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Surya G, Ajit N, Priya RR, Hemalatha DS, Devi BV, Kalawat T. An Uncommon Presentation of Leptomeningeal Metastases in Breast Carcinoma Detected by F-18 FDG PET/CT. World J Nucl Med 2023; 22:36-39. [PMID: 36923975 PMCID: PMC10010867 DOI: 10.1055/s-0042-1757254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Leptomeningeal carcinomatosis is a manifestation in which tumor cells migrate into meninges. Breast carcinoma presenting with leptomeningeal metastases is a rare phenomenon that can occur in an isolated form as well as with coexistent parenchymal brain metastases. The gold standard for diagnosis is cerebrospinal fluid analysis, while contrast-enhanced magnetic resonance imaging is the most commonly used imaging modality. Nuclear medicine imaging with flourine-18-fluorodeoxyglucose positron emission tomography/computed tomography has proved to be useful in detecting leptomeningeal metastases and, at times, even before anatomical changes occur. Here, we present a case of breast carcinoma presenting with both pachymeningeal and leptomeningeal metastases 10 years after treatment.
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Affiliation(s)
- Gavini Surya
- Department of Nuclear Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
| | - Nimmagadda Ajit
- Department of Nuclear Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
| | - Rallapeta Ramya Priya
- Department of Nuclear Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
| | - Dhamarcherla S Hemalatha
- Department of Nuclear Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
| | | | - Tekchand Kalawat
- Department of Nuclear Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
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2
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Ozcan G, Singh M, Vredenburgh JJ. Leptomeningeal Metastasis from Non-Small Cell Lung Cancer and Current Landscape of Treatments. Clin Cancer Res 2023; 29:11-29. [PMID: 35972437 DOI: 10.1158/1078-0432.ccr-22-1585] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/06/2022] [Accepted: 08/11/2022] [Indexed: 02/06/2023]
Abstract
Leptomeningeal metastasis (LM), also known as leptomeningeal carcinomatosis (LC), is a devastating complication of metastatic cancer that occurs when neoplastic cells invade the meningeal space. Diagnosis of LM remains challenging given the heterogeneous signs and symptoms at presentation and requires thorough neurological examination, cerebrospinal fluid (CSF) analysis, and MRI of the brain and spine with gadolinium. Detecting neoplastic cells in the CSF is the gold standard for diagnosing leptomeningeal metastases; however, it has low sensitivity and may require multiple CSF samples. New emerging technologies, such as liquid biopsy of CSF, have increased sensitivity and specificity for detecting circulating tumor cells in CSF. The management of LM in patients with NSCLC requires an individualized multidisciplinary approach. Treatment options include surgery for ventricular shunt placement, radiation therapy to bulky or symptomatic disease sites, systemic or intrathecal chemotherapy, molecularly targeted agents, and, more recently, immunotherapy. Targeting actionable mutations in LM from NSCLC, such as EGFR tyrosine kinase inhibitors or anaplastic lymphoma kinase gene rearrangement inhibitors, has shown encouraging results in terms of disease control and survival. Although there are limited data regarding the use of immunotherapy in LM, immunotherapy has produced promising results in several case reports. In this review, we focused on the epidemiology, pathophysiology, clinical presentation, diagnosis, and current treatment strategies, with a special emphasis on novel agents, including targeted therapies and immunotherapy of LM in patients with NSCLC.
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Affiliation(s)
- Gonca Ozcan
- Department of Medicine, University of Connecticut Health Center, Farmington, Connecticut
| | - Meghana Singh
- Department of Medicine, University of Connecticut Health Center, Farmington, Connecticut
| | - James J Vredenburgh
- Department of Medicine, Division of Hematology-Oncology, Saint Francis Hospital, Hartford, Connecticut
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3
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Pang H, Chan JL, Bannykh SI, Gezalian M, Lahiri S, Toossi S, Ayodele M. Intrathecal Methotrexate Toxicity Resulting in Brain Death due to Generalized Cerebral Edema Case Report. Neurohospitalist 2022; 12:697-701. [PMID: 36147762 PMCID: PMC9485701 DOI: 10.1177/19418744221106313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023] Open
Abstract
Intrathecal methotrexate (IT MTX) resulting in severe adverse events including life-threatening cerebral edema is not well described. We report a rare case of death in a 37-year-old BRCA1+ woman with metastatic triple-negative breast cancer status post mastectomy following administration of IT MTX for leptomeningeal carcinomatosis. Within the 24 hours after intraoperative IT MTX delivery, she developed neurologically devastating diffuse cerebral edema leading to uncal and cerebellar tonsillar herniation. This case report highlights a rare but devastating side effect of IT MTX.
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Affiliation(s)
- Haoming Pang
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Julie L. Chan
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Serguei I. Bannykh
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michael Gezalian
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Shouri Lahiri
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Shahed Toossi
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Maranatha Ayodele
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Abraham AA, T.M A, P. RJ, Vasudevan A, Kumar BS. Clinical Outcome of Neoplastic Meningitis Associated with Breast Cancer. J Neurosci Rural Pract 2022; 13:108-113. [PMID: 35110929 PMCID: PMC8803511 DOI: 10.1055/s-0041-1741505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background Neoplastic meningitis (NM) is considered as a terminal event with poor prognosis. Its impact in clinical oncology is growing. Objective To analyze the clinical outcome of patients with carcinoma breast diagnosed with NM. Materials and Methods This study was an observational study in breast cancer patients diagnosed with NM. Patients with typical clinical symptoms and signs with either presence of cerebrospinal fluid (CSF) cytology positive for neoplastic cells or typical radiological features of leptomeningeal involvement in the presence of neurological symptoms or signs were taken as leptomeningeal metastasis (LM) or NM. The estimation of survival was done by Kaplan-Meier method. Results Out of 1,200 patients diagnosed with carcinoma breast during the study period, 15 developed NM. The median age of study population was 51 (range: 44-55) years. Most common presentations were headache (47%), vomiting (47%), diplopia (20%), seizure (20%), and cerebellar signs (7%). Seven (46%) patients were hormone receptor positive, four (30%) were HER2 (Human epidermal growth factor receptor 2) positive and seven (46%) were triple-negative breast cancer. Median time to develop LM from the time of diagnosis of breast cancer was 6 (range: 3-8) months. Nine patients (90%) had features of NM in CSF cytology. Thirteen patients received palliative whole brain radiotherapy (20 Gy in five fractions). Nine out of 12 patients received single-agent Capecitabine as first-line chemotherapy after palliative radiation therapy (RT). Intrathecal methotrexate was given for seven patients. The median overall survival was 3 (range: 0.5-4) months. Conclusion LM is a very aggressive metastatic disease with poor outcome. There is an unmet need for proper guidelines and an overwhelming necessity for a better focus on research for new modalities of disease in this scenario.
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Affiliation(s)
- Anju Anna Abraham
- Department of Medical Oncology, Regional Cancer Center, Thiruvananthapuram, Kerala, India
| | - Anoop T.M
- Department of Medical Oncology, Regional Cancer Center, Thiruvananthapuram, Kerala, India
| | - Rona Joseph P.
- Department of Medical Oncology, Regional Cancer Center, Thiruvananthapuram, Kerala, India
| | - Arun Vasudevan
- Department of Medical Oncology, Regional Cancer Center, Thiruvananthapuram, Kerala, India
| | - Bhavya S. Kumar
- Department of Medical Oncology, Regional Cancer Center, Thiruvananthapuram, Kerala, India
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García Molina E, Penas-Prado M. Neoplastic meningitis in solid tumours: updated review of diagnosis, prognosis, therapeutic management, and future directions. NEUROLOGÍA (ENGLISH EDITION) 2021; 37:794-805. [PMID: 34663545 DOI: 10.1016/j.nrleng.2019.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 10/14/2019] [Indexed: 10/20/2022] Open
Abstract
Neoplastic meningitis (NM) is a relatively frequent metastatic complication of cancer associated with high levels of neurological morbidity and generally poor prognosis. It appears in 5%-15% of patients with solid tumours, the most frequent being breast and lung cancer and melanoma. Symptoms are caused by involvement of the cerebral hemispheres, cranial nerves, spinal cord, and nerve roots, and are often multifocal or present with signs and symptoms of intracranial hypertension. The main diagnostic tools are the neurological examination, brain and spinal cord contrast-enhanced magnetic resonance imaging, and cerebrospinal fluid analysis including cytology, although studies have recently been conducted into the detection of tumour cells and DNA in the cerebrospinal fluid, which increases diagnostic sensitivity. With the currently available therapies, treatment aims not to cure the disease, but to delay and ameliorate the symptoms and to preserve quality of life. Treatment of NM involves a multimodal approach that may include radiotherapy, intrathecal and/or systemic chemotherapy, and surgery. Treatment should be individualised, and is based mainly on clinical practice guidelines and expert opinion. Promising clinical trials are currently being conducted to evaluate drugs with molecular and immunotherapeutic targets. This article is an updated review of NM epidemiology, clinical presentation, diagnosis, prognosis, management, and treatment; it is aimed at general neurologists and particularly at neurologists practicing in hospital settings with oncological patients.
