Treatment of Leptomeningeal Carcinomatosis in a Patient with Metastatic Pancreatic Cancer: A Case Report and Review of the Literature

A Unique Case of a Patient With Pancreatic Cancer Developing Leptomeningeal Metastases While on Gemcitabine and Nab-Paclitaxel

Brain metastases and leptomeningeal disease are rare with pancreatic cancer. Leptomeningeal disease is a catastrophic complication to have as patients deteriorate rapidly. Patients can present with symptoms of cranial nerve neuropathies, headache, nausea, and focal neurological deficits. We present a patient with metastatic pancreatic cancer who was treated initially with FOLFIRINOX (5-fluorouracil, leucovorin, irinotecan, and oxaliplatin) which resulted in marked clinical and radiologic improvement. However, he started to develop severe peripheral neuropathy and was switched to maintenance gemcitabine and nab-paclitaxel. On this regimen, his systemic disease was well controlled but he developed leptomeningeal carcinomatosis. To our knowledge, this is the first case of leptomeningeal metastases developing in a patient with pancreatic adenocarcinoma while on treatment with gemcitabine and nab-paclitaxel after cessation of FOLFIRINOX. We should maintain high clinical suspicion for leptomeningeal disease in pancreatic cancer, especially when systemic disease is well controlled, as the chemotherapeutic agents may not be crossing the blood-brain barrier effectively contributing to high morbidity and mortality.

An overview of the therapeutic strategies for neoplastic meningitis due to breast cancer: when and why?

INTRODUCTION

Neoplastic meningitis (NM), also known as leptomeningeal carcinomatosis, is characterized by the infiltration of tumor cells into the meninges, and poses a significant therapeutic challenge owing to its aggressive nature and limited treatment options. Breast cancer is a common cause of NM among solid tumors, further highlighting the urgent need to explore effective therapeutic strategies. This review aims to provide insights into the evolving landscape of NM therapy in breast cancer by collating existing research, evaluating current treatments, and identifying potential emerging therapeutic options.

AREAS COVERED

This review explores the clinical features, therapeutic strategies, recent advances, and challenges of managing NM in patients with breast cancer. Its management includes multimodal strategies, including systemic and intrathecal chemotherapy, radiation therapy, and supportive care. This review also emphasizes targeted drug options and optimal drug concentrations, and discusses emerging therapies. Additionally, it highlights the variability in treatment outcomes and the potential of combination regimens to effectively manage NM in breast cancer.

EXPERT OPINION

Challenges in treating NM include debates over clinical trial end points and the management of adverse effects. Drug resistance and low response rates are significant hurdles, particularly inHER2-negative breast cancer. The development of more precise and cost-effective medications with improved selectivity is crucial. Additionally, global efforts are needed for infrastructure development and cancer control considering the diverse nature of the disease.

Leptomeningeal Carcinomatosis in a Patient with Pancreatic Cancer: A Rare Phenomenon?

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.

Treatment Outcome of Nab-paclitaxel Plus Gemcitabine for Leptomeningeal Carcinomatosis from Pancreatic Ductal Adenocarcinoma: An Autopsy Case Report

A 57-year-old woman with a sudden-onset seizure was hospitalized. Brain magnetic resonance imaging findings led to a suspicion of leptomeningeal carcinomatosis (LMC) without a brain parenchymal tumor, and abdominal computed tomography showed a tumor in the pancreatic tail. Endoscopic ultrasonography-guided fine needle aspiration of the pancreatic mass revealed adenocarcinoma. Therefore, LMC from pancreatic ductal adenocarcinoma was strongly suspected. She received three courses of nab-paclitaxel plus gemcitabine and whole-brain radiation. Shortly thereafter, she developed a severe consciousness impediment and died. A pathological autopsy showed adenocarcinoma in a wide area of the leptomeninges.

Unusual metastasis in BRCA mutated pancreatic cancer while on maintenance Olaparib: Two case reports and review of the literature

The most common metastatic sites of pancreatic cancer are the liver, lymph nodes, peritoneum and lung. Here we report two cases of BRCA mutated pancreatic cancer that developed unusual metastasis while treatment with maintenance Olaparib and leading to rapid death. We hereby review the literature and address the possibility of a different nature and tumour biology of BRCA mutated cancer treated with PARP inhibitors.

Leptomeningeal disease in pancreas ductal adenocarcinoma: A manifestation of longevity

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.

Pancreatic cancer with leptomeningeal carcinomatosis: case report and literature review

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.

Leptomeningeal Carcinomatosis in a Patient with Pancreatic Cancer Responding to Nab-Paclitaxel plus Gemcitabine

Leptomeningeal carcinomatosis is an extremely rare, but devastating complication in pancreatic cancer patients with a poor prognosis despite multimodal treatment. We present a 51-year-old male patient with the very rare condition of leptomeningeal carcinomatosis originating from pancreatic cancer. He presented to our hospital with severe headache and neck stiffness 30 months after systemic chemotherapy. Cerebral and spinal MRI as well as cerebrospinal fluid examination confirmed the diagnosis of leptomeningeal carcinomatosis. The patient responded to gemcitabine plus nab-paclitaxel in terms of elimination of tumor cells from the CSF and concurrent clinical improvement for 3 months. The observed findings suggest that the combination of gemcitabine plus nab-paclitaxel is potentially effective in affected cerebrospinal fluid of pancreatic carcinoma patients.