yields for Boc2-iso-[211At]SAGMB and Boc2-[211At]SAGMB synthesis, and efficiencies for coupling of iso-[211At]SAGMB and [211At]SAGMB to 5F7 were similar, with radiochemical purities of [211At]SAGMB-5F7 and iso-[211At]SAGMB-5F7 >98%. iso-[211At]SAGMB-5F7 and [211At]SAGMB-5F7 had immunoreactive fractions >80% and HER2 binding affinities of less than 5 nM. Internalization assays demonstrated high intracellular trapping of radioactivity, with little difference observed between corresponding 211At- and 131I-labeled 5F7 conjugates. Higher BT474M1 intracellular retention was observed from 1-6 h for the iso-conjugates (iso-[211At]SAGMB-5F7, 74.3 ± 2.8%, vs. [211At]SAGMB-5F7, 63.7 ± 0.4% at 2 h) with the opposite behavior observed at 24 h. Peak tumor uptake for iso-[211At]SAGMB-5F7 was 23.4 ± 2.2% ID/g at 4 h, slightly lower than its radioiodinated counterpart, but significantly higher than observed with [211At]SAGMB-5F7. Except in kidneys and lungs, tumor-to-normal organ ratios for iso-[211At]SAGMB-5F7 were greater than 10:1 by 2 h, and significantly higher than those for [211At]SAGMB-5F7. CONCLUSION These 211At-labeled sdAb conjugates, particularly iso-[211At]SAGMB-5F7, warrant further evaluation for targeted α-particle radiotherapy of HER2-expressing cancers.
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Affiliation(s)
- Jaeyeon Choi
- Department of Radiology, Duke University Medical Center, Durham, North Carolina, 27710, USA
| | - Ganesan Vaidyanathan
- Department of Radiology, Duke University Medical Center, Durham, North Carolina, 27710, USA
| | - Eftychia Koumarianou
- Department of Radiology, Duke University Medical Center, Durham, North Carolina, 27710, USA
| | - Choong Mo Kang
- Department of Radiology, Duke University Medical Center, Durham, North Carolina, 27710, USA
| | - Michael R Zalutsky
- Department of Radiology, Duke University Medical Center, Durham, North Carolina, 27710, USA.
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14
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Lin NU, Gaspar LE, Soffietti R. Breast Cancer in the Central Nervous System: Multidisciplinary Considerations and Management. Am Soc Clin Oncol Educ Book 2017; 37:45-56. [PMID: 28561683 DOI: 10.1200/edbk_175338] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Breast cancer is the second most common primary tumor associated with central nervous system (CNS) metastases. Patients with metastatic HER2-positive or triple-negative (estrogen receptor (ER)-negative, progesterone receptor (PR)-negative, HER2-negative) breast cancer are at the highest risk of developing parenchymal brain metastases. Leptomeningeal disease is less frequent but is distributed across breast cancer subtypes, including lobular breast cancer. Initial treatment strategies can include surgery, radiation, intravenous or intrathecal chemotherapy, and/or targeted approaches. In this article, we review the epidemiology of breast cancer brain metastases, differences in clinical behavior and natural history by tumor subtype, and important considerations in the multidisciplinary treatment of these patients. We will highlight new findings that impact current standards of care, clinical controversies, and notable investigational approaches in clinical testing.
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Affiliation(s)
- Nancy U Lin
- From the Breast Oncology Center, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO; Department of Neuro-Oncology, University of Turin and City of Health and Science Hospital, Turin, Italy
| | - Laurie E Gaspar
- From the Breast Oncology Center, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO; Department of Neuro-Oncology, University of Turin and City of Health and Science Hospital, Turin, Italy
| | - Riccardo Soffietti
- From the Breast Oncology Center, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO; Department of Neuro-Oncology, University of Turin and City of Health and Science Hospital, Turin, Italy
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15
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Durand B, Zairi F, Boulanger T, Bonneterre J, Mortier L, Le Rhun E. Chemical meningitis related to intra-CSF liposomal cytarabine. CNS Oncol 2017; 6:261-267. [PMID: 29057672 PMCID: PMC6004879 DOI: 10.2217/cns-2016-0046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 05/03/2017] [Indexed: 12/29/2022] Open
Abstract
Therapeutic options of leptomeningeal metastases include intra-cerebrospinal fluid (CSF) chemotherapy. Among intra-CSF agents, liposomal cytarabine has advantages but can induce specific toxicities. A BRAF-V600E-mutated melanoma leptomeningeal metastases patient, treated by dabrafenib and liposomal cytarabine, presented after the first injection of liposomal cytarabine with hyperthermia and headaches. Despite sterile CSF/blood analyses, extended intravenous antibiotics were given and the second injection was delayed. The diagnosis of chemical meningitis was finally made. Dose reduction and appropriate symptomatic treatment permitted the administration of 15 injections of liposomal cytarabine combined with dabrafenib. A confirmation of the diagnosis of chemical meningitis is essential in order (1) not to delay intra-CSF or systemic chemotherapy or (2) to limit the administration of unnecessary but potentially toxic antibiotics.
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Affiliation(s)
- Bénédicte Durand
- Lille University, F-59000 Lille, France
- Oscar Lambret Center, Medical Oncology Department, F-59000 Lille, France
| | - Fahed Zairi
- Lille University, F-59000 Lille, France
- Inserm, U-1192, F-59000 Lille, France
- CHU Lille, Neurosurgery Department, F-59000Lille, France
| | - Thomas Boulanger
- Oscar Lambret Center, Department of Radiology, F-59000 Lille, France
| | - Jacques Bonneterre
- Lille University, F-59000 Lille, France
- Oscar Lambret Center, Medical Oncology Department, F-59000 Lille, France
| | - Laurent Mortier
- Lille University, F-59000 Lille, France
- CHU Lille, Dermatology Department, F-59000Lille, France
| | - Emilie Le Rhun
- Lille University, F-59000 Lille, France
- Oscar Lambret Center, Medical Oncology Department, F-59000 Lille, France
- Inserm, U-1192, F-59000 Lille, France
- CHU Lille, Neurosurgery Department, F-59000Lille, France
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16
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Nayar G, Ejikeme T, Chongsathidkiet P, Elsamadicy AA, Blackwell KL, Clarke JM, Lad SP, Fecci PE. Leptomeningeal disease: current diagnostic and therapeutic strategies. Oncotarget 2017; 8:73312-73328. [PMID: 29069871 PMCID: PMC5641214 DOI: 10.18632/oncotarget.20272] [Citation(s) in RCA: 109] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 07/20/2017] [Indexed: 12/28/2022] Open
Abstract
Leptomeningeal disease has become increasingly prevalent as novel therapeutic interventions extend the survival of cancer patients. Although a majority of leptomeningeal spread occurs secondary to breast cancer, lung cancer, and melanoma, a wide variety of malignancies have been reported as primary sources. Symptoms on presentation are equally diverse, often involving a combination of neurological deficits with the possibility of obstructive hydrocephalus. Diagnosis is definitively made via cerebrospinal fluid cytology for malignant cells, but neuro-imaging with high quality T1-weighted magnetic resonance imaging can aid diagnosis and localization. While leptomeningeal disease is still a terminal, late-stage complication, a variety of treatment modalities, such as intrathecal chemotherapeutics and radiation therapy, have improved median survival from 4–6 weeks to 3–6 months. Positive prognosticative factors for survival include younger age, high performance scores, and controlled systemic disease. In looking to the future, diagnostics that improve early detection and chemotherapeutics tailored to the primary malignancy will likely be the most significant advances in improving survival.
