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Mehra S, Taylor J. Blastic Plasmacytoid Dendritic Cell Neoplasm: A Comprehensive Review of the Disease, Central Nervous System Presentations, and Treatment Strategies. Cells 2024; 13:243. [PMID: 38334635 PMCID: PMC10854688 DOI: 10.3390/cells13030243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/19/2024] [Accepted: 01/25/2024] [Indexed: 02/10/2024] Open
Abstract
Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a rare, aggressive hematologic malignancy with poor outcomes. The World Health Organization (WHO) redefined BDCN as a distinct disease entity in 2016. BPDCN arises from plasmacytoid dendritic cells, manifesting primarily in the skin, bone marrow, and lymph nodes, occasionally involving the central nervous system (CNS). This presents challenges in diagnosis and treatment, with CNS involvement often overlooked in standard diagnostic workups due to BPDCN's rarity and patients often being neurologically asymptomatic at diagnosis. CNS involvement typically emerges during relapse, yet clinical trials often exclude such cases, limiting our understanding of its development and treatment. Treatment options for CNS involvement include intrathecal (IT) chemotherapies like methotrexate and cytarabine, often in combination with systemic agents. Tagraxofusp and traditional regimens for acute myeloid leukemia show limited success at preventing CNS relapse, prompting exploration of combined therapies like hyperfractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone (HyperCVAD) with venetoclax and adding IT chemotherapy to other backbones. Ongoing clinical trials investigating emerging therapies offer hope despite limited focus on CNS implications. Trials incorporating CNS-involved patients aim to pioneer novel treatment approaches, potentially reshaping BPDCN management. Understanding CNS involvement's complexities in BPDCN remains crucial for tailored treatments and better patient outcomes.
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Affiliation(s)
| | - Justin Taylor
- Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL 33136, USA;
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Marowsky M, Müller V, Schmalfeldt B, Riecke K, Witzel I, Laakmann E. Intrathecal Therapy Options for Meningeal Carcinomatosis. Geburtshilfe Frauenheilkd 2024; 84:59-67. [PMID: 38205044 PMCID: PMC10781578 DOI: 10.1055/a-2185-0457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 09/29/2023] [Indexed: 01/12/2024] Open
Abstract
Around 5 percent of all patients with metastatic breast cancer go on to develop distant metastases in the meninges, also known as meningeal carcinomatosis. The median survival of these patients is between 3.5 and 4.5 months. Current treatment approaches are based on radiotherapy, systemic and intrathecal therapy. Methotrexate, liposomal cytarabine and trastuzumab are the most common substances used for intrathecal therapy. The aim of this review was to provide an overview of these intrathecal therapy options for meningeal carcinomatosis. A systematic search of the literature was carried out in PubMed using the following search terms: "meningeal metastases", "meningeal carcinomatosis", "leptomeningeal metastasis", "leptomeningeal carcinomatosis", "leptomeningeal disease", "breast cancer", "MTX", "methotrexate", "DepoCyte", "liposomal cytarabine", "trastuzumab" and "anti-HER2". This search resulted in 75 potentially relevant studies, 11 of which were included in this review after meeting the previously determined inclusion and exclusion criteria. The studies differ considerably with regards to study design, cohort size, and dosages of administered drugs. In principle, intrathecal therapy has a tolerable side-effects profile and offers promising results in terms of the median overall survival following treatment with trastuzumab for HER2-positive primary tumors. The focus when treating meningeal carcinomatosis must be on providing a multimodal individual therapeutic approach. However, comprehensive studies which compare the efficacy and side effects of individual pharmaceuticals are lacking. Because of the poor prognosis associated with meningeal carcinomatosis, an approach which treats only the symptoms (best supportive care) should always be considered and discussed with affected patients.
