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Nguyen A, Nguyen A, Dada OT, Desai PD, Ricci JC, Godbole NB, Pierre K, Lucke-Wold B. Leptomeningeal Metastasis: A Review of the Pathophysiology, Diagnostic Methodology, and Therapeutic Landscape. Curr Oncol 2023; 30:5906-5931. [PMID: 37366925 DOI: 10.3390/curroncol30060442] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 06/14/2023] [Accepted: 06/16/2023] [Indexed: 06/28/2023] Open
Abstract
The present review aimed to establish an understanding of the pathophysiology of leptomeningeal disease as it relates to late-stage development among different cancer types. For our purposes, the focused metastatic malignancies include breast cancer, lung cancer, melanoma, primary central nervous system tumors, and hematologic cancers (lymphoma, leukemia, and multiple myeloma). Of note, our discussion was limited to cancer-specific leptomeningeal metastases secondary to the aforementioned primary cancers. LMD mechanisms secondary to non-cancerous pathologies, such as infection or inflammation of the leptomeningeal layer, were excluded from our scope of review. Furthermore, we intended to characterize general leptomeningeal disease, including the specific anatomical infiltration process/area, CSF dissemination, manifesting clinical symptoms in patients afflicted with the disease, detection mechanisms, imaging modalities, and treatment therapies (both preclinical and clinical). Of these parameters, leptomeningeal disease across different primary cancers shares several features. Pathophysiology regarding the development of CNS involvement within the mentioned cancer subtypes is similar in nature and progression of disease. Consequently, detection of leptomeningeal disease, regardless of cancer type, employs several of the same techniques. Cerebrospinal fluid analysis in combination with varied imaging (CT, MRI, and PET-CT) has been noted in the current literature as the gold standard in the diagnosis of leptomeningeal metastasis. Treatment options for the disease are both varied and currently in development, given the rarity of these cases. Our review details the differences in leptomeningeal disease as they pertain through the lens of several different cancer subtypes in an effort to highlight the current state of targeted therapy, the potential shortcomings in treatment, and the direction of preclinical and clinical treatments in the future. As there is a lack of comprehensive reviews that seek to characterize leptomeningeal metastasis from various solid and hematologic cancers altogether, the authors intended to highlight not only the overlapping mechanisms but also the distinct patterning of disease detection and progression as a means to uniquely treat each metastasis type. The scarcity of LMD cases poses a barrier to more robust evaluations of this pathology. However, as treatments for primary cancers have improved over time, so has the incidence of LMD. The increase in diagnosed cases only represents a small fraction of LMD-afflicted patients. More often than not, LMD is determined upon autopsy. The motivation behind this review stems from the increased capacity to study LMD in spite of scarcity or poor patient prognosis. In vitro analysis of leptomeningeal cancer cells has allowed researchers to approach this disease at the level of cancer subtypes and markers. We ultimately hope to facilitate the clinical translation of LMD research through our discourse.
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Affiliation(s)
- Andrew Nguyen
- College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Alexander Nguyen
- College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | | | - Persis D Desai
- College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Jacob C Ricci
- College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Nikhil B Godbole
- School of Medicine, Tulane University, New Orleans, LA 70112, USA
| | - Kevin Pierre
- Department of Radiology, University of Florida, Gainesville, FL 32610, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL 32610, USA
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Khaled ML, Tarhini AA, Forsyth PA, Smalley I, Piña Y. Leptomeningeal Disease (LMD) in Patients with Melanoma Metastases. Cancers (Basel) 2023; 15:cancers15061884. [PMID: 36980770 PMCID: PMC10047692 DOI: 10.3390/cancers15061884] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/13/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023] Open
Abstract
Leptomeningeal disease (LMD) is a devastating complication caused by seeding malignant cells to the cerebrospinal fluid (CSF) and the leptomeningeal membrane. LMD is diagnosed in 5-15% of patients with systemic malignancy. Management of LMD is challenging due to the biological and metabolic tumor microenvironment of LMD being largely unknown. Patients with LMD can present with a wide variety of signs and/or symptoms that could be multifocal and include headache, nausea, vomiting, diplopia, and weakness, among others. The median survival time for patients with LMD is measured in weeks and up to 3-6 months with aggressive management, and death usually occurs due to progressive neurologic dysfunction. In melanoma, LMD is associated with a suppressive immune microenvironment characterized by a high number of apoptotic and exhausted CD4+ T-cells, myeloid-derived suppressor cells, and a low number of CD8+ T-cells. Proteomics analysis revealed enrichment of complement cascade, which may disrupt the blood-CSF barrier. Clinical management of melanoma LMD consists primarily of radiation therapy, BRAF/MEK inhibitors as targeted therapy, and immunotherapy with anti-PD-1, anti-CTLA-4, and anti-LAG-3 immune checkpoint inhibitors. This review summarizes the biology and anatomic features of melanoma LMD, as well as the current therapeutic approaches.
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Affiliation(s)
- Mariam Lotfy Khaled
- Metabolism and Physiology Department, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
- Biochemistry Department, Faculty of Pharmacy, Cairo University, Cairo 12613, Egypt
| | - Ahmad A Tarhini
- Departments of Cutaneous Oncology and Immunology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | - Peter A Forsyth
- Neuro-Oncology Department, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | - Inna Smalley
- Metabolism and Physiology Department, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | - Yolanda Piña
- Neuro-Oncology Department, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
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Leptomeningeal Carcinomatosis in a Patient with Pancreatic Cancer: A Rare Phenomenon? MEDICINES 2022; 9:medicines9070039. [PMID: 35877817 PMCID: PMC9317958 DOI: 10.3390/medicines9070039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 07/05/2022] [Accepted: 07/07/2022] [Indexed: 11/17/2022]
Abstract
Complication of leptomeningeal carcinomatosis (LMC) is critical. It causes rapid neurological deterioration, and subsequently, discontinuation of the ineffective treatment even in body tumor dormancy. Large molecular chemotherapeutic agents that are unlikely to penetrate the CSF space, are more likely to not treat LMC, typically in chemo-sensitive tumors. With the introduction of novel regimens, significant advances in overall survival have been observed even in formerly chemo-resistant tumors, such as pancreatic cancer. Although such cases are still rare, the number of pancreatic cancer patients complicated with LMC are increasing, and this therefore needs more recognition. A 49-year-old woman was diagnosed with stage IVa pancreatic cancer. She underwent surgery, and subsequent adjuvant chemotherapy. After three lines of chemotherapy over a 3-year period, where the body disease remained dormant, the patient was complicated by LMC. The diagnosis was made 4 months after the onset of headache. The patient received intrathecal methotrexate treatment but succumbed shortly after treatment induction. Pancreatic cancer is still relatively chemo-resistant and is one of the least likely types of tumor to be complicated by LMC due to patients dying of the primary tumor. Advancements in treatments have led to a prolonged period of primary tumor control, but not in the CNS due to the poor penetration of chemo-agents to this site. The present case seems to be a typical result of modern era anti-cancer therapy. Therefore, we emphasize the necessity of earlier recognition of this complication so that we can initiate specific treatment targeting the CSF space, especially in this formerly chemo-resistant tumor in order to improve its prognosis.
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Munankami S, Shrestha M, Basnet S, Rijal SS. A Rare Case of Leptomeningeal Carcinomatosis Secondary to Metastatic Non-Small Cell Lung Carcinoma. Cureus 2022; 14:e25436. [PMID: 35774640 PMCID: PMC9237378 DOI: 10.7759/cureus.25436] [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: 05/25/2022] [Indexed: 11/18/2022] Open
Abstract
Leptomeningeal carcinomatosis is a rare complication of metastatic systemic malignancy, with lung cancer being the most common cause. We present a case of a 75-year-old man with a past medical history of right non-small cell lung carcinoma and ischemic stroke who presented with a persistent headache and swallowing difficulties. On evaluation, the patient was initially diagnosed with a subacute infarct of the right posterior frontal lobe following magnetic resonance imaging (MRI). The patient’s headache and dysphagia worsened, increasing the possibility of brain metastasis. The patient underwent cerebrospinal fluid analysis including cytology and multiple MRI studies with no obvious explanation for the symptoms. The patient eventually developed multiple cranial nerve palsies, and a diagnosis of leptomeningeal carcinomatosis was made with neuroradiology consultation for the MRI.
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Kobayashi K, Tanaka K, Iwai A, Taki J, Kitagawa M, Hayashi T, Tsuzuki S, Yamamoto T, Yoshioka T, Hirato J, Maihara T, Yamada K, Usami I, Heike T. Primary Diffuse Leptomeningeal Atypical Teratoid/Rhabdoid Tumor Initially Masquerading as Guillain–Barré Syndrome: A Case Report and Literature Review. JOURNAL OF PEDIATRIC NEUROLOGY 2022. [DOI: 10.1055/s-0041-1742251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AbstractA 10-year-old male child patient was admitted with a chief complaint of progression of lower limb weakness lasting for 5 weeks. An initial clinical picture was reminiscent of Guillain–Barré syndrome. Repeated cerebrospinal fluid (CSF) cytological examinations were negative for neoplastic cells, but leptomeningeal biopsy targeting positron emission tomography (PET) avid lesion confirmed the invasion of tumor cells which were negatively stained with Brahma-related gene 1. An extensive literature review identified five cases of primary diffuse leptomeningeal atypical teratoid/rhabdoid tumors, and the clinical characteristics, including ours, were characterized as follows: (1) there was a bimodal age distribution in young children and adolescents with a male predominance, (2) roughly half of the patients fulfilled the diagnostic criteria of albuminocytologic dissociation and CSF cytology was neither sensitive nor specific to establish a definitive diagnosis, and (3) cerebrospinal magnetic resonance imaging findings were mostly indistinguishable from those of infectious or inflammatory diseases. We would like to suggest that primary leptomeningeal tumor should be included in the differential diagnosis of progressive polyneuropathy even in the absence of CSF cytological findings and implementation of preoperative PET may enhance the diagnostic accuracy of such a miscellaneous central nervous system tumor.