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Affiliation(s)
- Gautam Nayar
- Duke Brain Tumor Immunotherapy Program, Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.,The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA.,Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Tiffany Ejikeme
- Duke Brain Tumor Immunotherapy Program, Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.,The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA.,Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Pakawat Chongsathidkiet
- Duke Brain Tumor Immunotherapy Program, Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.,The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA.,Department of Pathology, Duke University Medical Center, Durham, NC, USA
| | - Aladine A Elsamadicy
- Duke Brain Tumor Immunotherapy Program, Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.,The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA.,Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Kimberly L Blackwell
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey M Clarke
- Division of Medical Oncology, Duke University Medical Center, Durham, NC, USA
| | - Shivanand P Lad
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Peter E Fecci
- Duke Brain Tumor Immunotherapy Program, Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.,The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA.,Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.,Department of Pathology, Duke University Medical Center, Durham, NC, USA
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17
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Yamashiro S, Hitoshi Y, Tajiri S, Uchikawa H, Ito K, Yoshida A, Kuratsu JI. Palliative lumboperitoneal shunt for leptomeningeal metastasis-related hydrocephalus: A case series. Palliat Med 2017; 31:93-96. [PMID: 27188875 DOI: 10.1177/0269216316649128] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Leptomeningeal metastasis-related hydrocephalus causes distress to patients with end-stage cancer through headache and other symptoms by elevating intracranial pressure, thus reducing quality of life. Ventriculoperitoneal shunt has been used as a treatment option in palliative care. We review four cases of patients who underwent lumboperitoneal shunt for leptomeningeal metastasis-related hydrocephalus. CASES All patients suffered from severe headache and nausea. The primary lesion was histologically diagnosed as lung adenocarcinoma in each case. The duration from diagnosis to onset of hydrocephalus symptoms ranged from 0 to 52 (mean 26) months. Cerebrospinal fluid pressure in every case was above the normal range due to high intracranial pressure. Case management: Conventional procedures for lumboperitoneal shunt were employed for all patients. Adjustable pressure valves were retrofitted into the shunt system. Case outcome: Three patients demonstrated significant improvement of clinical symptoms and quality of life after placement of lumboperitoneal shunts. In two cases, not only did performance status improve to independent daily activity but also comparatively long-term survival was achieved due to subsequent chemotherapies after surgery. No symptoms of peritoneal dissemination by floating cancer cells in cerebrospinal fluid were seen in any patients. CONCLUSION Lumboperitoneal shunt appears to improve quality of life if the patient is suffering from symptoms of leptomeningeal metastasis-related hydrocephalus. Compared to ventriculoperitoneal shunt, lumboperitoneal shunt is less invasive and simpler, providing a suitable option for frail patients with end-stage cancer. Adjustable pressure shunt valves can cope with varying symptoms and ventricle sizes.
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Affiliation(s)
- Shigeo Yamashiro
- 1 Department of Neurosurgery, Kumamoto Rosai Hospital, Kumamoto, Japan
| | - Yasuyuki Hitoshi
- 1 Department of Neurosurgery, Kumamoto Rosai Hospital, Kumamoto, Japan
| | - Seiji Tajiri
- 2 Department of Neurosurgery, Kumamoto City Hospital, Kumamoto, Japan
| | - Hiroki Uchikawa
- 1 Department of Neurosurgery, Kumamoto Rosai Hospital, Kumamoto, Japan
| | - Kiyotaka Ito
- 3 Department of Internal Medicine, Kumamoto Rosai Hospital, Kumamoto, Japan
| | - Akimasa Yoshida
- 1 Department of Neurosurgery, Kumamoto Rosai Hospital, Kumamoto, Japan
| | - Jun-Ichi Kuratsu
- 4 Department of Neurosurgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan
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Abstract
Patients with brain tumors and systemic malignancies are subject to diverse neurologic complications that require urgent evaluation and treatment. These neurologic conditions are commonly due to the tumor's direct effects on the nervous system, such as cerebral edema, increased intracranial pressure, seizures, spinal cord compression, and leptomeningeal metastases. In addition, neurologic complications can develop as a result of thrombocytopenia, coagulopathy, hyperviscosity syndromes, infection, immune-related disorders, and adverse effects of treatment. Patients may present with typical disease syndromes. However, it is not uncommon for patients to have more subtle, nonlocalizing manifestations, such as alteration of mental status, that could be attributed to other systemic, nonneurologic complications. Furthermore, neurologic complications are at times the initial manifestations of an undiagnosed malignancy. Therefore a high index of suspicion is essential for rapid assessment and management. Timely intervention may prolong survival and improve quality of life. In this chapter, we will discuss the common neuro-oncologic emergencies, including epidemiology, pathophysiology, clinical presentation, diagnosis, and treatment.
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Affiliation(s)
- J T Jo
- Neuro-Oncology Center, University of Virginia, Charlottesville, VA, USA
| | - D Schiff
- Neuro-Oncology Center, University of Virginia, Charlottesville, VA, USA.
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19
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Lee DW, Lee KH, Kim JW, Keam B. Molecular Targeted Therapies for the Treatment of Leptomeningeal Carcinomatosis: Current Evidence and Future Directions. Int J Mol Sci 2016; 17:ijms17071074. [PMID: 27399673 PMCID: PMC4964450 DOI: 10.3390/ijms17071074] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 06/26/2016] [Accepted: 06/28/2016] [Indexed: 12/16/2022] Open
Abstract
Leptomeningeal carcinomatosis (LMC) is the multifocal seeding of cerebrospinal fluid and leptomeninges by malignant cells. The incidence of LMC is approximately 5% in patients with malignant tumors overall and the rate is increasing due to increasing survival time of cancer patients. Eradication of the disease is not yet possible, so the treatment goals of LMC are to improve neurologic symptoms and to prolong survival. A standard treatment for LMC has not been established due to low incidences of LMC, the rapidly progressing nature of the disease, heterogeneous populations with LMC, and a lack of randomized clinical trial results. Treatment options for LMC include intrathecal chemotherapy, systemic chemotherapy, and radiation therapy, but the prognoses remain poor with a median survival of <3 months. Recently, molecular targeted agents have been applied in the clinic and have shown groundbreaking results in specific patient groups epidermal growth factor receptor (EGFR)-targeted therapy or an anaplastic lymphoma kinase (ALK) inhibitor in lung cancer, human epidermal growth factor receptor 2 (HER2)-directed therapy in breast cancer, and CD20-targeted therapy in B cell lymphoma). Moreover, there are results indicating that the use of these agents under proper dose and administration routes can be effective for managing LMC. In this article, we review molecular targeted agents for managing LMC.
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Affiliation(s)
- Dae-Won Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul 03080, Korea.
| | - Kyung-Hun Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul 03080, Korea.
- Cancer Research Institute, Seoul National University College of Medicine, Seoul 03080, Korea.
| | - Jin Wook Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul 03080, Korea.
| | - Bhumsuk Keam
- Department of Internal Medicine, Seoul National University Hospital, Seoul 03080, Korea.
- Cancer Research Institute, Seoul National University College of Medicine, Seoul 03080, Korea.
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20
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A rare case of leptomeningeal carcinomatosis in a patient with uveal melanoma: case report and review of literature. Melanoma Res 2016; 26:481-6. [PMID: 27285292 DOI: 10.1097/cmr.0000000000000274] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Uveal melanoma is a rare subtype of melanoma, accounting for only 3-5% of all melanoma cases in the USA. Although fewer than 4% of uveal melanoma patients present with metastasis at diagnosis, approximately half will develop metastasis, more than 90% of which disseminate to the liver. Infrequently, a number of malignancies can lead to leptomeningeal metastases, a devastating and terminal complication. In this case report, we present an exceedingly rare case of a patient with uveal melanoma who developed leptomeningeal carcinomatosis as the sole site of metastasis. After conventional methods to diagnose leptomeningeal carcinomatosis fell short, a diagnosis was confirmed on the basis of identification and genomic analysis of melanoma circulating tumor cells in the cerebrospinal fluid.
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21
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22
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Brower JV, Saha S, Rosenberg SA, Hullett CR, Ian Robins H. Management of leptomeningeal metastases: Prognostic factors and associated outcomes. J Clin Neurosci 2016; 27:130-7. [PMID: 26778048 DOI: 10.1016/j.jocn.2015.11.012] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 11/21/2015] [Indexed: 11/28/2022]
Abstract
Limited data are currently available to direct treatment recommendations in the management of leptomeningeal metastases (LM). Here we review treatment modalities clinicians should understand in order to manage patients with LM. We first describe our institution's experience with the treatment of LM and use this dataset to frame the discussion of LM management. Between 1999 and 2014, 1361 patients with central nervous system metastases were reviewed, 124 (9.1%) had radiographic evidence of LM, and these patients form the cohort for this analysis. Mean age at diagnosis of LM was 52years. Median survival for the entire cohort was 2.3months. The most common primary malignancies were non-small cell lung cancer (25.8%), breast cancer (17.7%), small cell lung cancer (16.9%) and melanoma (8.9%). Univariate analyses demonstrated that greater Karnofsky Performance Status (KPS) (p=0.001) and administration of systemic chemotherapy (p<0.001) resulted in improved median survival. Multivariate Cox analyses revealed that receipt of chemotherapy and a complete course of whole brain radiotherapy (WBRT) (median dose 30Gy in 10 fractions, range 24-40Gy) were predictive of longer survival, (p=0.013 and 0.019, respectively). These data suggest that there is a group of patients with good KPS who may experience significantly longer median survival than expected. Multivariate analysis from this single institution retrospective study demonstrated a benefit for WBRT and chemotherapy in individuals with good KPS. These findings provide contemporary data from a large cohort of LM patients, which may be utilized to guide treatment recommendations, assist in patient counseling and direct future investigations into optimization of treatment regimens.
