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Khaled ML, Tarhini AA, Forsyth PA, Smalley I, Piña Y. Leptomeningeal Disease (LMD) in Patients with Melanoma Metastases. Cancers (Basel) 2023; 15:cancers15061884. [PMID: 36980770 PMCID: PMC10047692 DOI: 10.3390/cancers15061884] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/13/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023] Open
Abstract
Leptomeningeal disease (LMD) is a devastating complication caused by seeding malignant cells to the cerebrospinal fluid (CSF) and the leptomeningeal membrane. LMD is diagnosed in 5-15% of patients with systemic malignancy. Management of LMD is challenging due to the biological and metabolic tumor microenvironment of LMD being largely unknown. Patients with LMD can present with a wide variety of signs and/or symptoms that could be multifocal and include headache, nausea, vomiting, diplopia, and weakness, among others. The median survival time for patients with LMD is measured in weeks and up to 3-6 months with aggressive management, and death usually occurs due to progressive neurologic dysfunction. In melanoma, LMD is associated with a suppressive immune microenvironment characterized by a high number of apoptotic and exhausted CD4+ T-cells, myeloid-derived suppressor cells, and a low number of CD8+ T-cells. Proteomics analysis revealed enrichment of complement cascade, which may disrupt the blood-CSF barrier. Clinical management of melanoma LMD consists primarily of radiation therapy, BRAF/MEK inhibitors as targeted therapy, and immunotherapy with anti-PD-1, anti-CTLA-4, and anti-LAG-3 immune checkpoint inhibitors. This review summarizes the biology and anatomic features of melanoma LMD, as well as the current therapeutic approaches.
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Affiliation(s)
- Mariam Lotfy Khaled
- Metabolism and Physiology Department, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
- Biochemistry Department, Faculty of Pharmacy, Cairo University, Cairo 12613, Egypt
| | - Ahmad A Tarhini
- Departments of Cutaneous Oncology and Immunology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | - Peter A Forsyth
- Neuro-Oncology Department, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | - Inna Smalley
- Metabolism and Physiology Department, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | - Yolanda Piña
- Neuro-Oncology Department, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
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Melanoma Brain Metastases: An Update on the Use of Immune Checkpoint Inhibitors and Molecularly Targeted Agents. Am J Clin Dermatol 2022; 23:523-545. [PMID: 35534670 DOI: 10.1007/s40257-022-00678-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2022] [Indexed: 11/01/2022]
Abstract
Brain metastases from melanoma are no longer uniformly associated with dismal outcomes. Impressive tumor tissue-based (craniotomy) translational research has consistently shown that distinct patient subgroups may have a favorable prognosis. This review provides a historical overview of the standard-of-care treatments until the early 2010s. It subsequently summarizes more recent advances in understanding the biology of melanoma brain metastases (MBMs) and treating patients with MBMs, mainly focusing upon prospective clinical trials of BRAF/MEK and PD-1/CTLA-4 inhibitors in patients with previously untreated MBMs. These additional systemic treatments have provided effective complementary treatment approaches and/or alternatives to radiation and craniotomy. The current role of radiation therapy, especially in conjunction with systemic therapies, is also discussed through the lens of various retrospective studies. The combined efficacy of systemic treatments with radiation has improved overall survival over the last 10 years and has sparked considerable research interest regarding optimal dosing and sequencing of radiation treatments with systemic treatments. Finally, the review describes ongoing clinical trials in patients with MBMs.
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Najem H, Marisetty A, Horbinski C, Long J, Huse JT, Glitza Oliva IC, Ferguson SD, Kumthekar PU, Wainwright DA, Chen P, Lesniak MS, Burks JK, Heimberger AB. CD11c+CD163+ Cells and Signal Transducer and Activator of Transcription 3 (STAT3) Expression Are Common in Melanoma Leptomeningeal Disease. Front Immunol 2021; 12:745893. [PMID: 34691054 PMCID: PMC8531809 DOI: 10.3389/fimmu.2021.745893] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 09/22/2021] [Indexed: 11/13/2022] Open
Abstract
Leptomeningeal disease (LMD) in melanoma patients is associated with significant neurological sequela and has a dismal outcome, with survival measured typically in weeks. Despite the therapeutic benefit of targeted therapies and immunotherapies for Stage IV melanoma, patients with LMD do not typically benefit. A deeper understanding of the tumor microenvironment (TME) of LMD may provide more appropriate therapeutic selection. A retrospective analysis of subjects who underwent surgical resection with LMD (n=8) were profiled with seven color multiplex staining to evaluate the expression of the global immune suppressive hub - the signal transducer and activator of transcription 3 (STAT3) and for the presence of CD3+ T cells, CD68+ monocyte-derived cells, CD163+ immune suppressive macrophages, and CD11c+ cells [potential dendritic cells (DCs)] in association with the melanoma tumor marker S100B and DAPI for cellular nuclear identification. High-resolution cellular imaging and quantification was conducted using the Akoya Vectra Polaris. CD11c+ cells predominate in the TME (10% of total cells), along with immunosuppressive macrophages (2%). Another potential subset of DCs co-expressing CD11c+ and the CD163+ immunosuppressive marker is frequently present (8/8 of specimens, 8%). Occasional CD3+ T cells are identified, especially in the stroma of the tumor (p=0.039). pSTAT3 nuclear expression is heterogeneous in the various immune cell populations. Occasional immune cluster interactions can be seen in the stroma and on the edge. In conclusion, the TME of LMD is largely devoid of CD3+ T cells but is enriched in immune suppression and innate immunity.
