Malignant invasion of the cerebrospinal fluid in adult and paediatric patients with haematological and solid malignancies: a monocentric retrospective study

OBJECTIVES

In this study, we describe the clinical presentation, the cerebrospinal fluid (CSF) characteristics and outcome of children and adults with leptomeningeal invasion due to haematological and solid malignancies.

METHODS

Routine CSF samples analyzed from 2008 to 2018 at our institution were retrospectively reviewed for the presence of malignant cells based on cytomorphological analysis.

RESULTS

Leptomeningeal invasion was identified in 212 patients: 45 children versus 167 adults, and 92 haematological versus 120 solid malignancies. Leukaemic invasion in childhood was mainly due to ALL, and lymphoma invasion was often due to a high-grade B-cell lymphoma in adults. Metastatic invasion by solid tumours was almost exclusively seen in adults. Patients suffered most frequently from cranial neuropathy and headache (both 32%), while asymptomatic presentations were seen mainly in children (33%) and haematological malignancies (17%). Laboratory CSF parameters often showed an elevated WBC count (87%), total protein (74%) and lactate (76%) and a decreased glucose (77%). These deviations were especially found in solid malignancies (>84%) and adults (>82%). Brain and/or spinal cord imaging was more often suggestive for the leptomeningeal invasion in solid than in haematological malignancies (86% vs. 46%). The 5-year overall survival (OS) rates for patients with haematological and solid malignancies were 21.5% and 5.9%, respectively. The 5-year OS rate for children (55.6%) was significantly better than for adults (3.5%).

CONCLUSION

Leptomeningeal invasion is more often asymptomatic, and CSF parameters and imaging are more often normal in children and haematological malignancies than in adults and solid malignancies, possibly leading to underdiagnosis.

Folic Acid-Appended Hydroxypropyl-β-Cyclodextrin Exhibits Potent Antitumor Activity in Chronic Myeloid Leukemia Cells via Autophagic Cell Death

Simple Summary

2-Hydroxypropyl-β-cyclodextrin (HP-β-CyD) is a cyclic oligosaccharide widely used as an excipient in pharmaceutical preparations, in addition to also being used as a cholesterol regulator. HP-β-CyD was used in clinical trials for patients with Niemann-Pick Type C disease to remove accumulated intracellular lipid. HP-β-CyD has anti-leukemia activity by inducing apoptosis and cell-cycle arrest; however, the antitumor activity of HP-β-CyD lacks tumor cell-selectivity. Taking advantage of the fact that folate receptors are highly expressed in many cancer cells, we synthesized folate-appended HP-β-CyD (FA-HP-β-CyD) to confer tumor cell-selectivity to HP-β-CyD. FA-HP-β-CyD inhibited the proliferation of chronic myeloid leukemia (CML) cells and the mechanism underlying the effect of FA-HP-β-CyD in inducing cell death may involve autophagy. The combination of FA-HP-β-CyD and ABL tyrosine kinase inhibitors (imatinib and ponatinib) had a synergistic inhibitory effect on CML cells. In a mouse model of BCR-ABL-induced leukemia, FA-HP-β-CyD had a stronger inhibitory effect on leukemia progression than HP-β-CyD or imatinib.

Abstract

2-Hydroxypropyl-β-cyclodextrin (HP-β-CyD) is widely used as an enabling excipient in pharmaceutical formulations. We previously demonstrated that HP-β-CyD disrupted cholesterol homeostasis, and inhibited the proliferation of leukemia cells by inducing apoptosis and cell-cycle arrest. Recently developed drug delivery systems using folic acid (FA) and folic acid receptors (FR) are currently being used in cancer treatment. To confer tumor cell-selectivity to HP-β-CyD, we synthesized folate-appended HP-β-CyD (FA-HP-β-CyD) and evaluated the potential of FA-HP-β-CyD as an anticancer agent using chronic myeloid leukemia (CML) cells in vitro and in vivo. FA-HP-β-CyD inhibited the growth of FR-expressing cells but not that of FR-negative cells. FA-HP-β-CyD had stronger anti-leukemia and cell-binding activities than HP-β-CyD in CML cells. Unlike HP-β-CyD, FA-HP-β-CyD entered CML cells through endocytosis and induced both apoptosis and autophagy via mitophagy. FA-HP-β-CyD increased the inhibitory effects of the ABL tyrosine kinase inhibitors imatinib mesylate and ponatinib, which are commonly used in CML. In vivo experiments in a BCR-ABL leukemia mouse model showed that FA-HP-β-CyD was more effective than HP-β-CyD at a ten-fold lower dose. These results indicate that FA-HP-β-CyD may be a novel tumor-targeting agent for the treatment of leukemia.