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Pabon CM, Yeboa DN, O'Brien BJ, Majd NK, Wang C, Blum Murphy MA. Intrathecal topotecan with systemic checkpoint inhibitor therapy for gastroesophageal cancer with leptomeningeal involvement: two case reports and review of the literature. J Gastrointest Oncol 2024; 15:1331-1340. [PMID: 38989402 PMCID: PMC11231862 DOI: 10.21037/jgo-24-70] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 04/26/2024] [Indexed: 07/12/2024] Open
Abstract
Background Leptomeningeal metastases (LM) in gastroesophageal (GE) malignancies are exceedingly rare. Historically, treatment for LM has included steroids, radiation, chemotherapy, and intrathecal (IT) chemotherapy. However, the outcomes in GE malignancies with LM remain poor. Unfortunately, clinical trials in GE malignancies have traditionally excluded those with LM, limiting advances in therapeutic strategies. Given that LM poses potentially devastating neurologic and psychologic sequelae, there is an urgent need for more effective treatments. Case Description Patient 1 is a 44-year-old woman with localized esophageal adenocarcinoma who undergoes neoadjuvant chemoradiation followed by esophagectomy. Seven months following surgery, she develops ataxia, weakness, and nausea/vomiting. Magnetic resonance imaging (MRI) reveals intracranial disease that is subsequently successfully resected and then treated with gamma knife (GK) radiation. Pathology confirms metastases. Three months later she is found to have LM. She receives palliative whole brain radiation therapy as well as focal radiation to the spine. Following this she transitioned to concurrent IT topotecan plus intravenous (IV) ipilumumab/nivolumab with durable response beyond 14 months. Patient 2 is a 71-year-old man with de novo metastatic esophageal adenocarcinoma with durable response to 5-fluorouracil plus irinotecan. Asymptomatic intracranial metastases are detected on surveillance scans 2 years after initial diagnosis for which he receives GK. Follow up MRI identifies new LM. As such, to treat the LM, he was transitioned to IT topotecan and IV pembrolizumab with good response for 6 months until death from a gastrointestinal bleed. Conclusions We present two cases of LM in patients with GE adenocarcinoma who had longer survival than what has been reported. They were treated with combination IT topotecan and IV checkpoint inhibition. Further studies evaluating the central nervous system tumor immune-microenvironment can help expand our understanding of how this combination has worked well in our patients and how to care for others with similar scenarios.
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Affiliation(s)
- Cindy M Pabon
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Debra N Yeboa
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Barbara J O'Brien
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nazanin K Majd
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Chenyang Wang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mariela A Blum Murphy
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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2
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Bardhan M, Dey D, Suresh V, Javed B, Venur VA, Joe N, Kalidindi R, Ozair A, Khan M, Mahtani R, Lo S, Odia Y, Ahluwalia MS. An overview of the therapeutic strategies for neoplastic meningitis due to breast cancer: when and why? Expert Rev Neurother 2024; 24:77-103. [PMID: 38145503 DOI: 10.1080/14737175.2023.2293223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 12/06/2023] [Indexed: 12/27/2023]
Abstract
INTRODUCTION Neoplastic meningitis (NM), also known as leptomeningeal carcinomatosis, is characterized by the infiltration of tumor cells into the meninges, and poses a significant therapeutic challenge owing to its aggressive nature and limited treatment options. Breast cancer is a common cause of NM among solid tumors, further highlighting the urgent need to explore effective therapeutic strategies. This review aims to provide insights into the evolving landscape of NM therapy in breast cancer by collating existing research, evaluating current treatments, and identifying potential emerging therapeutic options. AREAS COVERED This review explores the clinical features, therapeutic strategies, recent advances, and challenges of managing NM in patients with breast cancer. Its management includes multimodal strategies, including systemic and intrathecal chemotherapy, radiation therapy, and supportive care. This review also emphasizes targeted drug options and optimal drug concentrations, and discusses emerging therapies. Additionally, it highlights the variability in treatment outcomes and the potential of combination regimens to effectively manage NM in breast cancer. EXPERT OPINION Challenges in treating NM include debates over clinical trial end points and the management of adverse effects. Drug resistance and low response rates are significant hurdles, particularly inHER2-negative breast cancer. The development of more precise and cost-effective medications with improved selectivity is crucial. Additionally, global efforts are needed for infrastructure development and cancer control considering the diverse nature of the disease.
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Affiliation(s)
- Mainak Bardhan
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | | | - Vinay Suresh
- King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Binish Javed
- Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Vyshak Alva Venur
- Seattle Cancer Care Alliance, Fred Hutchinson Cancer Center, University of Washington, Seattle, WA, USA
| | - Neha Joe
- St John's Medical College Hospital, Bengaluru, India
| | | | - Ahmad Ozair
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Reshma Mahtani
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Simon Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Yazmin Odia
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Manmeet S Ahluwalia
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
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3
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Puri S, Chaudhry A, Bayable A, Ganesh A, Daher A, Gadi VK, Maraka S. Systemic Treatment for Brain Metastasis and Leptomeningeal Disease in Breast Cancer Patients. Curr Oncol Rep 2023; 25:1419-1430. [PMID: 37924439 DOI: 10.1007/s11912-023-01468-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2023] [Indexed: 11/06/2023]
Abstract
PURPOSE OF REVIEW Breast cancer with brain metastasis (BCBM) and leptomeningeal disease (LMD) are important clinical problems. Traditionally, patients with metastases to the brain and meninges were excluded from clinical trials; hence, robust, evidence-based treatment recommendations are lacking. In this review, we outline the systemic treatment options and ongoing clinical trials. RECENT FINDINGS Several recent studies have added to the systemic treatment options available. Antibody-drug conjugates have changed the therapeutic landscape. Combination treatment modalities that target multiple mechanisms including disruption of the blood brain barrier are increasingly being studied. Breast cancer with brain metastases and LMD is a heterogenous disease. While the prognosis remains grim, with more systemic treatment options, patients with BCBM are now living longer. Many ongoing clinical trials hold promise to further improve outcomes.
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Affiliation(s)
- Sushant Puri
- Neurooncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
- Department of Oncology, Sidney Kimmel Cancer Center, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Amina Chaudhry
- Division of Hematology and Oncology, Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Asnakech Bayable
- Department of Oncology, Sidney Kimmel Cancer Center, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Ashwin Ganesh
- Department of Neurology& Rehabilitation, University of Illinois at Chicago, 912 South Wood Street 174N m/c, Chicago, IL, 60612, USA
| | - Ahmad Daher
- Department of Neurology& Rehabilitation, University of Illinois at Chicago, 912 South Wood Street 174N m/c, Chicago, IL, 60612, USA
- Translational Oncology Program, University of Illinois Cancer Center, Chicago, IL, USA
| | - Vijayakrishna K Gadi
- Division of Hematology and Oncology, Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
- Translational Oncology Program, University of Illinois Cancer Center, Chicago, IL, USA
| | - Stefania Maraka
- Department of Neurology& Rehabilitation, University of Illinois at Chicago, 912 South Wood Street 174N m/c, Chicago, IL, 60612, USA.
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4
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Primdahl D, Cohen-Nowak A, Kumthekar P. Novel approaches to treatment of leptomeningeal metastases. Curr Opin Neurol 2023; 36:592-602. [PMID: 37865856 DOI: 10.1097/wco.0000000000001218] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
PURPOSE OF REVIEW The incidence of leptomeningeal metastases is increasing in the setting of improved survival from systemic cancers. In more recent years, our understanding of leptomeningeal metastasis pathogenesis, how to diagnose and treat has been evolving. RECENT FINDINGS Diagnosing leptomeningeal metastasis has been challenging due to the limitations of cytology and neuroimaging; However, newer techniques detecting circulating tumor cells (CTCs) or circulating tumor DNA (ctDNA) have shown potential advantage with diagnosis, quantification and detection of oncogenic mutations. The use of small molecule inhibitors and immunotherapy has shown some promise in specific leptomeningeal metastasis subtypes. SUMMARY These new discoveries have improved clinical trials' ability to assess treatment response and thereby more optimally compare different treatments. Furthermore, they have helped the individual clinician better diagnose, monitor the disease and provide novel therapies.
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Affiliation(s)
- Ditte Primdahl
- Department of Neurology at The Feinberg School of Medicine at Northwestern University and The Malnati Brain Tumor Institute at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | - Adam Cohen-Nowak
- Department of Internal Medicine, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Priya Kumthekar
- Department of Neurology at The Feinberg School of Medicine at Northwestern University and The Malnati Brain Tumor Institute at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University
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5
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Kumthekar P, Le Rhun E. Brain Metastases and Leptomeningeal Disease. Continuum (Minneap Minn) 2023; 29:1727-1751. [PMID: 38085896 DOI: 10.1212/con.0000000000001354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
OBJECTIVE Central nervous system (CNS) metastases include brain parenchymal, spinal cord, and leptomeningeal metastases. This article discusses the diagnostic and therapeutic advances of the last decade that have improved outcomes for patients with these CNS metastases. LATEST DEVELOPMENTS The diagnostic tools for CNS metastases, particularly leptomeningeal disease, have evolved over the past decade with respect to advancements in CSF analysis. Multiple medical therapies are now available for brain metastasis treatment that have shown CNS efficacy, including targeted therapies and antibody-drug conjugates. Molecular testing for CNS metastases has become more common and the repertoire of molecularly targeted therapies continues to expand. Advancements in radiation therapy, including improvements in stereotactic radiation techniques, whole-brain radiation with hippocampal avoidance, and proton beam radiation, have changed the radiation management of patients with CNS metastases. New intrathecal agents are currently being tested for the management of leptomeningeal metastases. ESSENTIAL POINTS CNS metastases are far more common than primary brain tumors and are increasing in prevalence in the setting of improved treatments and prolonged survival in patients with systemic cancers. There have been many changes in the diagnostics and treatment of CNS metastases, yielding subsequent improvements in patient outcomes with further advancements on the horizon.
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6
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Wilcox JA, Estrera R, Boire A. The Spectrum of Headache in Leptomeningeal Metastases: A Comprehensive Review with Clinical Management Guidelines. Curr Pain Headache Rep 2023; 27:695-706. [PMID: 37874457 PMCID: PMC10713777 DOI: 10.1007/s11916-023-01180-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2023] [Indexed: 10/25/2023]
Abstract
PURPOSE OF REVIEW Headaches are a common, oftentimes debilitating symptom in patients with leptomeningeal metastases. RECENT FINDINGS The third edition of the International Classification of Headache Disorders provides a useful diagnostic framework for headaches secondary to leptomeningeal metastases based on the temporal relationship of headache with disease onset, change in headache severity in correlation with leptomeningeal disease burden, and accompanying neurologic signs such as cranial nerve palsies and encephalopathy. However, headaches in patients with leptomeningeal metastases can be further defined by a wide range of varying cancer- and treatment-related pathophysiologies, each requiring a tailored approach. A thorough review of the literature and expert opinion on five observed headache sub-classifications in patients with leptomeningeal metastases is provided, with attention to necessary diagnostic testing, recommended first-line treatments, and prevention strategies.
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Affiliation(s)
- Jessica A Wilcox
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Rachel Estrera
- Human Oncology and Pathogenesis Program, Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Adrienne Boire
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Human Oncology and Pathogenesis Program, Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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7
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Pan K, Concannon K, Li J, Zhang J, Heymach JV, Le X. Emerging therapeutics and evolving assessment criteria for intracranial metastases in patients with oncogene-driven non-small-cell lung cancer. Nat Rev Clin Oncol 2023; 20:716-732. [PMID: 37592034 PMCID: PMC10851171 DOI: 10.1038/s41571-023-00808-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2023] [Indexed: 08/19/2023]
Abstract
The improved survival outcomes of patients with non-small-cell lung cancer (NSCLC), largely owing to the improved control of systemic disease provided by immune-checkpoint inhibitors and novel targeted therapies, have highlighted the challenges posed by central nervous system (CNS) metastases as a devastating yet common complication, with up to 50% of patients developing such lesions during the course of the disease. Early-generation tyrosine-kinase inhibitors (TKIs) often provide robust systemic disease control in patients with oncogene-driven NSCLCs, although these agents are usually unable to accumulate to therapeutically relevant concentrations in the CNS owing to an inability to cross the blood-brain barrier. However, the past few years have seen a paradigm shift with the emergence of several novel or later-generation TKIs with improved CNS penetrance. Such agents have promising levels of activity against brain metastases, as demonstrated by data from preclinical and clinical studies. In this Review, we describe current preclinical and clinical evidence of the intracranial activity of TKIs targeting various oncogenic drivers in patients with NSCLC, with a focus on newer agents with enhanced CNS penetration, leptomeningeal disease and the need for intrathecal treatment options. We also discuss evolving assessment criteria and regulatory considerations for future clinical investigations.
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Affiliation(s)
- Kelsey Pan
- Department of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kyle Concannon
- Department of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jing Li
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jianjun Zhang
- Department of Thoracic/Head and Neck Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - John V Heymach
- Department of Thoracic/Head and Neck Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xiuning Le
- Department of Thoracic/Head and Neck Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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8
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Le Rhun E, Weller M, van den Bent M, Brandsma D, Furtner J, Rudà R, Schadendorf D, Seoane J, Tonn JC, Wesseling P, Wick W, Minniti G, Peters S, Curigliano G, Preusser M. Leptomeningeal metastasis from solid tumours: EANO-ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up. ESMO Open 2023; 8:101624. [PMID: 37863528 PMCID: PMC10619142 DOI: 10.1016/j.esmoop.2023.101624] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 07/03/2023] [Accepted: 07/28/2023] [Indexed: 10/22/2023] Open
Abstract
•This Clinical Practice Guideline provides recommendations for managing leptomeningeal metastases from solid tumours. •The guideline covers clinical, imaging and cytological diagnosis, staging and risk assessment, treatment and follow-up. •A treatment and management algorithm is provided. •The author panel encompasses a multidisciplinary group of experts from different institutions and countries in Europe. •Recommendations are based on available scientific data and the authors’ collective expert opinion.