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Affiliation(s)
- Kenichiro Kobayashi
- Department of Pediatric Hematology and Oncology, Hyogo Prefectural Amagasaki General Medical Center, Japan
- Department of Pediatrics, Hyogo Prefectural Amagasaki General Medical Center, Japan
| | - Kuniaki Tanaka
- Department of Pediatric Hematology and Oncology, Hyogo Prefectural Amagasaki General Medical Center, Japan
- Department of Pediatrics, Hyogo Prefectural Amagasaki General Medical Center, Japan
| | - Atsushi Iwai
- Department of Pediatric Hematology and Oncology, Hyogo Prefectural Amagasaki General Medical Center, Japan
- Department of Pediatrics, Hyogo Prefectural Amagasaki General Medical Center, Japan
| | - Junya Taki
- Department of Neurosurgery, Hyogo Prefectural Amagasaki General Medical Center, Japan
| | - Masashi Kitagawa
- Department of Neurosurgery, Hyogo Prefectural Amagasaki General Medical Center, Japan
| | - Tomoko Hayashi
- Department of Neurosurgery, Hyogo Prefectural Amagasaki General Medical Center, Japan
| | - Sadatoshi Tsuzuki
- Department of Pathology, Hyogo Prefectural Amagasaki General Medical Center, Japan
| | - Tetsuro Yamamoto
- Department of Pathology, Hyogo Prefectural Amagasaki General Medical Center, Japan
| | - Takako Yoshioka
- Department of Pathology, National Research Institute for Child Health and Development, Japan
| | - Junko Hirato
- Department of Pathology, Public Tomioka General Hospital, Japan
| | - Toshiro Maihara
- Department of Pediatrics, Hyogo Prefectural Amagasaki General Medical Center, Japan
| | - Keisuke Yamada
- Department of Neurosurgery, Hyogo Prefectural Amagasaki General Medical Center, Japan
| | - Ikuya Usami
- Department of Pediatric Hematology and Oncology, Hyogo Prefectural Amagasaki General Medical Center, Japan
- Department of Pediatrics, Hyogo Prefectural Amagasaki General Medical Center, Japan
| | - Toshio Heike
- Department of Pediatrics, Hyogo Prefectural Amagasaki General Medical Center, Japan
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Pattanaik J, Goel V, Sehrawat P, Rathore R, Singh RK, Garg A, Biswas A. Leptomeningeal carcinomatosis in a patient with recurrent unresectable squamous cell carcinoma of the retromolar trigone—a brief report. J Egypt Natl Canc Inst 2022; 34:46. [PMID: 36336772 PMCID: PMC9638276 DOI: 10.1186/s43046-022-00147-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 08/17/2022] [Indexed: 11/09/2022] Open
Abstract
Background The reported incidence of leptomeningeal carcinomatosis is 3–8% in patients with solid tumours. More commonly, it has been described in the setting of advanced cancers of the lung, breast and malignant melanoma. Case presentation A 50-year-old diabetic patient with recurrent unresectable squamous cell carcinoma (SCC) of the right retromolar trigone (rT4bN0M0) presented with severe low backache and weakness in bilateral lower limbs 20 days after the completion of concurrent chemoradiotherapy. Contrast-enhanced MRI of the spine showed multiple nodular enhancing leptomeningeal lesions at the lumbar level and an intramedullary T2/FLAIR-hyperintense longitudinal lesion involving the central cord from C2 to C7 vertebral levels, suggestive of leptomeningeal metastases. Cerebrospinal fluid (CSF) analysis revealed pleocytosis, elevated protein and markedly decreased glucose. The CSF cytology revealed scattered large atypical cells, suspicious for metastasis. Non-contrast MRI of the brain showed a T2/FLAIR-hyperintense lesion involving the right caudate nucleus suggestive of either an acute infarct with haemorrhagic transformation or a haemorrhagic brain metastasis. During assessment, he had high-grade fever and was started on empirical intravenous antibiotics (ceftriaxone, vancomycin and subsequently meropenem) in line with the management for acute bacterial meningitis. Gram staining of CSF did not demonstrate the presence of any bacteria and the specimen was sterile on culture. He did not respond to empirical antibiotics, had a progressive downhill course and eventually died due to aspiration pneumonia. Conclusion This brief report highlights the importance of awareness of leptomeningeal carcinomatosis as a possible cause of backache with sensorimotor deficit and autonomic dysfunction in a previously treated case of head and neck SCC.
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Affiliation(s)
- Jhansi Pattanaik
- grid.413618.90000 0004 1767 6103Department of Radiotherapy & Oncology, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - Varshu Goel
- grid.413618.90000 0004 1767 6103Department of Radiotherapy & Oncology, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - Priyanka Sehrawat
- grid.413618.90000 0004 1767 6103Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Ruchi Rathore
- grid.413618.90000 0004 1767 6103Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Kumar Singh
- grid.413618.90000 0004 1767 6103Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Ajay Garg
- grid.413618.90000 0004 1767 6103Department of Neuroradiology, All India Institute of Medical Sciences, New Delhi, India
| | - Ahitagni Biswas
- grid.413618.90000 0004 1767 6103Department of Radiotherapy & Oncology, All India Institute of Medical Sciences, New Delhi, 110029 India
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Jiao L, Wei M, Fu Y. Characteristics of Patients with Meningeal Carcinomatosis Combined with Myelopathy. Neuropsychiatr Dis Treat 2022; 18:1069-1075. [PMID: 35615422 PMCID: PMC9126291 DOI: 10.2147/ndt.s329180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 10/22/2021] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To explore the disease manifestations and radiological characteristics of patients with meningeal carcinomatosis (MC) combined with myelopathy. PATIENTS AND METHODS The detailed medical information of patients who suffered from MC with myelopathy in record system were collected and reviewed. RESULTS In these patients, five cases were male and two cases were female. The age was from fifteen to fifty-seven years. In the course of disease, tumor cells were discovered in cerebrospinal fluid of three patients and in biopsy samples of four patients. Cerebrospinal fluid (CSF) test results showed white blood cell counts increased in seven patients, protein increased in six patients and glucose reduced in five patients. In addition, MRI revealed that the white matter abnormalities showed in all cases and pia mater was enhanced in four patients, meningeal enhanced was observed in three patients. All patients were given appropriate therapy during hospitalization. Follow-up result showed that all patients passed away two to five months after diagnosis. CONCLUSION MC causes spinal membrane, spinal nerve root to be involved besides, also can produce the matter of myelopathy. Early detection of intramedullary lesion is conducive to strengthening the awareness of the diagnosis of MC.
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Affiliation(s)
- Lidong Jiao
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, People's Republic of China
| | - Min Wei
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, People's Republic of China
| | - Yongjuan Fu
- Department of Pathology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, People's Republic of China
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Yu Z, Tu Q, Wang Z, Ding Y, Yang X, Zhu L. Meningeal carcinomatosis following a curative endoscopic submucosal dissection of early gastric cancer: a case report. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2021; 60:593-597. [PMID: 34820804 DOI: 10.1055/a-1668-0625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Meningeal carcinomatosis (MC) is reported to occur in 4%-15% of patients with solid tumors. MC is not commonly associated with gastric carcinoma and is extremely rare in patients with early gastric cancer (EGC). MC derived from EGC after curative endoscopic submucosal dissection (ESD) has not been reported before. We present a rare case of a 49-year-old patient who developed MC after curative ESD of EGC. The cancer was an ulcerated lesion approximately 1.0 cm in diameter in endoscopic appearance in the minor curvature of the gastric antrum. The pathological examination after ESD indicated high-grade intraepithelial neoplasia (1.3 × 2.1 cm in size) with localized moderately differentiated adenocarcinoma (0-IIc in tumor stage, intestinal type in Lauren classification), which was confined to the mucosal layer with an intact submucosal layer and muscularis propria. The lesion was removed entirely by curative dissection without vertical and horizontal resection margins involvement in pathology. Two months after ESD, the patient was readmitted for severe headache and vomiting. Cytological examination of the cerebrospinal fluid found malignant tumor cells, which were considered by pathologists to have metastasized from the stomach, further confirming MC derived from EGC. The patient's condition deteriorated dramatically, which prevented him from receiving further therapies, such as chemotherapy, and he died 3 days after the diagnosis of MC. In conclusion, EGC can cause MC, even after curative ESD. New neurological manifestations in patients with EGC can alert physicians to a diagnosis of MC, and more attention needs to be paid to evaluating the nervous system and establishing diagnostic and therapeutic strategies as soon as possible.
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Affiliation(s)
- Zhengping Yu
- Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Qi Tu
- Neurology, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Zhenwen Wang
- Gastroenterology, Gaoxin Hospital of the First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Ying Ding
- Medical Cosmetology, Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xueping Yang
- Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Liang Zhu
- Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, China
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Kumar A, Sardhara JC, Singh G, Kanjilal S, Maurya VP, Behari S. Malignant Meningitis Associated with Hydrocephalus. Neurol India 2021; 69:S443-S455. [PMID: 35103001 DOI: 10.4103/0028-3886.332278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Malignant meningitis (MM) is the diffuse involvement of the leptomeninges by infiltrating cancer cells, most frequently from lung and breast cancers. This review is aimed to discuss the current advances in the diagnosis and management of MM, along with management of MM-associated hydrocephalus. We reviewed the literature using PubMed and Google Scholar search engines, focusing on various recent randomized controlled trials and clinical trials on MM. Given the hallmark multifocal involvement, the clinical symptoms and signs are also random and asymmetric. There are three important pillars for establishing a diagnosis of MM: clinical examination, neuroimaging, and CSF cytological findings. Several factors should be considered in decision-making, including performance status, neurological findings (clinical, MRI, and CSF flow dynamic), and evaluation of the primary tumor (nature and systemic dissemination). Response Assessment in Neuro-Oncology (RANO) working group recommended the objective assessment of disease for evaluating the progression and response to therapy. Pillars of current management are mainly focal irradiation and intrathecal or systemic chemotherapy. Symptomatic hydrocephalus is managed with a ventriculoperitoneal shunt, lumboperitoneal shunt, or endoscopic third ventriculostomy as palliative procedures, providing significant improvement in performance scores in the limited survival time of patients with MM. Studies using novel therapeutic approaches, such as new biological or cytotoxic compounds, are ongoing. Despite the use of all the combinations, the overall prognosis remains grim; therefore, decision-making for treatment should predominantly be based on attaining an optimal quality of life.
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Affiliation(s)
- Ashutosh Kumar
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Jayesh C Sardhara
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Guramritpal Singh
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Soumen Kanjilal
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ved P Maurya
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sanjay Behari
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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O'Connor CA, Park JS, Kaley T, Kezlarian B, Edelweiss M, Yang TJ, Park W, Reidy D, Varghese AM, Yu KH, O'Reilly EM. Leptomeningeal disease in pancreas ductal adenocarcinoma: A manifestation of longevity. Pancreatology 2021; 21:599-605. [PMID: 33582005 PMCID: PMC8611374 DOI: 10.1016/j.pan.2021.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 01/30/2021] [Accepted: 02/01/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND /Objectives: Pancreatic adenocarcinoma (PDAC) metastatic to the leptomeninges is a rare and lethal event. Leptomeningeal disease (LMD) research is limited in PDAC, and insights into clinical descriptors, possible disease predictors, and treatment strategies is necessitated. METHODS Memorial Sloan Kettering databases were queried with Institutional Review Board approval to identify patients with LMD and PDAC treated between January 2000 and June 2020. Medical record review was used to abstract clinical, genomic, pathologic, and radiographic data. Overall survival was calculated from date of PDAC diagnosis to date of death. Previously published literature on LMD from PDAC was reviewed. RESULTS Four patients with LMD from PDAC were identified, two males and two females. Age at diagnosis ranged from 57 to 68 years. All four patients had predominant lung metastasis and a relatively low burden of intra-abdominal disease. Somatic testing indicated alterations typical of PDAC and no PDAC defining pathogenic germline mutations were identified. An extended clinical course prior to LMD diagnosis was observed in all patients, ranging from 16 to 148 months. Upon diagnosis of LMD, three patients elected for supportive care and one patient received a limited course of craniospinal radiation. The median survival following diagnosis of LMD was 1.6 months (range 0.5-2.8 months). CONCLUSIONS LMD from PDAC is a rare occurrence that may be more frequent in patients with lung metastasis and/or a more indolent clinical course. Following diagnosis of LMD, prognosis is poor, and survival is short. New treatment strategies for this manifestation of PDAC are needed.
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Affiliation(s)
| | - Jennifer S Park
- Department of Medicine, Memorial Sloan Kettering Cancer Center, USA
| | - Thomas Kaley
- Department of Neurology, Memorial Sloan Kettering Cancer Center, USA
| | - Brie Kezlarian
- Department of Pathology, Memorial Sloan Kettering Cancer Center, USA
| | - Marcia Edelweiss
- Department of Pathology, Memorial Sloan Kettering Cancer Center, USA
| | - T Jonathan Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, USA
| | - Wungki Park
- Department of Medicine, Memorial Sloan Kettering Cancer Center, USA; Department of Medicine, Weill Cornell Medical College, USA; David M. Rubenstein Center for Pancreas Cancer Research, USA
| | - Diane Reidy
- Department of Medicine, Memorial Sloan Kettering Cancer Center, USA; Department of Medicine, Weill Cornell Medical College, USA; David M. Rubenstein Center for Pancreas Cancer Research, USA
| | - Anna M Varghese
- Department of Medicine, Memorial Sloan Kettering Cancer Center, USA; Department of Medicine, Weill Cornell Medical College, USA; David M. Rubenstein Center for Pancreas Cancer Research, USA
| | - Kenneth H Yu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, USA; Department of Medicine, Weill Cornell Medical College, USA; David M. Rubenstein Center for Pancreas Cancer Research, USA
| | - Eileen M O'Reilly
- Department of Medicine, Memorial Sloan Kettering Cancer Center, USA; Department of Medicine, Weill Cornell Medical College, USA; David M. Rubenstein Center for Pancreas Cancer Research, USA.