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Affiliation(s)
- Madeleine Marowsky
- Klinik und Poliklinik für Gynäkologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Volkmar Müller
- Klinik und Poliklinik für Gynäkologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Barbara Schmalfeldt
- Klinik und Poliklinik für Gynäkologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Kerstin Riecke
- Klinik und Poliklinik für Gynäkologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Isabell Witzel
- Klinik für Gynäkologie, Universitätsspital Zürich, Universität Zürich, Zürich, Switzerland
| | - Elena Laakmann
- Klinik und Poliklinik für Gynäkologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
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Fernández-Torres B, Fontán-Atalaya IM, Peralta-Espinosa E, Díaz-Rodríguez D. Predictive factors for efficacy and safety of intrathecal infusion devices for oncological pain. Br J Pain 2023; 17:569-578. [PMID: 37974633 PMCID: PMC10642496 DOI: 10.1177/20494637231198231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023] Open
Abstract
Introduction In an important percentage of intrathecal infusion therapy, the pain after implantation of a spinal device does not improve. Our objective is to identify factors that can predict therapeutic success and complications, developing a predictive model based on univariate and multivariate analyses. Methods Retrospective observational study, including 132 patients with oncological pain who were implanted with a fixed-flow device for intrathecal infusion. Four time points were established for data collection and, in addition to demographic and anthropometric data, variables related to oncologic pain pathology, initiation of therapy, pain control and complications were collected. Based on univariate and multivariate analyses, we performed predictive models on efficacy and complications. Results The mean baseline pain intensity was VAS 7.78, and when comparing the values before implantation with those at month 1, we observed an overall decrease of 4.75 points, maintained at months 3 and 6. Nocturnal pain progressively decreased in incidence from 50.0% before implantation to 21.8%, 9.1% and 4.3% at 1, 3 and 6 months. Episodic pain was present in 90.1% of the patients before implantation (7.79 episodes/day), and at 6 months the incidence remained at 53.8%. Most of the patients (66.6%) had no complications related to therapy. We constructed a highly significant multivariate model for the efficacy of the therapy with a predictive capacity of 30.2% and composed of factors: absence of nocturnal pain before implantation and clinical improvement on day 2 after implant. Regarding the prediction of complications, it was not possible to achieve a significantly multivariate effective model. Conclusion We identify two factors that predict therapeutic success in a multivariate model: the absence of nocturnal pain before implantation and the improvement of pain on the second day after implantation.
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Affiliation(s)
- Bartolomé Fernández-Torres
- Anesthesiology and Reanimation, Virgen Macarena University Hospital, Sevilla, Spain
- Department of Surgery, Faculty of Medicine, University of Seville, Sevilla, Spain
| | | | | | - Diego Díaz-Rodríguez
- Anesthesiology and Reanimation, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
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Steininger J, Gellrich FF, Engellandt K, Meinhardt M, Westphal D, Beissert S, Meier F, Glitza Oliva IC. Leptomeningeal Metastases in Melanoma Patients: An Update on and Future Perspectives for Diagnosis and Treatment. Int J Mol Sci 2023; 24:11443. [PMID: 37511202 PMCID: PMC10380419 DOI: 10.3390/ijms241411443] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/10/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023] Open
Abstract
Leptomeningeal disease (LMD) is a devastating complication of cancer with a particularly poor prognosis. Among solid tumours, malignant melanoma (MM) has one of the highest rates of metastasis to the leptomeninges, with approximately 10-15% of patients with advanced disease developing LMD. Tumour cells that metastasise to the brain have unique properties that allow them to cross the blood-brain barrier, evade the immune system, and survive in the brain microenvironment. Metastatic colonisation is achieved through dynamic communication between metastatic cells and the tumour microenvironment, resulting in a tumour-permissive milieu. Despite advances in treatment options, the incidence of LMD appears to be increasing and current treatment modalities have a limited impact on survival. This review provides an overview of the biology of LMD, diagnosis and current treatment approaches for MM patients with LMD, and an overview of ongoing clinical trials. Despite the still limited efficacy of current therapies, there is hope that emerging treatments will improve the outcomes for patients with LMD.
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Affiliation(s)
- Julian Steininger
- Department of Dermatology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität (TU) Dresden, 01307 Dresden, Germany
| | - Frank Friedrich Gellrich
- Department of Dermatology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität (TU) Dresden, 01307 Dresden, Germany
| | - Kay Engellandt
- Department of Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität (TU) Dresden, 01307 Dresden, Germany
| | - Matthias Meinhardt
- Institute of Pathology, University Hospital Carl Gustav Carus, Technische Universität (TU) Dresden, 01307 Dresden, Germany
| | - Dana Westphal
- Department of Dermatology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität (TU) Dresden, 01307 Dresden, Germany
| | - Stefan Beissert
- Department of Dermatology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität (TU) Dresden, 01307 Dresden, Germany
| | - Friedegund Meier
- Department of Dermatology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität (TU) Dresden, 01307 Dresden, Germany
- Skin Cancer Center at the University Cancer Center, National Center for Tumor Diseases (NCT/UCC), 01307 Dresden, Germany
| | - Isabella C Glitza Oliva
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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Qin W, Zhao L, Liu B, Yang Y, Mao P, Xu L, Li P, Shang Y, Zhang L, Fan B. Comparison of external system and implanted system in intrathecal therapy for refractory cancer pain in China: A retrospective study. Brain Behav 2023; 13:e2851. [PMID: 36545706 PMCID: PMC9847588 DOI: 10.1002/brb3.2851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 11/30/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Intrathecal therapy (ITT) via an implanted system was demonstrated for the treatment of refractory cancer pain for decades. Recently, the dissemination of ITT is enhanced in an external system way in Asia for a lower implantation cost. This study compares the efficacy, safety, and cost of the two ITT systems in refractory cancer pain patients in China. METHODS One hundred and thirty-nine cancer pain patients who underwent implantation of the ITT system were included. One hundred and three patients received ITT via the external system (external group), while 36 patients received ITT via the implanted system (implanted group). A 1:2 propensity score matching procedure was used to yield a total of 89 patients for the final analysis. Medical records of included patients were retrospectively reviewed and pain scores, incidences of complications, and costs were compared. RESULTS ITT via the external system provided pain relief as potent as ITT via the implanted system but was less time-consuming in the implantation phase (13 vs. 19 days, p < .01). Nausea/vomiting and urinary retention were the most frequent adverse events in both external and implanted groups (32.14%, 16.07% vs. 36.36%, 21.21%). No significant difference was found in the incidences of all kinds of complications. Compared to the implanted group, the external group cost less for the initial implantation (7268 vs. 26,275 US dollar [USD], p < .001) but had a significant higher maintenance cost (606.62 vs. 20.23 USD calculated monthly, p < .001). CONCLUSIONS ITT via the external system is as effective and safe as that via the implanted system and has the advantage of being cheap in the upfront implantation but costs more during the maintenance process in China.