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Affiliation(s)
- Hinda Najem
- Department of Neurological Surgery, Northwestern Medicine Malnati Brain Tumor Institute of the Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Anantha Marisetty
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | - Craig Horbinski
- Department of Neurological Surgery, Northwestern Medicine Malnati Brain Tumor Institute of the Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - James Long
- Department of Biostatistics, University of Texas M.D. Anderson Cancer Center, Houston, TX, United States
| | - Jason T. Huse
- Department of Pathology, University of Texas M.D. Anderson Cancer Center, Houston, TX, United States
| | - Isabella C. Glitza Oliva
- Department of Melanoma, University of Texas M.D. Anderson Cancer Center, Houston, TX, United States
| | - Sherise D. Ferguson
- Department of Neurosurgery, University of Texas M.D. Anderson Cancer Center, Houston, TX, United States
| | - Priya U. Kumthekar
- Department of Neuro-oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Derek A. Wainwright
- Department of Neurological Surgery, Northwestern Medicine Malnati Brain Tumor Institute of the Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Peiwen Chen
- Department of Neurological Surgery, Northwestern Medicine Malnati Brain Tumor Institute of the Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Maciej S. Lesniak
- Department of Neurological Surgery, Northwestern Medicine Malnati Brain Tumor Institute of the Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Jared K. Burks
- Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston, TX, United States
| | - Amy B. Heimberger
- Department of Neurological Surgery, Northwestern Medicine Malnati Brain Tumor Institute of the Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
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Pellerino A, Brastianos PK, Rudà R, Soffietti R. Leptomeningeal Metastases from Solid Tumors: Recent Advances in Diagnosis and Molecular Approaches. Cancers (Basel) 2021; 13:2888. [PMID: 34207653 PMCID: PMC8227730 DOI: 10.3390/cancers13122888] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 06/05/2021] [Indexed: 12/13/2022] Open
Abstract
Leptomeningeal metastases (LM) from solid tumors represent an unmet need of increasing importance due to an early use of MRI for diagnosis and improvement of outcome of some molecular subgroups following targeted agents and immunotherapy. In this review, we first discussed factors limiting the efficacy of targeted agents in LM, such as the molecular divergence between primary tumors and CNS lesions and CNS barriers at the level of the normal brain, brain tumors and CSF. Further, we reviewed pathogenesis and experimental models and modalities, such as MRI (with RANO and ESO/ESMO criteria), CSF cytology and liquid biopsy, to improve diagnosis and monitoring following therapy. Efficacy and limitations of targeted therapies for LM from EGFR-mutant and ALK-rearranged NSCLC, HER2-positive breast cancer and BRAF-mutated melanomas are reported, including the use of intrathecal administration or modification of traditional cytotoxic compounds. The efficacy of checkpoint inhibitors in LM from non-druggable tumors, in particular triple-negative breast cancer, is discussed. Last, we focused on some recent techniques to improve drug delivery.
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Affiliation(s)
- Alessia Pellerino
- Department of Neuro-Oncology, University and City of Health and Science Hospital, 10126 Turin, Italy; (R.R.); (R.S.)
| | - Priscilla K. Brastianos
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA 02115, USA;
| | - Roberta Rudà
- Department of Neuro-Oncology, University and City of Health and Science Hospital, 10126 Turin, Italy; (R.R.); (R.S.)
- Department of Neurology, Castelfranco Veneto and Brain Tumor Board Treviso Hospital, 31100 Treviso, Italy
| | - Riccardo Soffietti
- Department of Neuro-Oncology, University and City of Health and Science Hospital, 10126 Turin, Italy; (R.R.); (R.S.)
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