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Affiliation(s)
- E Le Rhun
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland; Department of Neurology, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - M Weller
- Department of Neurology, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - M van den Bent
- Department of The Brain Tumour Center at the Erasmus MC Cancer Institute, Rotterdam
| | - D Brandsma
- Department of Neuro-Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - J Furtner
- Research Center for Medical Image Analysis and Artificial Intelligence (MIAAI), Faculty of Medicine and Dentistry, Danube Private University, Krems, Austria
| | - R Rudà
- Division of Neuro-Oncology, Department of Neuroscience, University of Turin, Turin, Italy
| | - D Schadendorf
- Department of Dermatology, University Hospital Essen, Essen; University of Duisburg-Essen, Essen; German Cancer Consortium (DKTK), Partner Site Essen, Essen, Germany
| | - J Seoane
- Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron University Hospital (HUVH), Universitat Autònoma de Barcelona, Institució Catalana de Recerca i Estudis Avançats (ICREA), CIBERONC, Barcelona, Spain
| | - J-C Tonn
- Department of Neurosurgery, Ludwig-Maximilians-University School of Medicine, Munich; German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - P Wesseling
- Department of Pathology, Amsterdam University Medical Centers/VUmc and Brain Tumour Center, Amsterdam; Princess Máxima Center for Paediatric Oncology, Utrecht, The Netherlands
| | - W Wick
- Neurology Clinic, Heidelberg University Hospital, Heidelberg; Clinical Cooperation Unit Neuro-Oncology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Centre (DKFZ), Heidelberg, Germany
| | - G Minniti
- Department of Radiological Sciences, Oncology and Anatomical Pathology, Sapienza University of Rome, Policlinico Umberto I, Rome; IRCCS Neuromed, Pozzilli IS, Italy
| | - S Peters
- Department of Oncology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne University, Lausanne, Switzerland
| | - G Curigliano
- European Institute of Oncology, IRCCS, Milan; Department of Oncology and Hemato-Oncology, University of Milano, Milan, Italy
| | - M Preusser
- Division of Oncology, Department of Medicine 1, Medical University, Vienna, Austria
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9
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Baskaran AB, Bhatia A, Kumthekar P, Boire A, Lukas RV. Cerebrospinal fluid-administered therapies for leptomeningeal metastases from solid tumors. Future Oncol 2023; 19:1801-1807. [PMID: 37737023 DOI: 10.2217/fon-2022-0926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023] Open
Abstract
Aims/purpose: Leptomeningeal metastases (LM) are associated with substantial morbidity and mortality. Several approaches are used to treat LM, including intrathecally administered therapies. We consolidated current studies exploring intrathecal therapies for LM treatment. Patients & methods: A review of clinical trials using intrathecal agents was conducted with outcomes tabulated and trends described. 48 trials met the inclusion criteria. Initial investigations began with cytotoxic agents; following this were formulations with longer cerebrospinal fluid half-lives, targeted antibodies and radionucleotides. Results & conclusion: Outcomes were not reported consistently. Survival, when reported, remained poor. Intrathecal therapies for LM remain a viable option. Their use can be informed by an understanding of efficacy, safety and toxicity. They may be an important component of future LM treatments.
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Affiliation(s)
- Archit B Baskaran
- Resident, Department of Neurology, The University of Chicago Medicine, Chicago, IL 60637, USA
| | - Ankush Bhatia
- Section Head of Neuro-Oncology, Department of Neurology, Medicine, & Human Oncology, University of Wisconsin School of Medicine & Public Health, Madison, WI 53705, USA
| | - Priya Kumthekar
- Department of Neurology, Lou & Jean Malnati Brain Tumor Institute, Northwestern University, Chicago, IL 60611, USA
| | - Adrienne Boire
- Geoffrey Beene Junior Faculty Chair, Department of Neurology, Human Oncology & Pathogenesis Program, Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Rimas V Lukas
- Neuro-Oncology Division, Associate Professor, Regional Ambulatory Medical Director, Neurology, Department of Neurology, Lou & Jean Malnati Brain Tumor Institute, Northwestern University, Chicago, IL 60611, USA
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10
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Warrior S, Cohen-Nowak A, Kumthekar P. Modern Management and Diagnostics in HER2+ Breast Cancer with CNS Metastasis. Cancers (Basel) 2023; 15:cancers15112908. [PMID: 37296873 DOI: 10.3390/cancers15112908] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/09/2023] [Accepted: 05/23/2023] [Indexed: 06/12/2023] Open
Abstract
Patients with HER2-positive breast cancer have seen improved survival and outcomes over the past two decades. As patients live longer, the incidence of CNS metastases has increased in this population. The authors' review outlines the most current data in HER2-positive brain and leptomeningeal metastases and discuss the current treatment paradigm in this disease. Up to 55% of HER2-positive breast cancer patients go on to experience CNS metastases. They may present with a variety of focal neurologic symptoms, such as speech changes or weakness, and may also have more diffuse symptoms related to high intracranial pressure, such as headaches, nausea, or vomiting. Treatment can include focal treatments, such as surgical resection or radiation (focal or whole-brain radiation), as well as systemic therapy options or even intrathecal therapy in the case of leptomeningeal disease. There have been multiple advancements in systemic therapy for these patients over the past few years, including the availability of tucatinib and trastuzumab-deruxtecan. Hope remains high as clinical trials for CNS metastases receive greater attention and as other HER2-directed methods are being studied in clinical trials with the goal of better outcomes for these patients.
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Affiliation(s)
- Surbhi Warrior
- Department of Hematology, Oncology Northwestern Memorial Hospital, Chicago, IL 60611, USA
| | - Adam Cohen-Nowak
- Department of Internal Medicine, Northwestern Memorial Hospital, Chicago, IL 60611, USA
| | - Priya Kumthekar
- Department of Neuro-Oncology, Northwestern Memorial Hospital, Chicago, IL 60611, USA
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11
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Abstract
Leptomeningeal metastases represent an aggressive stage of cancer with few durable treatment options. Improved understanding of cancer biology, neoplastic reliance on oncogenic driver mutations, and complex immune system interactions have resulted in an explosion in cancer-directed therapy in the last two decades to include small molecule inhibitors and immune checkpoint inhibitors. Most of these therapeutics are underexplored in patients with leptomeningeal metastases, limiting extrapolation of extracranial and even intracranial efficacy outcomes to the unique leptomeningeal space. Further confounding our interpretation of drug activity in the leptomeninges is an incomplete understanding of drug penetration through the blood-cerebrospinal fluid barrier of the choroid plexus. Nevertheless, a number of retrospective studies and promising prospective trials provide evidence of leptomeningeal activity of several small molecule and immune checkpoint inhibitors and underscore potential areas of further therapeutic development for patients harboring leptomeningeal disease.
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Affiliation(s)
- Jessica A Wilcox
- Department of Neurology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Adrienne A Boire
- Department of Neurology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
- Human Oncology and Pathogenesis Program, Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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12
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Wilcox JA, Li MJ, Boire AA. Leptomeningeal Metastases: New Opportunities in the Modern Era. Neurotherapeutics 2022; 19:1782-1798. [PMID: 35790709 PMCID: PMC9723010 DOI: 10.1007/s13311-022-01261-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2022] [Indexed: 02/07/2023] Open
Abstract
Leptomeningeal metastases arise from cancer cell entry into the subarachnoid space, inflicting significant neurologic morbidity and mortality across a wide range of malignancies. The modern era of cancer therapeutics has seen an explosion of molecular-targeting agents and immune-mediated strategies for patients with breast, lung, and melanoma malignancies, with meaningful extracranial disease control and improvement in patient survival. However, the clinical efficacy of these agents in those with leptomeningeal metastases remains understudied, due to the relative rarity of this patient population, the investigational challenges associated with studying this dynamic disease state, and brisk disease pace. Nevertheless, retrospective studies, post hoc analyses, and small prospective trials in the last two decades provide a glimmer of hope for patients with leptomeningeal metastases, suggesting that several cancer-directed strategies are not only active in the intrathecal space but also improve survival against historical odds. The continued development of clinical trials devoted to patients with leptomeningeal metastases is critical to establish robust efficacy outcomes in this patient population, define drug pharmacokinetics in the intrathecal space, and uncover new avenues for treatment in the face of leptomeningeal therapeutic resistance.
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Affiliation(s)
- Jessica A Wilcox
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Min Jun Li
- Brain Tumor Center, Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Adrienne A Boire
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Brain Tumor Center, Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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13
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Intrathecal therapy for the management of leptomeningeal metastatic disease: a scoping review of the current literature and ongoing clinical trials. J Neurooncol 2022; 160:79-100. [PMID: 35999434 DOI: 10.1007/s11060-022-04118-0] [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: 07/29/2022] [Accepted: 08/16/2022] [Indexed: 02/01/2023]
Abstract
PURPOSE Leptomeningeal metastatic disease (LMD) from advanced malignancies has poor prognoses and limited treatments. Intrathecal therapy (ITT) protocols are available, showing variable outcomes. We reviewed the therapeutic and toxicity profiles of ITT in LMD. METHODS PubMed, EMBASE, Web-of-Science, and Scopus were searched following the PRISMA-ScR guidelines to include studies reporting ITT for LMD. CLINICALTRIAL gov and Cochrane were searched to identify ongoing clinical trials. RESULTS We included 27 published studies encompassing 2161 patients and 4 ongoing trials. LMD originated from brain metastases (85.5%), lymphomas (5.4%), high-grade gliomas (4.6%), medulloblastomas (2.3%), and leukemias (2.1%). LMD was mostly diagnosed with the co-presence of neurological-related symptoms and positive imaging and/or cerebrospinal fluid cytology (60.8%). The most common ITT agents were methotrexate (35.9%), cytarabine (21.9%), and thiotepa (8.2%), standalone or combined. Patients received a median of 6.5 ITT cycles (range, 1.0-71.0) via intraventricular (58.8%) or lumbar intrathecal (41.2%) routes. The Ommaya reservoir was implanted in 38.5% cases. Concurrent systemic chemotherapy (45.2%) and/or radiotherapy (30.6%) were used. After 1-3 cycles, 44.7% patients had improved clinical status and 29.9% converted into negative cerebrospinal fluid cytology. The most common ITT-related severe adverse events were neutropenia (6.5%), meningitis (5.2%) and encephalopathy (4.5%). Median freedom from progression was 2.4 months (range, 0.1-59.5) and median overall survival 5.5 months (range, 0.1-148.0). CONCLUSION Current ITT protocols are variable but effective and well-tolerated in LMD. Ongoing trials are investigating dose-limiting toxicity profiles and long-term overall survival. Future studies should analyze the therapeutic and safety profiles of ITT compared to newer systemic therapies.
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14
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Stopa BM, Cuoco JA, Adhikari S, Grider DJ, Rogers CM, Marvin EA. Iatrogenic Leptomeningeal Carcinomatosis Following Craniotomy for Resection of Metastatic Serous Ovarian Carcinoma: A Systematic Literature Review and Case Report. Front Surg 2022; 9:850050. [PMID: 35548192 PMCID: PMC9082594 DOI: 10.3389/fsurg.2022.850050] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 02/14/2022] [Indexed: 11/13/2022] Open
Abstract
Metastasis of ovarian carcinoma to the central nervous system occurs in <2% of cases and classically localizes within the brain parenchyma. Moreover, leptomeningeal spread of these tumors is an exceedingly rare phenomenon. Here, we conduct a systematic review of the current literature on the natural history, treatment options, and proposed pathogenic mechanisms of leptomeningeal carcinomatosis in ovarian carcinoma. We also report a case of a 67-year-old female with stage IV metastatic ovarian serous carcinoma initially confined to the peritoneal cavity with a stable disease burden over the course of three years. Follow-up imaging demonstrated an intracranial lesion, which was resected via craniotomy, and pathology was consistent with the original diagnosis. Three months after surgery, she developed rapidly progressive dizziness, generalized weakness, fatigue, and ataxia. Repeat MRI demonstrated interval development of extensive and diffusely enhancing dural nodularity, numerous avidly enhancing supratentorial and infratentorial lesions, enhancement of the bilateral trigeminal nerves, internal auditory canals, and exit wound from the surgical site into the posterior aspect of the right-sided neck musculature consistent with diffuse leptomeningeal dissemination. The present case highlights that leptomeningeal dissemination of ovarian carcinoma is a potential yet rare consequence following surgical resection of an ovarian parenchymal metastasis. Progressive clinical symptomatology that develops postoperatively in this patient population should prompt urgent workup to rule out leptomeningeal disease and an expedited radiation oncology consultation if identified.