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Affiliation(s)
- Wangjun Qin
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
| | - Li Zhao
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
| | - Botao Liu
- Department of Pain Management, China-Japan Friendship Hospital, Beijing, China
| | - Yang Yang
- Department of Pain Management, China-Japan Friendship Hospital, Beijing, China
| | - Peng Mao
- Department of Pain Management, China-Japan Friendship Hospital, Beijing, China
| | - Liyuan Xu
- Department of Pain Management, China-Japan Friendship Hospital, Beijing, China
| | - Pengmei Li
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
| | - Yongguang Shang
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
| | - Lei Zhang
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
| | - Bifa Fan
- Department of Pain Management, China-Japan Friendship Hospital, Beijing, China
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Giglio M, Preziosa A, Mele R, Brienza N, Grasso S, Puntillo F. Effects of an Intrathecal Drug Delivery System Connected to a Subcutaneous Port on Pain, Mood and Quality of Life in End Stage Cancer Patients: An Observational Study. Cancer Control 2022; 29:10732748221133752. [PMID: 36281899 PMCID: PMC9607974 DOI: 10.1177/10732748221133752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In cancer patients with limited life expectancy, an implant of an intrathecal (IT) drug delivery system connected to a subcutaneous port (IDDS-SP) has been proposed as a successful strategy, but conflicting results are reported on quality of life (QoL). The aim of this prospective observational study is to report the effects on pain, mood and QoL of an IT combination therapy delivered by an IDDS-SP in malignant refractory pain. METHODS Adult patients in which IT therapy was recommended were recruited. An IT therapy with morphine and levobupivacaine was started: VASPI score, depression and anxiety (evaluated by the Edmonton Symptom Assessment System -ESAS-), the Pittsburgh Sleep Quality Index (PSQI), the 5-level EuroQol 5D version (EQ-5D-5L) and the requirements of breakthrough cancer pain (BTcP) medications were registered, with adverse events rate and the satisfaction of patients scored as Patient Global Impression of Change (PGIC). RESULTS Fifty patients, (16 F/34 M) were enrolled (age 69 ± 12). All had advanced cancer with metastasis. The median daily VASPI score was 75, the median depression score was 6, and the median anxiety score was 4, median PSQI was 16. At 28 days, a significant reduction in VASPI score was registered as well as in depression and anxiety item. Also, PSQI decreased significantly. The EQ-5D-5 L showed a significant improvement in all components at 14 and 28 days. Patient Global Impression of Change scores showed high level of satisfaction. A low incidence of adverse events and a reduction in BTCP episodes were also registered. CONCLUSION Intrathecal combination therapy delivered by an IDDS-SP could ensure adequate control of cancer related symptoms, such as pain, depression, anxiety and sleep disturbances. These effects, with low rate of AEs and reduced BTcP episodes, could explain the improvement in QoL and the overall high levels of patients' satisfaction.
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Affiliation(s)
- Mariateresa Giglio
- Anaesthesia, Intensive Care and Pain Unit, Policlinico Hospital, Bari, Italy
| | - Angela Preziosa
- Anaesthesia, Intensive Care and Pain Unit, Policlinico Hospital, Bari, Italy
| | - Roberta Mele
- Anaesthesia, Intensive Care and Pain Unit, Policlinico Hospital, Bari, Italy
| | - Nicola Brienza
- Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, Bari, Italy
| | - Salvatore Grasso
- Department of Emergency and Organ Transplantation, University of Bari “Aldo Moro”, Bari, Italy
| | - Filomena Puntillo
- Anaesthesia, Intensive Care and Pain Unit, Policlinico Hospital, Bari, Italy,Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, Bari, Italy,Filomena Puntillo, Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”. Anaesthesia, Intensive Care and Pain Unit, Piazza G. Cesare 11, 70124 Bari, Italy.