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Terasaki K, Mizuno C, Fujiishi S, Amioka S, Nonaka T, Itani J, Takahashi Y, Miura T, Yasufuku T, Oya H, Katayama T, Okuda K, Matsumoto J, Mitsumoto Y, Sawai N, Mizuno M, Shima T, Okanoue T. Garcin Syndrome Due to Meningeal Carcinomatosis from Gastric Cancer. Intern Med 2021; 60:855-858. [PMID: 33087672 PMCID: PMC8024967 DOI: 10.2169/internalmedicine.5797-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
A 58-year-old woman presented to our hospital with complaints of dysphagia. Esophagogastroduodenoscopy showed an esophagogastric junction tumor with multiple duodenal intramural metastases, and computed tomography showed peritoneal metastasis. In the middle of her fourth cycle of chemotherapy, she displayed symptoms of a left-sided multi-cranial nerve palsy. She was diagnosed with Garcin syndrome caused by meningeal carcinomatosis from gastric cancer based on the results of gadolinium-enhanced brain magnetic resonance imaging and cytology of the cerebrospinal fluid. It is important not to overlook meningeal irritation symptoms or paralysis of cranial nerves and to consider the possibility of Garcin syndrome caused by meningeal carcinomatosis.
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Affiliation(s)
- Kei Terasaki
- Department of Gastroenterology and Hepatology, Saiseikai Suita Hospital, Japan
| | - Chiemi Mizuno
- Department of Gastroenterology and Hepatology, Saiseikai Suita Hospital, Japan
| | - Shinsaku Fujiishi
- Department of Gastroenterology and Hepatology, Saiseikai Suita Hospital, Japan
| | - Shohei Amioka
- Department of Gastroenterology and Hepatology, Saiseikai Suita Hospital, Japan
| | - Takahiro Nonaka
- Department of Gastroenterology and Hepatology, Saiseikai Suita Hospital, Japan
| | - Junichiro Itani
- Department of Gastroenterology and Hepatology, Saiseikai Suita Hospital, Japan
| | - Yusuke Takahashi
- Department of Gastroenterology and Hepatology, Saiseikai Suita Hospital, Japan
| | - Takahiro Miura
- Department of Gastroenterology and Hepatology, Saiseikai Suita Hospital, Japan
| | - Tomoko Yasufuku
- Department of Gastroenterology and Hepatology, Saiseikai Suita Hospital, Japan
| | - Hirohisa Oya
- Department of Gastroenterology and Hepatology, Saiseikai Suita Hospital, Japan
| | - Takayuki Katayama
- Department of Gastroenterology and Hepatology, Saiseikai Suita Hospital, Japan
| | - Kotaro Okuda
- Department of Gastroenterology and Hepatology, Saiseikai Suita Hospital, Japan
| | - Junko Matsumoto
- Department of Gastroenterology and Hepatology, Saiseikai Suita Hospital, Japan
| | - Yasuhide Mitsumoto
- Department of Gastroenterology and Hepatology, Saiseikai Suita Hospital, Japan
| | - Naoki Sawai
- Department of Gastroenterology and Hepatology, Saiseikai Suita Hospital, Japan
| | - Masayuki Mizuno
- Department of Gastroenterology and Hepatology, Saiseikai Suita Hospital, Japan
| | - Toshihide Shima
- Department of Gastroenterology and Hepatology, Saiseikai Suita Hospital, Japan
| | - Takeshi Okanoue
- Department of Gastroenterology and Hepatology, Saiseikai Suita Hospital, Japan
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12
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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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13
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Kobayashi E, Masuda T, Nakao S, Yamaguchi K, Sakamoto S, Horimasu Y, Miyamoto S, Nakashima T, Iwamoto H, Fujitaka K, Hamada H, Hattori N. Two Cases of Cranial Nerve Metastasis Treated with Radiotherapy and Chemotherapy in Patients with Lung Adenocarcinoma. Case Rep Oncol 2021; 13:1495-1500. [PMID: 33564289 PMCID: PMC7841724 DOI: 10.1159/000510306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 07/19/2020] [Indexed: 11/30/2022] Open
Abstract
The incidence of central nervous system metastasis is known to be high among patients with lung cancer. The frequency of brain metastasis and carcinomatous meningitis during the entire clinical course of non-small cell lung cancer is reported to be about 40% and 5%, respectively. In contrast, the incidence of cranial nerve metastasis is extremely rare, and detailed reports of its clinical course remain limited. Herein, we report 2 patients diagnosed with cranial nerve metastasis of lung adenocarcinoma and treated with radiotherapy and systemic chemotherapy. Both patients had cranial nerve symptoms, and brain magnetic resonance imaging showed cranial nerve enhancement. However, no evidence of carcinomatous meningitis was noted on magnetic resonance imaging and cerebrospinal fluid cytology. Based on these observations, these patients were diagnosed with cranial nerve metastasis of lung adenocarcinoma. Radiotherapy and chemotherapy were performed in both cases. In both cases, neurological symptoms had not worsened and imaging findings did not indicate any deteriorations. Therefore, radiotherapy and systemic chemotherapy should be considered when treating cranial nerve metastasis of lung adenocarcinoma. Early therapeutic intervention may lead to attenuation of the cranial nerve dysfunction resulting from cranial nerve metastasis.
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Affiliation(s)
- Erika Kobayashi
- Department of Respiratory Internal Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Takeshi Masuda
- Department of Respiratory Internal Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Satoshi Nakao
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kakuhiro Yamaguchi
- Department of Respiratory Internal Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Shinjiro Sakamoto
- Department of Respiratory Internal Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Yasushi Horimasu
- Department of Respiratory Internal Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Shintaro Miyamoto
- Department of Respiratory Internal Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Taku Nakashima
- Department of Respiratory Internal Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Hiroshi Iwamoto
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kazunori Fujitaka
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hironobu Hamada
- Department of Physical Analysis and Therapeutic Sciences, Hiroshima University, Hiroshima, Japan
| | - Noboru Hattori
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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14
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Panda A, Hintermeister HA, Hunt CH, Kendi AT. Whole-body 18-F-FDG-PET in patients with leptomeningeal disease and correlation with MRI. Nucl Med Commun 2021; 42:205-215. [PMID: 33165256 DOI: 10.1097/mnm.0000000000001317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Studies evaluating leptomeningeal disease on whole-body 18F-FDG PET are lacking. The purpose was to evaluate PET imaging of leptomeningeal disease and investigate the incremental utility of newer PET reconstructions in leptomeningeal disease. METHODS PET imaging of 56 patients with leptomeningeal disease detected initially on MRI (n = 53) or cytopathology (n = 35) were retrospectively reviewed. Regular 3-dimensional iterative reconstruction (3D IR, n = 56) and advanced reconstruction (AdvRecon, n = 41) PET images were evaluated by readers blinded to clinical and MRI findings for uptake involving cauda equina, posterior fossa and spinal cord. Spinal cord uptake pattern was classified as normal (uptake < liver), uptake = liver, conus uptake > liver, conus and cervical cord uptake > liver and multifocal/diffuse uptake > liver. SUVmax ratios of conus/liver, conus/left atrium and conus/cervical cord were compared between 3D IR and AdvRecon datasets. RESULTS Cauda equina uptake was seen in 64% and 78% on 3D IR and AdvRecon; posterior fossa uptake was seen in 52% and 54% on 3D IR and AdvRecon, respectively. Twelve percent had cauda equina or posterior fossa uptake visible only on AdvRecon. On 3D IR, normal spinal cord uptake was most common (27%); on AdvRecon, conus and cervical cord uptake > liver was most common (32%). Seven of 11 patients with normal spinal cord uptake on 3D IR were upgraded to increased uptake on AdvRecon. AdvRecon showed significantly higher conus/liver, conus/blood pool and conus/cervical cord SUVmax ratios (P < 0.0001). CONCLUSION Abnormal uptake in cauda equina, posterior fossa and spinal cord uptake are visible on FDG PET in leptomeningeal disease with increased conspicuity advanced PET reconstructions.
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Affiliation(s)
- Ananya Panda
- Department of Radiology, Nuclear Medicine Division, Mayo Clinic
| | | | - Christopher H Hunt
- Department of Radiology, Nuclear Medicine Division, Mayo Clinic
- Neuroradiology Division, Mayo Clinic, Rochester, Minnesota, USA
| | - Ayse Tuba Kendi
- Department of Radiology, Nuclear Medicine Division, Mayo Clinic
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15
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Sands JM, Daly ME, Lee EQ. Neurologic complications of lung cancer. Cancer 2020; 126:4455-4465. [PMID: 33460079 DOI: 10.1002/cncr.32772] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 12/06/2019] [Accepted: 12/12/2019] [Indexed: 11/07/2022]
Abstract
Lung cancer and its associated treatments can cause various neurologic complications, including brain and leptomeningeal metastases, epidural spinal cord compression, cerebrovascular events, and treatment-related neurotoxicities. Lung cancer care has significantly changed in the last 5 to 10 years, with novel therapies that have affected aspects of neurologic complication management. Herein, the authors review the potential neurologic complications of lung cancer, including important clinical and therapeutic aspects of care.
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Affiliation(s)
| | - Megan E Daly
- Department of Radiation Oncology, University of California, Davis, Sacramento, California
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16
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Sugaoka S, Kanda T, Ito M, Takeuchi M. A Case of Meningeal Carcinomatosis Due to Signet-Ring Cell Carcinoma That Developed Severe Visual Impairment with Papillary Swelling. Int Med Case Rep J 2020; 13:153-158. [PMID: 32523382 PMCID: PMC7234965 DOI: 10.2147/imcrj.s241026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 02/27/2020] [Indexed: 11/25/2022] Open
Abstract
Purpose To report a case of meningeal carcinomatosis by metastasis of signet-ring cell carcinoma resulting in severe visual impairment. Case Presentation A 49-year-old man visited our hospital complaining of blurred vision in his left eye since 2 months ago. There was no particular history. Best corrected visual acuity (BCVA) was 25/20 in the right eye and 20/20 in the left eye. Papillary swelling in both eyes and disc hemorrhage in the left eye were observed. Gradually, the frequency of dizziness increased, and magnetic resonance imaging (MRI) suggested ventricular enlargement, infiltration around the optic nerve, and meningeal carcinomatosis. Increased cerebrospinal fluid pressure was found, and metastatic adenocarcinoma cells were observed by cerebrospinal fluid cytology. A gastroduodenal biopsy confirmed the diagnosis of poorly differentiated adenocarcinoma with signet-ring cells. Visual acuity at the final visit was 4/200 in both eyes. Conclusion If papillary swelling is observed in both eyes, meningeal carcinomatosis should be considered as a differential diagnosis.