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Affiliation(s)
- Brittany M. Stopa
- Virginia Tech Carilion School of Medicine, Roanoke, VA, United States
| | - Joshua A. Cuoco
- Virginia Tech Carilion School of Medicine, Roanoke, VA, United States
- Section of Neurosurgery, Carilion Clinic, Roanoke, VA, United States
- School of Neuroscience, Virginia Polytechnic Institute and State University, Blacksburg, VA, United States
| | - Srijan Adhikari
- Virginia Tech Carilion School of Medicine, Roanoke, VA, United States
- Section of Neurosurgery, Carilion Clinic, Roanoke, VA, United States
- School of Neuroscience, Virginia Polytechnic Institute and State University, Blacksburg, VA, United States
| | - Douglas J. Grider
- Virginia Tech Carilion School of Medicine, Roanoke, VA, United States
- Dominion Pathology Associates, Roanoke, VA, United States
| | - Cara M. Rogers
- Virginia Tech Carilion School of Medicine, Roanoke, VA, United States
- Section of Neurosurgery, Carilion Clinic, Roanoke, VA, United States
- School of Neuroscience, Virginia Polytechnic Institute and State University, Blacksburg, VA, United States
| | - Eric A. Marvin
- Virginia Tech Carilion School of Medicine, Roanoke, VA, United States
- Section of Neurosurgery, Carilion Clinic, Roanoke, VA, United States
- School of Neuroscience, Virginia Polytechnic Institute and State University, Blacksburg, VA, United States
- *Correspondence: Eric A. Marvin
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15
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Shim J, Reisner A, Esiashvili N, Rapkin L, Olson T. Intraventricular topotecan in the successful treatment of recurrent CNS pleuropulmonary blastoma. Pediatr Blood Cancer 2022; 69:e29529. [PMID: 34913589 DOI: 10.1002/pbc.29529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 11/16/2021] [Accepted: 11/24/2021] [Indexed: 11/12/2022]
Abstract
Pleuropulmonary blastoma (PPB) is a rare pediatric tumor of the pleura and pulmonary mesenchyme, associated with pathogenic germline DICER1 mutations. Although the most common site of metastasis is the central nervous system (CNS), patients with CNS metastasis have dismal outcome. We report a case of a patient presenting with type II PPB and intracranial and bone metastases. We describe a multimodal therapy approach and highlight the use of intraventricular topotecan for isolated CNS recurrence. In addition, a new pathogenic germline mutation heterozygous for the c.1234delT of DICER1 was identified. Patient remains in remission 3 years after recurrence.
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Affiliation(s)
- Jenny Shim
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.,Aflac Cancer and Blood Disorders Center at the Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Andrew Reisner
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Neurosurgery, Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Natia Esiashvili
- Department of Radiation Oncology, Winship Cancer Institute of Emory University School of Medicine, Atlanta, Georgia, USA
| | - Louis Rapkin
- Department of Oncology, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Thomas Olson
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.,Aflac Cancer and Blood Disorders Center at the Children's Healthcare of Atlanta, Atlanta, Georgia, USA
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16
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Central Nervous System Involvement in Adults with Acute Leukemia: Diagnosis, Prevention, and Management. Curr Oncol Rep 2022; 24:427-436. [PMID: 35141858 DOI: 10.1007/s11912-022-01220-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Recent treatment advances in both acute myeloid leukemia and acute lymphoblastic leukemia have drastically improved outcomes for these diseases, but central nervous system (CNS) relapses still occur. Treatment of CNS disease can be challenging due to the impermeability of the blood-brain barrier to many systemic therapies. RECENT FINDINGS The diagnosis of CNS leukemia relies on assessment of clinical symptoms, cerebrospinal fluid sampling for conventional cytology and/or flow cytometry, and neuroimaging. While treatment of CNS leukemia with systemic or intrathecal chemotherapy and/or radiation can be curative in some patients, these modalities can also lead to serious toxicities. In the modern era, prophylaxis with intrathecal chemotherapy is the most important strategy to prevent CNS relapses in high risk patients. Accurate risk stratification tools and the use of risk-adapted prophylactic therapy are imperative to improving the outcomes of patients with acute leukemias and preventing the development of CNS leukemia.
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17
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Lukas RV, Thakkar JP, Cristofanilli M, Chandra S, Sosman JA, Patel JD, Kumthekar P, Stupp R, Lesniak MS. Leptomeningeal metastases: the future is now. J Neurooncol 2022; 156:443-452. [DOI: 10.1007/s11060-021-03924-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 12/06/2021] [Indexed: 12/19/2022]
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18
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Joseph SK, M A A, Thomas S, Nair SC. Nanomedicine as a future therapeutic approach for treating meningitis. J Drug Deliv Sci Technol 2022. [DOI: 10.1016/j.jddst.2021.102968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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19
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Iwatsuka K, Kikuta D, Shibuya H, Ogawa M, Gotoda T, Moriyama M, Nakagawara H, Hemmi A, Yamao K. Treatment Outcome of Nab-paclitaxel Plus Gemcitabine for Leptomeningeal Carcinomatosis from Pancreatic Ductal Adenocarcinoma: An Autopsy Case Report. Intern Med 2021; 60:3743-3748. [PMID: 34148945 PMCID: PMC8710377 DOI: 10.2169/internalmedicine.4456-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
A 57-year-old woman with a sudden-onset seizure was hospitalized. Brain magnetic resonance imaging findings led to a suspicion of leptomeningeal carcinomatosis (LMC) without a brain parenchymal tumor, and abdominal computed tomography showed a tumor in the pancreatic tail. Endoscopic ultrasonography-guided fine needle aspiration of the pancreatic mass revealed adenocarcinoma. Therefore, LMC from pancreatic ductal adenocarcinoma was strongly suspected. She received three courses of nab-paclitaxel plus gemcitabine and whole-brain radiation. Shortly thereafter, she developed a severe consciousness impediment and died. A pathological autopsy showed adenocarcinoma in a wide area of the leptomeninges.
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Affiliation(s)
- Kunio Iwatsuka
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine Graduate School of Medicine, Japan
| | - Daiichiro Kikuta
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine Graduate School of Medicine, Japan
| | - Hitoshi Shibuya
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine Graduate School of Medicine, Japan
| | - Masahiro Ogawa
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine Graduate School of Medicine, Japan
| | - Takuji Gotoda
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine Graduate School of Medicine, Japan
| | - Mitsuhiko Moriyama
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine Graduate School of Medicine, Japan
| | | | - Akihiro Hemmi
- Division of Pathology, Nihon University School of Medicine Graduate School of Medicine, Japan
| | - Kenji Yamao
- Department of Gastroenterology, Narita Memorial Hospital, Japan
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20
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Leese EN, Weeder JL, Manikowski JJ, DeLaRue AM, Conger AR, Mahadevan A, Vogel VG, Mongelluzzo GJ, Gatson NTN. PA- and NP-led Ommaya clinics to manage leptomeningeal carcinomatosis. JAAPA 2021; 34:35-41. [PMID: 34772854 DOI: 10.1097/01.jaa.0000800264.81721.3d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Physician assistants (PAs) and NPs are essential to quality care delivery. The need to demonstrate value and optimize PA and NP roles in neurology subspecialty clinics is unmet. We outline the development of a PA- and NP-led neuro-oncology procedural clinic and provide metrics to support the institutional and clinician value added. METHODS We designed a PA- and NP-led Geisinger Ommaya Clinic (GOC) to manage leptomeningeal carcinomatosis (LMC) with defined clinician roles and the GOC treatment protocol. A retrospective review of 135 patients (2012-2019) compared survival outcomes for patients treated on the protocol compared with those treated off the protocol. RESULTS Centralized care in the GOCs minimized shared physician encounters and improved PA and NP autonomy and utility. LMC therapy as part of the GOC protocol improved care continuity and survival outcomes. CONCLUSIONS PA- and NP-led procedural clinics optimize use of these clinicians and open physician availability for nonprocedural duties. This research highlights the institutional patient and financial benefit while demonstrating the operational and leadership growth potential for PAs and NPs.
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Affiliation(s)
- Erika N Leese
- At Geisinger Medical Center in Danville, Pa., Erika N. Leese is lead neuro-oncology advanced practice provider in the Neuroscience Institute, Jamie L. Weeder is chief advanced practice provider of hematology/oncology for the central and western regions, Jesse J. Manikowski is a data scientist in the Geisinger Cancer Institute, Angela M. DeLaRue is lead LPN for the neuro-oncology division, Andrew R. Conger is a lead neurosurgeon in neurosurgical oncology, Anand Mahadevan is chair of the department of radiation oncology, Victor G. Vogel is director of breast medical oncology/radiology, Gino J. Mongelluzzo is chair of the department of neuroradiology, and Na Tosha N. Gatson is director of the neuro-oncology division. The authors have disclosed no potential conflicts of interest, financial or otherwise
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21
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Sener U, Kumthekar P, Boire A. Advances in the diagnosis, evaluation, and management of leptomeningeal disease. Neurooncol Adv 2021; 3:v86-v95. [PMID: 34859236 PMCID: PMC8633748 DOI: 10.1093/noajnl/vdab108] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Leptomeningeal metastasis (LM) is a devastating complication of cancer with variable clinical presentation and limited benefit from existing treatment options. In this review, we discuss advances in LM diagnostics and therapeutics with the potential to reverse this grim course. Emerging cerebrospinal fluid circulating tumor cell and cell-free tumor DNA analysis technologies will improve diagnosis of LM, while providing crucial genetic information, capturing tumor heterogeneity, and quantifying disease burden. Circulating tumor cells and cell-free tumor DNA have utility as biomarkers to track disease progression and treatment response. Treatment options for LM include ventriculoperitoneal shunting for symptomatic relief, radiation therapy including whole-brain radiation and focal radiation for bulky leptomeningeal involvement, and systemic and intrathecal medical therapies, including targeted and immunotherapies based on tumor mutational profiling. While existing treatments for LM have limited efficacy, recent advances in liquid biopsy together with increasing availability of targeted treatments will lead to rational multimodal individualized treatments and improved patient outcomes.
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Affiliation(s)
- Ugur Sener
- Department of Neurology, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Priya Kumthekar
- Department of Neurology, Malnati Brain Tumor Institute at the Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Adrienne Boire
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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22
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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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23
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Cerebrospinal fluid diversion for leptomeningeal metastasis: palliative, procedural and oncologic outcomes. J Neurooncol 2021; 154:301-313. [PMID: 34406564 DOI: 10.1007/s11060-021-03827-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 08/11/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Leptomeningeal metastasis (LM) occurs in 3-5% of patients with solid metastatic tumors and often portends a severe prognosis including symptomatic hydrocephalus and intracranial hypertension. Cerebrospinal fluid (CSF) shunting can provide symptomatic relief in this patient subset; however, few studies have examined the role of shunting in the palliation, prognosis and overall oncologic care of these patients. OBJECTIVE To identify and evaluate risk factors associated with prognosis after CSF diversion and assess surgical, symptomatic and oncologic outcomes in this population. METHODS A retrospective study was conducted on patients with solid-malignancy LM treated with a shunt at a NCI-designated Comprehensive Cancer Center between 2010 and 2019. RESULTS One hundred and ninety patients with metastatic LM underwent CSF diversion. Overall survival was 4.14 months from LM diagnosis (95% CI: 3.29-4.70) and 2.43 months (95% CI: 2.01-3.09) from shunting. Karnofsky performance status (KPS) at time of shunting and brain metastases (BrM) number at LM diagnosis demonstrated significant associations with survival (HR = 0.66; 95% CI [0.51-0.86], p = 0.002; HR = 1.40; 95% CI [1.01-1.93] per 10 BrM, p = 0.04, respectively). Eighty-three percent of patients experienced symptomatic relief, and 79% were discharged home or to rehabilitation facilities post-shunting. Post-shunt, 56% of patients received additional systemic therapy or started or completed WBRT. Complications included infection (5%), symptomatic subdural hygroma/hematoma (6.3%), and shunt externalization/removal/repair (8%). Abdominal seeding was not identified. CONCLUSIONS CSF diversion for LM with hydrocephalus and intracranial hypertension secondary to metastasis can achieve symptomatic relief, hospital discharge, and return to further oncologic therapy, with a complication profile unique to this pathophysiology. However, decision-making in this population must incorporate end-of-life goals of care given limited prognosis.
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24
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Kwon JW, Shim Y, Gwak HS, Park EY, Joo J, Yoo H, Shin SH. Cerebrospinal Fluid Profiles and Their Changes after Intraventricular Chemotherapy as Prognostic or Predictive Markers for Patients with Leptomeningeal Carcinomatosis. J Korean Neurosurg Soc 2021; 64:631-643. [PMID: 34185980 PMCID: PMC8273769 DOI: 10.3340/jkns.2020.0300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 12/30/2020] [Indexed: 11/27/2022] Open
Abstract
Objective Here, we evaluated whether cerebrospinal fluid (CSF) profiles and their changes after intraventricular chemotherapy for leptomeningeal carcinomatosis (LMC) could predict the treatment response or be prognostic for patient overall survival (OS) along with clinical factors.
Methods Paired 1) pretreatment lumbar, 2) pretreatment ventricular, and 3) posttreatment ventricular samples and their CSF profiles were collected retrospectively from 148 LMC patients who received Ommaya reservoir installation and intraventricular chemotherapy. CSF profile changes were assessed by calculating the differences between posttreatment and pretreatment samples from the same ventricular compartment. CSF cell counts were further differentiated into total and other based on clinical laboratory reports.
Results For the treatment response, a decreased CSF ‘total’ cell count tended to be associated with a ‘controlled’ increase in intracranial pressure (ICP) (p=0.059), but other profile changes were not associated with either the control of increased ICP or the cytology response. Among the pretreatment CSF profiles, lumbar protein level and ventricular cell count were significantly correlated with OS in univariable analysis, but they were not significant in multi-variable analysis. Among CSF profile changes, a decrease in ‘other’ cell count showed worse OS than ‘no change’ or increased groups (p=0.001). The cytological response was significant for OS, but the hazard ratio of partial remission was paradoxically higher than that of ‘no response’.