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Benli A, Şimşek-Yavuz S, Eraksoy H. Intrathecal Colistin Induced Chemical Meningitis in a Case of Multi-Drug Resistant Acinetobacter baumannii Meningitis. Infect Dis Clin Microbiol 2022; 4:76-80. [PMID: 38633541 PMCID: PMC11022816 DOI: 10.36519/idcm.2022.98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 01/28/2022] [Indexed: 04/19/2024]
Abstract
The possibility of encountering multi-drug resistant Gram-negative bacteria is higher in nosocomial meningitis. These bacteria are clinically important because of their higher mortality rate, and colistin is almost the only treatment option in resistant strains. However, intrathecal administration of colistin can result in chemical meningitis. We reported a case with chemical meningitis during the intravenous sulbactam plus colistin and intrathecal colistin therapy for multi-drug resistant Acinetobacter baumannii meningitis. Cerebrospinal fluid findings of the patient improved after discontinuation of intrathecal colistin therapy. This reversible complication may occur during intrathecal therapy. Discontinuation of intrathecal therapy or reducing the antibiotic dose will be the most appropriate approach to manage such cases.
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Affiliation(s)
- Aysun Benli
- Department of Infectious Diseases and Clinical Microbiology, İstanbul University School of Medicine, İstanbul, Turkey
| | - Serap Şimşek-Yavuz
- Department of Infectious Diseases and Clinical Microbiology, İstanbul University School of Medicine, İstanbul, Turkey
| | - Haluk Eraksoy
- Department of Infectious Diseases and Clinical Microbiology, İstanbul University School of Medicine, İstanbul, Turkey
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Ferguson SD, Fomchenko EI, Guerrieri RA, Glitza Oliva IC. Challenges and Advances in Diagnosis and Treatment of Leptomeningeal Disease (LMD). Front Oncol 2022; 11:800053. [PMID: 35096602 PMCID: PMC8789647 DOI: 10.3389/fonc.2021.800053] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 12/06/2021] [Indexed: 12/11/2022] Open
Abstract
Leptomeningeal disease (LMD) is a devastating category of CNS metastasis with a very poor prognosis and limited treatment options. With maximal aggressive therapy, survival times remain short and, without treatment, prognosis is measured in weeks. Both LMD diagnosis and treatment are challenging topics within neuro-oncology. In this review, we discuss the advances in LMD diagnosis with a focus on the role of circulating tumor DNA (ctDNA) and discuss the role of targeted and immunotherapy in LMD treatment.
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Affiliation(s)
- Sherise D Ferguson
- Department of Neurosurgery, University of Texas, MD Anderson Cancer Center, Houston, TX, United States
| | - Elena I Fomchenko
- Department of Neurosurgery, University of Texas, MD Anderson Cancer Center, Houston, TX, United States
| | - Renato A Guerrieri
- Department of Melanoma Medical Oncology, University of Texas, MD Anderson Cancer Center, Houston, TX, United States
| | - Isabella C Glitza Oliva
- Department of Melanoma Medical Oncology, University of Texas, MD Anderson Cancer Center, Houston, TX, United States
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Carausu M, Carton M, Darlix A, Pasquier D, Leheurteur M, Debled M, Mouret-Reynier MA, Goncalves A, Dalenc F, Verret B, Campone M, Augereau P, Ferrero JM, Levy C, Fumet JD, Lefeuvre-Plesse C, Petit T, Uwer L, Jouannaud C, Larrouquere L, Chevrot M, Courtinard C, Cabel L. Breast cancer patients treated with intrathecal therapy for leptomeningeal metastases in a large real-life database. ESMO Open 2021; 6:100150. [PMID: 33984675 DOI: 10.1016/j.esmoop.2021.100150] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 04/12/2021] [Accepted: 04/15/2021] [Indexed: 12/18/2022] Open
Abstract
Background Leptomeningeal metastasis (LM) is a rare complication of metastatic breast cancer (MBC), with high morbidity/mortality rates. Our study aimed to describe the largest-to-date real-life population of MBC patients treated with intrathecal (IT) therapy and to evaluate prognostic models. Methods The Epidemiological Strategy and Medical Economics (ESME) MBC database (NCT03275311) includes all consecutive patients who have initiated treatment for MBC since 2008. Overall survival (OS) of patients treated with IT therapy was estimated using the Kaplan–Meier method. Prognostic models were constructed using Cox proportional hazards models. Performance was evaluated using C-index and calibration plots. Results Of the 22 266 patients included in the database between 2008 and 2016, 312 received IT therapy and were selected for our analysis. Compared with non-IT-treated patients, IT-treated patients were younger at MBC relapse (median age: 52 years versus 61 years) and more often had lobular histology (23.4% versus 12.7%) or triple-negative subtype (24.7% versus 13.3%) (all P < 0.001). Median OS was 4.5 months [95% confidence interval (CI) 3.8-5.6] and 1-year survival rate was 25.6%. Significant prognostic factors associated with poorer outcome on multivariable analysis were triple-negative subtype (hazard ratio 1.81, 95% CI 1.32-2.47), treatment line ≥3 (hazard ratio 1.88, 95% CI 1.30-2.73), ≥3 other metastatic sites (hazard ratio 1.33, 95% CI 1.01-1.74) and IT cytarabine or thiotepa versus methotrexate (hazard ratio 1.68, 95% CI 1.28-2.22), while concomitant systemic therapy was associated with better OS (hazard ratio 0.47, 95% CI 0.35-0.62) (all P < 0.001). We validated two previously published prognostic scores, the Curie score and the Breast-graded prognostic assessment, both with C-index of 0.57. Conclusions MBC patients with LM treated with IT therapy have a poor prognosis. We could identify a subgroup of patients with better prognosis, when concomitant systemic therapy and IT methotrexate were used. The outcome of BC patients with IT-treated LM is poor, with a median OS of 4.5 months. Concomitant systemic therapy may improve the outcome in IT-treated patients. Patients treated with IT methotrexate had better outcome than those treated with IT cytarabine/thiotepa. The Curie and Breast-graded prognostic assessment scores were prognostic for IT-treated patients.