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Affiliation(s)
- E García Molina
- Servicio de Neurología, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain.
| | - M Penas-Prado
- Neuro-Oncology Branch, National Cancer Institute, Bethesda, Maryland, United States
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Karschnia P, Le Rhun E, Vogelbaum MA, van den Bent M, Grau SJ, Preusser M, Soffietti R, von Baumgarten L, Westphal M, Weller M, Tonn JC. The evolving role of neurosurgery for central nervous system metastases in the era of personalized cancer therapy. Eur J Cancer 2021; 156:93-108. [PMID: 34425408 DOI: 10.1016/j.ejca.2021.07.032] [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] [Received: 05/28/2021] [Revised: 07/21/2021] [Accepted: 07/26/2021] [Indexed: 12/13/2022]
Abstract
Recent therapeutic advances involving the use of systemic targeted treatments and immunotherapeutic agents in patients with advanced cancers have translated into improved survival rates. Despite the emergence of such promising pharmacological therapies and extended survival, the frequency of metastases in the central nervous system has steadily increased. Effective medical and surgical therapies are available for many patients with brain metastases and need to be incorporated into multi-disciplinary care protocols. The role of neurosurgeons is evolving within these multi-disciplinary care teams. Surgical resection of brain metastases can provide immediate relief from neurological symptoms due to large lesions and provides the histopathological diagnosis in cases of no known primary malignancy. In situations where immunotherapy is part of the oncological treatment plan, surgery may be proposed for expeditious relief of edema to remove the need for steroids. In patients with multiple brain metastases and mixed response to therapeutics or radiosurgery, tumour resampling allows tissue analysis for druggable targets or to distinguish radiation effects from progression. Ventriculo-peritoneal shunting may improve quality of life in patients with hydrocephalus associated with leptomeningeal tumour dissemination and may allow for time to administer more therapy thus prolonging overall survival. Addressing the limited efficacy of many oncological drugs for brain metastases due to insufficient blood-brain barrier penetrance, clinical trial protocols in which surgical specimens are analysed after pre-surgical administration of therapeutics offer pharmacodynamic insights. Comprehensive neurosurgical assessment remains an integral element of multi-disciplinary oncological care of patients with brain metastases and is integral to tumour biology research and therapeutic advancement.
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Affiliation(s)
- Philipp Karschnia
- Department of Neurosurgery, Ludwig-Maximilians-University School of Medicine, Munich, Germany; German Cancer Consortium (DKTK), Partner Site Munich, Germany
| | - Emilie Le Rhun
- Department of Neurosurgery & Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | | | - Martin van den Bent
- Department of Neurology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Stefan J Grau
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Matthias Preusser
- Department of Medicine I, Division of Oncology, Medical University of Vienna, Vienna, Austria
| | - Riccardo Soffietti
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
| | - Louisa von Baumgarten
- Department of Neurosurgery, Ludwig-Maximilians-University School of Medicine, Munich, Germany; German Cancer Consortium (DKTK), Partner Site Munich, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Hospital Hamburg, Hamburg, Germany
| | - Michael Weller
- Department of Neurology & Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Joerg-Christian Tonn
- Department of Neurosurgery, Ludwig-Maximilians-University School of Medicine, Munich, Germany; German Cancer Consortium (DKTK), Partner Site Munich, Germany.
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7
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García Molina E, Penas-Prado M. Neoplastic meningitis in solid tumours: Updated review of diagnosis, prognosis, therapeutic management, and future directions. Neurologia 2020; 37:S0213-4853(19)30141-0. [PMID: 31964538 DOI: 10.1016/j.nrl.2019.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 10/09/2019] [Accepted: 10/14/2019] [Indexed: 11/30/2022] Open
Abstract
Neoplastic meningitis (NM) is a relatively frequent metastatic complication of cancer associated with high levels of neurological morbidity and generally poor prognosis. It appears in 5%-15% of patients with solid tumours, the most frequent being breast and lung cancer and melanoma. Symptoms are caused by involvement of the cerebral hemispheres, cranial nerves, spinal cord, and nerve roots, and are often multifocal or present with signs and symptoms of intracranial hypertension. The main diagnostic tools are the neurological examination, brain and spinal cord contrast-enhanced magnetic resonance imaging, and cerebrospinal fluid analysis including cytology, although studies have recently been conducted into the detection of tumour cells and DNA in the cerebrospinal fluid, which increases diagnostic sensitivity. With the currently available therapies, treatment aims not to cure the disease, but to delay and ameliorate the symptoms and to preserve quality of life. Treatment of NM involves a multimodal approach that may include radiotherapy, intrathecal and/or systemic chemotherapy, and surgery. Treatment should be individualised, and is based mainly on clinical practice guidelines and expert opinion. Promising clinical trials are currently being conducted to evaluate drugs with molecular and immunotherapeutic targets. This article is an updated review of NM epidemiology, clinical presentation, diagnosis, prognosis, management, and treatment; it is aimed at general neurologists and particularly at neurologists practicing in hospital settings with oncological patients.
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Affiliation(s)
- E García Molina
- Servicio de Neurología, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España.
| | - M Penas-Prado
- Neuro-Oncology Branch, National Cancer Institute, Bethesda, Maryland, Estados Unidos
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8
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Walker DA, Meijer L, Coyle B, Halsey C. Leptomeningeal malignancy of childhood: sharing learning between childhood leukaemia and brain tumour trials. THE LANCET CHILD & ADOLESCENT HEALTH 2020; 4:242-250. [PMID: 31958415 DOI: 10.1016/s2352-4642(19)30333-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 09/26/2019] [Accepted: 09/30/2019] [Indexed: 01/02/2023]
Abstract
Leptomeningeal malignancy complicates childhood cancers, including leukaemias, brain tumours, and solid tumours. In leukaemia, such malignancy is thought to invade leptomeninges via the vascular route. In brain tumours, dissemination from the primary tumour, before or after surgery, via CSF pathways is assumed; however, evidence exists to support the vascular route of dissemination. Success in treating leptomeningeal malignancy represents a rate-limiting step to cure, which has been successfully overcome in leukaemia with intensified systemic therapy combined with intra-CSF therapy, which replaced cranial radiotherapy for many patients. This de-escalated CNS-directed therapy is still associated with some neurotoxicity. The balanced benefit justifies exploration of ways to further de-escalate CNS-directed therapy. For primary brain tumours, standard therapy is craniospinal radiotherapy, but attendant risk of acute and delayed brain injury and endocrine deficiencies compounds post-radiation impairment of spinal growth. Alternative ways of treating leptomeninges by intensifying drug therapy delivered to CSF are being investigated-preliminary evidence suggests improved outcomes. This Review seeks to describe methods of intra-CSF drug delivery and drugs in use, and consider how the technique could be modified and additional drugs might be selected for this route of administration.
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Affiliation(s)
- David A Walker
- Children's Brain Tumour Research Centre, University of Nottingham, School of Medicine, Queen's Medical Centre, Nottingham, UK.
| | - Lisethe Meijer
- Department of Paediatric Neuro-Oncology, Prinses Maxima Center for Paediatric Oncology, Bilthoven, Netherlands
| | - Beth Coyle
- Children's Brain Tumour Research Centre, University of Nottingham, School of Medicine, Queen's Medical Centre, Nottingham, UK
| | - Christina Halsey
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
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Prabhash K, Vallathol D, Patil V, Noronha V, Joshi A, Menon N. Leptomeningeal metastasis from extracranial solid tumors. CANCER RESEARCH, STATISTICS, AND TREATMENT 2020. [DOI: 10.4103/crst.crst_38_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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10
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Zambrano-Rodríguez PC, Bolaños-Puchet S, Reyes-Alva HJ, García-Orozco LE, Romero-Piña ME, Martinez-Cruz A, Guízar-Sahagún G, Medina LA. Micro-CT myelography using contrast-enhanced digital subtraction: feasibility and initial results in healthy rats. Neuroradiology 2019; 61:323-330. [PMID: 30693408 DOI: 10.1007/s00234-019-02162-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 01/09/2019] [Indexed: 12/27/2022]
Abstract
PURPOSE The spinal subarachnoid space (SSAS) is vital for neural performance. Although models of spinal diseases and trauma are used frequently, no methods exist to obtain high-resolution myelograms in rodents. Thereby, our aim was to explore the feasibility of obtaining high-resolution micro-CT myelograms of rats by contrast-enhanced dual-energy (DE) and single-energy (SE) digital subtraction. METHODS Micro-CT contrast-enhanced DE and SE imaging protocols were implemented with live adult rats (total of 18 animals). For each protocol, contrast agents based on iodine (Iomeron® 400 and Fenestra® VC) and gold nanoparticles (AuroVist™ 15 nm) were tested. For DE, images at low- and high-energy settings were acquired after contrast injection; for SE, one image was acquired before and the other after contrast injection. Post-processing consisted of region of interest selection, image registration, weighted subtraction, and longitudinal alignment. RESULTS High-resolution myelograms were obtained with contrast-enhanced digital subtraction protocols. After qualitative and quantitative (contrast-to-noise ratio) analyses, we found that the SE acquisition protocol with Iomeron® 400 provides the best images. 3D contour renderings allowed visualization of SSAS and identification of some anatomical structures within it. CONCLUSION This in vivo study shows the potential of SE contrast-enhanced myelography for imaging SSAS in rat. This approach yields high-resolution 3D images without interference from adjacent anatomical structures, providing an innovative tool for further assessment of studies involving rat SSAS.