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Affiliation(s)
- Jeffrey V Brower
- Department of Human Oncology, University of Wisconsin Carbone Cancer Center, University of Wisconsin Hospital and Clinics, 600 Highland Avenue, K4/334, Madison, WI 53792, USA.
| | - Sandeep Saha
- University of Wisconsin Department of Biostatistics and Medical Informatics, Madison, WI, USA
| | - Stephen A Rosenberg
- Department of Human Oncology, University of Wisconsin Carbone Cancer Center, University of Wisconsin Hospital and Clinics, 600 Highland Avenue, K4/334, Madison, WI 53792, USA
| | - Craig R Hullett
- Department of Human Oncology, University of Wisconsin Carbone Cancer Center, University of Wisconsin Hospital and Clinics, 600 Highland Avenue, K4/334, Madison, WI 53792, USA
| | - H Ian Robins
- Department of Human Oncology, University of Wisconsin Carbone Cancer Center, University of Wisconsin Hospital and Clinics, 600 Highland Avenue, K4/334, Madison, WI 53792, USA; Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; Department of Neurology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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23
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Mittica G, Senetta R, Richiardi L, Rudà R, Coda R, Castellano I, Sapino A, Cassoni P. Meningeal carcinomatosis underdiagnosis and overestimation: incidence in a large consecutive and unselected population of breast cancer patients. BMC Cancer 2015; 15:1021. [PMID: 26715407 PMCID: PMC4696095 DOI: 10.1186/s12885-015-2042-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 12/21/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The incidence of meningeal carcinomatosis appears to be higher than in the past due to advances in neuro-imaging diagnostic techniques and improvements in cancer survival. Among solid tumors, breast cancer is the cancer most commonly associated with meningeal carcinomatosis, with an incidence rate of between 0.8 and 16%. Aim of this study has been i) to evaluate the incidence of meningeal carcinomatosis in a continuous breast cancer unselected series treated in a dedicated Breast Unit and ii) to define the clinico-pathological and molecular parameters associated with meningeal carcinomatosis development. METHODS A retrospective series of 1915 consecutive patients surgically treated for breast cancer between 1998 and 2010 was collected. Clinico-pathological data were recorded from medical charts and pathological reports, including the date of development of symptomatic meningeal carcinomatosis. Meningeal carcinomatosis incidence was determined at both 5- and 10-year follow-ups. RESULTS Three patients in the first 5 years of follow-up and six patients in 10 years of follow-up developed meningeal carcinomatosis. An incidence rate of 5.44 per 10,000 patients (95% CI: 1.75-16.9) was observed, with a 5-year risk of 0.3%. At 10-year follow up, the rate increased to 7.55 per 10,000 patients (95% CI: 3.39-16.8). In a univariate analysis, young age, tumor size larger than 15 mm, histological grade 3, more than three metastatic lymph nodes, negative estrogen receptor, positive HER2 and high proliferative index were significantly associated with meningeal carcinomatosis development. CONCLUSIONS In an unselected breast cancer population, meningeal carcinomatosis is a rare event that is associated with adverse prognostic factors. Meningeal carcinomatosis incidence is overestimated when recorded in biased/high-risk selected breast cancer patients and should not be considered to accurately reflect the overall breast cancer population.
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Affiliation(s)
- Gloria Mittica
- Division of Medical Oncology, University of Turin Medical School, Fondazione del Piemonte per l'Oncologia-Institute for Cancer Research and Treatment of Candiolo, Strada Provinciale 142 km 3,95, 10060, Candiolo, Turin, Italy.
| | - Rebecca Senetta
- Department of Medical Sciences, University of Turin, Via Santena 7, 10126, Turin, Italy.
| | - Lorenzo Richiardi
- Department of Medical Sciences, University of Turin, Via Santena 7, 10126, Turin, Italy.
| | - Roberta Rudà
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Via Cherasco 15, 10126, Turin, Italy.
| | - Renato Coda
- Department of Medical Sciences, University of Turin, Via Santena 7, 10126, Turin, Italy.
| | - Isabella Castellano
- Department of Medical Sciences, University of Turin, Via Santena 7, 10126, Turin, Italy.
| | - Anna Sapino
- Department of Medical Sciences, University of Turin, Via Santena 7, 10126, Turin, Italy.
| | - Paola Cassoni
- Department of Medical Sciences, University of Turin, Via Santena 7, 10126, Turin, Italy.
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Takei H, Rouah E, Ishida Y. Brain metastasis: clinical characteristics, pathological findings and molecular subtyping for therapeutic implications. Brain Tumor Pathol 2015; 33:1-12. [DOI: 10.1007/s10014-015-0235-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 10/04/2015] [Indexed: 01/30/2023]
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Roguski M, Rughani A, Lin CT, Cushing DA, Florman JE, Wu JK. Survival following Ommaya reservoir placement for neoplastic meningitis. J Clin Neurosci 2015; 22:1467-72. [PMID: 26115896 DOI: 10.1016/j.jocn.2015.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Accepted: 04/05/2015] [Indexed: 11/25/2022]
Abstract
The objective of this study was to evaluate the outcomes of patients with neoplastic meningitis (NM) following Ommaya reservoir placement in order to determine whether any patient factors are associated with longer survival. NM is a devastating late manifestation of cancer, and given its dismal prognosis, identifying appropriate patients for Ommaya reservoir placement is difficult. The authors performed a retrospective review of 80 patients who underwent Ommaya reservoir placement at three medical centers from September 2001 through September 2012. The primary outcome was death. Differences in survival were assessed with Kaplan-Meier survival analyses. The Cox proportional hazards and logistic regression modeling were performed to identify factors associated with survival. The primary diagnoses were solid organ, hematologic, and primary central nervous system tumors in 53.8%, 41.3%, and 5%, respectively. The median overall survival was 72.5 days (95% confidence interval 36-122) with 30% expiring within 30 days and only 13.8% surviving more than 1 year. There were no differences in median overall survival between sites (p=0.37) despite differences in time from diagnosis of NM to Ommaya reservoir placement (p<0.001). Diagnosis of hematologic malignancy was inversely associated with death within 90 days (p=0.04; odds ratio 0.34), older age was associated with death within 90 days (p=0.05; odds ratio 1.5, per 10 year increase in age). The prognosis of NM remains poor despite the available treatment with intraventricular chemotherapy. There exists significant variability in treatment algorithms among medical centers and consideration of this variability is crucial when interpreting existing series of Ommaya reservoir use in the treatment of patients with NM.
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Affiliation(s)
- Marie Roguski
- Department of Neurosurgery, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA
| | - Anand Rughani
- Neuroscience Institute, Maine Medical Center, Portland, ME, USA
| | - Chih-Ta Lin
- Division of Neurosurgery, University of Vermont, Medical Center, Burlington, VT, USA
| | | | | | - Julian K Wu
- Department of Neurosurgery, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA.