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Zhang B, Lau R, van Why D, Saulino M. Effectiveness of Intrathecal Baclofen for Intractable Stiffperson Syndrome: a Case Report. J Rehabil Med Clin Commun 2021; 4:1000052. [PMID: 33884154 PMCID: PMC8054742 DOI: 10.2340/20030711-1000052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/04/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Intrathecal baclofen is considered an adjuvant therapy for patients with intractable spasms due to stiff-person syndrome. There is increasing evidence to support the use of intrathecal baclofen in the management of symptomatic stiffperson syndrome, with improvement in function. CASE REPORT A 38-year-old woman with stiff- person syndrome initially presented to inpatient rehabilitation for intractable muscle spasms. The symptoms made her non-ambulatory and limited her tolerance to wheelchair use for mobility. The patient underwent up-titration of oral baclofen and diazepam, with concurrent intravenous immunoglobulin cycles, leading to transient symptom relief. She agreed to explore intrathecal baclofen therapy. An initial trial of a single bolus of 50 μg intrathecal baclofen resulted in a significant decrease in spontaneous spasms, enabling modified independence in transfers and ambulation. The patient was subsequently implanted with a permanent intrathecal delivery system. To date, the intrathecal baclofen had been titrated to 186 μg per day with simple continuous delivery. The patient was weaned off oral baclofen. She attained complete functional independence with ambulation without the need for assistive devices, and has had no lasting post-procedural complications to date. CONCLUSION This case report adds to the increasing evidence of cases of refractory stiff-person syndrome managed successfully using intrathecal baclofen therapy.
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Affiliation(s)
- Bruce Zhang
- Department of Physical Medicine and Rehabilitation, Temple University Hospital, Philadelphia, PA, USA
| | - Richard Lau
- Department of Physical Medicine and Rehabilitation, Temple University Hospital, Philadelphia, PA, USA
| | - David van Why
- MossRehab, Elkins Park, PA, USA
- Department of Rehabilitation Medicine, Sidney Kimmel Medical College, Philadelphia, PA, USA
| | - Michael Saulino
- MossRehab, Elkins Park, PA, USA
- Department of Rehabilitation Medicine, Sidney Kimmel Medical College, Philadelphia, PA, USA
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Matis G, De Negri P, Dupoiron D, Likar R, Zuidema X, Rasche D. Intrathecal pain management with ziconotide: Time for consensus? Brain Behav 2021; 11 Suppl 1:e02055. [PMID: 33690987 PMCID: PMC7943290 DOI: 10.1002/brb3.2055] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 12/02/2020] [Accepted: 01/17/2021] [Indexed: 12/25/2022] Open
Abstract
This article summarizes recommendations made by six pain specialists who discussed the rationale for ziconotide intrathecal analgesia (ITA) and the requirement for evidence-based guidance on its use, from a European perspective. Riemser Pharma GmbH (Greifswald, Germany), which holds the European marketing authorization for ziconotide, hosted the meeting. The group agreed that ITA is under-used in Europe, adding that ziconotide ITA has potential to be a first-line alternative to morphine; both are already first-line options in the USA. Ziconotide ITA (initiated using a low-dose, slow-titration approach) is suitable for many patients with noncancer- or cancer-related chronic refractory pain and no history of psychosis. Adopting ziconotide as first-line ITA could reduce opioid usage in these patient populations. The group advocated a risk-reduction strategy for all candidate patients, including compulsory prescreening for neuropsychosis, and requested US-European alignment of the licensed starting dose for ziconotide: the low-and-slow approach practiced in the USA has a better tolerability profile than the fixed high starting dose licensed in Europe. Of note, an update to the European Summary of Product Characteristics is anticipated in early 2021. The group acknowledged that the Polyanalgesic Consensus Conference (PACC) treatment algorithms for ziconotide ITA provide useful guidance, but recommendations tailored specifically for European settings are required. Before a consensus process can formally begin, the group called for additional European prospective studies to investigate ziconotide in low-and-slow dosing strategies, in different patient settings. Such data would enable European guidance to have the most appropriate evidence at its core.