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Affiliation(s)
- Shimpei Sugaoka
- Department of Ophthalmology, National Defense Medical College, Tokorozawa City, Saitama 359-8513, Japan
| | - Takayuki Kanda
- Department of Ophthalmology, National Defense Medical College, Tokorozawa City, Saitama 359-8513, Japan
| | - Masataka Ito
- Department of Developmental Anatomy, National Defense Medical College, Tokorozawa City, Saitama 359-8513, Japan
| | - Masaru Takeuchi
- Department of Ophthalmology, National Defense Medical College, Tokorozawa City, Saitama 359-8513, Japan
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17
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Patil S, Rathnum KK. Management of leptomeningeal metastases in non-small cell lung cancer. Indian J Cancer 2020; 56:S1-S9. [PMID: 31793437 DOI: 10.4103/ijc.ijc_74_19] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
In leptomeningeal metastasis (LM), malignant lung cancer cells reach the sanctuary site of the leptomeningeal space through haematogenous or lymphatic route and thrive in the leptomeninges because of restricted access of chemotherapeutic agents across the blood brain barrier. The incidence of LM is 3%-5% in non-small cell lung cancer (NSCLC) patients; the incidence is higher in patients with anaplastic lymphoma kinase (ALK) gene rearrangement or epidermal growth factor receptor (EGFR) mutations. However, the real-world burden of undiagnosed cases may be higher. LM diagnosis is based on clinical, radiological, and cytological testing. Disease management remains a challenge because of low central nervous system penetration of drugs. The prognosis of NSCLC patients with LM is poor with an overall survival (OS) of 3 months with contemporary treatment and <11 months with novel therapies. Therapy goals in this patient population are to improve or stabilize neurologic status, improve quality of life, and prolong survival while limiting the toxicity of chemotherapeutic regimens. We reviewed therapeutic options for management of LM in NSCLC patients with or without genetic mutations. Radiotherapy, systemic, or intrathecal chemotherapy, and personalized molecularly targeted therapy prolong the OS in patients with LM. Newer third generation EGFR-tyrosine kinase inhibitors have considerable brain penetration property and have been vital in increasing the OS especially in patients with EGFR mutations. Sequential or combination therapy third generation EGFR agents with radiotherapy or chemotherapy might be effective in increasing the quality of life and overall survival.
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Affiliation(s)
- Shekar Patil
- Department of Medical Oncology, Sr. Consultant Medical Oncologist, Health Care Global Enterprises Limited, Bengaluru, Karnataka, India
| | - Krishna Kumar Rathnum
- Department of Medical Oncology, Sr. Consultant Medical Oncologist, Meenakshi Mission Hospital, Madurai, Tamil Nadu, India
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18
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Ikeda Y, Yoshida M, Ishikawa K, Kubo T, Murase K, Takada K, Miyanishi K, Kato J. Pancreatic cancer with leptomeningeal carcinomatosis: case report and literature review. Int Cancer Conf J 2020; 9:96-100. [PMID: 32257762 PMCID: PMC7109234 DOI: 10.1007/s13691-020-00405-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 03/05/2020] [Indexed: 12/26/2022] Open
Abstract
Leptomeningeal carcinomatosis (LMC) associated with pancreatic cancer is an extremely rare complication. Symptoms vary depending on the site of invasion and include intracranial pressure, and cranial and spinal dysfunction making early diagnosis difficult. We describe a rare case of leptomeningeal metastasis from pancreatic cancer. A 59-year-old man was diagnosed with unresectable pancreatic cancer and subsequently received systemic chemotherapy. Initial chemotherapy was effective. After 12 months the patient's serum carbohydrate antigen (CA)19-9 level had become elevated, and he presented with neck and back pain, and shoulder stiffness. Tumor enlargement was not detected by computed tomography (CT) and positron emission tomography-CT. Contrast CT of the brain revealed evidence of leptomeningeal enhancement. Cerebrospinal fluid cytology showed atypical, but not malignant cells; the CA19-9 level was further elevated. The patient was finally diagnosed with LMC and, being in poor general condition, received palliative care. During the treatment of pancreatic cancer, the potential existence of LMC should be contemplated when a serum tumor marker becomes rapidly elevated despite the control of primary or metastatic sites.
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Affiliation(s)
- Yuki Ikeda
- Department of Medical Oncology, Sapporo Medical University School of Medicine, South 1 West 16, Chuo-ku, Sapporo, 060-8543 Japan
| | - Makoto Yoshida
- Department of Medical Oncology, Sapporo Medical University School of Medicine, South 1 West 16, Chuo-ku, Sapporo, 060-8543 Japan
| | - Kazuma Ishikawa
- Department of Medical Oncology, Sapporo Medical University School of Medicine, South 1 West 16, Chuo-ku, Sapporo, 060-8543 Japan
| | - Tomohiro Kubo
- Department of Medical Oncology, Sapporo Medical University School of Medicine, South 1 West 16, Chuo-ku, Sapporo, 060-8543 Japan
| | - Kazuyuki Murase
- Department of Medical Oncology, Sapporo Medical University School of Medicine, South 1 West 16, Chuo-ku, Sapporo, 060-8543 Japan
| | - Kohichi Takada
- Department of Medical Oncology, Sapporo Medical University School of Medicine, South 1 West 16, Chuo-ku, Sapporo, 060-8543 Japan
| | - Koji Miyanishi
- Department of Medical Oncology, Sapporo Medical University School of Medicine, South 1 West 16, Chuo-ku, Sapporo, 060-8543 Japan
| | - Junji Kato
- Department of Medical Oncology, Sapporo Medical University School of Medicine, South 1 West 16, Chuo-ku, Sapporo, 060-8543 Japan
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19
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Sindhu KK, Chang S, Liu J, Bakst RL, Dharmarajan KV. In a Patient With Cancer, Not All That Enhances Is Leptomeningeal Carcinomatosis. J Oncol Pract 2019; 15:558-559. [PMID: 31600463 DOI: 10.1200/jop.19.00324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Sanders Chang
- Icahn School of Medicine, New York, NY.,NYC Health + Hospitals/Elmhurst, Queens, NY
| | - Jerry Liu
- Icahn School of Medicine, New York, NY
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20
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Bönig L, Möhn N, Ahlbrecht J, Wurster U, Raab P, Puppe W, Sühs KW, Stangel M, Skripuletz T, Schwenkenbecher P. Leptomeningeal Metastasis: The Role of Cerebrospinal Fluid Diagnostics. Front Neurol 2019; 10:839. [PMID: 31481919 PMCID: PMC6710356 DOI: 10.3389/fneur.2019.00839] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 07/19/2019] [Indexed: 01/30/2023] Open
Abstract
Background: Metastatic spread into the cerebrospinal fluid (CSF) represents a severe complication of malignant disease with poor prognosis. Although early diagnosis is crucial, broad spectrums of clinical manifestations, and pitfalls of magnetic resonance imaging (MRI) and CSF diagnostics can be challenging. Data are limited how CSF parameters and MRI findings relate to each other in patients with leptomeningeal metastasis. Methods: Patients with malignant cells in CSF cytology examination diagnosed between 1998 and 2016 at the Department of Neurology in the Hannover Medical School were included in this study. Clinical records, MRI findings and CSF parameters were retrospectively analyzed. Results: One hundred thirteen patients with leptomeningeal metastasis were identified. Seventy-six patients (67%) suffered from a solid malignancy while a hematological malignancy was found in 37 patients (33%). Cerebral signs and symptoms were most frequently found (78% in solid vs. 49% in hematological malignancies) followed by cranial nerve impairment (26% in solid vs. 46% in hematological malignancies) and spinal symptoms (26% in solid vs. 27% in hematological malignancies). In patients with malignant cells in CSF MRI detected signs of leptomeningeal metastasis in 62% of patients with solid and in only 33% of patients with hematological malignancies. Investigations of standard CSF parameters revealed a normal CSF cell count in 21% of patients with solid malignancies and in 8% of patients with hematological malignancies. Blood-CSF-barrier dysfunction was found in most patients (80% in solid vs. 92% in hematological malignancies). Elevated CSF lactate levels occurred in 68% of patients in solid and in 48% of patients with hematological malignancies. A high number of patients (30% in solid vs. 26% in hematological malignancies) exhibited oligoclonal bands in CSF. Significant correlations between the presence of leptomeningeal enhancement demonstrated by MRI and CSF parameters (cell count, lactate levels, and CSF/Serum albumin quotient) were not found in both malignancy groups. Conclusion: CSF examination is helpful to detect leptomeningeal metastasis since the diagnosis can be challenging especially when MRI is negative. CSF cytological investigation is mandatory whenever leptomeningeal metastasis is suspected, even when CSF cell count is normal.
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Affiliation(s)
- Lena Bönig
- Department of Neurology, Clinical Neuroimmunology and Neurochemistry, Hannover Medical School, Hanover, Germany
| | - Nora Möhn
- Department of Neurology, Clinical Neuroimmunology and Neurochemistry, Hannover Medical School, Hanover, Germany
| | - Jonas Ahlbrecht
- Department of Neurology, Clinical Neuroimmunology and Neurochemistry, Hannover Medical School, Hanover, Germany
| | - Ulrich Wurster
- Department of Neurology, Clinical Neuroimmunology and Neurochemistry, Hannover Medical School, Hanover, Germany
| | - Peter Raab
- Department of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hanover, Germany
| | - Wolfram Puppe
- Department of Virology, Hannover Medical School, Hanover, Germany
| | - Kurt-Wolfram Sühs
- Department of Neurology, Clinical Neuroimmunology and Neurochemistry, Hannover Medical School, Hanover, Germany
| | - Martin Stangel
- Department of Neurology, Clinical Neuroimmunology and Neurochemistry, Hannover Medical School, Hanover, Germany
| | - Thomas Skripuletz
- Department of Neurology, Clinical Neuroimmunology and Neurochemistry, Hannover Medical School, Hanover, Germany
| | - Philipp Schwenkenbecher
- Department of Neurology, Clinical Neuroimmunology and Neurochemistry, Hannover Medical School, Hanover, Germany
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21
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Zammar SG, Hennessy M, Warrick J, Goyal N, Zacharia BE. Leptomeningeal Carcinomatosis from Squamous Cell Carcinoma of the Ethmoid Sinus: A Case Report. Cureus 2019; 11:e5281. [PMID: 31576272 PMCID: PMC6764644 DOI: 10.7759/cureus.5281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Leptomeningeal carcinomatosis (LMC) is an end-stage disease with poor prognosis. This disease has not yet been reported with sinonasal carcinomatosis. We present a case of a patient who presented with posterior ethmoid/anterior cranial mass which turned out to be poorly differentiated squamous cell carcinoma (SCC). Later the patient presented with enhancement of the spinal roots and a lumbar puncture diagnosed the leptomeningeal spread of her primary disease. After intrathecal chemotherapy and palliative radiation, the patient failed to resist her disease seven months after the diagnosis. We present the first case report of leptomeningeal spread of sinonasal cancer. Although it seems rare, LMC should be on the differential of patients presenting with neurological deficits.