Conclusion A decrease in other cell count of CSF after intraventricular chemotherapy was associated with poor OS in LMC patients. We suggest that more specific CSF biomarkers of cancer cell origin are needed.
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Affiliation(s)
- Ji-Woong Kwon
- Neuro-oncology Clinic, National Cancer Center, Goyang, Korea
| | - Youngbo Shim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Ho-Shin Gwak
- Department of Cancer Biomedical Science, Graduate School of Cancer Science and Policy, Goyang, Korea
| | - Eun Young Park
- Biostatistics Collaboration Team, National Cancer Center, Goyang, Korea
| | - Jungnam Joo
- Biostatistics Collaboration Team, National Cancer Center, Goyang, Korea
| | - Heon Yoo
- Neuro-oncology Clinic, National Cancer Center, Goyang, Korea
| | - Sang-Hoon Shin
- Neuro-oncology Clinic, National Cancer Center, Goyang, Korea
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25
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Dankner M, Lam S, Degenhard T, Garzia L, Guiot MC, Petrecca K, Siegel PM. The Underlying Biology and Therapeutic Vulnerabilities of Leptomeningeal Metastases in Adult Solid Cancers. Cancers (Basel) 2021; 13:cancers13040732. [PMID: 33578853 PMCID: PMC7916586 DOI: 10.3390/cancers13040732] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/03/2021] [Accepted: 02/06/2021] [Indexed: 01/18/2023] Open
Abstract
Metastasis to the central nervous system occurs in approximately 20% of patients with advanced solid cancers such as lung cancer, breast cancer, and melanoma. While central nervous system metastases most commonly form in the brain parenchyma, metastatic cancer cells may also reside in the subarachnoid space surrounding the brain and spinal cord to form tumors called leptomeningeal metastases. Leptomeningeal metastasis involves cancer cells that reach the subarachnoid space and proliferate in the cerebrospinal fluid compartment within the leptomeninges, a sequela associated with a myriad of symptoms and poor prognosis. Cancer cells exposed to cerebrospinal fluid in the leptomeninges must contend with a unique microenvironment from those that establish within the brain or other organs. Leptomeningeal lesions provide a formidable clinical challenge due to their often-diffuse infiltration within the subarachnoid space. The molecular mechanisms that promote the establishment of leptomeningeal metastases have begun to be elucidated, demonstrating that it is a biological entity distinct from parenchymal brain metastases and is associated with specific molecular drivers. In this review, we outline the current state of knowledge pertaining to the diagnosis, treatment, and molecular underpinnings of leptomeningeal metastasis.
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Affiliation(s)
- Matthew Dankner
- Goodman Cancer Research Centre, Faculty of Medicine, McGill University, Montreal, QC H3A 1A3, Canada; (M.D.); (M.-C.G.)
| | - Stephanie Lam
- Department of Diagnostic Radiology, Faculty of Medicine, Research Institute of the McGill University Health Centre, Montreal, QC H3T 1E2, Canada;
- Research Institute of the McGill University Health Centre, Montreal, QC H4A 3J1, Canada;
| | - Theresa Degenhard
- Department of Neurology and Neurosurgery, Montreal Neurological Institute-Hospital, Goodman Cancer Research Centre, McGill University, Montreal, QC H3A 2B4, Canada; (T.D.); (K.P.)
- Department of Neurology and Neurosurgery, Montreal Neurological Institute-Hospital, McGill University, Montreal, QC H3A 2B4, Canada
| | - Livia Garzia
- Research Institute of the McGill University Health Centre, Montreal, QC H4A 3J1, Canada;
| | - Marie-Christine Guiot
- Goodman Cancer Research Centre, Faculty of Medicine, McGill University, Montreal, QC H3A 1A3, Canada; (M.D.); (M.-C.G.)
- Department of Neurology and Neurosurgery, Montreal Neurological Institute-Hospital, Goodman Cancer Research Centre, McGill University, Montreal, QC H3A 2B4, Canada; (T.D.); (K.P.)
- Department of Neurology and Neurosurgery, Montreal Neurological Institute-Hospital, McGill University, Montreal, QC H3A 2B4, Canada
- Department of Pathology, McGill University, Montreal, QC H3A 1A3, Canada
| | - Kevin Petrecca
- Department of Neurology and Neurosurgery, Montreal Neurological Institute-Hospital, Goodman Cancer Research Centre, McGill University, Montreal, QC H3A 2B4, Canada; (T.D.); (K.P.)
- Department of Neurology and Neurosurgery, Montreal Neurological Institute-Hospital, McGill University, Montreal, QC H3A 2B4, Canada
| | - Peter M. Siegel
- Goodman Cancer Research Centre, Faculty of Medicine, McGill University, Montreal, QC H3A 1A3, Canada; (M.D.); (M.-C.G.)
- Department of Diagnostic Radiology, Faculty of Medicine, Research Institute of the McGill University Health Centre, Montreal, QC H3T 1E2, Canada;
- Department of Neurology and Neurosurgery, Montreal Neurological Institute-Hospital, Goodman Cancer Research Centre, McGill University, Montreal, QC H3A 2B4, Canada; (T.D.); (K.P.)
- Department of Biochemistry, McGill University, Montreal, QC H3A 1A3, Canada
- Department of Anatomy & Cell Biology, McGill University, Montreal, QC H3A 1A3, Canada
- Department of Oncology, McGill University, Montreal, QC H3A 1A3, Canada
- Correspondence: ; Tel.: +1-514-398-4259; Fax: +1-514-398-6769
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26
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Jaeckle KA, Dixon JG, Anderson SK, Moreno‐Aspitia A, Colon‐Otero G, Hebenstreit K, Patel TA, Reddy SL, Perez EA. Intra-CSF topotecan in treatment of breast cancer patients with leptomeningeal metastases. Cancer Med 2020; 9:7935-7942. [PMID: 32885617 PMCID: PMC7643683 DOI: 10.1002/cam4.3422] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 07/24/2020] [Accepted: 08/07/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND There are few treatment options for patients with leptomeningeal metastases (LM). METHODS We report a case series of patients with breast cancer and LM treated with intra-CSF topotecan (TOPO). Outcome was assessed by clinical exam and MRI at baseline, at end of induction (4-5 weeks), then every 3 months; CSF cytology was determined at baseline and with each treatment. RESULTS Thirty-one women [median age, 58 (37-81); median KPS 60 (40-100)] received treatment. At baseline, 68% had positive CSF cytology, and 90%, leptomeningeal enhancement on MRI. 84% of patients also received focal RT (not during TOPO) and 77% received concomitant systemic hormonal or chemotherapy. Median number of TOPO treatments was 14.5 (range, 3-71); median duration of treatment, 11 weeks (1-176); and median OS, 6.9 months (range, 0.9-48.8). Patients remaining progression-free during 4-6 weeks of induction (81%) had a median OS of 11.5 months (range, 1.8-48.8). Overall neurologic PFS at 6, 12, and 24 months was 39%, 26%, and 6%, respectively. Clearing of CSF malignant cells for >3 consecutive samples occurred in 10/21 (48%) patients with positive CSF cytology at baseline, remaining clear for a median duration of 15.9 months (range, 1.4-34.5). Grade 3 adverse events included headache or vomiting (3pts), T2 hyperintensity surrounding the ventricular catheter (2 pts), and meningitis (2 pts). CONCLUSIONS Intra-CSF TOPO, with focal RT as needed for symptomatic areas of enhancement produced durable clearing of CSF malignant cells in 48% of patients positive at baseline, with promising median PFS and OS.
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Pan Z, Yang G, He H, Cui J, Li W, Yuan T, Chen K, Jiang T, Gao P, Sun Y, Cong X, Li Z, Wang Y, Pang X, Song Y, Zhao G. Intrathecal pemetrexed combined with involved-field radiotherapy as a first-line intra-CSF therapy for leptomeningeal metastases from solid tumors: a phase I/II study. Ther Adv Med Oncol 2020; 12:1758835920937953. [PMID: 32733606 PMCID: PMC7370561 DOI: 10.1177/1758835920937953] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 05/21/2020] [Indexed: 12/22/2022] Open
Abstract
Purpose: A phase I/II study of intrathecal pemetrexed (IP) combined with involved-field radiotherapy (IFRT) was performed to determine feasibility, safety, and antitumor activity for leptomeningeal metastases (LM) from solid tumors. Methods: Participants first received induction IP administration, followed by concomitant radiotherapy within 3 days. The concomitant regimen consisted of IP (pemetrexed 10 mg, dexamethasone 5 mg, once per week, 4 times in 4 weeks) and IFRT (40 Gy in 20 fractions). Six participants were recruited to assess feasibility in phase I, and then 28 patients were recruited further. All patients were assessed to investigate safety, efficacy, and outcomes. Results: Between April 2018 and December 2018, 34 patients (male: 15; female: 19; median age: 56 years) were enrolled, including non-small-cell lung cancer (21), small-cell lung cancer (5), breast cancer (4), and others (4). Thirty-two patients received concurrent therapy and 25 (74%) patients completed the treatment. Major adverse events (AEs) consisted of myelosuppression, the elevation of hepatic aminotransferases, and radiculitis. Total AEs rate was 53% (18/34), including 6 (18%) patients with grade 3 and 1 (3%) with grade 4 AEs. The response rate was 68% (23/34). The median overall survival was 5.5 (0.3–16.6) months. Median neurological progression-free survival (NPFS) was 3.5 (0.3–15.2) months. Six-month NPFS rate was 47%. One-year survival rate was 21.6%. Conclusion: IP at a 10 mg dose on a schedule of 1–2 times per week presented good efficacy and safety in CSF. The concomitant regimen is an efficacious therapeutic option for LM patients with solid tumors. Trial Registration: This study (IPLM) was registered at https://register.clinicaltrials.gov [ClinicalTrials.gov identifier: NCT03507244].
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Affiliation(s)
- Zhenyu Pan
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, China
| | - Guozi Yang
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, China
| | - Hua He
- Cancer Center, The First Hospital of Jilin University, Changchun, China
| | - Jiuwei Cui
- Cancer Center, The First Hospital of Jilin University, Changchun, China
| | - Wei Li
- Cancer Center, The First Hospital of Jilin University, Changchun, China
| | - Tingting Yuan
- Department of Radiology, The First Hospital of Jilin University, Changchun, China
| | - Kunzhi Chen
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, China
| | - Tongchao Jiang
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, China
| | - Pengxiang Gao
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, China
| | - Yanan Sun
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, China
| | - Xiaofeng Cong
- Cancer Center, The First Hospital of Jilin University, Changchun, China
| | - Zhi Li
- Cancer Center, The First Hospital of Jilin University, Changchun, China
| | - Yongxiang Wang
- Department of Clinical Laboratory, The First Hospital of Jilin University, Changchun, China
| | - Xiaochuan Pang
- Department of Clinical Laboratory, The First Hospital of Jilin University, Changchun, China
| | - Yuanyuan Song
- Department of Clinical Laboratory, The First Hospital of Jilin University, 71 Xinmin Street, Changchun, 130021, China
| | - Gang Zhao
- Department of Neuro-Oncological Surgery, The First Hospital of Jilin University, 71 Xinmin Street, Changchun, 130021, China
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Thakkar JP, Kumthekar P, Dixit KS, Stupp R, Lukas RV. Leptomeningeal metastasis from solid tumors. J Neurol Sci 2020; 411:116706. [PMID: 32007755 DOI: 10.1016/j.jns.2020.116706] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 01/17/2020] [Accepted: 01/22/2020] [Indexed: 01/13/2023]
Abstract
Central nervous system (CNS) metastasis from systemic cancers can involve the brain parenchyma, leptomeninges (pia, subarachnoid space and arachnoid mater), and dura. Leptomeningeal metastases (LM), also known by different terms including neoplastic meningitis and carcinomatous meningitis, occur in both solid tumors and hematologic malignancies. This review will focus exclusively on LM arising from solid tumors with a goal of providing the reader an understanding of the epidemiology, pathophysiology, clinical presentation, prognostication, current management and future directions.
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Affiliation(s)
- Jigisha P Thakkar
- Loyola University Medical Center, Department of Neurology, United States of America; Department of Neurosurgery, United States of America
| | - Priya Kumthekar
- Northwestern University, Department of Neurology, United States of America; Lou & Jean Malnati Brain Tumor institute of the Robert H. Lurie Comprehensive Cancer Center, United States of America; Division of Hematology/Oncology, United States of America
| | - Karan S Dixit
- Northwestern University, Department of Neurology, United States of America; Lou & Jean Malnati Brain Tumor institute of the Robert H. Lurie Comprehensive Cancer Center, United States of America
| | - Roger Stupp
- Northwestern University, Department of Neurology, United States of America; Lou & Jean Malnati Brain Tumor institute of the Robert H. Lurie Comprehensive Cancer Center, United States of America; Department of Neurological Surgery, United States of America; Division of Hematology/Oncology, United States of America
| | - Rimas V Lukas
- Northwestern University, Department of Neurology, United States of America; Lou & Jean Malnati Brain Tumor institute of the Robert H. Lurie Comprehensive Cancer Center, United States of America.