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Affiliation(s)
- Georgios Matis
- Department of Stereotactic and Functional NeurosurgeryFaculty of Medicine and University Hospital CologneUniversity of CologneCologneGermany
| | - Pasquale De Negri
- Department of Anaesthesia, Intensive Care and Pain MedicineSan Giuliano HospitalGiugliano, NaplesItaly
| | - Denis Dupoiron
- Anesthesiology and Pain DepartmentInstitut de Cancérologie de l’OuestICO Paul PapinAngersFrance
| | - Rudolf Likar
- Department of Anaesthesiology and Intensive CareKlagenfurt ClinicKlagenfurtAustria
| | - Xander Zuidema
- Department of Anaesthesiology and Pain MedicineDiakonessenhuis Utrecht/ZeistZeistThe Netherlands
| | - Dirk Rasche
- Functional Neurosurgery and Neurosurgical Pain TherapyUniversity Hospital Schleswig‐HolsteinLübeckGermany
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Mayr L, Gojo J, Peyrl A, Azizi AA, Stepien NM, Pletschko T, Czech T, Dorfer C, Lambo S, Dieckmann K, Haberler C, Kool M, Slavc I. Potential Importance of Early Focal Radiotherapy Following Gross Total Resection for Long-Term Survival in Children With Embryonal Tumors With Multilayered Rosettes. Front Oncol 2020; 10:584681. [PMID: 33392079 PMCID: PMC7773839 DOI: 10.3389/fonc.2020.584681] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 11/12/2020] [Indexed: 01/04/2023] Open
Abstract
Embryonal tumor with multilayered rosettes (ETMR) is a rare, aggressive embryonal central nervous system tumor characterized by LIN28A expression and alterations in the C19MC locus. ETMRs predominantly occur in young children, have a dismal prognosis, and no definitive treatment guidelines have been established. We report on nine consecutive patients and review the role of initiation/timing of radiotherapy on survival. Between 2006 and 2018, nine patients were diagnosed with ETMR. Diagnosis was confirmed histopathologically, immunohistochemically and molecularly. Median age was 25 months (5–38). Location was supratentorial in five, pineal in three, and brainstem in one. Seven patients had a gross total resection, one a partial resection and one a biopsy at initial diagnosis. Chemotherapy augmented with intrathecal therapy started a median of 10 days (7–20) after surgery. Only two patients who after gross total resection received radiotherapy very early on (six weeks after diagnosis) are alive and in complete remission 56 and 50 months after diagnosis. All remaining patients for whom radiotherapy was deferred until the end of chemotherapy recurred, albeit none with leptomeningeal disease. A literature research identified 228 patients with ETMR. Including our patients only 26 (11%) of 237 patients survived >36 months with no evidence of disease at last follow-up. All but two long-term (>36 months) survivors received radiotherapy, ten of whom early on following gross total resection (GTR). GTR followed by early focal radiotherapy and intrathecal therapy to prevent leptomeningeal disease are potentially important to improve survival of ETMR in the absence of effective targeted therapies.
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Affiliation(s)
- Lisa Mayr
- Department of Pediatrics and Adolescent Medicine and Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Johannes Gojo
- Department of Pediatrics and Adolescent Medicine and Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Andreas Peyrl
- Department of Pediatrics and Adolescent Medicine and Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Amedeo A Azizi
- Department of Pediatrics and Adolescent Medicine and Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Natalia M Stepien
- Department of Pediatrics and Adolescent Medicine and Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Thomas Pletschko
- Department of Pediatrics and Adolescent Medicine and Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Thomas Czech
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Christian Dorfer
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Sander Lambo
- Division of Pediatric Neurooncology, Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany.,Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ) and German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Karin Dieckmann
- Department of Radiotherapy, Medical University of Vienna, Vienna, Austria
| | - Christine Haberler
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Marcel Kool
- Division of Pediatric Neurooncology, Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany.,Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ) and German Cancer Consortium (DKTK), Heidelberg, Germany.,Research Department, Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Irene Slavc
- Department of Pediatrics and Adolescent Medicine and Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
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13
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Li LM, Zheng WJ, Shi SW. Spinal arachnoiditis followed by intrathecal tigecycline therapy for central nervous system infection by extremely drug-resistant Acinetobacter baumannii. J Int Med Res 2020; 48:300060520920405. [PMID: 32628870 PMCID: PMC7343364 DOI: 10.1177/0300060520920405] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
In prior research, intrathecal tigecycline was successfully used to treat central nervous system infection by extensively drug-resistant Acinetobacter baumannii. However, little is known about its safe dose and adverse reactions. This study reports the case of a 28-year-old male patient who was diagnosed with central nervous system infection by extensively drug-resistant A. baumannii after the removal of a ventriculoperitoneal shunt. Intravenous and intrathecal tigecycline were administrated simultaneously. Spinal arachnoiditis was discovered after nine doses of intrathecal tigecycline. Spinal arachnoiditis was resolved after discontinuation of the antibiotic. This is the first report of an adverse reaction to intrathecal tigecycline. The case was complicated by spinal arachnoiditis, which obstructed the assessment of cerebrospinal fluid. The appropriate dose and administration schedule of intrathecal tigecycline remain to be determined.