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Affiliation(s)
- Samer G Zammar
- Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Max Hennessy
- Otolaryngology, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Joshua Warrick
- Pathology, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Neerav Goyal
- Otolaryngology, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Brad E Zacharia
- Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
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22
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Yan W, Jing W, An N, Tian Y, Guo D, Kong L, Zhu H, Yu J. The clinical characteristic and prognostic factors of leptomeningeal metastasis in patients with non-small-cell lung cancer-a retrospective study from one single cancer institute. Cancer Med 2019; 8:2769-2776. [PMID: 30993909 PMCID: PMC6558588 DOI: 10.1002/cam4.2156] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 03/27/2019] [Accepted: 03/27/2019] [Indexed: 12/19/2022] Open
Abstract
Background Leptomeningeal metastasis (LM) is a detrimental complication of advanced non‐small‐cell lung cancer (NSCLC), and the optimal therapeutic approach for LM patients is in shortage. This retrospective study aimed to investigate the clinical features and prognostic factors of NSCLC patients with LM. Methods We retrospectively reviewed the medical records of NSCLC patients with LM at the Shandong Cancer Hospital and Institute between July 2014 and March 2018. Identified cases had pathology‐proven NSCLC with either positive cerebrospinal fluid cytology or leptomeningeal enhancement by MRI. Results One hundred and thirty‐six NSCLC patients (58 men, 78 women) with LM were enrolled in the retrospective study; median age was 55 years (range, 29‐89 years). Fifty‐one patients harbored EGFR mutations, ALK rearrangement was detected in 6 patients. Treatment for LM consisted of EGFR‐TKIs alone in 11 patients, whole brain radiotherapy (WBRT) alone in 19 patients, Chemotherapy (ChT) alone in 12 patients, EGFR‐TKIs plus WBRT in 30 patients, WBRT plus ChT in 25 patients, and EGFR‐TKIs plus ChT in 24 patients. The median progression‐free survival was 3.9 months (95% confidence interval [CI]: 3.178‐4.622), and the median overall survival (OSLM) was 9.8 months (95% CI:7.5‐12.1). Thirty patients who received WBRT plus EGFR‐TKIs achieved longer survival than those who only received WBRT (median 13.6 vs 8.8 months; P = 0.027), but did not add any survival benefit than those only received EGFR‐TKIs (median 13.6 vs 13.9 months; P = 0.352). A multivariate analysis indicated that KPS ≥ 80 (hazard ratio [HR] = 0.592, 95% CI:0.369‐0.95; P = 0.03) and EGFR‐TKIs (HR = 0.507, 95% CI:0.283‐0.908; P = 0.022) after LM diagnosis were independent favourable predictors of survival, whereas smoking (HR = 1.181, 95% CI:1.009‐3.246; P = 0.047) was an independent predictor of poor survival. Conclusions Our results suggest that patients with good performance statuses, non‐smoking patients, and the administration of EGFR‐TKIs might improve clinical outcomes in NSCLC patients with LM.
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Affiliation(s)
- Weiwei Yan
- School of Medicine and Life Sciences, University of Jinan-Shandong Academy of Medical Sciences, Jinan, Shandong, China.,Department of Radiation Oncology, Shandong Cancer Hospital Affiliated to Shandong University, Shandong Academy of Medical Sciences, Jinan, China
| | - Wang Jing
- Department of Radiation Oncology, Shandong Cancer Hospital Affiliated to Shandong University, Shandong Academy of Medical Sciences, Jinan, China
| | - Ning An
- Department of Radiation Oncology, Shandong Cancer Hospital Affiliated to Shandong University, Shandong Academy of Medical Sciences, Jinan, China
| | - Yaru Tian
- Department of Radiation Oncology, Shandong Cancer Hospital Affiliated to Shandong University, Shandong Academy of Medical Sciences, Jinan, China
| | - Dong Guo
- Department of Radiation Oncology, Shandong Cancer Hospital Affiliated to Shandong University, Shandong Academy of Medical Sciences, Jinan, China
| | - Li Kong
- Department of Radiation Oncology, Shandong Cancer Hospital Affiliated to Shandong University, Shandong Academy of Medical Sciences, Jinan, China
| | - Hui Zhu
- Department of Radiation Oncology, Shandong Cancer Hospital Affiliated to Shandong University, Shandong Academy of Medical Sciences, Jinan, China
| | - Jinming Yu
- Department of Radiation Oncology, Shandong Cancer Hospital Affiliated to Shandong University, Shandong Academy of Medical Sciences, Jinan, China
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Abstract
The spine is frequently involved in systemic diseases, including those with neuropathic, infectious, inflammatory, rheumatologic, metabolic, and neoplastic etiologies. This article provides an overview of systemic disorders that may affect the spine, which can be subdivided into disorders predominantly involving the musculoskeletal system (including bones, joints, disks, muscles, and tendons) versus those predominantly involving the nervous system. By identifying the predominant pattern of spine involvement, a succinct, appropriate differential diagnosis can be generated. The importance of reviewing the medical record, as well as prior medical imaging (including nonspine imaging), which may confer greater specificity to the differential diagnosis, is stressed.
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Affiliation(s)
- Sean C Dodson
- Radiology Specialists of Florida, 2600 Westhall Lane, Maitland, FL 32751, USA
| | - Nicholas A Koontz
- Indiana University School of Medicine, 340 West 10th Street, Fairbanks Hall, Suite 6200, Indianapolis, IN 46202-3082, USA.
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24
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Kawagoe Y, Nakayama T, Matuzawa S, Fukushima K, Onishi J, Sato Y, Nagai K, Sameshima H. Epithelial Ovarian Carcinoma Associated with Metastases to Central Nervous System: Two Case Reports. Case Rep Obstet Gynecol 2018; 2018:4301247. [PMID: 30386663 PMCID: PMC6189680 DOI: 10.1155/2018/4301247] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 09/18/2018] [Indexed: 11/30/2022] Open
Abstract
We experienced two rare cases of metastases to the central nervous system (cerebral and leptomeningeal metastases) from primary epithelial ovarian carcinoma. The first case was a 55-year-old woman who developed carcinomatous meningitis while on chemotherapy for ovarian cancer stage IIIC. Cytological analysis confirmed carcinomatous cells of ovarian origin in the cerebrospinal fluid. Magnetic resonance imaging demonstrated abnormal hyperintensity in the cerebral sulci on fluid attenuated inversion recovery (FLAIR) sequence with enhanced gadolinium indicating leptomeningeal metastases. Her consciousness rapidly declined and she died 42 days after diagnosis. The second case was a 63-year-old woman who underwent surgery for ovarian cancer and who was diagnosed as stage IA. Thirty-eight months after surgery, she developed weakness of the left hand and headaches. A CT scan revealed metastases to the right cerebrum and she was treated with surgical resection followed by radiotherapy. Five months after resection, she developed ileus caused by multiple relapses in the pelvis. Despite chemotherapy, her performance status declined and she died nine months after the resection. Both cases were rare because the first case was isolated leptomeningeal metastases, and the second case was confirmed relapse site in the cerebrum due to neurological symptoms despite her early clinical stage.
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Affiliation(s)
- Yasuyuki Kawagoe
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki 889-1692, Japan
| | - Tetsuo Nakayama
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki 889-1692, Japan
| | - Satoshi Matuzawa
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki 889-1692, Japan
| | - Kazuko Fukushima
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki 889-1692, Japan
| | - Junji Onishi
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki 889-1692, Japan
| | - Yuichiro Sato
- Department of Diagnostic Pathology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki 889-1692, Japan
| | - Kimihiro Nagai
- Department of Palliative Care, Miyazaki Medical Association Hospital, 738-1 Funado, Shinbeppu, Miyazaki City, Miyazaki 889-0834, Japan
| | - Hiroshi Sameshima
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki 889-1692, Japan
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Jing W, Wang H, Kong L, Yu J, Zhu H. Great efficacy of bevacizumab plus erlotinib for leptomeningeal metastases from non-small cell lung cancer with initially positive EGFR mutation: a case report. Cancer Biol Ther 2018; 19:1073-1077. [PMID: 30067451 DOI: 10.1080/15384047.2018.1491504] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Leptomeningeal metastases (LMs) were devastating metastatic complications of non-small cell lung cancer (NSCLC). Management of LMs relied on conventional therapy but with poor survival, lacking effective treatment strategies. We present the case of a 52-year-old female non-smoker with advanced lung adenocarcinoma and initially positive EGFR-mutation, who failed to the treatment of standard first-line chemotherapy (pemetrexed plus cisplatin) and bevacizumab (BEV), and maintenance therapy with pemetrexed plus BEV. Under the progression-free survival of 6 months, suffered from LMs, then erlotinib combined with BEV were delivered, and symptoms were significantly alleviated, remained stable and even relieved slightly for at least 18 months. The combination of bevacizumab and erlotinib could be an optional effective management strategy for patients with LMs from NSCLC and harboring EGFR-mutation.
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Affiliation(s)
- Wang Jing
- a Department of Radiation Oncology , Shandong Cancer Hospital Affiliated to Shandong University , Jinan , Shandong Province , China
| | - Haiyong Wang
- b Department of Medical Oncology , Shandong Cancer Hospital Affiliated to Shandong University , Jinan , Shandong Province , China
| | - Li Kong
- a Department of Radiation Oncology , Shandong Cancer Hospital Affiliated to Shandong University , Jinan , Shandong Province , China.,c Shandong Academy of Medical Sciences , Jinan , Shandong Province , China
| | - Jinming Yu
- a Department of Radiation Oncology , Shandong Cancer Hospital Affiliated to Shandong University , Jinan , Shandong Province , China.,c Shandong Academy of Medical Sciences , Jinan , Shandong Province , China
| | - Hui Zhu
- a Department of Radiation Oncology , Shandong Cancer Hospital Affiliated to Shandong University , Jinan , Shandong Province , China.,c Shandong Academy of Medical Sciences , Jinan , Shandong Province , China
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Assi HI, Mahmoud T, Saadeh FS, El Darsa H. Management of leptomeningeal metastasis in breast cancer. Clin Neurol Neurosurg 2018; 172:151-159. [PMID: 30015053 DOI: 10.1016/j.clineuro.2018.07.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 06/22/2018] [Accepted: 07/01/2018] [Indexed: 10/28/2022]
Abstract
Leptomeningeal metastasis (LM), which occurs when malignant cells spread to the central nervous system, is becoming an increasingly common complication in patients with breast cancer. Diagnosis and treatment of LM is challenging. Moreover, prognosis of patients with LM is poor, with a median survival of 6 months after diagnosis. This review highlights the strengths and limitations of currently available diagnostic tools and therapies for LM. The current treatments for LM, including radiotherapy, systemic therapy, and intrathecal treatment, aim to maintain the quality of life of patients by correcting neurological deficits and arresting neurological degeneration. However, there is no standardized therapy for LM because of a lack of randomized trials on this condition.
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Affiliation(s)
- Hazem I Assi
- Department of Internal Medicine, Naef K. Basile Cancer Institute, American University of Beirut Medical Center, Lebanon.
| | - Tala Mahmoud
- Faculty of Medicine, University of Balamand, Lebanon.
| | - Fadi S Saadeh
- Faculty of Medicine, American University of Beirut, Lebanon.
| | - Haidar El Darsa
- Department of Internal Medicine, Naef K. Basile Cancer Institute, American University of Beirut Medical Center, Lebanon.
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Tinsley N, Yemula N, Ramalingam S, Madathil S. An unusual case of leptomeningeal carcinomatosis in a patient with primary adenocarcinoma of the lung. BMJ Case Rep 2018; 2018:bcr-2017-223649. [DOI: 10.1136/bcr-2017-223649] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Wang N, Bertalan MS, Brastianos PK. Leptomeningeal metastasis from systemic cancer: Review and update on management. Cancer 2018; 124:21-35. [PMID: 29165794 PMCID: PMC7418844 DOI: 10.1002/cncr.30911] [Citation(s) in RCA: 146] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 06/27/2017] [Accepted: 07/06/2017] [Indexed: 12/23/2022]
Abstract
Leptomeningeal metastasis is an uncommon and typically late complication of cancer with a poor prognosis and limited treatment options. Diagnosis is often challenging, with nonspecific presenting symptoms ranging from headache and confusion to focal neurologic deficits, such as cranial nerve palsies. Standard diagnostic evaluation involves a neurologic examination, magnetic resonance imaging of the brain and spine with gadolinium, and cytologic evaluation of the cerebral spinal fluid. Therapy entails a multimodal approach focused on palliation with surgery, radiation, and/or chemotherapy, which may be administered systemically or directly into the cerebral spinal fluid. Limited trial data exist to guide treatment, and current regimens are based primarily on expert opinion. Although newer targeted and immunotherapeutic agents are under investigation and have shown promise, an improved understanding of the biology of leptomeningeal metastasis and treatment resistance as well as additional randomized controlled studies are needed to guide the optimal treatment of this devastating disease. Cancer 2018;124:21-35. © 2017 American Cancer Society.