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Affiliation(s)
- Pablo C Zambrano-Rodríguez
- Department of Neurology, Facultad de Medicina Veterinaria y Zootecnia, Universidad Autónoma del Estado de México, 50090, Toluca, Mexico
| | - Sirio Bolaños-Puchet
- Unidad de Investigación Biomédica en Cáncer INCan/UNAM, Instituto Nacional de Cancerología, 14280, Mexico City, Mexico
| | - Horacio J Reyes-Alva
- Department of Neurology, Facultad de Medicina Veterinaria y Zootecnia, Universidad Autónoma del Estado de México, 50090, Toluca, Mexico
| | - Luis E García-Orozco
- Unidad de Investigación Biomédica en Cáncer INCan/UNAM, Instituto Nacional de Cancerología, 14280, Mexico City, Mexico
| | - Mario E Romero-Piña
- Unidad de Investigación Biomédica en Cáncer INCan/UNAM, Instituto Nacional de Cancerología, 14280, Mexico City, Mexico
| | - Angelina Martinez-Cruz
- Department of Experimental Surgery, Proyecto Camina A.C, Calzada de Tlalpan 4430, 14050, Mexico City, Mexico
| | - Gabriel Guízar-Sahagún
- Department of Experimental Surgery, Proyecto Camina A.C, Calzada de Tlalpan 4430, 14050, Mexico City, Mexico. .,Research Unit for Neurological Diseases, Hospital de Especialidades Centro Médico Nacional Siglo XXI, IMSS, 06720, Mexico City, Mexico.
| | - Luis A Medina
- Unidad de Investigación Biomédica en Cáncer INCan/UNAM, Instituto Nacional de Cancerología, 14280, Mexico City, Mexico. .,Instituto de Física, Universidad Nacional Autónoma de México, 04510, Mexico City, Mexico.
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Montes de Oca Delgado M, Cacho Díaz B, Santos Zambrano J, Guerrero Juárez V, López Martínez MS, Castro Martínez E, Avendaño Méndez-Padilla J, Mejía Pérez S, Reyes Moreno I, Gutiérrez Aceves A, González Aguilar A. The Comparative Treatment of Intraventricular Chemotherapy by Ommaya Reservoir vs. Lumbar Puncture in Patients With Leptomeningeal Carcinomatosis. Front Oncol 2018; 8:509. [PMID: 30524956 PMCID: PMC6256195 DOI: 10.3389/fonc.2018.00509] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 10/17/2018] [Indexed: 12/05/2022] Open
Abstract
Object: Leptomeningeal Carcinomatosis (LCM) represents a state of systemic malignant disease with poor prognosis. The purpose of this study is to compare overall survival (OS) between intraventricular chemotherapy through Ommaya reservoir (OR) and chemotherapy through lumbar puncture (LP) in LCM. Patients and Methods: Forty adult patients with LCM were included. All patients underwent lumbar puncture and Magnetic resonance imaging (MRI). Thirty patients received chemotherapy through LP and 10 undergone colocation of Ommaya reservoir for intraventricular chemotherapy. Results: The most common symptom was headache (Present in 50%). The cranial nerves most affected were VI and VII. Leptomeningeal enhancement was the most frequent finding in MRI. The OS in the LP group was 4 months and Ommaya group was 9.2 months (p = 0.0006; CI:1.8-3), with statistical differences in favor to Intraventricular treatment. Proportional hazard regression showed that receiving chemotherapy through Ommaya reservoir was a protective factor (Hazard ratio = 0.258, Standard Error = 0.112, p = 0.002 and 95% CI 0.110-0.606). Using KPS as a factor did not affect the hazard ratio of Ommaya reservoir itself. Conclusions: OS was significantly higher in patients with Ommaya reservoir in spite of Karnofsky Performance Status (KPS) previous to chemotherapy. Therefore, intraventricular chemotherapy should be preferred over lumbar puncture chemotherapy administration if there are resources available.
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Affiliation(s)
- Mariano Montes de Oca Delgado
- Emergency Department, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez" (INNN), Mexico City, Mexico
| | | | - José Santos Zambrano
- Emergency Department, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez" (INNN), Mexico City, Mexico
| | - Vicente Guerrero Juárez
- Emergency Department, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez" (INNN), Mexico City, Mexico
| | - Manuel Salvador López Martínez
- Emergency Department, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez" (INNN), Mexico City, Mexico
| | - Elvira Castro Martínez
- Emergency Department, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez" (INNN), Mexico City, Mexico
| | - Javier Avendaño Méndez-Padilla
- Neurosurgery Department, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez" (INNN), Mexico City, Mexico.,Neurooncology Department, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez" (INNN), Mexico City, Mexico
| | - Sonia Mejía Pérez
- Neurosurgery Department, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez" (INNN), Mexico City, Mexico.,Neurooncology Department, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez" (INNN), Mexico City, Mexico
| | - Ignacio Reyes Moreno
- Neurological Service, The American British Cowdray Medical Center, Mexico City, Mexico
| | - Axayacatl Gutiérrez Aceves
- Neurological Service, The American British Cowdray Medical Center, Mexico City, Mexico.,Radioneurosurgery Department, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez" (INNN), Mexico City, Mexico
| | - Alberto González Aguilar
- Emergency Department, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez" (INNN), Mexico City, Mexico.,Neurosurgery Department, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez" (INNN), Mexico City, Mexico.,Neurooncology Department, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez" (INNN), Mexico City, Mexico.,Neurological Service, The American British Cowdray Medical Center, Mexico City, Mexico
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Abstract
Leptomeningeal metastasis (LM) results from dissemination of cancer cells to both the leptomeninges (pia and arachnoid) and cerebrospinal fluid (CSF) compartment. Breast cancer, lung cancer, and melanoma are the most common solid tumors that cause LM. Recent approval of more active anticancer therapies has resulted in improvement in survival that is partly responsible for an increased incidence of LM. Neurologic deficits, once manifest, are mostly irreversible, and often have a significant impact on patient quality of life. LM-directed therapy is based on symptom palliation, circumscribed use of neurosurgery, limited field radiotherapy, intra-CSF and systemic therapies. Novel methods of detecting LM include detection of CSF circulating tumor cells and tumor cell-free DNA. A recent international guideline for a standardization of response assessment in LM may improve cross-trial comparisons as well as within-trial evaluation of treatment. An increasing number of retrospective studies suggest that molecular-targeted therapy, such as EGFR and ALK inhibitors in lung cancer, trastuzumab in HER2+ breast cancer, and BRAF inhibitors in melanoma, may be effective as part of the multidisciplinary management of LM. Prospective randomized trials with standardized response assessment are needed to further validate these preliminary findings.
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13
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Kountourakis P, Papamichael D, Haralambous H, Michael M, Nakos G, Lazaridou S, Fotiou E, Vassiliou V, Andreopoulos D. Leptomeningeal metastases originated from esophagogastric junction/gastric cancer: A brief report of two cases. World J Gastrointest Oncol 2018; 10:56-61. [PMID: 29375749 PMCID: PMC5767794 DOI: 10.4251/wjgo.v10.i1.56] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 10/22/2017] [Accepted: 12/05/2017] [Indexed: 02/05/2023] Open
Abstract
Leptomeningeal carcinomatosis is a very rare manifestation in patients diagnosed with esophagogastric junction and gastric cancer. Its prognosis is ominous and therapy outcomes are disappointing. Herein, we present two patients; one initially diagnosed with gastric cancer and leptomeningeal carcinomatosis but no other evidence of metastatic disease and the other one initially diagnosed with esophagogastric junction cancer, who recurred solitary with leptomeningeal seedings several years after the initial diagnosis and treatment. Furthermore, a thorough and short review of the literature is carried out.
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Affiliation(s)
| | | | | | - Michael Michael
- Department of Cytology, General Hospital of Nicosia, Nicosia 2029, Cyprus
| | - Georgios Nakos
- Department of Pathology, General Hospital of Nicosia, Nicosia 2029, Cyprus
| | - Sylvia Lazaridou
- Department of Medical Oncology, BOC Oncology Centre, Nicosia 2006, Cyprus
| | - Eleni Fotiou
- Department of Medical Oncology, BOC Oncology Centre, Nicosia 2006, Cyprus
| | | | - Demetrios Andreopoulos
- Department of Radiology, BOC Oncology Centre, Nicosia 2006, Cyprus
- Department of Radiation Oncology, BOC Oncology Centre, Nicosia 2029, Cyprus
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14
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Lin NU, Gaspar LE, Soffietti R. Breast Cancer in the Central Nervous System: Multidisciplinary Considerations and Management. Am Soc Clin Oncol Educ Book 2017; 37:45-56. [PMID: 28561683 DOI: 10.1200/edbk_175338] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Breast cancer is the second most common primary tumor associated with central nervous system (CNS) metastases. Patients with metastatic HER2-positive or triple-negative (estrogen receptor (ER)-negative, progesterone receptor (PR)-negative, HER2-negative) breast cancer are at the highest risk of developing parenchymal brain metastases. Leptomeningeal disease is less frequent but is distributed across breast cancer subtypes, including lobular breast cancer. Initial treatment strategies can include surgery, radiation, intravenous or intrathecal chemotherapy, and/or targeted approaches. In this article, we review the epidemiology of breast cancer brain metastases, differences in clinical behavior and natural history by tumor subtype, and important considerations in the multidisciplinary treatment of these patients. We will highlight new findings that impact current standards of care, clinical controversies, and notable investigational approaches in clinical testing.