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Affiliation(s)
- Liang-Ming Li
- Department of Neurosurgery, Zhongshan City People's Hospital, Zhongshan, China
| | - Wen-Jian Zheng
- Department of Neurosurgery, Zhongshan City People's Hospital, Zhongshan, China
| | - Shang-Wen Shi
- Department of Neonatology, Zhongshan City People's Hospital, Zhongshan, China
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14
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Glitza IC, Smalley KSM, Brastianos PK, Davies MA, McCutcheon I, Liu JKC, Ahmed KA, Arrington JA, Evernden BR, Smalley I, Eroglu Z, Khushalani N, Margolin K, Kluger H, Atkins MB, Tawbi H, Boire A, Forsyth P. Leptomeningeal disease in melanoma patients: An update to treatment, challenges, and future directions. Pigment Cell Melanoma Res 2020; 33:527-541. [PMID: 31916400 PMCID: PMC10126834 DOI: 10.1111/pcmr.12861] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 11/26/2019] [Accepted: 01/03/2020] [Indexed: 01/31/2023]
Abstract
In February 2018, the Melanoma Research Foundation and the Moffitt Cancer Center hosted the Second Summit on Melanoma Central Nervous System Metastases in Tampa, Florida. The meeting included investigators from multiple academic centers and disciplines. A consensus summary of the progress and challenges in melanoma parenchymal brain metastases was published (Eroglu et al., Pigment Cell & Melanoma Research, 2019, 32, 458). Here, we will describe the current state of basic, translational, clinical research, and therapeutic management, for melanoma patients with leptomeningeal disease. We also outline key challenges and barriers to be overcome to make progress in this deadly disease.
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Affiliation(s)
- Isabella C. Glitza
- Department of Melanoma Medical Oncology, UT MD Anderson Cancer Center, Houston, TX, USA
| | - Keiran S. M. Smalley
- Melanoma Research Center of Excellence, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | | | - Michael A. Davies
- Department of Melanoma Medical Oncology, UT MD Anderson Cancer Center, Houston, TX, USA
| | - Ian McCutcheon
- Department of Neurosurgery, UT MD Anderson Cancer Center, Houston, TX, USA
| | - James K. C. Liu
- Department of Neuro-Oncology & Tumor Biology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Kamran A. Ahmed
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - John A. Arrington
- Head of Neuroradiology Section, Department of Radiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Brittany R. Evernden
- Department of Neuro-Oncology & Tumor Biology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Inna Smalley
- Department of Tumor Biology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Zeynep Eroglu
- Department of Cutaneous Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Nikhil Khushalani
- Department of Cutaneous Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Kim Margolin
- Department of Medical Oncology and Therapeutics Research, City of Hope National Medical Center, Duarte, CA, USA
| | - Harriet Kluger
- Department of Medical Oncology, Yale Cancer Center, New Haven, CT, USA
| | - Michael B. Atkins
- Department of Medical Oncology, Georgetown University Medical Center, Washington, DC, USA
| | - Hussein Tawbi
- Department of Melanoma Medical Oncology, UT MD Anderson Cancer Center, Houston, TX, USA
| | - Adrienne Boire
- Department of Neuro-Oncology, Memorial Sloan Kettering, New York, NY, USA
| | - Peter Forsyth
- Department of Neuro-Oncology & Tumor Biology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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15
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Sindt JE, Odell DW, Dalley AP, Brogan SE. Initiation of Intrathecal Drug Delivery Dramatically Reduces Systemic Opioid Use in Patients With Advanced Cancer. Neuromodulation 2020; 23:978-983. [PMID: 32459393 DOI: 10.1111/ner.13175] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 04/06/2020] [Accepted: 04/22/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Pain is common in cancer, affecting more than 70% of patients with advanced disease. Intrathecal drug delivery systems (IDDS) are a well-established treatment for patients with refractory cancer pain, improving pain control and reducing associated side effects. To date, details of systemic opioid use before and after IDDS implant have not been reported. MATERIALS AND METHODS We conducted a retrospective review of patients at Huntsman Cancer Institute-University of Utah treated with IDDS for cancer pain from May 2014 to May 2018. Oral, transdermal, and parenteral opioid use before IDDS implant was compared to use 30 days postoperatively. RESULTS A total of 173 patients were included, 93% with stage IV disease. The pre-implant median daily oral morphine equivalent (OME) was 240 mg (interquartile range 130-390, range 0-2616 mg). OME doses >200 mg/day were required by 57% of patients, and >500 mg OME by 19% of patients. The post-implant median OME was 0 mg (interquartile range 0-0, range 0-480 mg) and 82.6% of patients discontinued systemic opioids completely. 11.0% of patients used <100 mg OME, and only 1.7% of patients used >200 mg OME. Mean OME decreased by 94% following IDDS implant (p < 0.0001) and all patients who continued to use systemic opioids required a lower OME compared to pre-implant. CONCLUSIONS In the largest cohort of patients with advanced cancer and refractory pain treated with IDDS, implantation was associated with a dramatic reduction in systemic opioid use 30 days postoperatively, with a large majority of patients discontinuing systemic opioids. Those patients that continued systemic opioids utilized significantly lower doses as compared to their pre-implant dose.