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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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30
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Pan Z, Yang G, Cui J, Li W, Li Y, Gao P, Jiang T, Sun Y, Dong L, Song Y, Zhao G. A Pilot Phase 1 Study of Intrathecal Pemetrexed for Refractory Leptomeningeal Metastases From Non-small-cell Lung Cancer. Front Oncol 2019; 9:838. [PMID: 31544065 PMCID: PMC6730526 DOI: 10.3389/fonc.2019.00838] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 08/14/2019] [Indexed: 12/29/2022] Open
Abstract
Objectives: We aim to determine the feasibility, safety, maximally tolerated dose (MTD), recommended dose and potential anti-tumor activity of intrathecal pemetrexed (IP). Materials and Methods: Lung adenocarcinoma patients with recurrent or progressive leptomeningeal metastases (LM) after intrathecal chemotherapy were recruited. IP dose was escalated from 10 mg. A minimum of three patients and a maximum of six were enrolled in each cohort. Schedule protocol was IP twice per week for 2 weeks in induction therapy, followed by once per week for 4 weeks in consolidation therapy. Serial samples of plasma and cerebrospinal fluid (CSF) were obtained for pharmacokinetic studies. Results: Thirteen patients were enrolled between March 2017 and July 2018. EGFR driver oncogene was identified in most of the patients. Severe adverse events (AEs) were encountered in 31% (4/13) of the cases, including myelosuppression, radiculitis, and elevation of hepatic aminotransferases (EHA). Study protocol was revised due to lethal myelosuppression. Following protocol revision, vitamin B12 and folic acid supplementation was given at the beginning of treatment, and myelosuppression was well-controlled. Dose-limiting toxicities (DLT) were myelosuppression, radiculitis, and EHA. Two patients (2/2) developed dose-limiting myelosuppression at 15 mg level. One patient (1/6) experienced dose-limiting radiculitis and EHA at 10 mg level. MTD was 10 mg. Response rate was 31% (4/13) and disease control rate was 54% (7/13). The drug concentration showed a decreasing trend in serial CSF samples following each IP. After IP, the peak plasma concentration was reached at 4 h in two cases, 6 h in two cases, 9 h in one case, and 12 h in one case, respectively. Conclusion: Pemetrexed was appropriate for intrathecal administration. IP at 10 mg dose in combination with vitamin supplementation on the schedule of 1–2 times per week showed controllable toxicity and good efficacy. This regimen paves the way for subsequent clinical trial. Clinical Trial Registration:www.ClinicalTrials.gov, identifier NCT03101579.
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Affiliation(s)
- Zhenyu Pan
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, China.,Department of Neuro-Oncological Surgery, The First Hospital of Jilin University, Changchun, China
| | - Guozi Yang
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, China
| | - Jiuwei Cui
- Cancer Center, The First Hospital of Jilin University, Changchun, China
| | - Wei Li
- Cancer Center, The First Hospital of Jilin University, Changchun, China
| | - Yu Li
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, China
| | - Pengxiang Gao
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, China
| | - Tongchao Jiang
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, China
| | - Yanan Sun
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, China
| | - Lihua Dong
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, China
| | - Yuanyuan Song
- Department of Clinical Laboratory, The First Hospital of Jilin University, Changchun, China
| | - Gang Zhao
- Department of Neuro-Oncological Surgery, The First Hospital of Jilin University, Changchun, China
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Complications of Intrathecal Chemotherapy in Adults: Single-Institution Experience in 109 Consecutive Patients. JOURNAL OF ONCOLOGY 2019; 2019:4047617. [PMID: 31186634 PMCID: PMC6521528 DOI: 10.1155/2019/4047617] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/26/2019] [Accepted: 04/11/2019] [Indexed: 11/17/2022]
Abstract
Acute lymphoblastic leukemia and other aggressive lymphoid malignancies like Burkitt leukemia/lymphoma have high incidence of central nervous system (CNS) involvement. Various solid tumors, most notably breast cancer, can also metastasize into the CNS as a late stage complication causing devastating effects. Intrathecal (IT) chemotherapy consisting of methotrexate, cytarabine, or the two in combination is frequently used for the prophylaxis and treatment of CNS metastasis. Because of the high toxicity of these chemotherapeutic agents, however, their side effect profiles are potentially catastrophic. The incidence of neurotoxicity secondary to IT chemotherapy is well defined in the pediatric literature but is poorly reported in adults. Here, we investigated the incidence of neurologic and nonneurologic side effects secondary to IT chemotherapy in 109 consecutive adult patients over a two-year time period at hospitals associated with our institution. Of 355 IT chemotherapy treatments received by these patients, 11 (3.10%) resulted in paresthesias or paralysis, which we defined as significant neurologic events in our analysis. We also examined minor events that arose after IT chemotherapy, including back pain, headache, fever, vomiting, and asthenia. At least one of these occurred after 30.70% of IT chemotherapy doses. Clinicians involved in the care of patients receiving IT chemotherapy should be aware of these findings and consider treatment options lower rate of neurotoxicity such as high-dose systemic methotrexate.
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32
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Franzoi MA, Hortobagyi GN. Leptomeningeal carcinomatosis in patients with breast cancer. Crit Rev Oncol Hematol 2019; 135:85-94. [PMID: 30819451 DOI: 10.1016/j.critrevonc.2019.01.020] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 01/26/2019] [Accepted: 01/26/2019] [Indexed: 12/11/2022] Open
Abstract
Leptomeningeal carcinomatosis (LC) is defined as infiltration of the leptomeninges by metastatic carcinoma, a relatively uncommon but devastating complication of many malignancies. Although only 5% of patients with breast cancer develop leptomeningeal involvement, it remains the most common etiology of LC. It can occur as a late-stage complication of systemic progression or present as the first sign of metastatic disease, with or without parenchymal brain metastases. Lobular carcinomas have a higher propensity to metastasize into the meninges when compared to ductal carcinoma, especially the triple-negative subtype, which usually is associated with a shorter interval between metastatic breast cancer diagnosis and the development of LC. Prognosis remains poor, with median survival of 4 months for patients receiving state-of-the-art treatment. The main factors associated with survival are performance status at diagnosis, CSF protein level and triple-negative subtype. Headache is commonly the first clinical presentation of LC, and the diagnostic workup usually requires CSF-cytological analysis and or/MRI. The current management of LC consists of a combination of intra-CSF chemotherapy, systemic therapy, radiotherapy and/or best-supportive care. The standard intra-CSF chemotherapy regimen is methotrexate. Radiotherapy is used for relieving obstruction points on CSF-outflow channels due to ependymal nodules, tumor deposits or bulky disease. Objective responses have been reported with intrathecal administration of trastuzumab for HER2-positive disease, yet this strategy is still under investigation. Further prospective trials are needed to better address the impact of these treatment modalities on overall survival and quality of life.
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Affiliation(s)
| | - Gabriel N Hortobagyi
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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33
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El Shafie RA, Böhm K, Weber D, Lang K, Schlaich F, Adeberg S, Paul A, Haefner MF, Katayama S, Sterzing F, Hörner-Rieber J, Löw S, Herfarth K, Debus J, Rieken S, Bernhardt D. Outcome and prognostic factors following palliative craniospinal irradiation for leptomeningeal carcinomatosis. Cancer Manag Res 2019; 11:789-801. [PMID: 30697071 PMCID: PMC6340499 DOI: 10.2147/cmar.s182154] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background Leptomeningeal carcinomatosis (LC) is a severe complication of metastatic tumor spread to the central nervous system. Prognosis is dismal with a median overall survival (OS) of ~10–15 weeks. Treatment options include radiotherapy (RT) to involved sites, systemic chemo- or targeted therapy, intrathecal chemotherapy and best supportive care with dexamethasone. Craniospinal irradiation (CSI) is a more aggressive radiotherapeutic approach, for which very limited data exists. Here, we report on our 10-year experience with palliative CSI of selected patients with LC. Patients and methods Twenty-five patients received CSI for the treatment of LC at our institution between 2008 and 2018. Patients were selected individually for CSI based on clinical performance, presenting symptoms and estimated benefit. Median patient age was 53 years (IQR: 45–59), and breast cancer was the most common primary. Additional brain metastases were found in 18 patients (72.0%). RT was delivered at a TomoTherapy machine, using helical intensity-modulated radiotherapy (IMRT). The most commonly prescribed dose was 36 Gy in 20 fractions, corresponding to a median biologically equivalent dose of 40.8 Gy (IQR: 39.0–2.5). Clinical performance and neurologic function were assessed before and in response to therapy, and deficits were retrospectively quantified on the 5-point neurologic function scale (NFS). A Cox proportional hazards model with univariate and multivariate analyses was fitted for survival. Results Twenty-one patients died and four were alive at the time of analysis. Median OS from LC diagnosis was 19.3 weeks (IQR: 9.3–34.0, 95% CI: 11.0–32.0). In univariate analysis, a Karnofsky performance scale index (KPI) ≥70% (P=0.001), age ≤55 years at LC diagnosis (P=0.022), cerebrospinal fluid (CSF) protein <100 mg/dL (P=0.018) and no more than mild or moderate neurologic deficits (NFS ≤2; P=0.007) were predictive of longer OS. So were the neurologic response to treatment (P=0.018) and the application of systemic therapy after RT completion (P=0.029). The presence of CSF flow obstruction was predictive of shorter OS (P=0.026). In multivariate analysis, age at LC diagnosis (P=0.018), KPI (P<0.001) and neurologic response (P=0.037) remained as independent prognostic factors for longer OS. Treatment-associated toxicity was manageable and mostly grades I and II according to the Common Terminology Criteria for Adverse Events v4.0. Eight patients (32%) developed grade III myelosuppression. Neurologic symptom stabilization could be achieved in 40.0% and a sizeable improvement in 28.0% of all patients. Conclusion CSI for the treatment of LC is feasible and may have therapeutic value in carefully selected patients, alleviating symptoms or delaying neurologic deterioration. OS after CSI was comparable to the rates described in current literature for patients with LC. The use of modern irradiation techniques such as helical IMRT is warranted to limit toxicity. Patient selection should take into account prognostic factors such as age, clinical performance, neurologic function and the availability of systemic treatment options.
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Affiliation(s)
- Rami A El Shafie
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany,
| | - Karina Böhm
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany,
| | - Dorothea Weber
- Institute of Medical Biometry and Informatics (IMBI), Heidelberg University Hospital, Heidelberg 69120, Germany
| | - Kristin Lang
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany,
| | - Fabian Schlaich
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany,
| | - Sebastian Adeberg
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany,
| | - Angela Paul
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany, .,Heavy Ion Therapy Center (HIT), Heidelberg University Hospital, Heidelberg 69120, Germany
| | - Matthias F Haefner
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany,
| | - Sonja Katayama
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany,
| | - Florian Sterzing
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany, .,Department of Radiation Oncology, Klinikum Kempten, Kempten 87439, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany,
| | - Sarah Löw
- Department of Neurology, University Hospital of Heidelberg, Heidelberg 69120, Germany
| | - Klaus Herfarth
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany, .,Heavy Ion Therapy Center (HIT), Heidelberg University Hospital, Heidelberg 69120, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany, .,Heavy Ion Therapy Center (HIT), Heidelberg University Hospital, Heidelberg 69120, Germany.,German Cancer Research Center (DKFZ), Heidelberg 69120, Germany
| | - Stefan Rieken
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany, .,Heavy Ion Therapy Center (HIT), Heidelberg University Hospital, Heidelberg 69120, Germany
| | - Denise Bernhardt
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany,
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Moosavi L, D’Assumpcao C, Bowen J, Heidari A, Cobos E. Leptomeningeal Carcinomatosis From Carcinoma of Unknown Primary in a Young Patient: A Case Report and a Literature Review. J Investig Med High Impact Case Rep 2019; 7:2324709619869380. [PMID: 31423841 PMCID: PMC6699001 DOI: 10.1177/2324709619869380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 07/14/2019] [Accepted: 07/18/2019] [Indexed: 11/15/2022] Open
Abstract
Leptomeningeal carcinomatosis, leptomeningeal meningitis, or, as referred here, leptomeningeal metastasis (LM), is a rare but frequently fatal complication seen in advanced stage of cancer either locally advanced or after a metastasis of a known primary cancer. We present a rare and uncommon case of leptomeningeal metastases from carcinoma of unknown primary. A 32-year-old female was diagnosed with LM; however, no known primary carcinoma was identified after 2 separate biopsies. The first biopsy of the right pre-tracheal lymph node showed poorly differentiated pan-keratin (AE1 and AE3) and placental alkaline phosphatase with the possibility of germ cell origin. Second cytology of cervical lymphadenopathy was remarkable for cytokeratin 7 and 20, placental alkaline phosphatase, and CDX2 suggestive of germ line tumor with both mucinous ovarian and gastrointestinal carcinomas. Unfortunately, the LM progressed rapidly despite multiple cycles of germ cell origin directed systemic and intrathecal chemotherapy, and the patient opted for hospice care without getting a chance to identify the primary source.
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35
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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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36
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Assi HI, Mahmoud T, Saadeh FS, El Darsa H. Management of leptomeningeal metastasis in breast cancer. Clin Neurol Neurosurg 2018; 172:151-159. [PMID: 30015053 DOI: 10.1016/j.clineuro.2018.07.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 06/22/2018] [Accepted: 07/01/2018] [Indexed: 10/28/2022]
Abstract
Leptomeningeal metastasis (LM), which occurs when malignant cells spread to the central nervous system, is becoming an increasingly common complication in patients with breast cancer. Diagnosis and treatment of LM is challenging. Moreover, prognosis of patients with LM is poor, with a median survival of 6 months after diagnosis. This review highlights the strengths and limitations of currently available diagnostic tools and therapies for LM. The current treatments for LM, including radiotherapy, systemic therapy, and intrathecal treatment, aim to maintain the quality of life of patients by correcting neurological deficits and arresting neurological degeneration. However, there is no standardized therapy for LM because of a lack of randomized trials on this condition.