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Affiliation(s)
- Nancy U Lin
- From the Breast Oncology Center, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO; Department of Neuro-Oncology, University of Turin and City of Health and Science Hospital, Turin, Italy
| | - Laurie E Gaspar
- From the Breast Oncology Center, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO; Department of Neuro-Oncology, University of Turin and City of Health and Science Hospital, Turin, Italy
| | - Riccardo Soffietti
- From the Breast Oncology Center, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO; Department of Neuro-Oncology, University of Turin and City of Health and Science Hospital, Turin, Italy
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15
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Abstract
Among the various routes of drug administration, perhaps the least studied is intracerebroventricular (ICV) administration. This route has been shown to be particularly useful in administering to the central nervous system (CNS) drugs that do not cross the blood-brain barrier readily. As such, the ICV route is a valuable option for providing therapeutic CNS drug concentrations to treat patients with CNS infectious and neoplastic diseases. This route of drug administration also has the advantage of minimizing systemic toxicity.
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Affiliation(s)
- Arthur J Atkinson
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University Chicago, Illinois, USA
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16
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Nayar G, Ejikeme T, Chongsathidkiet P, Elsamadicy AA, Blackwell KL, Clarke JM, Lad SP, Fecci PE. Leptomeningeal disease: current diagnostic and therapeutic strategies. Oncotarget 2017; 8:73312-73328. [PMID: 29069871 PMCID: PMC5641214 DOI: 10.18632/oncotarget.20272] [Citation(s) in RCA: 106] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 07/20/2017] [Indexed: 12/28/2022] Open
Abstract
Leptomeningeal disease has become increasingly prevalent as novel therapeutic interventions extend the survival of cancer patients. Although a majority of leptomeningeal spread occurs secondary to breast cancer, lung cancer, and melanoma, a wide variety of malignancies have been reported as primary sources. Symptoms on presentation are equally diverse, often involving a combination of neurological deficits with the possibility of obstructive hydrocephalus. Diagnosis is definitively made via cerebrospinal fluid cytology for malignant cells, but neuro-imaging with high quality T1-weighted magnetic resonance imaging can aid diagnosis and localization. While leptomeningeal disease is still a terminal, late-stage complication, a variety of treatment modalities, such as intrathecal chemotherapeutics and radiation therapy, have improved median survival from 4–6 weeks to 3–6 months. Positive prognosticative factors for survival include younger age, high performance scores, and controlled systemic disease. In looking to the future, diagnostics that improve early detection and chemotherapeutics tailored to the primary malignancy will likely be the most significant advances in improving survival.
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Affiliation(s)
- Gautam Nayar
- Duke Brain Tumor Immunotherapy Program, Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.,The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA.,Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Tiffany Ejikeme
- Duke Brain Tumor Immunotherapy Program, Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.,The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA.,Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Pakawat Chongsathidkiet
- Duke Brain Tumor Immunotherapy Program, Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.,The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA.,Department of Pathology, Duke University Medical Center, Durham, NC, USA
| | - Aladine A Elsamadicy
- Duke Brain Tumor Immunotherapy Program, Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.,The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA.,Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Kimberly L Blackwell
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey M Clarke
- Division of Medical Oncology, Duke University Medical Center, Durham, NC, USA
| | - Shivanand P Lad
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Peter E Fecci
- Duke Brain Tumor Immunotherapy Program, Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.,The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA.,Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.,Department of Pathology, Duke University Medical Center, Durham, NC, USA
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17
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Chowdhary S, Damlo S, Chamberlain MC. Cerebrospinal Fluid Dissemination and Neoplastic Meningitis in Primary Brain Tumors. Cancer Control 2017; 24:S1-S16. [PMID: 28557973 DOI: 10.1177/107327481702400118] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Neoplastic meningitis, also known as leptomeningeal disease, affects the entire neuraxis. The clinical manifestations of the disease may affect the cranial nerves, cerebral hemispheres, or the spine. Because of the extent of disease involvement, treatment options and disease staging should involve all compartments of the cerebrospinal fluid (CSF) and subarachnoid space. Few studies of patients with primary brain tumors have specifically addressed treatment for the secondary complication of neoplastic meningitis. Therapy for neoplastic meningitis is palliative in nature and, rarely, may have a curative intent. METHODS A review of the medical literature pertinent to neoplastic meningitis in primary brain tumors was performed. The complication of neoplastic meningitis is described in detail for the various types of primary brain tumors. RESULTS Treatment of neoplastic meningitis is complicated because determining who should receive aggressive, central nervous system (CNS)-directed therapy is difficult. In general, the therapeutic response of neoplastic meningitis is a function of CSF cytology and, secondarily, of the clinical improvement in neurological manifestations related to the disease. CSF cytology may manifest a rostrocaudal disassociation; thus, consecutive, negative findings require that both lumbar and ventricular cytological testing are performed to confirm the complete response. Based on data from several prospective, randomized trials extrapolated to primary brain tumors, the median rate of survival for neoplastic meningitis is several months. Oftentimes, therapy directed at palliation may improve quality of life by protecting patients from experiencing continued neurological deterioration. CONCLUSIONS Neoplastic meningitis is a complicated disease in which response to therapy varies by histology. Thus, survival rates after CNS-directed therapy will differ by the underlying primary tumor. Optimal therapy of neoplastic meningitis is poorly defined, and few guidelines exist to guide clinicians on the most appropriate choice of therapy.
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Affiliation(s)
| | | | - Marc C Chamberlain
- Seattle Cancer Care Alliance, Cascadian Therapeutics, Seattle, Washington, USA.
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18
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Chamberlain M, Junck L, Brandsma D, Soffietti R, Rudà R, Raizer J, Boogerd W, Taillibert S, Groves MD, Le Rhun E, Walker J, van den Bent M, Wen PY, Jaeckle KA. Leptomeningeal metastases: a RANO proposal for response criteria. Neuro Oncol 2017; 19:484-492. [PMID: 28039364 PMCID: PMC5464328 DOI: 10.1093/neuonc/now183] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Leptomeningeal metastases (LM) currently lack standardization with respect to response assessment. A Response Assessment in Neuro-Oncology (RANO) working group with expertise in LM developed a consensus proposal for evaluating patients treated for this disease. Three basic elements in assessing response in LM are proposed: a standardized neurological examination, cerebral spinal fluid (CSF) cytology or flow cytometry, and radiographic evaluation. The group recommends that all patients enrolling in clinical trials undergo CSF analysis (cytology in all cancers; flow cytometry in hematologic cancers), complete contrast-enhanced neuraxis MRI, and in instances of planned intra-CSF therapy, radioisotope CSF flow studies. In conjunction with the RANO Neurological Assessment working group, a standardized instrument was created for assessing the neurological exam in patients with LM. Considering that most lesions in LM are nonmeasurable and that assessment of neuroimaging in LM is subjective, neuroimaging is graded as stable, progressive, or improved using a novel radiological LM response scorecard. Radiographic disease progression in isolation (ie, negative CSF cytology/flow cytometry and stable neurological assessment) would be defined as LM disease progression. The RANO LM working group has proposed a method of response evaluation for patients with LM that will require further testing, validation, and likely refinement with use.
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Affiliation(s)
- Marc Chamberlain
- Department of Neurology, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington, USA
| | - Larry Junck
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - Dieta Brandsma
- Department of Neuro-Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | | | - Roberta Rudà
- Department of Neuro-Oncology, University Hospital, Torino, Italy
| | - Jeffrey Raizer
- Department of Neurology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois, USA
| | - Willem Boogerd
- Department of Neuro-Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Sophie Taillibert
- Departments of Neuro-Oncology Marazin and Radiation Oncology, Pitie-Salpetrieree Hospital and University Pierre et Marie Curie, Paris VI, Paris, France
| | - Morris D Groves
- Austin Brain Tumor Center, Texas Oncology/US Oncology Research, Austin, Texas, USA
| | - Emilie Le Rhun
- Department of Neuro-Oncology, University Hospital, Department of Neurology, Oscar Lambret Center, Lille, France
| | - Julie Walker
- Department of Neuro-Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Martin van den Bent
- Department of Neuro-oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, Netherlands
| | - Patrick Y Wen
- Center for Neuro-Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts, USA
| | - Kurt A Jaeckle
- Departments of Neurology and Oncology, Mayo Clinic Florida, Jacksonville, Florida, USA
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19
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Korfel A, Nowosielski M, Pardo-Moreno J, Penalver FJ, Buda G, Bennani H, Costopoulos M, Le Garff-Tavernier M, Soussain C, Schmid M, Orfao JA, Glantz M. How to facilitate early diagnosis of CNS involvement in malignant lymphoma. Expert Rev Hematol 2016; 9:1081-1091. [PMID: 27677656 DOI: 10.1080/17474086.2016.1242405] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Making the diagnosis of secondary CNS involvement in lymphoma can be difficult due to unspecific signs and symptoms, limited accessibility of brain/myelon parenchyma and low sensitivity and/or specifity of imaging and cerebrospinal fluid (CSF) examination currently available. Areas covered: MRI of the total neuroaxis followed by CSF cytomorphology and flow cytometry are methods of choice when CNS lymphoma (CNSL) is suspected. To reduce the numerous pitfalls of these examinations several aspects should be considered. New CSF biomarkers might be of potential diagnostic value. Attempts to standardize response criteria are presented. Expert commentary: Diagnosing CNSL remains challenging. Until diagnostic methods combining high sensitivity with high specifity are routinely introduced, high level of awareness and optimal utilization of examinations currently available are needed to early diagnose this potentially devastating disease.