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26
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Complications related to the use of an intraventricular access device for the treatment of leptomeningeal metastases from solid tumor: a single centre experience in 112 patients. J Neurooncol 2015; 124:317-23. [DOI: 10.1007/s11060-015-1842-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 06/08/2015] [Indexed: 11/26/2022]
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Chamberlain M, Soffietti R, Raizer J, Rudà R, Brandsma D, Boogerd W, Taillibert S, Groves MD, Le Rhun E, Junck L, van den Bent M, Wen PY, Jaeckle KA. Leptomeningeal metastasis: a Response Assessment in Neuro-Oncology critical review of endpoints and response criteria of published randomized clinical trials. Neuro Oncol 2014; 16:1176-85. [PMID: 24867803 PMCID: PMC4136900 DOI: 10.1093/neuonc/nou089] [Citation(s) in RCA: 110] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 04/16/2014] [Indexed: 12/30/2022] Open
Abstract
PURPOSE To date, response criteria and optimal methods for assessment of outcome have not been standardized in patients with leptomeningeal metastasis (LM). METHODS A Response Assessment in Neuro-Oncology working group of experts in LM critically reviewed published literature regarding randomized clinical trials (RCTs) and trial design in patients with LM. RESULTS A literature review determined that 6 RCTs regarding the treatment of LM have been published, all of which assessed the response to intra-CSF based chemotherapy. Amongst these RCTs, only a single trial attempted to determine whether intra-CSF chemotherapy was of benefit compared with systemic therapy. Otherwise, this pragmatic question has not been formally addressed in patients with solid cancers and LM. The methodology of the 6 RCTs varied widely with respect to pretreatment evaluation, type of treatment, and response to treatment. Additionally there was little uniformity in reporting of treatment-related toxicity. One RCT suggests no advantage of combined versus single-agent intra-CSF chemotherapy in patients with LM. No specific intra-CSF regimen has shown superior efficacy in the treatment of LM, with the exception of liposomal cytarabine in patients with lymphomatous meningitis. Problematic with all RCTs is the lack of standardization with respect to response criteria. There was considerable variation in definitions of response by clinical examination, neuroimaging, and CSF analysis. CONCLUSION Based upon a review of published RCTs in LM, there exists a significant unmet need for guidelines for evaluating patients with LM in clinical practice as well as for response assessment in clinical trials.
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Affiliation(s)
- Marc Chamberlain
- Department of Neurology, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington (M.C.); Department of Neuroscience, Division of Neuro-Oncology, University Hospital, Torino, Italy (R.S., R.R.); Department of Neurology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois (J.R.); Department of Neuro-Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands (D.B., W.B.); Departments of Neuro-Oncology Mazarin and Radiation Oncology, Pitie-Salpetriere Hospital and University Pierre et Marie Curie, Paris VI, Paris, France (S.T.); Austin Brain Tumor Center, Texas Oncology/US Oncology Research, Austin, Texas (M.D.G.); Department of Neuro-Oncology, University Hospital, Lille, France (E.L.R.); Department of Neurology, Oscar Lambret Center, Lille, France (E.L.R.); Department of Neurology, University of Michigan, Ann Arbor, Michigan (L.J.); Department of Neuro-oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, Netherlands (M.v.d.B.); Department of Neurology, Dana-Farber Cancer Institute, Massachusetts General Hospital, Boston, Massachusetts (P.Y.W.); Department of Neurology and Oncology, Mayo Clinic Florida, Jacksonville, Florida (K.A.J.)
| | - Riccardo Soffietti
- Department of Neurology, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington (M.C.); Department of Neuroscience, Division of Neuro-Oncology, University Hospital, Torino, Italy (R.S., R.R.); Department of Neurology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois (J.R.); Department of Neuro-Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands (D.B., W.B.); Departments of Neuro-Oncology Mazarin and Radiation Oncology, Pitie-Salpetriere Hospital and University Pierre et Marie Curie, Paris VI, Paris, France (S.T.); Austin Brain Tumor Center, Texas Oncology/US Oncology Research, Austin, Texas (M.D.G.); Department of Neuro-Oncology, University Hospital, Lille, France (E.L.R.); Department of Neurology, Oscar Lambret Center, Lille, France (E.L.R.); Department of Neurology, University of Michigan, Ann Arbor, Michigan (L.J.); Department of Neuro-oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, Netherlands (M.v.d.B.); Department of Neurology, Dana-Farber Cancer Institute, Massachusetts General Hospital, Boston, Massachusetts (P.Y.W.); Department of Neurology and Oncology, Mayo Clinic Florida, Jacksonville, Florida (K.A.J.)
| | - Jeffrey Raizer
- Department of Neurology, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington (M.C.); Department of Neuroscience, Division of Neuro-Oncology, University Hospital, Torino, Italy (R.S., R.R.); Department of Neurology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois (J.R.); Department of Neuro-Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands (D.B., W.B.); Departments of Neuro-Oncology Mazarin and Radiation Oncology, Pitie-Salpetriere Hospital and University Pierre et Marie Curie, Paris VI, Paris, France (S.T.); Austin Brain Tumor Center, Texas Oncology/US Oncology Research, Austin, Texas (M.D.G.); Department of Neuro-Oncology, University Hospital, Lille, France (E.L.R.); Department of Neurology, Oscar Lambret Center, Lille, France (E.L.R.); Department of Neurology, University of Michigan, Ann Arbor, Michigan (L.J.); Department of Neuro-oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, Netherlands (M.v.d.B.); Department of Neurology, Dana-Farber Cancer Institute, Massachusetts General Hospital, Boston, Massachusetts (P.Y.W.); Department of Neurology and Oncology, Mayo Clinic Florida, Jacksonville, Florida (K.A.J.)
| | - Roberta Rudà
- Department of Neurology, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington (M.C.); Department of Neuroscience, Division of Neuro-Oncology, University Hospital, Torino, Italy (R.S., R.R.); Department of Neurology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois (J.R.); Department of Neuro-Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands (D.B., W.B.); Departments of Neuro-Oncology Mazarin and Radiation Oncology, Pitie-Salpetriere Hospital and University Pierre et Marie Curie, Paris VI, Paris, France (S.T.); Austin Brain Tumor Center, Texas Oncology/US Oncology Research, Austin, Texas (M.D.G.); Department of Neuro-Oncology, University Hospital, Lille, France (E.L.R.); Department of Neurology, Oscar Lambret Center, Lille, France (E.L.R.); Department of Neurology, University of Michigan, Ann Arbor, Michigan (L.J.); Department of Neuro-oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, Netherlands (M.v.d.B.); Department of Neurology, Dana-Farber Cancer Institute, Massachusetts General Hospital, Boston, Massachusetts (P.Y.W.); Department of Neurology and Oncology, Mayo Clinic Florida, Jacksonville, Florida (K.A.J.)
| | - Dieta Brandsma
- Department of Neurology, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington (M.C.); Department of Neuroscience, Division of Neuro-Oncology, University Hospital, Torino, Italy (R.S., R.R.); Department of Neurology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois (J.R.); Department of Neuro-Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands (D.B., W.B.); Departments of Neuro-Oncology Mazarin and Radiation Oncology, Pitie-Salpetriere Hospital and University Pierre et Marie Curie, Paris VI, Paris, France (S.T.); Austin Brain Tumor Center, Texas Oncology/US Oncology Research, Austin, Texas (M.D.G.); Department of Neuro-Oncology, University Hospital, Lille, France (E.L.R.); Department of Neurology, Oscar Lambret Center, Lille, France (E.L.R.); Department of Neurology, University of Michigan, Ann Arbor, Michigan (L.J.); Department of Neuro-oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, Netherlands (M.v.d.B.); Department of Neurology, Dana-Farber Cancer Institute, Massachusetts General Hospital, Boston, Massachusetts (P.Y.W.); Department of Neurology and Oncology, Mayo Clinic Florida, Jacksonville, Florida (K.A.J.)
| | - Willem Boogerd
- Department of Neurology, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington (M.C.); Department of Neuroscience, Division of Neuro-Oncology, University Hospital, Torino, Italy (R.S., R.R.); Department of Neurology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois (J.R.); Department of Neuro-Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands (D.B., W.B.); Departments of Neuro-Oncology Mazarin and Radiation Oncology, Pitie-Salpetriere Hospital and University Pierre et Marie Curie, Paris VI, Paris, France (S.T.); Austin Brain Tumor Center, Texas Oncology/US Oncology Research, Austin, Texas (M.D.G.); Department of Neuro-Oncology, University Hospital, Lille, France (E.L.R.); Department of Neurology, Oscar Lambret Center, Lille, France (E.L.R.); Department of Neurology, University of Michigan, Ann Arbor, Michigan (L.J.); Department of Neuro-oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, Netherlands (M.v.d.B.); Department of Neurology, Dana-Farber Cancer Institute, Massachusetts General Hospital, Boston, Massachusetts (P.Y.W.); Department of Neurology and Oncology, Mayo Clinic Florida, Jacksonville, Florida (K.A.J.)