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Affiliation(s)
- Hazem I Assi
- Department of Internal Medicine, Naef K. Basile Cancer Institute, American University of Beirut Medical Center, Lebanon.
| | - Tala Mahmoud
- Faculty of Medicine, University of Balamand, Lebanon.
| | - Fadi S Saadeh
- Faculty of Medicine, American University of Beirut, Lebanon.
| | - Haidar El Darsa
- Department of Internal Medicine, Naef K. Basile Cancer Institute, American University of Beirut Medical Center, Lebanon.
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Johnson WR, Theeler BJ, Van Echo D, Young P, Kwok M. Treatment of Leptomeningeal Carcinomatosis in a Patient with Metastatic Pancreatic Cancer: A Case Report and Review of the Literature. Case Rep Oncol 2018; 11:281-288. [PMID: 29867436 PMCID: PMC5981627 DOI: 10.1159/000489085] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 04/09/2018] [Indexed: 01/05/2023] Open
Abstract
Pancreatic cancer is the fourth leading cause of cancer-related death with a median survival of 3–11 months when metastatic. We present a patient with metastatic pancreatic cancer and an exceptional response to initial systemic chemotherapy with FOLFIRINOX (fluorouracil, leucovorin, irinotecan, and oxaliplatin). Despite evidence of disease control on body imaging, he developed symptomatic leptomeningeal disease and brain metastases 29 months into treatment. He received aggressive treatment with capecitabine and irinotecan, intrathecal topotecan, and eventually bevacizumab. He did well for 36 weeks on this regimen until developing sepsis. This patient significantly outlived his expected survival and, moreover, did so with very good quality of life. This case demonstrates the natural history of pancreatic cancer progressing to involve the central nervous system when systemic disease is otherwise responsive to chemotherapy. It is the first case to demonstrate the potential effectiveness of intrathecal topotecan in combination with systemic chemotherapy for the treatment of leptomeningeal metastases of pancreatic cancer.
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Affiliation(s)
| | - Brett J Theeler
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - David Van Echo
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Patrick Young
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Mary Kwok
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
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Abstract
OPINION STATEMENT Treatment options for leptomeningeal metastases are expanding with greater tolerability and efficacy than in the past. Improved knowledge of molecular subtypes of some cancers can guide in choosing more effective therapeutic options; however, physicians should be mindful that these molecular types can be different in the central nervous system compared to the rest of the body. This is particularly true in breast and lung cancer, in which some patients now can live for many months or even years after diagnosis of leptomeningeal metastases. Options for intrathecal therapies are expanding, but physicians should be mindful that this is a passive delivery system that relies on normal CSF flow, so therapies will not penetrate bulky or parenchymal disease sites, especially in the presence of abnormal CSF flow. When chemotherapeutic options are lacking or unsuccessful, focal radiosurgery which can provide symptomatic relief and proton craniospinal radiation remain effective options. Hopefully more formal studies will be conducted in the future to verify which treatments are indeed most effective for particular types of cancer.
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Affiliation(s)
- Jerome J Graber
- Department of Neurology, Ben and Catherine Ivy Center for Advanced Brain Tumor Treatment, Swedish Neuroscience Institute, Seattle, WA, 98122-4470, USA.
| | - Santosh Kesari
- Department of Translational Neurosciences and Neurotherapeutics, John Wayne Cancer Institute, Pacific Neuroscience Institute, Providence Saint John's Health Center, Santa Monica, CA, 90404, USA.
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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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40
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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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Inno A, Di Noia V, D'Argento E, Modena A, Gori S. State of the art of chemotherapy for the treatment of central nervous system metastases from non-small cell lung cancer. Transl Lung Cancer Res 2016; 5:599-609. [PMID: 28149755 DOI: 10.21037/tlcr.2016.11.01] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Chemotherapy is the mainstay of treatment of advanced non-small cell lung cancer (NSCLC) without molecular drivers. Despite a low penetration of central nervous system (CNS), chemotherapy drugs demonstrated encouraging activity against CNS metastases from NSCLC. Based on the available data, chemotherapy should be considered as an important part of the multidisciplinary treatment of CNS metastases. Particularly, platinum-based regimens represent the most active combinations and pemetrexed is associated with a meaningful clinical benefit for patients with non-squamous histology. How to integrate chemotherapy and radiotherapy for newly diagnosed brain metastases (BMs) is still debated. Although flawed by some limitations, the available evidence suggests a role for upfront chemotherapy for the treatment of NSCLC patients with synchronous, asymptomatic BMs, thus allowing a delay of radiotherapy. Despite the introduction of modern and more effective chemotherapy, however, the prognosis of NSCLC patients with CNS metastases remains poor, especially for those with progressive BMs or leptomeningeal carcinomatosis (LC).
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Affiliation(s)
- Alessandro Inno
- Medical Oncology Unit, Sacro Cuore don Calabria Hospital, Cancer Care Center, Verona, Italy
| | - Vincenzo Di Noia
- Medical Oncology Unit, Policlinico Gemelli Foundation, Catholic University of the Sacred Heart, Rome, Italy
| | - Ettore D'Argento
- Medical Oncology Unit, Policlinico Gemelli Foundation, Catholic University of the Sacred Heart, Rome, Italy
| | - Alessandra Modena
- Medical Oncology Unit, Sacro Cuore don Calabria Hospital, Cancer Care Center, Verona, Italy
| | - Stefania Gori
- Medical Oncology Unit, Sacro Cuore don Calabria Hospital, Cancer Care Center, Verona, Italy
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42
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Wu YL, Zhou L, Lu Y. Intrathecal chemotherapy as a treatment for leptomeningeal metastasis of non-small cell lung cancer: A pooled analysis. Oncol Lett 2016; 12:1301-1314. [PMID: 27446430 PMCID: PMC4950629 DOI: 10.3892/ol.2016.4783] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 04/22/2016] [Indexed: 02/05/2023] Open
Abstract
Leptomeningeal metastasis (LM) is increasingly common in patients with non-small cell lung cancer (NSCLC) due to improved treatment, and ultimately, prolonged patient survival. The current study is a pooled analysis that evaluated intrathecal chemotherapy (ITC) as a treatment for NSCLC patients with LM. The PUBMED, OVID, EBSCO and Cochrane Library databases were searched for published studies involving ITC in NSCLC patients with LM. The primary outcomes of interest included response (symptomatic, radiographic and cytological) and survival. Overall, 4 prospective studies and 5 retrospective studies were included. In total, 37 patients received ITC only, and 552 patients received multiple interventions (ITC, whole-brain radiotherapy, epidermal growth factor receptor tyrosine kinase inhibitors, systemic chemotherapy and support care). In patients with available individual information, the reevaluated cytological, clinical and radiographic rates of response to ITC were 55% (53-60%; n=49), 64% (53-79%; n=58), and 53% (n=32), respectively, and the reevaluated median survival time (from the onset of treatment, n=50) was 6.0 months (95% CI, 5.2-6.8). In patients without available individual information, the reported cytological and clinical rates of response to ITC are 14-52% and 13-50%, respectively, and the reported median survival time (from the diagnosis of LM) was 3.0-4.3 months. The clinical response rates of patients only receiving ITC varied from 71 to 79% (100% if including stable disease). The median survival time of patients who only received ITC (7.5 months) was much longer than that of patients who received multiple interventions (3.0-5.0 months). Accordingly, in NSCLC patients with LM, ITC may offer a promising response rate and survival benefits under a suitable regimen. In addition, a suitable combination strategy of multidisciplinary therapy is extremely important for these particular patients.
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Affiliation(s)
- Ya-Lan Wu
- Department of Oncology, Chengdu Shang Jin Nan Fu Hospital, Chengdu, Sichuan 610041, P.R. China
- Department of Thoracic Oncology, Cancer Center, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan 610041, P.R. China
- State Key Laboratory of Biotherapy, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Lin Zhou
- Department of Thoracic Oncology, Cancer Center, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan 610041, P.R. China
- State Key Laboratory of Biotherapy, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - You Lu
- Department of Thoracic Oncology, Cancer Center, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan 610041, P.R. China
- State Key Laboratory of Biotherapy, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan 610041, P.R. China
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43
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Dudani S, Mazzarello S, Hilton J, Hutton B, Vandermeer L, Fernandes R, Ibrahim MFK, Smith S, Majeed H, Al-Baimani K, Caudrelier JM, Shorr R, Clemons M. Optimal Management of Leptomeningeal Carcinomatosis in Breast Cancer Patients-A Systematic Review. Clin Breast Cancer 2016; 16:456-470. [PMID: 27553811 DOI: 10.1016/j.clbc.2016.07.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 06/22/2016] [Accepted: 07/20/2016] [Indexed: 11/19/2022]
Abstract
The incidence of leptomeningeal carcinomatosis in breast cancer patients (LC-BC) is increasing. Despite significantly affecting patient quality of life (QoL) and overall survival (OS), little is known about its optimal management. A systematic review of treatment strategies for LC-BC was performed. EMBASE, Ovid Medline, Pubmed, and the Cochrane Central Register of Controlled Trials were searched from 1946 to 2015 for trials reporting on treatments for LC-BC. All treatment modalities and study types were considered. The outcome measures of interest included OS, time to neurologic progression (TTNP), QoL, and treatment toxicity. Of 718 unique citations, 173 studies met the prespecified eligibility criteria. Most were not specific to LC-BC patients. Of 4 identified randomized controlled trials (RCTs), 1 was specific to LC-BC patients and compared systemic therapy and involved-field radiotherapy with or without intrathecal (IT) methotrexate (35 patients), and the remaining 3 had compared different IT chemotherapy regimens (58 of 157 with LC-BC). Of the remaining studies, 19 were nonrandomized interventional studies (225 LC-BC patients), 148 were observational studies (3230 LC-BC patients), and 2 systematic reviews. Minimal prospective data were available on OS, TTNP, QoL, and toxicity. Owing to study heterogeneity, meta-analyses of the endpoint data could not be performed. Limited high-quality evidence exists regarding optimal treatment of LC-BC. The identified studies were heterogeneous and often methodologically poor. The only RCT that specifically assessed the role of IT chemotherapy showed no benefit, and, if anything, harm. Further prospective, tumor-specific trials with improved interstudy methodologic consistency and transparently reported data on OS, TTNP, QoL, and toxicity are urgently needed.
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Affiliation(s)
- Shaan Dudani
- Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, ON, Canada
| | | | - John Hilton
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada; Division of Medical Oncology, Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, ON, Canada
| | - Brian Hutton
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Ricardo Fernandes
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, ON, Canada
| | - Mohammed F K Ibrahim
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, ON, Canada
| | | | - Habeeb Majeed
- Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, ON, Canada
| | - Khalid Al-Baimani
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, ON, Canada
| | - Jean-Michel Caudrelier
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Radiation Medicine, The Ottawa Hospital Cancer Centre, Ottawa, ON, Canada
| | | | - Mark Clemons
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada; Division of Medical Oncology, Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, ON, Canada.
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44
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Pan Z, Yang G, He H, Zhao G, Yuan T, Li Y, Shi W, Gao P, Dong L, Li Y. Concurrent radiotherapy and intrathecal methotrexate for treating leptomeningeal metastasis from solid tumors with adverse prognostic factors: A prospective and single-arm study. Int J Cancer 2016; 139:1864-72. [PMID: 27243238 PMCID: PMC5096248 DOI: 10.1002/ijc.30214] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 05/17/2016] [Accepted: 05/20/2016] [Indexed: 12/15/2022]
Abstract
The prognosis of leptomeningeal metastasis (LM) from solid tumors is extremely poor, especially for patients with adverse prognostic factors. In this phase II clinical trial, we evaluated the efficacy and safety of intrathecal chemotherapy (IC) combined with concomitant involved‐field radiotherapy (IF‐RT) for treating LM from solid tumors with adverse prognostic factors. Fifty‐nine patients with LM from various solid tumors were enrolled between May 2010 and December 2014. Concurrent therapy consisted of concomitant IC (methotrexate 12.5–15 mg and dexamethasone 5 mg, weekly) and IF‐RT (whole brain and/or spinal canal RT, 40 Gy/20f). For patients with low Karnofsky performance status (KPS) score and radiotherapy intolerance, induction IC (1–3 times) was given before concurrent therapy. Thirty‐eight patients (64.4%) received subsequent treatments. All patients were followed up at least 6 months after LM diagnosis or until death. Primary endpoint evaluated was clinical response rate. Secondary endpoints were overall survival (OS) and safety. The pathological types included lung cancer (n = 42), breast cancer (n = 11) and others (n = 6). Median KPS score was 40 (range 20–70). Fifty‐one patients (86.4%) completed concurrent therapy. The overall response rate was 86.4% (51/59). OS ranged from 0.4 to 36.7 months (median 6.5 months), and 1‐year‐survival rate was 21.3%. Treatment‐related adverse events mainly included acute meningitis, chronic‐delayed encephalopathy, radiculitis, myelosuppression and mucositis. Twelve patients (20.3%) had grade III–V toxic reactions. We concluded that IC combined with concomitant IF‐RT, with significant efficacy and acceptable toxicity, may be an optimal therapeutic option for treatment of LM from solid tumors with adverse prognostic factors. LM, in which cancer cells spread to membranes enveloping the brain and spinal cord, is a devastating complication of solid cancers. Existing LM therapies center on IC. In this prospective clinical study, the authors combined intrathecal methotrexate with involved‐field radiotherapy in a concomitant regimen, showing that the approach can potentially improve quality of life for patients with adverse prognostic factors. Concurrent radiotherapy‐bolstered IC by contributing to prolonged remission of neurological symptoms and increasing OS. The findings suggest that the concomitant regimen could be an optimal treatment option for LM. What's new? Leptomeningeal metastasis (LM), in which cancer cells spread to membranes enveloping the brain and spinal cord, is a devastating complication of solid cancers. Existing LM therapies center on intrathecal chemotherapy (IC). In this prospective clinical study, the authors combined intrathecal methotrexate with involved‐field radiotherapy in a concomitant regimen, showing that the approach can potentially improve quality of life for patients with adverse prognostic factors. Concurrent radiotherapy bolstered IC by contributing to prolonged remission of neurological symptoms and increasing overall survival. The findings suggest that the concomitant regimen could be an optimal treatment option for LM.