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Affiliation(s)
- Agnieszka Korfel
- a Department of Hematology, Oncology and Tumor Immunology , Charite University Medicine Berlin , Berlin , Germany
| | - Martha Nowosielski
- b Department of Neurology , Medical University Innsbruck , Innsbruck , Austria
| | - Javier Pardo-Moreno
- c Department of Neurology , University Hospital King Juan Carlos , Madrid , Spain
| | | | - Gabriele Buda
- e Department of Hematology and Oncology , University of Pisa , Pisa , Italy
| | - Hind Bennani
- f Department of Biology , Hôpital Foch , Suresnes , France
| | - Myrto Costopoulos
- g Department of Biological Hematology , Pitie Salpetriere Hospital , Paris , France
| | | | - Carole Soussain
- h Department of Hematology , Institut Curie - Hôpital René Huguenin , Paris , France
| | - Mathias Schmid
- i Department of Hematology and Oncology , Stadtspital Triemli Zürich , Zürich , Switzerland
| | - Jose Alberto Orfao
- j Department of Medicine and Cytometry Service , University of Salamanca , Salamanca , Spain
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20
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Temporal changes of spinal subarachnoid space patency after graded spinal cord injury in rats. Injury 2015; 46:634-7. [PMID: 25616676 DOI: 10.1016/j.injury.2015.01.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 01/03/2015] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Disturbances in spinal subarachnoid space (SSAS) patency after SCI have been reported as an incidental finding, but there is a lack of information on its in vivo extent and time course. For substances and cells carried in the cerebrospinal fluid (CSF) to reach damaged neural tissue and promote reparative processes, CSF must be able to flow freely in SASS. OBJECTIVE To characterise the extent and time course of SSAS patency disruption in vivo in a rat model after graded SCI. MATERIALS AND METHODS Anaesthetised rats were subjected to mild or severe cord contusion at T9. Estimation of SSAS patency was carried out at 1h and 1, 3, 7, 15, 30 and 90 days postinjury, as well as in naïve rats, by quantifying the passage of superparamagnetic beads injected into the CSF at the cisterna magna and recovered at spinal level L2. CSF volume recovery was measured simultaneously. Data were analysed by the two-way ANOVA test. RESULTS Estimation of SSAS patency revealed nearly complete blockage early after contusion that was unevenly restored entering the chronic stages. Volume of CSF recovered was also significantly decreased early after injury compared to naïve rats, but was fully restored by 1 month postinjury. Overall, although modestly different from each other, changes in both parameters were more pronounced after severe rather than mild injuries for each time point examined. CONCLUSIONS SCI alters SSAS patency. Its extent is a function primarily of time elapsed after lesion and secondly of injury severity. It is reasonable to expect that disturbances in SASS patency might alter CSF dynamics and impair self-reparative mechanisms and intrathecal therapeutics, making SSAS patency blockage a key target for SCI management.
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21
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Chamberlain MC. Comprehensive neuraxis imaging in leptomeningeal metastasis: a retrospective case series. CNS Oncol 2015; 2:121-8. [PMID: 25057975 DOI: 10.2217/cns.12.45] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM Quantify imaging abnormalities in a retrospective case series of patients with leptomeningeal metastasis (LM). METHODS A total of 240 adult patients with LM (125 nonbrain solid tumor patients with positive cerebrospinal fluid [CSF] cytology; 40 nonbrain solid tumor patients with negative CSF cytology and positive MRI; and 50 lymphoma and 25 leukemia patients with positive CSF-flow cytometry) underwent brain and entire spine MRI and radioisotope CSF-flow studies prior to treatment. RESULTS MRI was more often abnormal in solid tumors (40 CSF defined and 100% in MRI defined) compared with hematologic cancers (16-20%; p = 0.03). Similarly, CSF-flow studies was more often abnormal in solid tumors (25-28%) compared with hematologic cancers (10-20%; p = 0.04). MRI and flow-study abnormalities altered therapy in a third of solid tumors and 15% of hematologic cancers. CONCLUSION Although imaging abnormalities are less often seen in hematologic cancers compared with solid tumor LM, imaging abnormalities frequently result in treatment alteration.
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Affiliation(s)
- Marc C Chamberlain
- University of Washington, Department of Neurology/Division of Neuro-Oncology, Fred Hutchinson Cancer Research Center, Seattle Cancer Care Alliance, 825 Eastlake Avenue E, PO Box 19023, MS G4940, Seattle, WA 98109-1023, USA.
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22
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Comprehensive craniospinal radiation for controlling central nervous system leukemia. Int J Radiat Oncol Biol Phys 2015; 90:1119-25. [PMID: 25539370 DOI: 10.1016/j.ijrobp.2014.08.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 07/18/2014] [Accepted: 08/02/2014] [Indexed: 11/24/2022]
Abstract
PURPOSE To determine the benefit of radiation therapy (RT) in resolution of neurologic symptoms and deficits and whether the type of RT fields influences central nervous system (CNS) control in adults with CNS leukemia. METHODS AND MATERIALS A total of 163 adults from 1996 to 2012 were retrospectively analyzed. Potential associations between use of radiation and outcome were investigated by univariate and multivariate analysis. RESULTS The median survival time was 3.8 months after RT. Common presenting symptoms were headache in 79 patients (49%), cranial nerve VII deficit in 46 (28%), and cranial nerve II deficit in 44 (27%). RT was delivered to the base of skull in 48 patients (29%), to the whole brain (WB) in 67 (41%), and to the craniospinal axis (CS) in 48 (29%). Among 149 patients with a total of 233 deficits, resolution was observed in 34 deficits (15%), improvement in 126 deficits (54%), stability in 34 deficits (15%), and progression in 39 deficits (17%). The 12-month CNS progression-free survival was 77% among those receiving CS/WB and 51% among those receiving base of skull RT (P=.02). On multivariate analysis, patients who did not undergo stem cell transplantation after RT and base of skull RT were associated with worse CNS progression-free survival. CONCLUSIONS Improvement or resolution of symptoms occurred in two thirds of deficits after RT. Comprehensive radiation to the WB or CS seems to offer a better outcome, especially in isolated CNS involvement.
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23
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Genoni S, Palus V, Eminaga S, Cherubini GB. Safety of intrathecal administration of cytosine arabinoside and methotrexate in dogs and cats. Vet Comp Oncol 2014; 14:331-6. [DOI: 10.1111/vco.12109] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Revised: 05/27/2014] [Accepted: 06/10/2014] [Indexed: 11/27/2022]
Affiliation(s)
- S. Genoni
- Dick White Referrals; Veterinary Specialist Centre; Suffolk UK
| | - V. Palus
- Dick White Referrals; Veterinary Specialist Centre; Suffolk UK
| | - S. Eminaga
- Dick White Referrals; Veterinary Specialist Centre; Suffolk UK
| | - G. B. Cherubini
- Dick White Referrals; Veterinary Specialist Centre; Suffolk UK
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24
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Kumar DS, Noronha V, Joshi A, Jain H, Prabhash K. Carcinomatous meningitis in non-small cell lung cancer: Palliation with intrathecal treatment. Indian J Med Paediatr Oncol 2014; 35:75-8. [PMID: 25006289 PMCID: PMC4080668 DOI: 10.4103/0971-5851.133726] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Carcinomatous meningitis or meningeal carcinomatosis is seen in up to 5% of patients of metastatic non-small cell lung cancer. However, isolated carcinomatous meningitis without brain parenchymal metastasis is less common. Patients with carcinomatous meningitis have limited treatment options. However, intrathecal therapy if used optimally along with targeted therapy when indicated result in good palliation with improvement in survival.