| | - Sophie Taillibert
- Department of Neurology, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington (M.C.); Department of Neuroscience, Division of Neuro-Oncology, University Hospital, Torino, Italy (R.S., R.R.); Department of Neurology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois (J.R.); Department of Neuro-Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands (D.B., W.B.); Departments of Neuro-Oncology Mazarin and Radiation Oncology, Pitie-Salpetriere Hospital and University Pierre et Marie Curie, Paris VI, Paris, France (S.T.); Austin Brain Tumor Center, Texas Oncology/US Oncology Research, Austin, Texas (M.D.G.); Department of Neuro-Oncology, University Hospital, Lille, France (E.L.R.); Department of Neurology, Oscar Lambret Center, Lille, France (E.L.R.); Department of Neurology, University of Michigan, Ann Arbor, Michigan (L.J.); Department of Neuro-oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, Netherlands (M.v.d.B.); Department of Neurology, Dana-Farber Cancer Institute, Massachusetts General Hospital, Boston, Massachusetts (P.Y.W.); Department of Neurology and Oncology, Mayo Clinic Florida, Jacksonville, Florida (K.A.J.)
| | - Morris D Groves
- Department of Neurology, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington (M.C.); Department of Neuroscience, Division of Neuro-Oncology, University Hospital, Torino, Italy (R.S., R.R.); Department of Neurology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois (J.R.); Department of Neuro-Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands (D.B., W.B.); Departments of Neuro-Oncology Mazarin and Radiation Oncology, Pitie-Salpetriere Hospital and University Pierre et Marie Curie, Paris VI, Paris, France (S.T.); Austin Brain Tumor Center, Texas Oncology/US Oncology Research, Austin, Texas (M.D.G.); Department of Neuro-Oncology, University Hospital, Lille, France (E.L.R.); Department of Neurology, Oscar Lambret Center, Lille, France (E.L.R.); Department of Neurology, University of Michigan, Ann Arbor, Michigan (L.J.); Department of Neuro-oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, Netherlands (M.v.d.B.); Department of Neurology, Dana-Farber Cancer Institute, Massachusetts General Hospital, Boston, Massachusetts (P.Y.W.); Department of Neurology and Oncology, Mayo Clinic Florida, Jacksonville, Florida (K.A.J.)
| | - Emilie Le Rhun
- Department of Neurology, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington (M.C.); Department of Neuroscience, Division of Neuro-Oncology, University Hospital, Torino, Italy (R.S., R.R.); Department of Neurology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois (J.R.); Department of Neuro-Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands (D.B., W.B.); Departments of Neuro-Oncology Mazarin and Radiation Oncology, Pitie-Salpetriere Hospital and University Pierre et Marie Curie, Paris VI, Paris, France (S.T.); Austin Brain Tumor Center, Texas Oncology/US Oncology Research, Austin, Texas (M.D.G.); Department of Neuro-Oncology, University Hospital, Lille, France (E.L.R.); Department of Neurology, Oscar Lambret Center, Lille, France (E.L.R.); Department of Neurology, University of Michigan, Ann Arbor, Michigan (L.J.); Department of Neuro-oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, Netherlands (M.v.d.B.); Department of Neurology, Dana-Farber Cancer Institute, Massachusetts General Hospital, Boston, Massachusetts (P.Y.W.); Department of Neurology and Oncology, Mayo Clinic Florida, Jacksonville, Florida (K.A.J.)
| | - Larry Junck
- Department of Neurology, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington (M.C.); Department of Neuroscience, Division of Neuro-Oncology, University Hospital, Torino, Italy (R.S., R.R.); Department of Neurology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois (J.R.); Department of Neuro-Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands (D.B., W.B.); Departments of Neuro-Oncology Mazarin and Radiation Oncology, Pitie-Salpetriere Hospital and University Pierre et Marie Curie, Paris VI, Paris, France (S.T.); Austin Brain Tumor Center, Texas Oncology/US Oncology Research, Austin, Texas (M.D.G.); Department of Neuro-Oncology, University Hospital, Lille, France (E.L.R.); Department of Neurology, Oscar Lambret Center, Lille, France (E.L.R.); Department of Neurology, University of Michigan, Ann Arbor, Michigan (L.J.); Department of Neuro-oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, Netherlands (M.v.d.B.); Department of Neurology, Dana-Farber Cancer Institute, Massachusetts General Hospital, Boston, Massachusetts (P.Y.W.); Department of Neurology and Oncology, Mayo Clinic Florida, Jacksonville, Florida (K.A.J.)
| | - Martin van den Bent
- Department of Neurology, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington (M.C.); Department of Neuroscience, Division of Neuro-Oncology, University Hospital, Torino, Italy (R.S., R.R.); Department of Neurology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois (J.R.); Department of Neuro-Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands (D.B., W.B.); Departments of Neuro-Oncology Mazarin and Radiation Oncology, Pitie-Salpetriere Hospital and University Pierre et Marie Curie, Paris VI, Paris, France (S.T.); Austin Brain Tumor Center, Texas Oncology/US Oncology Research, Austin, Texas (M.D.G.); Department of Neuro-Oncology, University Hospital, Lille, France (E.L.R.); Department of Neurology, Oscar Lambret Center, Lille, France (E.L.R.); Department of Neurology, University of Michigan, Ann Arbor, Michigan (L.J.); Department of Neuro-oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, Netherlands (M.v.d.B.); Department of Neurology, Dana-Farber Cancer Institute, Massachusetts General Hospital, Boston, Massachusetts (P.Y.W.); Department of Neurology and Oncology, Mayo Clinic Florida, Jacksonville, Florida (K.A.J.)
| | - Patrick Y Wen
- Department of Neurology, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington (M.C.); Department of Neuroscience, Division of Neuro-Oncology, University Hospital, Torino, Italy (R.S., R.R.); Department of Neurology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois (J.R.); Department of Neuro-Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands (D.B., W.B.); Departments of Neuro-Oncology Mazarin and Radiation Oncology, Pitie-Salpetriere Hospital and University Pierre et Marie Curie, Paris VI, Paris, France (S.T.); Austin Brain Tumor Center, Texas Oncology/US Oncology Research, Austin, Texas (M.D.G.); Department of Neuro-Oncology, University Hospital, Lille, France (E.L.R.); Department of Neurology, Oscar Lambret Center, Lille, France (E.L.R.); Department of Neurology, University of Michigan, Ann Arbor, Michigan (L.J.); Department of Neuro-oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, Netherlands (M.v.d.B.); Department of Neurology, Dana-Farber Cancer Institute, Massachusetts General Hospital, Boston, Massachusetts (P.Y.W.); Department of Neurology and Oncology, Mayo Clinic Florida, Jacksonville, Florida (K.A.J.)
| | - Kurt A Jaeckle
- Department of Neurology, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington (M.C.); Department of Neuroscience, Division of Neuro-Oncology, University Hospital, Torino, Italy (R.S., R.R.); Department of Neurology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois (J.R.); Department of Neuro-Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands (D.B., W.B.); Departments of Neuro-Oncology Mazarin and Radiation Oncology, Pitie-Salpetriere Hospital and University Pierre et Marie Curie, Paris VI, Paris, France (S.T.); Austin Brain Tumor Center, Texas Oncology/US Oncology Research, Austin, Texas (M.D.G.); Department of Neuro-Oncology, University Hospital, Lille, France (E.L.R.); Department of Neurology, Oscar Lambret Center, Lille, France (E.L.R.); Department of Neurology, University of Michigan, Ann Arbor, Michigan (L.J.); Department of Neuro-oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, Netherlands (M.v.d.B.); Department of Neurology, Dana-Farber Cancer Institute, Massachusetts General Hospital, Boston, Massachusetts (P.Y.W.); Department of Neurology and Oncology, Mayo Clinic Florida, Jacksonville, Florida (K.A.J.)