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Affiliation(s)
- Zhenyu Pan
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, 130021, China
| | - Guozi Yang
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, 130021, China
| | - Hua He
- Cancer Center, The First Hospital of Jilin University, Changchun, 130021, China
| | - Gang Zhao
- Department of Neuro-Oncological Surgery, The First Hospital of Jilin University, Changchun, 130021, China
| | - Tingting Yuan
- Department of Radiology, The First Hospital of Jilin University, Changchun, 130021, China
| | - Yu Li
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, 130021, China
| | - Weiyan Shi
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, 130021, China
| | - Pengxiang Gao
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, 130021, China
| | - Lihua Dong
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, 130021, China
| | - Yunqian Li
- Department of Neuro-Oncological Surgery, The First Hospital of Jilin University, Changchun, 130021, China
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45
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Smalley KSM, Fedorenko IV, Kenchappa RS, Sahebjam S, Forsyth PA. Managing leptomeningeal melanoma metastases in the era of immune and targeted therapy. Int J Cancer 2016; 139:1195-201. [PMID: 27084046 DOI: 10.1002/ijc.30147] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 03/24/2016] [Accepted: 04/08/2016] [Indexed: 12/11/2022]
Abstract
Melanoma frequently metastasizes to the brain, with CNS involvement being clinically evident in ∼30% of patients (as high as 75% at autopsy). In ∼5% cases melanoma cells also metastasize to the leptomeninges, the sub-arachnoid space and cerebrospinal fluid (CSF). Patients with leptomeningeal melanoma metastases (LMM) have the worst prognosis and are characterized by rapid disease progression (mean survival 8-10 weeks) and a death from neurological causes. The recent years have seen tremendous progress in the development of targeted and immune therapies for melanoma that has translated into an increased survival benefit. Despite these gains, the majority of patients fail therapy and there is a suspicion that the brain and the leptomeninges are a "sanctuary" sites for melanoma cells that escape both targeted therapy and immunologic therapies. Emerging evidence suggests that (1) Cancer cells migrating to the CNS may have unique molecular properties and (2) the CNS/leptomeningeal microenvironment represents a pro-survival niche that influences therapeutic response. In this Mini-Review, we will outline the clinical course of LMM development and will describe how the intracranial immune and cellular microenvironments offer both opportunities and challenges for the successful management of this disease. We will further discuss the latest data demonstrating the potential use of BRAF inhibitors and immune therapy in the management of LMM, and will review future potential therapeutic strategies for the management of this most devastating complication of advanced melanoma.
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Affiliation(s)
- Keiran S M Smalley
- The Department of Tumor Biology, Moffitt Cancer Center & Research Institute, Tampa, FL.,Department of Cutaneous Oncology, Moffitt Cancer Center & Research Institute, Tampa, FL
| | - Inna V Fedorenko
- The Department of Tumor Biology, Moffitt Cancer Center & Research Institute, Tampa, FL
| | - Rajappa S Kenchappa
- The Department of Tumor Biology, Moffitt Cancer Center & Research Institute, Tampa, FL.,Department of NeuroOncology, Moffitt Cancer Center & Research Institute, Tampa, FL
| | - Solmaz Sahebjam
- Department of NeuroOncology, Moffitt Cancer Center & Research Institute, Tampa, FL
| | - Peter A Forsyth
- The Department of Tumor Biology, Moffitt Cancer Center & Research Institute, Tampa, FL.,Department of NeuroOncology, Moffitt Cancer Center & Research Institute, Tampa, FL.,Department of Oncology, Tom Baker Cancer Center & University of Calgary, Calgary, AB, Canada
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46
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Mack F, Baumert B, Schäfer N, Hattingen E, Scheffler B, Herrlinger U, Glas M. Therapy of leptomeningeal metastasis in solid tumors. Cancer Treat Rev 2016; 43:83-91. [DOI: 10.1016/j.ctrv.2015.12.004] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 12/16/2015] [Accepted: 12/18/2015] [Indexed: 11/25/2022]
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47
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Abstract
This chapter will review the challenges in pharmacotherapy in primary brain tumors that include the presence of the blood-brain barrier, a blood-tumor barrier, active drug efflux pumps, and high plasma protein binding of agents. The approaches to improve the delivery of drugs to the brain will be discussed. Often the management of brain tumors involves the use of corticosteroids and enzyme-inducing antiseizure medications that can have significant drug interactions that may impact the efficacy or toxicity of drugs used to treat these patients. Various techniques used to assess drug distribution to the brain will be reviewed.
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48
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Wu PF, Lin CH, Kuo CH, Chen WW, Yeh DC, Liao HW, Huang SM, Cheng AL, Lu YS. A pilot study of bevacizumab combined with etoposide and cisplatin in breast cancer patients with leptomeningeal carcinomatosis. BMC Cancer 2015; 15:299. [PMID: 25928457 PMCID: PMC4403836 DOI: 10.1186/s12885-015-1290-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 03/30/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Elevated vascular endothelial growth factor (VEGF) was associated with poor prognosis in leptomeningeal carcinomatosis and anti-angiogenic therapy was found to prolong the survival of mice in preclinical studies. This prospective pilot study investigated the efficacy of anti-VEGF therapy plus chemotherapy in patients with leptomeningeal carcinomatosis originating from breast cancer. METHODS Eligible patients were scheduled to receive bevacizumab combined with etoposide and cisplatin (BEEP) every 3 weeks for a maximum of 6 cycles or until unacceptable toxicity. The primary objective was the central nervous system (CNS)-specific response rate, which was defined as disappearance of cancer cells in the cerebrospinal fluid (CSF) and an improved or stabilized neurologic status. The impact of VEGF inhibition on etoposide penetration into the CSF was analyzed. RESULTS Eight patients were enrolled. The CNS-specific response rate was 60% in 5 evaluable patients. According to intent-to-treat analysis, the median overall survival of the eight patients was 4.7 months (95% confidence interval, CI, 0.3-9.0) and the neurologic progression-free survival was 4.7 months (95% CI 0-10.5). The most common grade 3/4 adverse events were neutropenia (23.1%), leukopenia (23.1%), and hyponatremia (23.1%). The etoposide concentrations in the CSF were much lower than those in plasma, and bevacizumab did not increase etoposide delivery to the CSF. CONCLUSIONS BEEP exhibited promising efficacy in breast cancer patients with leptomeningeal carcinomatosis. Additional studies are warranted to verify its efficacy and clarify the role of anti-angiogenic therapy in this disease. TRIAL REGISTRATION ClinicalTrials.gov identifying number NCT01281696 .
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Affiliation(s)
- Pei-Fang Wu
- National Center of Excellence for Clinical Trial and Research, National Taiwan University Hospital, Taipei City, 10002, Taiwan.
| | - Ching-Hung Lin
- Department of Oncology, National Taiwan University Hospital, Taipei City, 10002, Taiwan.
| | - Ching-Hua Kuo
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei City, 10002, Taiwan.
| | - Wei-Wu Chen
- Department of Oncology, National Taiwan University Hospital, Taipei City, 10002, Taiwan.
| | - Dah-Cherng Yeh
- Department of Surgery, Taichung Veterans General Hospital, Taichung, 40705, Taiwan.
| | - Hsiao-Wei Liao
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei City, 10002, Taiwan.
| | - Shu-Min Huang
- Department of Oncology, National Taiwan University Hospital, Taipei City, 10002, Taiwan.
| | - Ann-Lii Cheng
- Department of Oncology, National Taiwan University Hospital, Taipei City, 10002, Taiwan. .,Department of Internal Medicine, National Taiwan University Hospital, Taipei City, 10002, Taiwan. .,Graduate Institute of Oncology, National Taiwan University College of Medicine, Taipei City, 10002, Taiwan.
| | - Yen-Shen Lu
- Department of Oncology, National Taiwan University Hospital, Taipei City, 10002, Taiwan. .,Department of Internal Medicine, National Taiwan University Hospital, Taipei City, 10002, Taiwan.
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49
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Yoo IK, Lee HS, Kim CD, Chun HJ, Jeen YT, Keum B, Kim ES, Choi HS, Lee JM, Kim SH, Nam SJ, Hyun JJ. Rare case of pancreatic cancer with leptomeningeal carcinomatosis. World J Gastroenterol 2015; 21:1020-1023. [PMID: 25624740 PMCID: PMC4299319 DOI: 10.3748/wjg.v21.i3.1020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 07/06/2014] [Accepted: 09/05/2014] [Indexed: 02/07/2023] Open
Abstract
Leptomeningeal carcinomatosis occurs very rarely in patients with pancreatic cancer. Leptomeningeal carcinomatosis is characterized by multifocal seeding of the leptomeninges by malignant cells that originate from a solid tumor. To the best of our knowledge, brain metastasis from pancreatic cancer is extremely rare. Leptomeningeal carcinomatosis is estimated to occur in 3% to 8% of cases of solid tumors. The clinical manifestation usually involves neurological symptoms, including dizziness, headache, vomiting, nausea, and hemiparesis, symptoms similar to those of meningitis or brain tumors. Diagnostic methods for leptomeningeal carcinomatosis include brain magnetic resonance imaging and cerebrospinal fluid examination. Here, we describe a case of leptomeningeal carcinomatosis in which the primary tumor was later determined to be pancreatic cancer. Brain magnetic resonance imaging findings showed mild enhancement of the leptomeninges, and cerebrospinal fluid cytology was negative at first. However, after repeated spinal taps, atypical cells were observed on cerebrospinal fluid analysis and levels of tumor markers such as carbohydrate antigen 19-9 in cerebrospinal fluid were elevated. Abdominal computed tomography, performed to determine the presence of extracerebral tumors, revealed pancreatic cancer. Pancreatic cancer was confirmed histopathologically on examination of an endoscopic ultrasound-guided fine needle aspiration specimen.
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Chamberlain M, Soffietti R, Raizer J, Rudà R, Brandsma D, Boogerd W, Taillibert S, Groves MD, Le Rhun E, Junck L, van den Bent M, Wen PY, Jaeckle KA. Leptomeningeal metastasis: a Response Assessment in Neuro-Oncology critical review of endpoints and response criteria of published randomized clinical trials. Neuro Oncol 2014; 16:1176-85. [PMID: 24867803 PMCID: PMC4136900 DOI: 10.1093/neuonc/nou089] [Citation(s) in RCA: 110] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 04/16/2014] [Indexed: 12/30/2022] Open
Abstract
PURPOSE To date, response criteria and optimal methods for assessment of outcome have not been standardized in patients with leptomeningeal metastasis (LM). METHODS A Response Assessment in Neuro-Oncology working group of experts in LM critically reviewed published literature regarding randomized clinical trials (RCTs) and trial design in patients with LM. RESULTS A literature review determined that 6 RCTs regarding the treatment of LM have been published, all of which assessed the response to intra-CSF based chemotherapy. Amongst these RCTs, only a single trial attempted to determine whether intra-CSF chemotherapy was of benefit compared with systemic therapy. Otherwise, this pragmatic question has not been formally addressed in patients with solid cancers and LM. The methodology of the 6 RCTs varied widely with respect to pretreatment evaluation, type of treatment, and response to treatment. Additionally there was little uniformity in reporting of treatment-related toxicity. One RCT suggests no advantage of combined versus single-agent intra-CSF chemotherapy in patients with LM. No specific intra-CSF regimen has shown superior efficacy in the treatment of LM, with the exception of liposomal cytarabine in patients with lymphomatous meningitis. Problematic with all RCTs is the lack of standardization with respect to response criteria. There was considerable variation in definitions of response by clinical examination, neuroimaging, and CSF analysis. CONCLUSION Based upon a review of published RCTs in LM, there exists a significant unmet need for guidelines for evaluating patients with LM in clinical practice as well as for response assessment in clinical trials.