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Affiliation(s)
- D Santhosh Kumar
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Vanita Noronha
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Amit Joshi
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Hasmukh Jain
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Kumar Prabhash
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
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25
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Guo JW, Zhang XT, Chen XS, Zhang XC, Zheng GJ, Zhang BP, Cai YF. Leptomeningeal carcinomatosis as the initial manifestation of gastric adenocarcinoma: A case report. World J Gastroenterol 2014; 20:2120-2126. [PMID: 24587686 PMCID: PMC3934485 DOI: 10.3748/wjg.v20.i8.2120] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Accepted: 01/08/2014] [Indexed: 02/06/2023] Open
Abstract
Leptomeningeal involvement is usually reported as a secondary event in advanced gastric carcinoma. Leptomeningeal carcinomatosis (LMC), as the initial manifestation of asymptomatic gastric cancer, is exceedingly rare with only a few cases reported in recent years. The presenting neurologic symptoms include headache, vomiting and seizures and are usually clinically atypical. The diagnosis of LMC is made via identification of malignant cells that originate from epithelial cells in the cerebrospinal fluid by cytological examination and provides cues to track the primary tumor. Endoscopic examinations are crucial to confirm the presence of gastric cancer, and imaging studies, especially gadolinium-enhanced magnetic resonance imaging of the brain, are sometimes helpful in diagnosis. Thus far, there is no standard therapy for LMC, and despite all measures, the prognosis of the condition is extremely poor. Here, we report on the clinical features and diagnostic procedures for a patient with occult gastric cancer with Bormann type I macroscopic appearance and poor differentiation in pathology, who presented with LMC-induced neurological symptoms as the initial clinical manifestation. Additionally, we review the similar cases reported over the past years, making comparison among cases in order to provide more information for the future diagnosis.
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26
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Franco-Bourland RE, Guízar-Sahagún G, Quintana-Armenta A, Reyes-Alva HJ, Martínez-Cruz A, Madrazo I. Superparamagnetic beads for estimation of spinal subarachnoid space permeability in rats. J Neurosci Methods 2013; 219:271-5. [DOI: 10.1016/j.jneumeth.2013.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Revised: 07/24/2013] [Accepted: 08/05/2013] [Indexed: 01/27/2023]
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27
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Papisov MI, Belov VV, Gannon KS. Physiology of the intrathecal bolus: the leptomeningeal route for macromolecule and particle delivery to CNS. Mol Pharm 2013; 10:1522-32. [PMID: 23316936 PMCID: PMC3646927 DOI: 10.1021/mp300474m] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Presently, there are no effective treatments for several diseases involving the CNS, which is protected by the blood-brain, blood-CSF, and blood-arachnoid barriers. Traversing any of these barriers is difficult, especially for macromolecular drugs and particulates. However, there is significant experimental evidence that large molecules can be delivered to the CNS through the cerebrospinal fluid (CSF). The flux of the interstitial fluid in the CNS parenchyma, as well as the macro flux of CSF in the leptomeningeal space, are believed to be generally opposite to the desirable direction of CNS-targeted drug delivery. On the other hand, the available data suggest that the layer of pia mater lining the CNS surface is not continuous, and the continuity of the leptomeningeal space (LMS) with the perivascular spaces penetrating into the parenchyma provides an unexplored avenue for drug transport deep into the brain via CSF. The published data generally do not support the view that macromolecule transport from the LMS to CNS is hindered by the interstitial and CSF fluxes. The data strongly suggest that leptomeningeal transport depends on the location and volume of the administered bolus and consists of four processes: (i) pulsation-assisted convectional transport of the solutes with CSF, (ii) active "pumping" of CSF into the periarterial spaces, (iii) solute transport from the latter to and within the parenchyma, and (iv) neuronal uptake and axonal transport. The final outcome will depend on the drug molecule behavior in each of these processes, which have not been studied systematically. The data available to date suggest that many macromolecules and nanoparticles can be delivered to CNS in biologically significant amounts (>1% of the administered dose); mechanistic investigation of macromolecule and particle behavior in CSF may result in a significantly more efficient leptomeningeal drug delivery than previously thought.
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Affiliation(s)
- Mikhail I. Papisov
- Massachusetts General Hospital, Shriners Hospitals for Children – Boston, and Harvard Medical School, 51 Blossom St, Boston, MA 02114 USA
| | - Vasily V. Belov
- Massachusetts General Hospital, Shriners Hospitals for Children – Boston, and Harvard Medical School, 51 Blossom St, Boston, MA 02114 USA
| | - Kimberley S. Gannon
- NeuroPhage Pharmaceuticals, Inc. 3222 Third Street, Suite 31203 Cambridge, MA 02142 USA
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Le Rhun E, Taillibert S, Chamberlain MC. Carcinomatous meningitis: Leptomeningeal metastases in solid tumors. Surg Neurol Int 2013; 4:S265-88. [PMID: 23717798 PMCID: PMC3656567 DOI: 10.4103/2152-7806.111304] [Citation(s) in RCA: 180] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 04/11/2013] [Indexed: 11/04/2022] Open
Abstract
Leptomeningeal metastasis (LM) results from metastatic spread of cancer to the leptomeninges, giving rise to central nervous system dysfunction. Breast cancer, lung cancer, and melanoma are the most frequent causes of LM among solid tumors in adults. An early diagnosis of LM, before fixed neurologic deficits are manifest, permits earlier and potentially more effective treatment, thus leading to a better quality of life in patients so affected. Apart from a clinical suspicion of LM, diagnosis is dependent upon demonstration of cancer in cerebrospinal fluid (CSF) or radiographic manifestations as revealed by neuraxis imaging. Potentially of use, though not commonly employed, today are use of biomarkers and protein profiling in the CSF. Symptomatic treatment is directed at pain including headache, nausea, and vomiting, whereas more specific LM-directed therapies include intra-CSF chemotherapy, systemic chemotherapy, and site-specific radiotherapy. A special emphasis in the review discusses novel agents including targeted therapies, that may be promising in the future management of LM. These new therapies include anti-epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors erlotinib and gefitinib in nonsmall cell lung cancer, anti-HER2 monoclonal antibody trastuzumab in breast cancer, anti-CTLA4 ipilimumab and anti-BRAF tyrosine kinase inhibitors such as vermurafenib in melanoma, and the antivascular endothelial growth factor monoclonal antibody bevacizumab are currently under investigation in patients with LM. Challenges of managing patients with LM are manifold and include determining the appropriate patients for treatment as well as the optimal route of administration of intra-CSF drug therapy.
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Affiliation(s)
- Emilie Le Rhun
- Breast Unit, Department of Medical Oncology, Centre Oscar Lambret and Department of Neuro Oncology, Roger Salengro Hospital, University Hospital, Lille, France
| | - Sophie Taillibert
- Neurology, Mazarin and Radiation Oncology, Pitié Salpétrière Hospital, University Pierre et Marie Curie, Paris VI, Paris, France
| | - Marc C. Chamberlain
- Neurology and Neurological Surgery, University of Washington, Fred Hutchinson Research Cancer Center, Seattle, WA, USA
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Palma JA, Fernandez-Torron R, Esteve-Belloch P, Fontes-Villalba A, Hernandez A, Fernandez-Hidalgo O, Gallego Perez-Larraya J, Martinez-Vila E. Leptomeningeal carcinomatosis: Prognostic value of clinical, cerebrospinal fluid, and neuroimaging features. Clin Neurol Neurosurg 2013; 115:19-25. [DOI: 10.1016/j.clineuro.2012.03.048] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Revised: 03/25/2012] [Accepted: 03/31/2012] [Indexed: 11/17/2022]
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Martins SJ, Azevedo CRASD, Chinen LTD, Cruz MRS, Peterlevitz MA, Gimenes DL. Meningeal carcinomatosis in solid tumors. ARQUIVOS DE NEURO-PSIQUIATRIA 2012; 69:973-80. [PMID: 22297890 DOI: 10.1590/s0004-282x2011000700024] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 06/13/2011] [Accepted: 07/01/2011] [Indexed: 02/06/2023]
Abstract
The involvement of the leptomeninges by metastatic tumors can be observed in solid tumors, in which case it is termed meningeal carcinomatosis (MC), and in lymphoproliferative malignant disease. It is more common in breast and lung cancer, as well as melanoma, with adenocarcinoma being the most frequent histological type. MC is usually a late event, with disseminated and progressive disease already present and, it is characterized by multifocal neurological signs and symptoms. Diagnosis is based on the evaluation of clinical presentation, cerebrospinal fluid and neuroimaging studies. The better systemic disease control is observed with new therapeutic agents, and the development of neuroimaging methods is responsible for the increasing incidence of such metastatic evolution. Intrathecal chemotherapy is generally the treatment of choice, although frequently palliative. Prognosis is guarded, although a higher performance status may indicate a subgroup of patients with a more favorable outcome.
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Affiliation(s)
- Marc C Chamberlain
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA.