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Abouharb S, Ensor J, Loghin ME, Katz R, Moulder SL, Esteva FJ, Smith B, Valero V, Hortobagyi GN, Melhem-Bertrandt A. Leptomeningeal disease and breast cancer: the importance of tumor subtype. Breast Cancer Res Treat 2014; 146:477-86. [PMID: 25038877 DOI: 10.1007/s10549-014-3054-z] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 07/03/2014] [Indexed: 02/03/2023]
Abstract
Breast cancer (BC) is one of the most common tumors to involve the leptomeninges. We aimed to characterize clinical features and outcomes of patients with LMD based on BC subtypes. We retrospectively reviewed records of 233 patients diagnosed with LMD from BC between 1997 and 2012. Survival was estimated by the Kaplan-Meier method and significant differences in survival were determined by Cox proportional hazards or log-rank tests. Of 190 patients with BC subtype available, 67 (35 %) had hormone receptor positive (HR+)/human epidermal growth factor receptor 2 (HER2)-negative BC, 56 (29 %) had HER2+BC, and 67 (35 %) had triple-negative BC (TNBC). Median age at LMD diagnosis was 50 years. Median overall survival (OS) from LMD diagnosis was 4.4 months for HER2+BC (95 % CI 2.8, 6.9), 3.7 months (95 % CI 2.4, 6.0) for HR+/HER2-BC, and 2.2 months (95 % CI 1.5, 3.0) for TNBC (p = 0.0002). Older age was associated with worse outcome (p < 0.0001). Patients with HER2+BC and LMD were more likely to receive systemic therapy (ST) (p = 0.001). Use of intrathecal therapy (IT) (52 %) was similar (p = 0.35). Both IT (p < 0.0001) and ST (p < 0.0001) administration were associated with improved OS. After adjusting for age, IT, extracranial disease, and ST, patients with HER2+BC had better OS compared with HR+/HER2-BC (HR 1.72; 95 %CI 1.07-2.76) and TNBC (HR 3.30; 95 %CI 1.98-5.52). LMD carries a dismal prognosis. Modest survival differences by tumor subtype were seen. Patients with HER2+BC had the best outcome. There is an urgent need to develop effective treatment strategies.
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Affiliation(s)
- Sausan Abouharb
- Department of General Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA,
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Kwon J, Chie EK, Kim K, Kim HJ, Wu HG, Kim IH, Oh DY, Lee SH, Kim DW, Im SA, Kim TY, Heo DS, Bang YJ, Ha SW. Impact of multimodality approach for patients with leptomeningeal metastases from solid tumors. J Korean Med Sci 2014; 29:1094-101. [PMID: 25120319 PMCID: PMC4129201 DOI: 10.3346/jkms.2014.29.8.1094] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 05/08/2014] [Indexed: 11/20/2022] Open
Abstract
The purpose of this study was to evaluate treatment patterns, outcome and prognosticators for patients with leptomeningeal metastases from solid tumor. Medical records of 80 patients from January 1, 2004 to May 31, 2011 were retrospectively reviewed. Most frequent site of origin was the lung (59%) followed by the breast (25%). Most patients were treated with intrathecal chemotherapy (90%) and/or whole brain radiotherapy (67.5%). Systemic therapy was offered to 27 patients (33.8%). Percentage of patients treated with single, dual, and triple modality were 32.5%, 43.8%, and 23.8%, respectively. Median survival was 2.7 months and 1 yr survival rate was 11.3%. Multivariate analysis showed that negative cerebrospinal fluid cytology, fewer chemotherapy regimen prior to leptomeningeal metastases, whole brain radiotherapy, systemic therapy, and combined modality treatment (median survival; single 1.4 vs. dual 2.8 vs. triple 8.3 months, P<0.001) had statistical significance on survival. Subgroup analysis of non-small cell lung cancer (NSCLC) patients showed that targeted therapy had significant independent impact on survival (median survival; 10.5 vs. 3.0 months, P=0.008). Unlike previous reports, survival of patients with NSCLC primary was comparable to breast primary. Furthermore, combined modality treatment for all patients and additionally targeted therapy for NSCLC patients should be considered in the treatment of leptomeningeal metastases from solid tumor.
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Affiliation(s)
- Jeanny Kwon
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
| | - Eui Kyu Chie
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
- Institute of Radiation Medicine, Medical Research Center, Seoul National University, Seoul, Korea
| | - Kyubo Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
- Institute of Radiation Medicine, Medical Research Center, Seoul National University, Seoul, Korea
| | - Hak Jae Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
- Institute of Radiation Medicine, Medical Research Center, Seoul National University, Seoul, Korea
| | - Hong-Gyun Wu
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
- Institute of Radiation Medicine, Medical Research Center, Seoul National University, Seoul, Korea
| | - Il Han Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
- Institute of Radiation Medicine, Medical Research Center, Seoul National University, Seoul, Korea
| | - Do-Youn Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Se-Hoon Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Dong-Wan Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Seock-Ah Im
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Tae-You Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Dae-Seog Heo
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yung-Jue Bang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Sung W. Ha
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
- Institute of Radiation Medicine, Medical Research Center, Seoul National University, Seoul, Korea
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Jung TY, Chung WK, Oh IJ. The prognostic significance of surgically treated hydrocephalus in leptomeningeal metastases. Clin Neurol Neurosurg 2014; 119:80-3. [PMID: 24635931 DOI: 10.1016/j.clineuro.2014.01.023] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 01/16/2014] [Accepted: 01/18/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The median survival of leptomeningeal metastases is short despite therapy and is sometime associated with hydrocephalus. We investigated the prognostic significance of surgically treated hydrocephalus in leptomeningeal metastases. MATERIALS AND METHODS Between December 2005 and November 2012, 1343 patients had brain metastases from systemic solid tumors. Of these, 71 patients (5.3%) experienced leptomeningeal metastases from 45 lung cancers, 14 breast cancers, 4 gastric cancers and 8 other cancers. The mean age was 60 years (range 37-89). The clinical symptoms presented in the cerebral hemisphere and cerebellum in 58 patients, cranial nerve in 7 patients and spinal cord and nerves in 6 patients. Twenty-nine (40.8%) patients were Radiation Therapy Oncology Group recursive partitioning analysis (RTOG-RPA) class II and 42 (59.2%) were class III. Hydrocephalus was associated in 18 (25.4%) patients and 7 patients underwent ventriculoperioneal shunt. The primary cancer, clinical symptoms, RTOG-RPA class, surgically treated hydrocephalus and systemic chemotherapy were analyzed as the prognostic factors for overall survival. RESULTS The overall incidence of leptomeningeal seeding was 5.0% of the brain metastases. The median duration of leptomeningeal metastases from first brain metastasis was 4.0 months and 24 (33.8%) patients showed leptomeningeal metastases as the first form of brain metastasis. The median overall survival (OS) was 2.1 months. Based on the univariate and multivariate analyses, RTOG-RPA class II patients, treatment of leptomeningeal metastases (such as radiotherapy or intrathecal chemotherapy) and systemic chemotherapy improved OS with statistical significance. Surgically untreated hydrocephalus (median OS, 1.7 months) showed poor OS compared with surgically treated hydrocephalus (median OS, 5.7 months) and no hydrocephalus (median OS, 2.3 months) without statistical significance. CONCLUSIONS The leptomeningeal metastases were often associated with hydrocephalus and the surgical treatment was helpful in limited patients. The prognosis was related with RTOG-RPA class and treatment of local and systemic treatment.
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Affiliation(s)
- Tae-Young Jung
- Department of Neurosurgery, Chonnam National University Hwasun Hospital & Medical School, Gwangju, South Korea.
| | - Woong-Ki Chung
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital & Medical School, Gwangju, South Korea
| | - In-Jae Oh
- Department of Internal Medicine, Chonnam National University Hwasun Hospital & Medical School, Gwangju, South Korea
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Three cases of neoplastic meningitis initially diagnosed with infectious meningitis in emergency department. Case Rep Emerg Med 2013; 2013:561475. [PMID: 23840976 PMCID: PMC3690228 DOI: 10.1155/2013/561475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Accepted: 05/27/2013] [Indexed: 12/03/2022] Open
Abstract
Neoplastic meningitis (NM) is diagnosed by the presence of malignant cells in the cerebrospinal fluid (CSF). We report 3 patients with NM, who were misdiagnosed with infectious meningitis in emergency department (ED). Case 1. A 68-year-old man visited our ED with a 3-month history of headache. With MRI and CSF study, he was diagnosed with tuberculous meningitis. After 20 days, repeated CSF cytology showed malignant cells. His diagnosis was lung cancer with NM. Case 2. A 57-year-old man visited regional hospital ED with a 3-week history of headache and diplopia. Brain MRI was not contributory. With CSF examination, his diagnosis was aseptic meningitis. With worsening headache, he was referred to our ED. Repeated CSF showed malignant cells. His diagnosis was stomach cancer with NM.