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Affiliation(s)
- Nancy Wang
- Division of Neuro-Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mia S Bertalan
- Division of Neuro-Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Division of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Priscilla K Brastianos
- Division of Neuro-Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Division of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Nolan C, Deangelis LM. Overview of metastatic disease of the central nervous system. HANDBOOK OF CLINICAL NEUROLOGY 2018; 149:3-23. [PMID: 29307359 DOI: 10.1016/b978-0-12-811161-1.00001-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
In 2016, the American Society of Clinical Oncology reported that 1.7 million Americans were diagnosed with cancer; this number will rise to 2.3 million in the United States and 22 million worldwide in 2030. This rising need is being met by an explosion of new cancer therapies, including: immune checkpoint inhibitors, T-cell therapies, tumor vaccines, antiangiogenic therapies, and various targeted therapies. This armamentarium of targeted therapies has led to better systemic control of disease and longer patient overall survival (OS). The incidence of metastatic disease to the central nervous system (CNS) is rising as patients are living longer with these more effective systemic therapies. Prolonged OS allows increased time to develop CNS metastases. The CNS is also a sanctuary for metastatic tumor cells that are protected from full exposure to therapeutic concentrations of most anticancer agents by the blood-brain barrier, the tumor microenvironment, and immune system. In addition, CNS metastases often develop late in the course of the disease, so patients are frequently heavily pretreated, resulting in drug resistance. Although genomic profiling has led to more effective therapies for systemic disease, the same therapy may not be effective in treating CNS disease, not only due to failure of blood-brain barrier penetration, but from discordance between the molecular profile in systemic and CNS tumor.
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Affiliation(s)
- Craig Nolan
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, United States.
| | - Lisa M Deangelis
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
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Kim H, Lee EM. A Retrospective Analysis of the Clinical Outcomes of Leptomeningeal Metastasis in Patients with Solid Tumors. Brain Tumor Res Treat 2018; 6:54-59. [PMID: 30381917 PMCID: PMC6212684 DOI: 10.14791/btrt.2018.6.e12] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 09/14/2018] [Accepted: 09/18/2018] [Indexed: 01/14/2023] Open
Abstract
Background Leptomeningeal metastasis (LM) is an uncommon, but devastating complication of advanced cancer and has no standard treatment. Herein, we analyzed the clinical characteristics and outcomes of patients with solid tumors who were diagnosed with LM. Methods Between January 2007 and December 2017, we retrospectively analyzed the medical records of patients with solid tumors who were diagnosed with LM. Results A total of 58 patients were enrolled in this study. The median age of patients was 51 years (range, 27–72 years), and 62.1% had a poor Eastern Cooperative Oncology Group (ECOG) performance status (PS) (>2). The common types of primary tumor were breast cancer (39.7%), gastric cancer (25.9%), and non-small cell lung cancer (20.7%). Forty-two patients (72.4%) were diagnosed with LM by MRI of the brain and/or spine and cerebrospinal fluid (CSF) analysis, 14 were diagnosed by CSF analysis alone, and 2 were diagnosed by MRI alone. Treatments for LM were performed in 53 patients (91.4%), and best supportive care was provided for 5 patients (8.6%). Intrathecal chemotherapy, radiotherapy, and systemic chemotherapy were administered in 43 (74.1%), 17 (29.3%), and 24 (41.4%) patients, respectively. The median overall survival of the entire cohort was 2.4 months (95% confidence interval, 1.0–3.7). In the analysis of prognostic factors for survival, a good ECOG PS (≤2), administration of systemic chemotherapy after LM diagnosis, and a prior history of brain radiation were associated with prolonged survival. Conclusion Although the prognosis of LM in patients with solid tumors is poor, systemic chemotherapy might improve survival in selected patients with a good PS.
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Affiliation(s)
- Hyojeong Kim
- Department of Hemato-Oncology, Pusan University Hospital, Busan, Korea
| | - Eun Mi Lee
- Department of Internal Medicine, Kosin University Gaspel Hospital, Busan, Korea.
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Baud MO, Vitt JR, Robbins NM, Wabl R, Wilson MR, Chow FC, Gelfand JM, Josephson SA, Miller S. Pleocytosis is not fully responsible for low CSF glucose in meningitis. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2017; 5:e425. [PMID: 29296633 PMCID: PMC5745359 DOI: 10.1212/nxi.0000000000000425] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 10/03/2017] [Indexed: 12/14/2022]
Abstract
Objective The mechanism of hypoglycorrhachia-low CSF glucose-in meningitis remains unknown. We sought to evaluate the relative contribution of CSF inflammation vs microorganisms (bacteria and fungi) in lowering CSF glucose levels. Methods We retrospectively categorized CSF profiles into microbial and aseptic meningitis and analyzed CSF leukocyte count, glucose, and protein concentrations. We assessed the relationship between these markers using multivariate and stratified linear regression analysis for initial and repeated CSF sampling. We also calculated the receiver operating characteristics of CSF glucose and CSF-to-serum glucose ratios to presumptively diagnose microbial meningitis. Results We found that increasing levels of CSF inflammation were associated with decreased CSF glucose levels in the microbial but not aseptic category. Moreover, elevated CSF protein levels correlated more strongly than the leukocyte count with low CSF glucose levels on initial (R2 = 36%, p < 0.001) and repeated CSF sampling (R2 = 46%, p < 0.001). Hypoglycorrhachia (<40 mg/dL) was observed in 50.1% of microbial cases, but only 9.6% of aseptic cases, most of which were neurosarcoidosis. Absolute CSF glucose and CSF-to-serum glucose ratios had similar low sensitivity and moderate-to-high specificity in diagnosing microbial meningitis at thresholds commonly used. Conclusions The main driver of hypoglycorrhachia appears to be a combination of microbial meningitis with moderate to high degrees of CSF inflammation and proteins, suggesting that the presence of microorganisms capable of catabolizing glucose is a determinant of hypoglycorrhachia in meningitis. A major notable exception is neurosarcoidosis. Low CSF glucose and CSF-to-serum glucose ratios are useful markers for the diagnosis of microbial meningitis.
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Affiliation(s)
- Maxime O Baud
- Department of Neurology (M.O.B., J.R.V., N.M.R., M.R.W., F.C.C., J.M.G., S.A.J.) and Department of Laboratory Medicine (S.M.), University of California, San Francisco; and Department of Neurology (R.W.), University of Michigan, Ann Arbor. N.M.R. is currently affiliated with the Department of Neurology, Dartmouth Geisel School of Medicine
| | - Jeffrey R Vitt
- Department of Neurology (M.O.B., J.R.V., N.M.R., M.R.W., F.C.C., J.M.G., S.A.J.) and Department of Laboratory Medicine (S.M.), University of California, San Francisco; and Department of Neurology (R.W.), University of Michigan, Ann Arbor. N.M.R. is currently affiliated with the Department of Neurology, Dartmouth Geisel School of Medicine
| | - Nathaniel M Robbins
- Department of Neurology (M.O.B., J.R.V., N.M.R., M.R.W., F.C.C., J.M.G., S.A.J.) and Department of Laboratory Medicine (S.M.), University of California, San Francisco; and Department of Neurology (R.W.), University of Michigan, Ann Arbor. N.M.R. is currently affiliated with the Department of Neurology, Dartmouth Geisel School of Medicine
| | - Rafael Wabl
- Department of Neurology (M.O.B., J.R.V., N.M.R., M.R.W., F.C.C., J.M.G., S.A.J.) and Department of Laboratory Medicine (S.M.), University of California, San Francisco; and Department of Neurology (R.W.), University of Michigan, Ann Arbor. N.M.R. is currently affiliated with the Department of Neurology, Dartmouth Geisel School of Medicine
| | - Michael R Wilson
- Department of Neurology (M.O.B., J.R.V., N.M.R., M.R.W., F.C.C., J.M.G., S.A.J.) and Department of Laboratory Medicine (S.M.), University of California, San Francisco; and Department of Neurology (R.W.), University of Michigan, Ann Arbor. N.M.R. is currently affiliated with the Department of Neurology, Dartmouth Geisel School of Medicine
| | - Felicia C Chow
- Department of Neurology (M.O.B., J.R.V., N.M.R., M.R.W., F.C.C., J.M.G., S.A.J.) and Department of Laboratory Medicine (S.M.), University of California, San Francisco; and Department of Neurology (R.W.), University of Michigan, Ann Arbor. N.M.R. is currently affiliated with the Department of Neurology, Dartmouth Geisel School of Medicine
| | - Jeffrey M Gelfand
- Department of Neurology (M.O.B., J.R.V., N.M.R., M.R.W., F.C.C., J.M.G., S.A.J.) and Department of Laboratory Medicine (S.M.), University of California, San Francisco; and Department of Neurology (R.W.), University of Michigan, Ann Arbor. N.M.R. is currently affiliated with the Department of Neurology, Dartmouth Geisel School of Medicine
| | - S Andrew Josephson
- Department of Neurology (M.O.B., J.R.V., N.M.R., M.R.W., F.C.C., J.M.G., S.A.J.) and Department of Laboratory Medicine (S.M.), University of California, San Francisco; and Department of Neurology (R.W.), University of Michigan, Ann Arbor. N.M.R. is currently affiliated with the Department of Neurology, Dartmouth Geisel School of Medicine
| | - Steve Miller
- Department of Neurology (M.O.B., J.R.V., N.M.R., M.R.W., F.C.C., J.M.G., S.A.J.) and Department of Laboratory Medicine (S.M.), University of California, San Francisco; and Department of Neurology (R.W.), University of Michigan, Ann Arbor. N.M.R. is currently affiliated with the Department of Neurology, Dartmouth Geisel School of Medicine
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Candy N, Young A, Allinson K, Carr O, McMillen J, Trivedi R. Metastatic Neuroendocrine Carcinoma of Unknown Origin Arising in the Femoral Nerve Sheath. World Neurosurg 2017; 104:1047.e1-1047.e6. [PMID: 28502684 DOI: 10.1016/j.wneu.2017.05.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 04/29/2017] [Accepted: 05/02/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Metastatic neuroendocrine carcinoma of unknown origin is a rare condition, usually presenting with lesions in the liver and/or lung. We present the first reported case of a metastatic neuroendocrine carcinoma of unknown origin arising in the femoral nerve sheath. CASE DESCRIPTION Magnetic resonance imaging demonstrated what was thought to be a schwannoma in the left femoral nerve sheath in the proximal femoral triangle, immediately inferior to the anterior inferior iliac spine. At the time of operation, the tumor capsule was invading surrounding tissue, as well as three trunks of the femoral nerve. The patient underwent a subtotal resection, preserving the integrity of the residual functioning femoral nerve trunks. Histologic evaluation determined that the tumor had features consistent with a metastatic neuroendocrine carcinoma of unknown primary origin. The patient recovered well postoperatively, and subsequent radiologic evaluation failed to demonstrate a potential primary site. Unfortunately, the patient re-presented with disease progression and was subsequently referred to palliative care. CONCLUSIONS We recommend that there is a definite role for surgery in the management of solitary neuroendocrine carcinoma of unknown origin.
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Affiliation(s)
- Nicholas Candy
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Adam Young
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Kieren Allinson
- Department of Pathology, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Oliver Carr
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Jason McMillen
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Rikin Trivedi
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, United Kingdom.