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Lombardi G, Zustovich F, Farina P, Della Puppa A, Manara R, Cecchin D, Brunello A, Cappetta A, Zagonel V. Neoplastic meningitis from solid tumors: new diagnostic and therapeutic approaches. Oncologist 2011; 16:1175-88. [PMID: 21795431 PMCID: PMC3228160 DOI: 10.1634/theoncologist.2011-0101] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Accepted: 05/17/2011] [Indexed: 01/19/2023] Open
Abstract
Neoplastic meningitis is a result of the spread of malignant cells to the leptomeninges and subarachnoid space and their dissemination within the cerebrospinal fluid. This event occurs in 4%-15% of all patients with solid tumors and represents an important prognostic factor for poor survival. Neoplastic meningitis should be diagnosed in the early stages of disease to prevent important neurological deficits and to provide the most appropriate treatment. Despite new diagnostic approaches developed in recent years, such as positron emission tomography-computed tomography and new biological markers, the combination of magnetic resonance imaging without and with gadolinium enhancement and cytology still has the greatest diagnostic sensitivity. Recently, no new randomized studies comparing intrathecal (i.t.) with systemic treatment have been performed, yet there have been a few small phase II studies and case reports about new molecularly targeted substances whose successful i.t. or systemic application has been reported. Trastuzumab, gefitinib, and sorafenib are examples of possible future treatments for neoplastic meningitis, in order to better individualize therapy thus allowing better outcomes. In this review, we analyze the most recent and interesting developments on diagnostic and therapeutic approaches.
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Affiliation(s)
- Giuseppe Lombardi
- Medical Oncology 1 Unit, Istituto Oncologico Veneto–IRCCS, Padova, Italy.
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Abstract
PURPOSE OF REVIEW Leptomeningeal metastasis occurs in approximately 5% of all patients with cancer. This review summarizes recent literature regarding methods of diagnosis and treatment of leptomeningeal metastasis. RECENT FINDINGS Staging of leptomeningeal metastasis should include contrast-enhanced brain and spine MRI, and though controversial, radionuclide cerebrospinal fluid (CSF) flow study. Treatment of leptomeningeal metastasis often requires involved-field radiotherapy to bulky or symptomatic disease sites as well as intra-CSF and systemic chemotherapy. The use of high-dose systemic therapy may benefit patients with leptomeningeal metastasis and obviate the need for intra-CSF chemotherapy. Intra-CSF drug therapy primarily utilizes one of three chemotherapeutic agents [i.e. methotrexate, cytosine arabinoside (both free and liposomal) and thio-tetraethylenepentamine] administered by a variety of schedules either by intralumbar or intraventricular drug delivery. Novel intra-CSF agents increasingly utilized in the treatment of leptomeningeal metastasis are targeted mAbs such as rituximab and trastuzumab. SUMMARY Although treatment of leptomeningeal metastasis is palliative with median patient survival of 2-3 months, treatment may afford stabilization and protection from further neurologic deterioration in patients with leptomeningeal metastasis.
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Beauchesne P. Intrathecal chemotherapy for treatment of leptomeningeal dissemination of metastatic tumours. Lancet Oncol 2010; 11:871-9. [PMID: 20598636 DOI: 10.1016/s1470-2045(10)70034-6] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Neoplastic meningitis consists of diffuse involvement of the leptomeninges by infiltrating cancer cells, and can be caused by systemic or primary CNS tumours, such as solid cancers or lymphoproliferative malignant disease. Neoplastic meningitis is characterised by multifocal neurological signs and symptoms. Thus, careful neurological examination is needed for diagnosis of secondary diffuse involvement. Survival of patients with neoplastic meningitis is short (3-4 months), although some patients have long-lasting remission. Because most patients with neoplastic meningitis have diffuse systemic disease, treatment is typically palliative. However, more aggressive treatments are available to low-risk patients, which could increase survival. Therefore, identification of low-risk patients is important. Intrathecal chemotherapy is currently the main treatment for patients with neoplastic meningitis, but optimum anticancer chemotherapy is being studied.
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Glantz MJ, Van Horn A, Fisher R, Chamberlain MC. Route of intracerebrospinal fluid chemotherapy administration and efficacy of therapy in neoplastic meningitis. Cancer 2010; 116:1947-52. [DOI: 10.1002/cncr.24921] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Abstract
Secondary involvement of the leptomeninges represents an infrequent but devastating (and nearly always fatal) complication of solid tumors, hematologic malignancies (both leukemia and lymphoma), and primary brain tumors. Clinical suspicion of neoplastic meningitis (NM) may be raised by the appearance of multivariate neurological symptoms; however, a definitive diagnosis is often difficult to obtain. Improved treatments for primary malignancies and advances in diagnostic imaging technology have led to an apparent increase in the number of patients diagnosed with NM. Unfortunately, therapeutic options remain limited, particularly for patients with chemoresistant tumors. Optimized treatment remains controversial and may rely upon a combination of chemotherapy (intrathecal and/or intravenous) and concurrent focal radiotherapy. This review discusses the advantages and disadvantages of intra-cerebrospinal fluid (CSF) versus systemic strategies for treating NM. Clinical trial evidence is presented for the different treatment modalities. In addition, the therapeutic potential of intra-CSF therapy for cancer prophylaxis is discussed. Earlier diagnosis and more aggressive preventive treatment regimens may provide substantial increases in survival and favorably affect quality of life. Additional data from large-scale, well-controlled trials are required to more accurately assess the efficacy of intra-CSF versus systemic treatment in NM. Future treatment options using novel targets for intra-CSF therapy will be addressed as well.
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Affiliation(s)
- William R Shapiro
- Division of Neurology, Director Neuro-Oncology Program, Barrow Neurological Institute, Phoenix, AZ 85013, USA.
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de Lemos ML, Monfared S, Denyssevych T, Hamata L, Jennings S, Thiessen B, Smith S, Waterhouse D. Evaluation of osmolality and pH of various concentrations of methotrexate, cytarabine, and thiotepa prepared in normal saline, sterile water for injection, and lactated Ringer's solution for intrathecal administration. J Oncol Pharm Pract 2008; 15:45-52. [DOI: 10.1177/1078155208096902] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. Neurotoxicity of intrathecal (IT) chemotherapy has been variously attributed to the preservatives, volume, osmolality, and pH of the preparations. There has been little evaluation of how different drug concentrations or diluents can affect the osmolality and pH of the final solution. We conducted a three-part study: survey of cancer centers regarding the drug concentrations and diluent used in preparing IT chemotherapy; review of the literature on common practice of preparing IT chemotherapy; evaluation of the pH and osmolality of commonly used chemotherapy preparations for IT. Method. We surveyed selected cancer centers to provide information on their standard volume, drug concentrations, and choice of diluents. MEDLINE was searched for clinical reports using the MeSH terms of `cytarabine,' `methotrexate,' or `thiotepa' with the subheading `Cerebrospinal fluid' and combined with `intrathecal' in all database fields. Data retrieved included the choice of diluent, volume, and/or drug concentration. We evaluated the pH and osmolality of methotrexate (1, 2, 5, and 10 mg/mL), cytarabine (2, 5, 10, and 25 mg/mL), and thiotepa (1, 2, and 5 mg/mL) in normal saline, sterile water for injection (SWFI), and lactated Ringer's solution. Results. Nine centers were surveyed (seven in Canada, one in Australia, one in United Kingdom). Most centers used 5mL of preservative-free normal saline, irrespective of the drug or drug concentration used. Forty-four reports in the literature were reviewed. Most reported 5 mL of preservative-free normal saline. Most information on drug concentrations was provided for methotrexate, with an average concentration of about 1—2.5 mg/ mL. Cytarabine 0.4—20 mg/mL and thiotepa 1 mg/mL were also reported. In our in vitro evaluation, there was a trend of increased pH associated with increasing concentration of methotrexate and cytarabine. There was no apparent impact of thiotepa concentration on the pH values of the final preparations, irrespective of the diluent used. Except for cytarabine 10 and 25 mg/mL, all the tested solutions have pH within 10% of the physiologic range of CSF. There was a concentration-dependent change in osmolality with methotrexate and cytarabine preparations. Osmolality was increased with increased concentrations in all except methotrexate mixed in SWFI and thiotepa mixed in normal saline and lactated Ringer's solution. Except for some thiotepa solutions, all the tested solutions have osmolality within 10% of the physiologic range of CSF. Conclusions. There is limited published literature on the potential impact of diluent and drug concentration on the pH and osmolality of IT chemotherapy preparation. Most cancer centers conventionally prepare IT chemotherapy with 5mL of preservative diluent normal saline, irrespective of the specific drug or dose used. The conventional practice means that most methotrexate preparations are likely to have comparable pH and osmolality to CSF. In contrast, cytarabine preparations may show significantly higher pH than the CSF, while thiotepa preparations generally have lower osmolality than the CSF. J Oncol Pharm Practice (2009) 15: 45—52.