Case 3. A 75-year-old man visited a regional hospital with headache lasting for 4 months. His diagnosis was sinusitis. Persistent symptom brought him back, and he developed recurrent generalized seizures. Brain MRI showed diffuse leptomeningeal enhancement suggesting meningitis, and he was transferred to our ED. CSF exam showed malignant cells. His diagnosis was NM with unknown primary focus. When evaluating the patients with headache in ED, NM should be kept in mind as a differential diagnosis of meningitis.
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Le Rhun E, Taillibert S, Chamberlain MC. Carcinomatous meningitis: Leptomeningeal metastases in solid tumors. Surg Neurol Int 2013; 4:S265-88. [PMID: 23717798 PMCID: PMC3656567 DOI: 10.4103/2152-7806.111304] [Citation(s) in RCA: 180] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 04/11/2013] [Indexed: 11/04/2022] Open
Abstract
Leptomeningeal metastasis (LM) results from metastatic spread of cancer to the leptomeninges, giving rise to central nervous system dysfunction. Breast cancer, lung cancer, and melanoma are the most frequent causes of LM among solid tumors in adults. An early diagnosis of LM, before fixed neurologic deficits are manifest, permits earlier and potentially more effective treatment, thus leading to a better quality of life in patients so affected. Apart from a clinical suspicion of LM, diagnosis is dependent upon demonstration of cancer in cerebrospinal fluid (CSF) or radiographic manifestations as revealed by neuraxis imaging. Potentially of use, though not commonly employed, today are use of biomarkers and protein profiling in the CSF. Symptomatic treatment is directed at pain including headache, nausea, and vomiting, whereas more specific LM-directed therapies include intra-CSF chemotherapy, systemic chemotherapy, and site-specific radiotherapy. A special emphasis in the review discusses novel agents including targeted therapies, that may be promising in the future management of LM. These new therapies include anti-epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors erlotinib and gefitinib in nonsmall cell lung cancer, anti-HER2 monoclonal antibody trastuzumab in breast cancer, anti-CTLA4 ipilimumab and anti-BRAF tyrosine kinase inhibitors such as vermurafenib in melanoma, and the antivascular endothelial growth factor monoclonal antibody bevacizumab are currently under investigation in patients with LM. Challenges of managing patients with LM are manifold and include determining the appropriate patients for treatment as well as the optimal route of administration of intra-CSF drug therapy.
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Affiliation(s)
- Emilie Le Rhun
- Breast Unit, Department of Medical Oncology, Centre Oscar Lambret and Department of Neuro Oncology, Roger Salengro Hospital, University Hospital, Lille, France
| | - Sophie Taillibert
- Neurology, Mazarin and Radiation Oncology, Pitié Salpétrière Hospital, University Pierre et Marie Curie, Paris VI, Paris, France
| | - Marc C. Chamberlain
- Neurology and Neurological Surgery, University of Washington, Fred Hutchinson Research Cancer Center, Seattle, WA, USA
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Gaviani P, Corsini E, Salmaggi A, Lamperti E, Botturi A, Erbetta A, Milanesi I, Legnani F, Pollo B, Silvani A. Liposomal cytarabine in neoplastic meningitis from primary brain tumors: a single institutional experience. Neurol Sci 2013; 34:2151-7. [DOI: 10.1007/s10072-013-1358-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2012] [Accepted: 03/08/2013] [Indexed: 11/29/2022]
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Chamberlain MC. Neoplastic Meningitis and Metastatic Epidural Spinal Cord Compression. Hematol Oncol Clin North Am 2012; 26:917-31. [DOI: 10.1016/j.hoc.2012.04.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Leptomeningeal metastases from breast cancer: intrinsic subtypes may affect unique clinical manifestations. Breast Cancer Res Treat 2011; 129:809-17. [DOI: 10.1007/s10549-011-1682-0] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2011] [Accepted: 07/11/2011] [Indexed: 11/26/2022]
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Abstract
Tumors associated with the spinal cord can have devastating effects on patient function and quality of life. Most of these tumors are from metastatic disease, usually to the epidural space. Less frequently, the tumors are intrinsic to the spinal cord itself (ie, primary tumor). Regardless of the etiology, spinal cord tumors often present first with progressive local or radicular pain, or both. Other symptoms include weakness, sensory changes, or sphincter dysfunction. The timeliness of diagnosis of spinal cord tumors and promptness of treatment are important, as they directly affect outcome. Dexamethasone, a corticosteroid, is used as a temporizing measure to improve or stabilize neurologic function until definitive treatment. For nonambulatory patients with epidural metastatic tumors, surgery followed by radiation therapy maximizes neurologic function and modestly lengthens survival. However, palliative radiotherapy alone is recommended for those with neurologic deficits lasting longer than 48 hours, survival prognosis less than 3 months, inability to tolerate surgery, multiple areas of compression, or radiosensitive tumors. An ambulatory patient with a stable spine should be considered for radiation treatment only. The role of chemotherapy for epidural metastatic tumors is not well established. For intramedullary metastases, the role of surgery and chemotherapy remains controversial and radiation is the mainstay. For low-grade or benign primary spinal cord tumors, resective surgery is of benefit and can be curative. For high-grade tumors, the benefit of resection is less clear, and radiotherapy and/or chemotherapy may be helpful. The use of chemotherapy for primary spinal cord tumors has rarely been assessed. Agents reported in the literature for treatment of spinal cord gliomas include temozolomide, irinotecan, cisplatin, and carboplatin. A multidisciplinary approach is often required to maximize the therapeutic and functional outcome of patients with metastatic and primary spinal cord tumors.
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de Broucker T, Martinez-Almoyna L. Diagnostic des méningites chroniques. Rev Med Interne 2011; 32:159-72. [DOI: 10.1016/j.revmed.2010.04.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Revised: 03/26/2010] [Accepted: 04/10/2010] [Indexed: 12/26/2022]
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Abstract
PURPOSE OF REVIEW Leptomeningeal metastasis occurs in approximately 5% of all patients with cancer. This review summarizes recent literature regarding methods of diagnosis and treatment of leptomeningeal metastasis. RECENT FINDINGS Staging of leptomeningeal metastasis should include contrast-enhanced brain and spine MRI, and though controversial, radionuclide cerebrospinal fluid (CSF) flow study. Treatment of leptomeningeal metastasis often requires involved-field radiotherapy to bulky or symptomatic disease sites as well as intra-CSF and systemic chemotherapy. The use of high-dose systemic therapy may benefit patients with leptomeningeal metastasis and obviate the need for intra-CSF chemotherapy. Intra-CSF drug therapy primarily utilizes one of three chemotherapeutic agents [i.e. methotrexate, cytosine arabinoside (both free and liposomal) and thio-tetraethylenepentamine] administered by a variety of schedules either by intralumbar or intraventricular drug delivery. Novel intra-CSF agents increasingly utilized in the treatment of leptomeningeal metastasis are targeted mAbs such as rituximab and trastuzumab. SUMMARY Although treatment of leptomeningeal metastasis is palliative with median patient survival of 2-3 months, treatment may afford stabilization and protection from further neurologic deterioration in patients with leptomeningeal metastasis.
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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]
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Ohnishi S, Dazai M, Iwasaki Y, Tsuzaka K, Takahashi T, Miyagishima T. Undiagnosed collecting duct carcinoma presenting as meningeal carcinomatosis and multiple bone metastases. Intern Med 2010; 49:1541-4. [PMID: 20686287 DOI: 10.2169/internalmedicine.49.3427] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 54-year-old woman presented with blepharoptosis, numbness in the lower lip, dysgeusia and pain in the extremities and back. MRI showed marked meningeal thickening and multiple bone lesions accompanying a prominent enhancing effect. CT scan of the chest and abdomen appeared to be unremarkable for primary cancer. She died 3 months after the admission, and postmortem autopsy showed a mass of about 2.5 cm in diameter in the renal medulla. Histological examination including immunohistochemistry confirmed the presence of a collecting duct carcinoma (CDC). This case is of particular interest because it emphasizes the possible fulminate clinical course of a small CDC.
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Affiliation(s)
- Shunsuke Ohnishi
- Department of Internal Medicine, Kushiro Rosai Hospital, Kushiro.