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Eze C, Hegemann NS, Roengvoraphoj O, Dantes M, Manapov F. Concurrent Afatinib and Whole-Brain Radiotherapy in Exon 19-del-EGFR Mutant Lung Adenocarcinoma: A Case Report and Mini Review of the Literature. Front Oncol 2017; 7:88. [PMID: 28540256 PMCID: PMC5423895 DOI: 10.3389/fonc.2017.00088] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 04/20/2017] [Indexed: 11/18/2022] Open
Abstract
Leptomeningeal metastases (LM) are found in approximately 3.8% of non-small cell lung cancer cases with an increased incidence in adenocarcinoma, and approximately one-third of patients will present with concomitant brain metastases. We report the case of a 50-year-old male patient with stage IV exon 19-del-EGFR mutant lung adenocarcinoma who progressed on second-generation TKI therapy with manifestation of symptomatic simultaneous diffuse brain and LM. Whole-brain radiotherapy with concurrent afatinib resulted in an almost complete regression of neurological symptoms as well as good, durable radiological response. Furthermore, treatment was well tolerated with no relevant adverse effects.
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Affiliation(s)
- Chukwuka Eze
- Department of Radiation Oncology, LMU Munich, Munich, Germany
| | | | | | - Maurice Dantes
- Department of Radiation Oncology, LMU Munich, Munich, Germany
| | - Farkhad Manapov
- Department of Radiation Oncology, LMU Munich, Munich, Germany
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Krupa M, Byun K. Leptomeningeal carcinomatosis and bilateral internal auditory canal metastases from ovarian carcinoma. Radiol Case Rep 2017; 12:386-390. [PMID: 28491194 PMCID: PMC5417755 DOI: 10.1016/j.radcr.2017.03.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Revised: 01/31/2017] [Accepted: 03/06/2017] [Indexed: 12/11/2022] Open
Abstract
Ovarian cancer, a leading cause of death in women, typically spreads locally and rarely metastasizes to the brain or seeds the leptomeninges. We present a case of a 62-year-old woman with a history of treated ovarian cell carcinoma who developed bilateral sensorineural deafness and right-sided facial weakness and on imaging was found to have bilateral internal auditory canal (IAC) masses and leptomeningeal carcinomatosis, pathologically proven by cerebrospinal fluid cytology. We discuss her magnetic resonance imaging and positron emission tomography-computed tomography findings and review the imaging characteristics of IAC metastases. Finally, we review the literature on leptomeningeal carcinomatosis from ovarian cancer and discuss the high incidence of bilateral IAC metastases in patients with leptomeningeal carcinomatosis.
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Affiliation(s)
- Martin Krupa
- Department of Radiology, Eastern Virginia Medical School, 600 Gresham Drive, Norfolk, VA 23507, USA
| | - Kathy Byun
- Department of Radiology, Eastern Virginia Medical School, 600 Gresham Drive, Norfolk, VA 23507, USA
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Toyoshima M, Tsuji K, Shigeta S, Tokunaga H, Ito K, Watanabe Y, Yoshinaga K, Otsuki T, Niikura H, Yaegashi N. Leptomeningeal metastasis from gynecologic cancers diagnosed by brain MRI. Clin Imaging 2017; 41:42-47. [DOI: 10.1016/j.clinimag.2016.09.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 09/23/2016] [Accepted: 09/26/2016] [Indexed: 11/25/2022]
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Remon J, Le Rhun E, Besse B. Leptomeningeal carcinomatosis in non-small cell lung cancer patients: A continuing challenge in the personalized treatment era. Cancer Treat Rev 2016; 53:128-137. [PMID: 28110254 DOI: 10.1016/j.ctrv.2016.12.006] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 12/11/2016] [Accepted: 12/20/2016] [Indexed: 01/15/2023]
Abstract
Leptomeningeal metastasis is a fatal manifestation seen in advanced cancer patients. Its incidence is increasing, reaching 3.8% in molecularly unselected non-small cell lung cancer patients and up to 5% and 9% in ALK-rearranged and EGFR-mutant lung cancer patients, respectively. The prognosis remains poor despite systemic treatment, intrathecal chemotherapy, radiation therapy and personalized treatments in molecularly selected patients. However, new therapies with improved cerebral-spinal fluid penetration have been developed for subgroups of molecular selected patients indicating they could be promising therapeutic options for managing leptomeningeal disease. Systemic chemotherapy, which may be combined with intrathecal chemotherapy, remains standard treatment for lung cancer patients with leptomeningeal disease and a good-risk profile. We summarize evidence reported in the literature for managing this complication in lung cancer patients. Based on this, we have selected potential therapeutic strategies that could be used in daily clinical practice.
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Affiliation(s)
- J Remon
- Gustave Roussy, Medical Oncology Department, Villejuif, France.
| | - E Le Rhun
- Neurology, Oscar Lambert Center Lille, Neuro-Oncology Department, Lille University Hospital and Lille University, INSERM U-1192, France.
| | - B Besse
- Gustave Roussy, Medical Oncology Department, Villejuif, France; Paris Sud University, France.
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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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Espenel S, Vallard A, Langrand-Escure J, Ben Mrad M, Méry B, Rivoirard R, Moriceau G, Guy JB, Trone JC, Moncharmont C, Wang G, Diao P, Bernichon É, Chanal É, Fournel P, Magné N. [Carcinomatous meningitis: The radiation therapist's point of view]. Cancer Radiother 2016; 20:54-9. [PMID: 26867467 DOI: 10.1016/j.canrad.2015.09.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Revised: 09/09/2015] [Accepted: 09/11/2015] [Indexed: 11/28/2022]
Abstract
Carcinomatous meningitis complicates 5 to 10% of cancers, essentially with breast cancers, lung cancers and melanomas. The incidence probably increased because of therapeutic advances in oncology. Treatment is based on external beam radiotherapy, systemic treatment, intrathecal chemotherapy and supportive care. The aim of this work was to review data on external radiation therapy and carcinomatous meningitis. There are few evidences on the subject, but it is a major topic of interest. A whole brain radiation therapy is indicated in case of brain metastases or clinical encephalitis. Focal radiation therapy is recommended on symptomatic, bulky or obstructive sites. The dose depends on performance status (20 to 40 Gy in five to 20 fractions), volume to treat and available techniques (classic fractionation or hypofractionation via stereotactic radiosurgery). The objective of radiation therapy is to improve quality of life. Association with systemic therapy improves overall survival. Administration of sequential intrathecal chemotherapy may also improve overall survival, but induces more toxicity. The use of new radiotherapy techniques and development of radiosensitizing molecules in patients with good performance status could improve survival in this frequent complication of cancer.
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Affiliation(s)
- S Espenel
- Département de radiothérapie, institut de cancérologie Lucien-Neuwirth, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest-en-Jarez cedex, France
| | - A Vallard
- Département de radiothérapie, institut de cancérologie Lucien-Neuwirth, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest-en-Jarez cedex, France
| | - J Langrand-Escure
- Département de radiothérapie, institut de cancérologie Lucien-Neuwirth, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest-en-Jarez cedex, France
| | - M Ben Mrad
- Département de radiothérapie, institut de cancérologie Lucien-Neuwirth, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest-en-Jarez cedex, France
| | - B Méry
- Département d'oncologie médicale, institut de cancérologie Lucien-Neuwirth, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest-en-Jarez cedex, France
| | - R Rivoirard
- Département d'oncologie médicale, institut de cancérologie Lucien-Neuwirth, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest-en-Jarez cedex, France
| | - G Moriceau
- Département d'oncologie médicale, institut de cancérologie Lucien-Neuwirth, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest-en-Jarez cedex, France
| | - J-B Guy
- Département de radiothérapie, institut de cancérologie Lucien-Neuwirth, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest-en-Jarez cedex, France
| | - J-C Trone
- Département de radiothérapie, institut de cancérologie Lucien-Neuwirth, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest-en-Jarez cedex, France
| | - C Moncharmont
- Département de radiothérapie, institut de cancérologie Lucien-Neuwirth, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest-en-Jarez cedex, France
| | - G Wang
- Département de radiothérapie, institut de cancérologie Lucien-Neuwirth, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest-en-Jarez cedex, France
| | - P Diao
- Département de radiothérapie, institut de cancérologie Lucien-Neuwirth, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest-en-Jarez cedex, France
| | - É Bernichon
- Département d'oncologie médicale, institut de cancérologie Lucien-Neuwirth, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest-en-Jarez cedex, France
| | - É Chanal
- Département de radiothérapie, institut de cancérologie Lucien-Neuwirth, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest-en-Jarez cedex, France
| | - P Fournel
- Département d'oncologie médicale, institut de cancérologie Lucien-Neuwirth, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest-en-Jarez cedex, France
| | - N Magné
- Département de radiothérapie, institut de cancérologie Lucien-Neuwirth, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest-en-Jarez cedex, France.
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Assi R, Hamieh L, Mukherji D, Haydar A, Temraz S, El-Dika I, Shamseddine A. Leptomeningeal metastasis as initial manifestation of signet ring colorectal adenocarcinoma: a case report with review of literature. J Gastrointest Oncol 2015; 6:E89-E101. [PMID: 26697206 DOI: 10.3978/j.issn.2078-6891.2015.087] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Leptomeningeal carcinomatosis (LMC) is an exceedingly rare event especially as a first manifestation of an occult primary colorectal cancer and even when there is a known history of malignancy. Sensorineural hearing loss is by itself an unusual isolated presentation of LMC with unsolved pathophysiology in this setting. In this paper, we report such a case and review the literature for similar cases, focusing on postulated mechanisms of spread. In view of the poor prognosis they carry, we highly recommend that physicians be aware of the risk of rare metastasis from colorectal adenocarcinoma in order to establish an early confirmative diagnosis.
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Affiliation(s)
- Rita Assi
- 1 Department of Internal Medicine, Division of Hematology-Oncology, 2 Department of Radiology, American University of Beirut Medical Center, Beirut 1103, Lebanon
| | - Lana Hamieh
- 1 Department of Internal Medicine, Division of Hematology-Oncology, 2 Department of Radiology, American University of Beirut Medical Center, Beirut 1103, Lebanon
| | - Deborah Mukherji
- 1 Department of Internal Medicine, Division of Hematology-Oncology, 2 Department of Radiology, American University of Beirut Medical Center, Beirut 1103, Lebanon
| | - Ali Haydar
- 1 Department of Internal Medicine, Division of Hematology-Oncology, 2 Department of Radiology, American University of Beirut Medical Center, Beirut 1103, Lebanon
| | - Sally Temraz
- 1 Department of Internal Medicine, Division of Hematology-Oncology, 2 Department of Radiology, American University of Beirut Medical Center, Beirut 1103, Lebanon
| | - Imane El-Dika
- 1 Department of Internal Medicine, Division of Hematology-Oncology, 2 Department of Radiology, American University of Beirut Medical Center, Beirut 1103, Lebanon
| | - Ali Shamseddine
- 1 Department of Internal Medicine, Division of Hematology-Oncology, 2 Department of Radiology, American University of Beirut Medical Center, Beirut 1103, Lebanon
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Chen TC, Napolitano GR, Adell F, Schönthal AH, Shachar Y. Development of the Metronomic Biofeedback Pump for leptomeningeal carcinomatosis: technical note. J Neurosurg 2015; 123:362-72. [DOI: 10.3171/2014.10.jns14343] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Patients with leptomeningeal carcinomatosis face a particularly grim prognosis. Current treatment consists of intrathecal delivery of methotrexate (MTX) or cytosine arabinoside (Ara-C) via Ommaya reservoir or lumbar puncture. Yet despite these interventions, the median survival after diagnosis is only 4–7 months. To address inherent shortcomings of current treatments and provide a more effective therapeutic approach, the Pharmaco-Kinesis Corporation has developed a novel type of implantable pump capable of delivering intrathecal chemotherapy (i.e., MTX) in a metronomic fashion with electronic feedback. The Metronomic Biofeedback Pump (MBP) consists of 3 components: 1) a 2-lumen catheter; 2) a microfluidic delivery pump with 2 reservoirs; and 3) a spectrophotometer monitoring MTX concentrations in the CSF. Using an animal model of intraventricular drug delivery, the authors demonstrate that the MBP can reliably deliver volumes of 500 μl/min, consistently measure real-time intrathecal MTX concentrations via CSF aspiration, and provide biofeedback with the possibility of instant control and delivery adjustments. Therefore, this novel approach to chemotherapy minimizes toxic drug levels and ensures continuous exposure at precisely adjusted, individualized therapeutic levels. Altogether, application of the MBP is expected to increase survival of patients with leptomeningeal carcinomatosis, and appropriate Phase I and II trials are pending.