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Affiliation(s)
- Marc Chamberlain
- Department of Neurology, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington (M.C.); Department of Neuroscience, Division of Neuro-Oncology, University Hospital, Torino, Italy (R.S., R.R.); Department of Neurology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois (J.R.); Department of Neuro-Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands (D.B., W.B.); Departments of Neuro-Oncology Mazarin and Radiation Oncology, Pitie-Salpetriere Hospital and University Pierre et Marie Curie, Paris VI, Paris, France (S.T.); Austin Brain Tumor Center, Texas Oncology/US Oncology Research, Austin, Texas (M.D.G.); Department of Neuro-Oncology, University Hospital, Lille, France (E.L.R.); Department of Neurology, Oscar Lambret Center, Lille, France (E.L.R.); Department of Neurology, University of Michigan, Ann Arbor, Michigan (L.J.); Department of Neuro-oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, Netherlands (M.v.d.B.); Department of Neurology, Dana-Farber Cancer Institute, Massachusetts General Hospital, Boston, Massachusetts (P.Y.W.); Department of Neurology and Oncology, Mayo Clinic Florida, Jacksonville, Florida (K.A.J.)
| | - Riccardo Soffietti
- Department of Neurology, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington (M.C.); Department of Neuroscience, Division of Neuro-Oncology, University Hospital, Torino, Italy (R.S., R.R.); Department of Neurology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois (J.R.); Department of Neuro-Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands (D.B., W.B.); Departments of Neuro-Oncology Mazarin and Radiation Oncology, Pitie-Salpetriere Hospital and University Pierre et Marie Curie, Paris VI, Paris, France (S.T.); Austin Brain Tumor Center, Texas Oncology/US Oncology Research, Austin, Texas (M.D.G.); Department of Neuro-Oncology, University Hospital, Lille, France (E.L.R.); Department of Neurology, Oscar Lambret Center, Lille, France (E.L.R.); Department of Neurology, University of Michigan, Ann Arbor, Michigan (L.J.); Department of Neuro-oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, Netherlands (M.v.d.B.); Department of Neurology, Dana-Farber Cancer Institute, Massachusetts General Hospital, Boston, Massachusetts (P.Y.W.); Department of Neurology and Oncology, Mayo Clinic Florida, Jacksonville, Florida (K.A.J.)
| | - Jeffrey Raizer
- Department of Neurology, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington (M.C.); Department of Neuroscience, Division of Neuro-Oncology, University Hospital, Torino, Italy (R.S., R.R.); Department of Neurology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois (J.R.); Department of Neuro-Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands (D.B., W.B.); Departments of Neuro-Oncology Mazarin and Radiation Oncology, Pitie-Salpetriere Hospital and University Pierre et Marie Curie, Paris VI, Paris, France (S.T.); Austin Brain Tumor Center, Texas Oncology/US Oncology Research, Austin, Texas (M.D.G.); Department of Neuro-Oncology, University Hospital, Lille, France (E.L.R.); Department of Neurology, Oscar Lambret Center, Lille, France (E.L.R.); Department of Neurology, University of Michigan, Ann Arbor, Michigan (L.J.); Department of Neuro-oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, Netherlands (M.v.d.B.); Department of Neurology, Dana-Farber Cancer Institute, Massachusetts General Hospital, Boston, Massachusetts (P.Y.W.); Department of Neurology and Oncology, Mayo Clinic Florida, Jacksonville, Florida (K.A.J.)
| | - Roberta Rudà
- Department of Neurology, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington (M.C.); Department of Neuroscience, Division of Neuro-Oncology, University Hospital, Torino, Italy (R.S., R.R.); Department of Neurology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois (J.R.); Department of Neuro-Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands (D.B., W.B.); Departments of Neuro-Oncology Mazarin and Radiation Oncology, Pitie-Salpetriere Hospital and University Pierre et Marie Curie, Paris VI, Paris, France (S.T.); Austin Brain Tumor Center, Texas Oncology/US Oncology Research, Austin, Texas (M.D.G.); Department of Neuro-Oncology, University Hospital, Lille, France (E.L.R.); Department of Neurology, Oscar Lambret Center, Lille, France (E.L.R.); Department of Neurology, University of Michigan, Ann Arbor, Michigan (L.J.); Department of Neuro-oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, Netherlands (M.v.d.B.); Department of Neurology, Dana-Farber Cancer Institute, Massachusetts General Hospital, Boston, Massachusetts (P.Y.W.); Department of Neurology and Oncology, Mayo Clinic Florida, Jacksonville, Florida (K.A.J.)
| | - Dieta Brandsma
- Department of Neurology, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington (M.C.); Department of Neuroscience, Division of Neuro-Oncology, University Hospital, Torino, Italy (R.S., R.R.); Department of Neurology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois (J.R.); Department of Neuro-Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands (D.B., W.B.); Departments of Neuro-Oncology Mazarin and Radiation Oncology, Pitie-Salpetriere Hospital and University Pierre et Marie Curie, Paris VI, Paris, France (S.T.); Austin Brain Tumor Center, Texas Oncology/US Oncology Research, Austin, Texas (M.D.G.); Department of Neuro-Oncology, University Hospital, Lille, France (E.L.R.); Department of Neurology, Oscar Lambret Center, Lille, France (E.L.R.); Department of Neurology, University of Michigan, Ann Arbor, Michigan (L.J.); Department of Neuro-oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, Netherlands (M.v.d.B.); Department of Neurology, Dana-Farber Cancer Institute, Massachusetts General Hospital, Boston, Massachusetts (P.Y.W.); Department of Neurology and Oncology, Mayo Clinic Florida, Jacksonville, Florida (K.A.J.)
| | - Willem Boogerd
- Department of Neurology, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington (M.C.); Department of Neuroscience, Division of Neuro-Oncology, University Hospital, Torino, Italy (R.S., R.R.); Department of Neurology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois (J.R.); Department of Neuro-Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands (D.B., W.B.); Departments of Neuro-Oncology Mazarin and Radiation Oncology, Pitie-Salpetriere Hospital and University Pierre et Marie Curie, Paris VI, Paris, France (S.T.); Austin Brain Tumor Center, Texas Oncology/US Oncology Research, Austin, Texas (M.D.G.); Department of Neuro-Oncology, University Hospital, Lille, France (E.L.R.); Department of Neurology, Oscar Lambret Center, Lille, France (E.L.R.); Department of Neurology, University of Michigan, Ann Arbor, Michigan (L.J.); Department of Neuro-oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, Netherlands (M.v.d.B.); Department of Neurology, Dana-Farber Cancer Institute, Massachusetts General Hospital, Boston, Massachusetts (P.Y.W.); Department of Neurology and Oncology, Mayo Clinic Florida, Jacksonville, Florida (K.A.J.)
| | - Sophie Taillibert
- Department of Neurology, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington (M.C.); Department of Neuroscience, Division of Neuro-Oncology, University Hospital, Torino, Italy (R.S., R.R.); Department of Neurology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois (J.R.); Department of Neuro-Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands (D.B., W.B.); Departments of Neuro-Oncology Mazarin and Radiation Oncology, Pitie-Salpetriere Hospital and University Pierre et Marie Curie, Paris VI, Paris, France (S.T.); Austin Brain Tumor Center, Texas Oncology/US Oncology Research, Austin, Texas (M.D.G.); Department of Neuro-Oncology, University Hospital, Lille, France (E.L.R.); Department of Neurology, Oscar Lambret Center, Lille, France (E.L.R.); Department of Neurology, University of Michigan, Ann Arbor, Michigan (L.J.); Department of Neuro-oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, Netherlands (M.v.d.B.); Department of Neurology, Dana-Farber Cancer Institute, Massachusetts General Hospital, Boston, Massachusetts (P.Y.W.); Department of Neurology and Oncology, Mayo Clinic Florida, Jacksonville, Florida (K.A.J.)
| | - Morris D Groves
- Department of Neurology, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington (M.C.); Department of Neuroscience, Division of Neuro-Oncology, University Hospital, Torino, Italy (R.S., R.R.); Department of Neurology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois (J.R.); Department of Neuro-Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands (D.B., W.B.); Departments of Neuro-Oncology Mazarin and Radiation Oncology, Pitie-Salpetriere Hospital and University Pierre et Marie Curie, Paris VI, Paris, France (S.T.); Austin Brain Tumor Center, Texas Oncology/US Oncology Research, Austin, Texas (M.D.G.); Department of Neuro-Oncology, University Hospital, Lille, France (E.L.R.); Department of Neurology, Oscar Lambret Center, Lille, France (E.L.R.); Department of Neurology, University of Michigan, Ann Arbor, Michigan (L.J.); Department of Neuro-oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, Netherlands (M.v.d.B.); Department of Neurology, Dana-Farber Cancer Institute, Massachusetts General Hospital, Boston, Massachusetts (P.Y.W.); Department of Neurology and Oncology, Mayo Clinic Florida, Jacksonville, Florida (K.A.J.)
| | - Emilie Le Rhun
- Department of Neurology, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington (M.C.); Department of Neuroscience, Division of Neuro-Oncology, University Hospital, Torino, Italy (R.S., R.R.); Department of Neurology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois (J.R.); Department of Neuro-Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands (D.B., W.B.); Departments of Neuro-Oncology Mazarin and Radiation Oncology, Pitie-Salpetriere Hospital and University Pierre et Marie Curie, Paris VI, Paris, France (S.T.); Austin Brain Tumor Center, Texas Oncology/US Oncology Research, Austin, Texas (M.D.G.); Department of Neuro-Oncology, University Hospital, Lille, France (E.L.R.); Department of Neurology, Oscar Lambret Center, Lille, France (E.L.R.); Department of Neurology, University of Michigan, Ann Arbor, Michigan (L.J.); Department of Neuro-oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, Netherlands (M.v.d.B.); Department of Neurology, Dana-Farber Cancer Institute, Massachusetts General Hospital, Boston, Massachusetts (P.Y.W.); Department of Neurology and Oncology, Mayo Clinic Florida, Jacksonville, Florida (K.A.J.)
| | - Larry Junck
- Department of Neurology, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington (M.C.); Department of Neuroscience, Division of Neuro-Oncology, University Hospital, Torino, Italy (R.S., R.R.); Department of Neurology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois (J.R.); Department of Neuro-Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands (D.B., W.B.); Departments of Neuro-Oncology Mazarin and Radiation Oncology, Pitie-Salpetriere Hospital and University Pierre et Marie Curie, Paris VI, Paris, France (S.T.); Austin Brain Tumor Center, Texas Oncology/US Oncology Research, Austin, Texas (M.D.G.); Department of Neuro-Oncology, University Hospital, Lille, France (E.L.R.); Department of Neurology, Oscar Lambret Center, Lille, France (E.L.R.); Department of Neurology, University of Michigan, Ann Arbor, Michigan (L.J.); Department of Neuro-oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, Netherlands (M.v.d.B.); Department of Neurology, Dana-Farber Cancer Institute, Massachusetts General Hospital, Boston, Massachusetts (P.Y.W.); Department of Neurology and Oncology, Mayo Clinic Florida, Jacksonville, Florida (K.A.J.)
| | - Martin van den Bent
- Department of Neurology, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington (M.C.); Department of Neuroscience, Division of Neuro-Oncology, University Hospital, Torino, Italy (R.S., R.R.); Department of Neurology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois (J.R.); Department of Neuro-Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands (D.B., W.B.); Departments of Neuro-Oncology Mazarin and Radiation Oncology, Pitie-Salpetriere Hospital and University Pierre et Marie Curie, Paris VI, Paris, France (S.T.); Austin Brain Tumor Center, Texas Oncology/US Oncology Research, Austin, Texas (M.D.G.); Department of Neuro-Oncology, University Hospital, Lille, France (E.L.R.); Department of Neurology, Oscar Lambret Center, Lille, France (E.L.R.); Department of Neurology, University of Michigan, Ann Arbor, Michigan (L.J.); Department of Neuro-oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, Netherlands (M.v.d.B.); Department of Neurology, Dana-Farber Cancer Institute, Massachusetts General Hospital, Boston, Massachusetts (P.Y.W.); Department of Neurology and Oncology, Mayo Clinic Florida, Jacksonville, Florida (K.A.J.)
| | - Patrick Y Wen
- Department of Neurology, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington (M.C.); Department of Neuroscience, Division of Neuro-Oncology, University Hospital, Torino, Italy (R.S., R.R.); Department of Neurology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois (J.R.); Department of Neuro-Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands (D.B., W.B.); Departments of Neuro-Oncology Mazarin and Radiation Oncology, Pitie-Salpetriere Hospital and University Pierre et Marie Curie, Paris VI, Paris, France (S.T.); Austin Brain Tumor Center, Texas Oncology/US Oncology Research, Austin, Texas (M.D.G.); Department of Neuro-Oncology, University Hospital, Lille, France (E.L.R.); Department of Neurology, Oscar Lambret Center, Lille, France (E.L.R.); Department of Neurology, University of Michigan, Ann Arbor, Michigan (L.J.); Department of Neuro-oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, Netherlands (M.v.d.B.); Department of Neurology, Dana-Farber Cancer Institute, Massachusetts General Hospital, Boston, Massachusetts (P.Y.W.); Department of Neurology and Oncology, Mayo Clinic Florida, Jacksonville, Florida (K.A.J.)
| | - Kurt A Jaeckle
- Department of Neurology, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington (M.C.); Department of Neuroscience, Division of Neuro-Oncology, University Hospital, Torino, Italy (R.S., R.R.); Department of Neurology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois (J.R.); Department of Neuro-Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands (D.B., W.B.); Departments of Neuro-Oncology Mazarin and Radiation Oncology, Pitie-Salpetriere Hospital and University Pierre et Marie Curie, Paris VI, Paris, France (S.T.); Austin Brain Tumor Center, Texas Oncology/US Oncology Research, Austin, Texas (M.D.G.); Department of Neuro-Oncology, University Hospital, Lille, France (E.L.R.); Department of Neurology, Oscar Lambret Center, Lille, France (E.L.R.); Department of Neurology, University of Michigan, Ann Arbor, Michigan (L.J.); Department of Neuro-oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, Netherlands (M.v.d.B.); Department of Neurology, Dana-Farber Cancer Institute, Massachusetts General Hospital, Boston, Massachusetts (P.Y.W.); Department of Neurology and Oncology, Mayo Clinic Florida, Jacksonville, Florida (K.A.J.)
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