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Affiliation(s)
| | - Shirin Monfared
- at the time of the study, Pharmacy, Vancouver Centre, BC Cancer Agency
| | | | | | - Sarah Jennings
- Provincial Systemic Therapy Program, Vancouver Centre, BC Cancer Agency
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Abstract
Leptomeningeal metastasis is becoming an increasingly important late complication of cancer as survival from systemic disease increases, and due to the fact that many novel cancer drugs fail to achieve therapeutic concentrations in the central nervous system. It occurs when neoplastic cells enter cerebrospinal fluid (CSF) pathways, causing diffuse infiltration of the subarachnoid space of the brain and spinal cord. Definitive diagnosis is established by the demonstration of malignant cells in the CSF. However, in certain circumstances the presence of leptomeningeal enhancement on brain or spinal MRI may be sufficient to make the diagnosis. Early diagnosis and aggressive treatment may delay neurologic progression and can lead to prolonged survival and improvement of neurologic function in certain patients. The prognosis depends on the underlying malignancy but is often poor, with a median survival of 4 months, and most treatment interventions are palliative. Nevertheless, some patients respond to treatment, and some survive beyond 1 or 2 years after diagnosis. Areas of radiographic bulky disease or symptomatic tumor should receive radiotherapy. Intrathecal chemotherapy is most effective in patients with lymphoma, leukemia, or breast cancer and without evidence of bulky disease on neuroimaging. Intrathecal chemotherapy requires normal CSF flow, and the most commonly used agents are methotrexate, cytarabine, and thiotepa. In lieu of intrathecal therapy, systemic chemotherapy may occasionally be indicated in select patients in part based on its ability to penetrate into bulky disease. When hydrocephalus occurs, ventriculoperitoneal shunting frequently leads to rapid clinical improvement. There is hope that progress in diagnostic modalities and the development of more effective intrathecal antineoplastic drugs may decrease neurologic morbidity and improve quality of life and survival.
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Affiliation(s)
- Jan Drappatz
- Jan Drappatz, MD Harvard Medical School, Department of Neurology, Brigham and Women’s Hospital and Dana-Farber/Brigham and Women’s Cancer Center, Center for Neuro-Oncology, 44 Binney Street SW 430, Boston, MA 02115, USA.
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Affiliation(s)
- William P O'Meara
- Department Radiation Oncology, National Naval Medical Center, Bethesda, Maryland, USA
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Taillibert S, Hildebrand J. Treatment of central nervous system metastases: parenchymal, epidural, and leptomeningeal. Curr Opin Oncol 2008; 18:637-43. [PMID: 16988587 DOI: 10.1097/01.cco.0000245323.19411.d7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW With prolonged survival from systemic therapies in the adjuvant and salvage setting, and because these agents cannot cross the intact blood-brain barrier, central nervous system metastases are becoming a therapeutic challenge in oncology. RECENT FINDINGS Recent therapeutic achievements include an extended use of surgery and radiosurgery. Although each of these treatment modalities has its own indications, in patients eligible for both treatments the upfront comparison of these two techniques has not been performed yet. Systemic chemotherapies and biotherapies may be effective in the management of central nervous system metastases as they may act on both neurologic and extra-central nervous system lesions. In the treatment of epidural metastases, a surgical procedure providing immediate direct circumferential decompression of the spinal cord followed by local irradiation has been demonstrated in a prospective randomized trial. The management of leptomeningeal metastases remains controversial and of limited efficacy especially in chemoresistant tumours and still relies on the combination of chemotherapy (intrathecal and intravenous) and focal radiotherapy. SUMMARY Aggressive treatments in patients with early diagnosis and in whom central nervous system metastases are the life-threatening location may provide a substantial increase in survival and favourably affect quality of life.
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Boogerd W. Leptomeningeal metastasis in solid tumours: Is there a role for intrathecal therapy? EJC Suppl 2007. [DOI: 10.1016/s1359-6349(07)70022-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Abstract
Cerebral metastases remain a common complication among patients with cancer. Surgery and radiotherapy remain the principal therapeutic interventions. In contrast, the benefit of chemotherapy has long been viewed with skepticism. Nonetheless, as survival in cancer patients improves and the incidence of cerebral metastases increases, so does the demand for effective therapies. It is now recognized that the blood-brain barrier within metastases is permeable and thus allows entry of otherwise excluded drugs. Limited data have suggested that cerebral metastases have modest sensitivity to chemotherapy. Furthermore, novel agents and delivery strategies have been developed to facilitate central nervous system penetration. Nonetheless, data are limited by methodological flaws, including heterogeneous inclusion criteria, small sample sizes, lack of randomization, and inconsistencies in defined end points and response assessment criteria. Well-designed clinical trials are needed to address the effect of chemotherapy. Acceptable control arms must be established to measure the effect of chemotherapies. Standardized response criteria and disease-specific studies are essential.
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Affiliation(s)
- Robert Cavaliere
- Dardinger Neuro-Oncology Center, The Ohio State University, Columbus, Ohio, USA
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Abstract
✓Lymphomatous meningitis (LM) due to primary central nervous system (CNS) lymphoma is an uncommon problem in neurooncology and can occur at time of diagnosis or recurrence. Notwithstanding frequent focal signs and symptoms, LM is a disease affecting the entire neuraxis, and therefore staging and treatment need to encompass all cere-brospinal fluid (CSF) compartments. Central nervous system staging of LM includes contrast agent–enhanced cranial computed tomography (CT) or Gd-enhanced magnetic resonance (MR) imaging, Gd-enhanced spinal MR imaging, CT myelography, and radionuclide CSF flow study. Treatment of LM includes involved-field radiotherapy of bulky or symptomatic disease sites and intra-CSF drug therapy. The inclusion of concomitant systemic therapy can benefit patients with LM and can obviate the need for intra-CSF chemotherapy. At present, intra-CSF drug therapy is confined to three chemotherapeutic agents (methotrexate, cytosine arabinoside, and thiotepa) administered by a variety of schedules either by intralumbar or intraventricular drug delivery. Although treatment of LM is palliative and the expected median survival of patients is 4 to 6 months, it often provides stabilization and protection from further neurological deterioration. In patients with primary CNS lymphoma, CNS prophylaxis has been recommended (using a combination of high-dose systemic chemotherapy and intra-CSF chemotherapy), but the strategy remains controversial because high-dose systemic methotrexate is commonly used as an adjuvant therapy. Patients with primary CNS lymphoma at high risk as defined by positive CSF cytology or neuroradiography consistent with LM may benefit from the inclusion of intra-CSF chemotherapy.
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Affiliation(s)
- Marc C Chamberlain
- Department of Interdisciplinary Oncology, NeuroProgram, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Avenue, Tampa, Florida 33612-0804, USA.
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Abstract
BACKGROUND Neoplastic meningitis (NM) is a common problem in neuro-oncology, occurring in approximately 5% of all patients with cancer. REVIEW SUMMARY Notwithstanding frequent focal signs and symptoms in NM, NM is a disease affecting the entire neuraxis, and therefore staging and treatment need encompass all cerebrospinal fluid (CSF) compartments. RESULTS Central nervous system (CNS) staging of NM includes contrast-enhanced cranial computed tomography (CE-CT) or magnetic resonance imaging (MR-Gd), contrast-enhanced spine magnetic resonance imaging (MR-S) or computed tomographic myelography (CT-M), and radionuclide CSF flow study (FS). Treatment of NM incorporates involved-field radiotherapy of bulky or symptomatic disease sites and intra-CSF drug therapy. The inclusion of concomitant systemic therapy may benefit patients with NM and may obviate the need for intra-CSF chemotherapy. At present, intra-CSF drug therapy is confined to 3 chemotherapeutic agents (ie, methotrexate, cytosine arabinoside, and thio-TEPA) administered by a variety of schedules either by intralumbar or intraventricular drug delivery. CONCLUSIONS Although treatment of NM is palliative, with an expected median patient survival of 2 to 6 months, it often affords stabilization and protection from further neurologic deterioration in patients with NM.
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Affiliation(s)
- Marc C Chamberlain
- Department of Interdisciplinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, University of Southern Florida, Neuro-Oncology Program, Tampa, Florida 33612, USA.
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Abstract
Long-term survival is occasionally observed in patients with neoplastic meningitis (NM) accompanying breast cancer (13% one-year and 6% 2-year survival), melanoma, and lymphoma, but in general the survival of most patients is short and averages only 3 to 4 months. The incidence of NM appears to be increasing, in part due to earlier detection by magnetic resonance imaging (MRI), and in part due to development of more effective therapies for systemic cancer, which has resulted in a larger subset at risk for late-stage development of this complication. Survival of NM patients is negatively affected by concomitant progression of systemic disease despite multiple prior therapies. However, there are certain prognostic factors that have been identified as "favorable" in retrospective series, including age less than 60 years, long symptom duration, controlled systemic disease, Karnofsky performance status (KPS) > or =70, lack of encephalopathy or cranial nerve deficits, low initial cerebrospinal fluid (CSF) protein level, history of breast primary tumor, and lack of evidence of CSF compartmentalization or bulky meningeal disease as determined by CSF flow studies. Standard treatment has traditionally involved radiotherapy (RT) to sites of symptomatic or bulky disease, as detected by neuroimaging, and in selected patients, the administration of intrathecal, intraventricular, or systemic chemotherapy. However, treatment remains palliative and many patients and physicians choose supportive care only. Future hope is provided by studies that have improved our understanding of the disease pathogenesis, have identified prognostic variables associated with outcome, and have provided new therapeutic approaches, such as administration of high-dose systemic chemotherapy and investigations of novel therapeutic agents.
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Affiliation(s)
- Kurt A Jaeckle
- Department of Neurology and Oncology, Mayo Clinic Jacksonville, Jacksonsville, FL 32224, USA.
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