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Galloway M, Thom M. Brain and cerebrospinal fluid. Diagn Cytopathol 2010. [DOI: 10.1016/b978-0-7020-3154-0.00031-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Boskovitz A, McLendon RE, Okamura T, Sampson JH, Bigner DD, Zalutsky MR. Treatment of HER2-positive breast carcinomatous meningitis with intrathecal administration of alpha-particle-emitting (211)At-labeled trastuzumab. Nucl Med Biol 2009; 36:659-69. [PMID: 19647172 DOI: 10.1016/j.nucmedbio.2009.04.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2009] [Revised: 02/19/2009] [Accepted: 04/02/2009] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Carcinomatous meningitis (CM) is a devastating disease characterized by the dissemination of malignant tumor cells into the subarachnoid space along the brain and spine. Systemic treatment with monoclonal antibody (mAb) trastuzumab can be effective against HER2-positive systemic breast carcinoma but, like other therapies, is ineffective against CM. The goal of this study was to evaluate the therapeutic effect of alpha-particle emitting (211)At-labeled trastuzumab following intrathecal administration in a rat model of breast carcinoma CM. METHODS Athymic rats were injected intrathecally with MCF-7/HER2-18 breast carcinoma cells through a surgically implanted indwelling intrathecal catheter. In Experiment 1, animals received 33 or 66 muCi (211)At-labeled trastuzumab, cold trastuzumab or saline. In Experiment 2, animals were inoculated with a lower tumor burden and received 46 or 92 muCi (211)At-labeled trastuzumab or saline. In Experiment 3, animals received 28 muCi (211)At-labeled trastuzumab, 30 muCi (211)At-labeled TPS3.2 control mAb or saline. Histopathological analysis of the neuroaxis was performed at the end of the study. RESULTS In Experiment 1, median survival increased from 21 days for the saline and cold trastuzumab groups to 45 and 48 days for 33 and 66 muCi (211)At-labeled trastuzumab, respectively. In Experiment 2, median survival increased from 23 days for saline controls to 68 and 92 days for 46 and 92 muCi (211)At-labeled trastuzumab, respectively. In Experiment 3, median survival increased from 20 days to 29 and 36 days for animals treated with (211)At-labeled TPS3.2 and (211)At-labeled trastuzumab, respectively. Long-term survivors were observed exclusively in the (211)At-trastuzumab-treated groups. CONCLUSION Intrathecal (211)At-labeled trastuzumab shows promise as a treatment for patients with HER2-positive breast CM.
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Affiliation(s)
- Abraham Boskovitz
- Department of Pathology, Duke University Medical Center, Durham, NC 27710 USA
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Abstract
Secondary involvement of the leptomeninges represents an infrequent but devastating (and nearly always fatal) complication of solid tumors, hematologic malignancies (both leukemia and lymphoma), and primary brain tumors. Clinical suspicion of neoplastic meningitis (NM) may be raised by the appearance of multivariate neurological symptoms; however, a definitive diagnosis is often difficult to obtain. Improved treatments for primary malignancies and advances in diagnostic imaging technology have led to an apparent increase in the number of patients diagnosed with NM. Unfortunately, therapeutic options remain limited, particularly for patients with chemoresistant tumors. Optimized treatment remains controversial and may rely upon a combination of chemotherapy (intrathecal and/or intravenous) and concurrent focal radiotherapy. This review discusses the advantages and disadvantages of intra-cerebrospinal fluid (CSF) versus systemic strategies for treating NM. Clinical trial evidence is presented for the different treatment modalities. In addition, the therapeutic potential of intra-CSF therapy for cancer prophylaxis is discussed. Earlier diagnosis and more aggressive preventive treatment regimens may provide substantial increases in survival and favorably affect quality of life. Additional data from large-scale, well-controlled trials are required to more accurately assess the efficacy of intra-CSF versus systemic treatment in NM. Future treatment options using novel targets for intra-CSF therapy will be addressed as well.
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Affiliation(s)
- William R Shapiro
- Division of Neurology, Director Neuro-Oncology Program, Barrow Neurological Institute, Phoenix, AZ 85013, USA.
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Silvestris N, Di Palma T, Rabitti C, Pericoli MN, Pisani L, D'Aprile M. Rapidly Progressive Coma in Leptomeningeal Carcinomatosis From Undiagnosed Bronchioloalveolar Carcinoma. J Clin Oncol 2009; 27:e65-6. [DOI: 10.1200/jco.2008.21.6499] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Nicola Silvestris
- Medical and Experimental Oncology Unit, Oncology Institute “Giovanni Paolo II,” Bari, Italy
| | - Teresa Di Palma
- Medical Oncology Unit, Hospital Santa Maria Goretti, Latina, Italy
| | - Carla Rabitti
- Histopathology Unit, University Campus Bio-Medico, Rome, Italy
| | | | - Luisa Pisani
- Radiology Unit, Hospital Santa Maria Goretti, Latina, Italy
| | - Modesto D'Aprile
- Medical Oncology Unit, Hospital Santa Maria Goretti, Latina, Italy
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Life-threatening Neurological Complications in Patients with Malignancies. Intensive Care Med 2009. [DOI: 10.1007/978-0-387-92278-2_76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Schneider S, Krikmann U, Lüüs SM, Kulla A, Haldre S. Neoplastic meningitis as the presenting manifestation of gastric adenocarcinoma. BMJ Case Rep 2009; 2009:bcr07.2008.0565. [PMID: 21785656 DOI: 10.1136/bcr.07.2008.0565] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A middle aged man presented with clinical signs of chronic meningitis, including bilateral hearing loss and progressive blindness. Lumbar puncture revealed a mild elevation in lymphocyte number, an elevation in protein levels, and diminished glucose levels, without malignant cells. Magnetic resonance imaging (MRI) T2 weighted seqeunces showed bilateral enhancement of the acoustic nerves. The aetiology of the chronic meningitis was revealed gastric cancer by gastroscopy, and micrometastasis by bone marrow trephine biopsy. Although cerebrospinal fluid (CSF) cytology was negative, neoplastic meningitis (NM) was diagnosed based on clinical and MRI data. The patient's condition worsened rapidly and he died shortly thereafter. Autopsy confirmed the presence of advanced gastric cancer (adenocarcinoma of signet-ring cell type) with pancreatic involvement, and NM with cancer cells on the meninges, but without infiltration tumour cells into underlying brain parenchyma. We conclude that NM as an initial symptom of gastric cancer is rare and ultimately fatal.
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Affiliation(s)
- Siim Schneider
- University of Tartu, Department of Neurology and Neurosurgery, Puusepa 2, Tartu, 51014, Estonia
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Affiliation(s)
- William P O'Meara
- Department Radiation Oncology, National Naval Medical Center, Bethesda, Maryland, USA
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50
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Bernardi RJ, Bomgaars L, Fox E, Balis FM, Egorin MJ, Lagattuta TF, Aikin A, Whitcomb P, Renbarger J, Lieberman FS, Berg SL, Blaney SM. Phase I clinical trial of intrathecal gemcitabine in patients with neoplastic meningitis. Cancer Chemother Pharmacol 2007; 62:355-61. [PMID: 17909804 DOI: 10.1007/s00280-007-0601-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2007] [Accepted: 09/10/2007] [Indexed: 10/22/2022]
Abstract
PURPOSE A phase I study of intrathecal (IT) gemcitabine was performed to define a safe dose and characterize the toxicity profile and CSF pharmacokinetics of gemcitabine and its major metabolite 2',2'-difluoro-deoxyuridine (dFdU) in patients 3 years of age and older with neoplastic meningitis. EXPERIMENTAL DESIGN Gemcitabine was administered via Ommaya reservoir or lumbar puncture at three dose levels: 5 mg weekly, 5 mg twice-weekly, and 10 mg twice-weekly using a standard phase I dose escalation design. Serial CSF samples were obtained for pharmacokinetic studies in seven patients with Ommaya reservoirs. Serial blood samples for pharmacokinetic studies were also obtained from three patients. RESULTS Ten patients were enrolled in this study. Significant neurological toxicities occurred in two patients including myelitis in a patient at the 5 mg twice-weekly dose level and somnolence in a patient at the 10 mg twice-weekly dose level. No complete responses were seen; however, three patients had stable disease. Gemcitabine was rapidly eliminated from the CSF with a terminal half-life of 61 +/- 50 min. No gemcitabine or dFdU was detected in plasma. CONCLUSIONS IT gemcitabine was associated with significant neurotoxicity; therefore, its further development for IT use is not recommended.
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Affiliation(s)
- Ronald J Bernardi
- Texas Children's Hospital, Baylor College of Medicine, Houston, TX, 77030, USA
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