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Affiliation(s)
| | | | - Frank Adell
- 2Pharmaco-Kinesis Corporation, Inglewood; and
| | - Axel H. Schönthal
- 3Molecular Microbiology & Immunology, Keck School of Medicine, University of Southern California, Los Angeles
| | - Yehoshua Shachar
- 2Pharmaco-Kinesis Corporation, Inglewood; and
- 4Magnetecs Corporation, Inglewood, California
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Chen IC, Lin CH, Jan IS, Cheng AL, Lu YS. Bevacizumab might potentiate the chemotherapeutic effect in breast cancer patients with leptomeningeal carcinomatosis. J Formos Med Assoc 2015; 115:243-8. [PMID: 25890495 DOI: 10.1016/j.jfma.2015.03.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 02/26/2015] [Accepted: 03/16/2015] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND/PURPOSE Patients with leptomeningeal carcinomatosis (LC) from breast cancer is generally resistant to systemic chemotherapy. Bevacizumab may increase intratumor concentration of the chemotherapeutic agents through vascular normalization, although the overall clinical benefit of bevacizumab for metastatic breast cancer is under debate. METHODS Successful treatment of two breast cancer patients who developed LC after whole brain irradiation treatment for the brain metastases is reported here. Both patients have refractory disease to taxane and anthracycline, and both of them have disease progression under intrathecal methotrexate treatment for LC. RESULTS The two patients received systemic chemotherapy with bevacizumab (7.5 mg/kg infusion on Day 1), cisplatin (80 mg/m(2) infusion for 24 hours on Day 2), and etoposide (80 mg/m(2) infusion for 2 hours on Days 2-4) at 21-28 day intervals. Both patients achieved best response of negative cerebral spinal fluid cytology study and dramatic improvement of neurologic deficit after treatment. Their overall survival after development of LC was 8 months and 7.5 months respectively. CONCLUSION Bevacizumab plus etoposide and cisplatin might be a new option for breast cancer patients with LC. Further prospective study is warranted.
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Affiliation(s)
- I-Chun Chen
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - Ching-Hung Lin
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - I-Shiow Jan
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ann-Lii Cheng
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Graduate Institute of Oncology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yen-Shen Lu
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
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Kawasaki A, Suzuki K, Takekawa H, Nakamura T, Yamamoto M, Asakawa Y, Okamura M, Hirata K. Co-occurrence of multiple cerebral infarctions due to hypercoagulability associated with malignancy and meningeal carcinomatosis as the initial manifestation of gastric cancer. BMC Neurol 2014; 14:160. [PMID: 25103421 PMCID: PMC4131164 DOI: 10.1186/s12883-014-0160-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Accepted: 07/30/2014] [Indexed: 11/26/2022] Open
Abstract
Background Meningeal carcinomatosis and hypercoagulability associated with malignancy are typical late stage complications in cancer patients. The co-occurrence of meningeal carcinomatosis and cerebral infarction related to hypercoagulability associated with malignancy in an individual as the initial manifestation of malignancy has not been previously reported. Case presentation Herein, we report the case of an 80-year-old patient who presented with meningeal carcinomatosis and hypercoagulability related to malignancy as the initial manifestation of occult gastric cancer. The patient displayed consciousness disturbance, mild left facial paralysis, and bilateral positive Babinski’s sign. Using brain magnetic resonance imaging, the patient was diagnosed as having acute multiple cerebral infarctions. Cerebrospinal fluid (CSF) cytology showed adenocarcinoma and upper gastrointestinal endoscopy disclosed scirrhous gastric cancer. The patient presented with headache, fever, and meningeal irritation with a subacute course. Tuberculous or fungal meningitis was initially suspected; however, cytological evidence of adenocarcinoma in the CSF led to the diagnosis of meningeal carcinomatosis. Conclusion The comorbidity of hypercoagulability associated with malignancy and meningeal carcinomatosis should be considered in a patient presenting with multiple cerebral infarctions, progressive disturbance of consciousness, fever, and meningeal irritation.
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Affiliation(s)
| | - Keisuke Suzuki
- Department of Neurology, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Shimotsuga 321-0293, Tochigi, Japan.
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Yokote A, Kawamoto T, Namioka T, Moteki Y, Kawamata T. Diagnosis of leptomeningeal metastasis without a history of malignancy in the absence of cerebrospinal fluid abnormalities. Clin Neurol Neurosurg 2014; 119:88-90. [PMID: 24635933 DOI: 10.1016/j.clineuro.2014.01.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 12/13/2013] [Accepted: 01/19/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Akiyoshi Yokote
- Department of Neurosurgery, Tokyo Women's Medical University Yachiyo Medical Center, Chiba, Japan
| | - Takemasa Kawamoto
- Department of Neurosurgery, Tokyo Women's Medical University Yachiyo Medical Center, Chiba, Japan
| | - Takahiro Namioka
- Department of Neurosurgery, Tokyo Women's Medical University Yachiyo Medical Center, Chiba, Japan
| | - Yosuke Moteki
- Department of Neurosurgery, Tokyo Women's Medical University Yachiyo Medical Center, Chiba, Japan
| | - Takakazu Kawamata
- Department of Neurosurgery, Tokyo Women's Medical University Yachiyo Medical Center, Chiba, Japan.
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Marcinowska A, Constantino‐Casas F, Dobson JM. Histiocytic sarcoma in a flat‐coated retriever with central and peripheral nervous system sarcomatosis. VETERINARY RECORD CASE REPORTS 2014. [DOI: 10.1136/vetreccr-2013-000029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- A. Marcinowska
- Department of Veterinary MedicineUniversity of CambridgeCambridgeUK
| | | | - J. M. Dobson
- Department of Veterinary MedicineUniversity of CambridgeCambridgeUK
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Neoplastic meningitis: How MRI and CSF cytology are influenced by CSF cell count and tumor type. ScientificWorldJournal 2013; 2013:248072. [PMID: 24453817 PMCID: PMC3881671 DOI: 10.1155/2013/248072] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Accepted: 09/30/2013] [Indexed: 11/17/2022] Open
Abstract
Background. Although CSF cytology and MRI are standard methods to diagnose neoplastic meningitis (NM), this complication of neoplastic disease remains difficult to detect. We therefore reevaluated the sensitivity of gadolinium (GD)-enhanced MRI and cerebrospinal-fluid (CSF)-cytology and the relevance of tumor type and CSF cell count. Methods. We retrospectively identified 111 cases of NM diagnosed in our CSF laboratory since 1990 with complete documentation of both MRI and CSF cytology. 37 had haematological and 74 solid neoplasms. CSF cell counts were increased in 74 and normal in 37 patients. Results. In hematological neoplasms, MRI was positive in 49% and CSF cytology in 97%. In solid tumors, the sensitivity of MRI was 80% and of cytology 78%. With normal CSF cell counts, MRI was positive in 59% (50% hematological, 72% solid malignancies) and CSF cytology in 76% (92% in hematological, 68% in solid neoplasms). In cases of elevated cell counts, the sensitivity of MRI was 72% (50% for hematological, 83% for solid malignancies) and of CSF cytology 91% (100% for haematological and 85% for solid neoplasms). 91% of cytologically positive cases were diagnosed at first and another 7% at second lumbar puncture. Routine protein analyses had a low sensitivity in detecting NM. Conclusions. The high overall sensitivity of MRI was only confirmed for NM from solid tumors and for elevated CSF cell counts. With normal cell counts and haematological neoplasms, CSF-cytology was superior to MRI. None of the analysed routine CSF proteins had an acceptable sensitivity and specificity in detecting leptomeningeal disease.
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Leptomeningeal Carcinomatosis with Involvement of the Cerebellar Hemispheres and the Spinal Cord as First Manifestation of a Metastasizing Breast Carcinoma. Clin Neuroradiol 2013; 24:281-4. [DOI: 10.1007/s00062-013-0239-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Accepted: 07/02/2013] [Indexed: 10/26/2022]
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Huang CC, Huang TL, Hsu HC, Chen HC, Lin HC, Chien CY, Fang FM, Chang HW, Tsai NW, Chang WN, Chen SF, Lin TK, Tan TY, Chang CR, Wang HC, Lin WC, Lu CH. Long-term effects of neck irradiation on cardiovascular autonomic function: a study in nasopharyngeal carcinoma patients after radiotherapy. Muscle Nerve 2013; 47:344-50. [PMID: 23386577 DOI: 10.1002/mus.23530] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2012] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Baroreflex failure has been reported as a late sequalum of neck radiotherapy. In this study we investigated cardiovascular autonomic function in patients after neck radiotherapy to determine predictive factors associated with outcome. METHODS Eighty-nine patients with nasopharyngeal carcinoma were evaluated ≥6 months after radiotherapy for cardiovascular autonomic function and compared with 48 control subjects. Inflammatory markers and carotid intima-media thickness were also assessed. RESULTS Autonomic parameters of heart rate response to deep breathing and Valsalva ratio were significantly lower in the patient group. Cardiovascular autonomic impairment was generally mild with relative sparing of the efferent cardiovagal pathway. By univariate and multivariate analyses, the time after radiotherapy and C-reactive protein level were significantly associated with the degree of cardiovascular autonomic dysfunction. CONCLUSIONS Radiation-induced cardiovascular autonomic impairment is a dynamic and progressive process that occurs long after radiotherapy. Chronic inflammation plays a major role in this process.
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Affiliation(s)
- Chih-Cheng Huang
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta Pei Road, Niao Sung District, Kaohsiung, Taiwan
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Jung JM, Kim S, Joo J, Shin KH, Gwak HS, Lee SH. Incidence and risk factors for leptomeningeal carcinomatosis in breast cancer patients with parenchymal brain metastases. J Korean Neurosurg Soc 2012; 52:193-9. [PMID: 23115660 PMCID: PMC3483318 DOI: 10.3340/jkns.2012.52.3.193] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Revised: 06/14/2012] [Accepted: 09/17/2012] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE The objective of study is to evaluate the incidence of leptomeningeal carcinomatosis (LMC) in breast cancer patients with parenchymal brain metastases (PBM) and clinical risk factors for the development of LMC. METHODS We retrospectively analyzed 27 patients who had undergone surgical resection (SR) and 156 patients with whole brain radiation therapy (WBRT) as an initial treatment for their PBM from breast cancer in our institution and compared the difference of incidence of LMC according to clinical factors. The diagnosis of LMC was made by cerebrospinal fluid cytology and/or magnetic resonance imaging. RESULTS A total of 27 patients (14%) in the study population developed LMC at a median of 6.0 months (range, 1.0-50). Ten of 27 patients (37%) developed LMC after SR, whereas 17 of 156 (11%) patients who received WBRT were diagnosed with LMC after the index procedure. The incidence of LMC was significantly higher in the SR group compared with the WBRT group and the hazard ratio was 2.95 (95% confidence interval; 1.33-6.54, p<0.01). Three additional factors were identified in the multivariable analysis : the younger age group (<40 years old), the progressing systemic disease showed significantly increased incidence of LMC, whereas the adjuvant chemotherapy reduce the incidence. CONCLUSION There is an increased risk of LMC after SR for PBM from breast cancer compared with WBRT. The young age (<40) and systemic burden of cancer in terms of progressing systemic disease without adjuvant chemotherapy could be additional risk factors for the development of LMC.
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Affiliation(s)
- Jong-Myung Jung
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
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