Osimertinib is associated with improved outcomes in pre-treated non-small cell lung cancer leptomeningeal metastases: A systematic review and meta-analysiss

Purpose

Leptomeningeal metastasis (LM) is a severe complication of non-small cell lung cancer (NSCLC). In patients with NSCLC LM harboring epidermal growth factor receptor (EGFR) mutations, osimertinib is favored over alternative EGFR tyrosine kinase inhibitors (TKIs). However, the efficacy of osimertinib relative to other EGFR-TKIs is not well established for patients with LM. We aimed to compare the efficacy of EGFR-TKIs in EGFR-mutated NSCLC LM.

Methods

This systematic review and meta-analysis performed according to PRISMA guidelines included studies of adult patients with EGFR-mutated NSCLC and a diagnosis of LM who received an EGFR-TKI for the treatment of LM. We searched Medline ALL, Embase, Cochrane Central Register of Controlled Trials, Scopus, and Web of Science Core Collection. The evaluation of biases was done by using the Ottawa-Newscastle scale. The hazard ratio was used as the parameter of interest for overall survival (OS) and central nervous system-specific progression-free survival (PFS).

Results

128 publications were included with 243 patients and 282 lines of EGFR-TKI for NSCLC LM that met inclusion criteria. The median PFS in patients receiving any EGFR-TKI was 9.1 months, and the median OS was 14.5 months. In univariate analyses of the entire cohort, osimertinib treatment demonstrated significantly prolonged PFS, but not OS, compared to other EGFR-TKIs. Osimertinib demonstrated significantly prolonged PFS and OS in the subset of patients who were previously treated with EGFR-TKIs, but not in EGFR-TKI naïve patients.

Conclusion

Osimertinib is associated with improved outcomes compared to other EGFR-TKIs, particularly in patients previously treated with EGFR-TKIs. An important limitation is that most patients were derived from retrospective reports. These results highlight the need for prospective studies for this difficult-to-treat patient population.

A Rare Case of Leptomeningeal Carcinomatosis Secondary to Metastatic Non-Small Cell Lung Carcinoma

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.

Elemene treatment for NSCLC with multiple CNS metastases: a case report and literature review

CNS metastases are common in patients with non-small-cell lung cancer (NSCLC) and is associated with poor prognosis. In NSCLC patients with EGFR mutations, and ALK fusion oncogene, chemotherapy is ineffective; however, targeted and pulse therapies may be used as alternative treatment options. Elemene can cross the blood-brain barrier and enter the brain tissue. In this paper, treatment consisting of elemene injections in a case of NSCLC with brain metastases, spinal metastases and a possible complication of leptomeningeal metastases is reported, and the efficacy of elemene in treating NSCLC with CNS metastases was investigated.

Experimental Treatments for Leptomeningeal Metastases From Solid Malignancies

BACKGROUND

Leptomeningeal metastasis is a consequence of advanced solid malignancies and has limited treatment options. It is possible that it is becoming more common as the leptomeninges act as a sanctuary site for recurrence from systemic cancer.

METHODS

Potential targeted and immunotherapy agents for the most common types of solid-tumor leptomeningeal metastasis are reviewed, as are their dosing/delivery strategies and novel, immunological approaches.

RESULTS

Historically, patients with leptomeningeal metastasis have been excluded from clinical trials, and data on the management of leptomeningeal metastasis come from single case reports and retrospective analyses.

CONCLUSION

For the first time ever, published reports suggest the tide may be turning in this challenging disease.

Leptomeningeal Disease and the Evolving Role of Molecular Targeted Therapy and Immunotherapy

BACKGROUND

Leptomeningeal disease (LMD) is a complication that results from solid tumor metastasis. Prognosis is extremely poor. As therapeutic options for solid tumors improve, the rate of LMD continues to increase. Until recently, treatment has been limited to radiation therapy, intrathecal chemotherapy, and systemic chemotherapy, with an overall survival of 2-3 months. Targeted molecular therapy and immunotherapies are promising new options for increasing overall survival and clinical improvement; however, optimal clinical management remains unknown.

METHODS

In this review, we discuss targeted molecular therapy and immunotherapy treatment options for LMD resulting from primary lung, breast, and melanoma tumors. In addition, we summarize dosing strategies, overall survival, clinical outcomes, and novel approaches to treatment.

RESULTS

Our review indicates a deficiency in the current literature. Presently, intrathecal trastuzumab administration may be an effective option for patients with HER2-positive breast cancer. BRAF inhibitors and cytotoxic T lymphocyte-associated antigen-4 targets have shown promising results in LMD resulting from melanoma. Finally, tyrosine kinase inhibitors may increase overall survival in epidermal growth factor receptor (EGFR)-mutant non-small cell lung cancer. Pulsatile drug administration or dual therapy may be beneficial for patients who progress to LMD while being treated with EGFR targets for their primary malignancy.

CONCLUSION

Targeted molecular therapy and immunotherapy in LMD may provide favorable treatment options. Current literature is lacking in safety, efficacy, and overall response rates from the use of targeted therapy. Research is needed to draw significant conclusions about the most appropriate therapy for patients with LMD.

[Intrathecal methotrexate in breast cancer meningeal carcinomatosis - Experience with a new administration schedule]

Methotrexate represents the standard intrathecal treatment of breast cancer meningeal carcinomatosis. However, its optimal schedule remains undefined. The aim of the present study was to evaluate results obtained with the methotrexate schedule used in Saint-Louis hospital (Paris). Patients followed in Saint-Louis hospital for breast cancer and who received intrathecal methotrexate were included in this retrospective monocentric study. Intrathecal treatment received contained methotrexate 12 mg/day (days: 1-5) and then 15 mg/week until progression or toxicity. Between 2003 and 2015, 41 patients were included. Primitive tumours were RH+/HER2-, HER2+ and triple-negative in respectively 66%, 14%, 5% and 15% of patients, 22% of them had meningeal carcinomatosis as metastatic disease initial manifestation. Objective response rate was 54%, median overall survival was 4.0 mois [CI 95%: 3-7.3] and 1-year survival rate was 15.2% (11.4%, 50% et 0% in RH+/HER2-, HER2+ and triple-negative subgroups; HR=0.45 [0.21-0.97] between HER2+ and RH+/HER2-). In univariate analysis, prognostic factors were brain involvement (p=0.049), initial cerebrospinal fluid protein level (p=0.0002) and concomitant systemic treatment received (p=0.049). This intrathecal methotrexate schedule demonstrates a similar median overall survival as the one obtained with a dose-dense schedule and an improved quality of life. Nevertheless, as the objective response and 1-year survival rates are slightly inferior, a dose-dense schedule remains still preferred in HER2+ patients or in those harboring a mainly meningeal progression.