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Affiliation(s)
- Jill E Sindt
- Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT, USA
| | - Daniel W Odell
- Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT, USA
| | - Andrew P Dalley
- Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT, USA
| | - Shane E Brogan
- Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT, USA
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16
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Abstract
Introduction: There is a growing recognition of the role of interventional techniques (IT) for the management of cancer pain (CP). However, there are many controversies on how and when to use such techniques. Areas covered: Patients who are unresponsive to systemic opioid analgesics or patients unable to tolerate systemic opioids may benefit from different IT for which the successful use depends on the selection of the right therapy for the right patient. The evidence regarding these techniques is often anecdotal and the potential risks, benefits, alternatives, and complications should be balanced to take a decision. Expert opinion: The successful use of IT depends on many factors, including a careful assessment of previous treatments, patient's characteristics, and the logistics. Risks, benefits, alternatives, and complications should be balanced to take a decision. Although IT have been described as effective in patients with CP, the evidence is still limited, unless for celiac plexus block, which has a high benefit-risk ratio. The intrathecal therapy should be chosen in patients who were poorly responding to opioid therapy, after an appropriate trial with different opioids. A careful selection of patients and techniques, a large experience in performing the procedures, sufficient logistics and staff skills, appropriate indications, and assessment of benefits and risks may help to achieve the best benefit for patients in individual cases.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center for Pain Relief & Supportive Care, La Maddalena Cancer Center , Palermo , Italy
| | - Kenneth D Candido
- Department of Anaesthesiology, Advocate Illinois Masonic Medical Center , Chicago , USA
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17
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Nelson MES, McGuire JR. Intrathecal Baclofen Therapy in Patients With Multiple Sclerosis: Improved Outcomes and Reduced Costs Through Identification of Catheter Malfunction. Neuromodulation 2019; 22:839-842. [PMID: 31157471 DOI: 10.1111/ner.12974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 03/21/2019] [Accepted: 04/25/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Two patients previously implanted with intrathecal Baclofen (ITB) pumps for management of intractable spasticity due to multiple sclerosis (MS) were referred to our center for ongoing management of their spasticity. Initial evaluation of these patients revealed high levels of spasticity in the presence of ITB doses 10 times the average daily dose of our other MS patients. CLINICAL FACTS High doses of ITB required frequent clinical visits and result in high drug and procedure costs. Both patients' daily doses were greater than 1000 mcg/day resulting in clinical visits every 1-2 months with drug and procedure costs ranging from 16 to 23 thousand dollars annually based on Medicare national average pricing for physician's office. Of the 59 MS patients receiving ITB therapy at our institution, the mean, median, and mode daily doses for ITB are 184, 115, and 159 mcg/day, respectively. The high ITB doses in these patients and poor spasticity control raised suspicion for pump/catheter malfunction and prompted immediate troubleshooting. FINDINGS One patient's catheter was found to be disconnected from the pump and the other's catheter tip was outside the intrathecal space. In both cases, the patients were not receiving the therapy. After pump/catheter replacement, both patients received excellent clinical benefits from ITB at significantly lower daily doses. This reduction in dose resulted in decreased frequency of medication refills (twice annually) which resulted in decreased cost of care (12-19 thousand dollars savings annually per patient). DISCUSSION These cases illustrate the need for early ITB pump troubleshooting to identify catheter problems, improve efficacy, and avoid unnecessary healthcare costs.
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Affiliation(s)
- Mary Elizabeth S Nelson
- Department of Physical Medicine and Rehabilitation, Medical College of Wisconsin, Milwaukee, WI, USA
| | - John R McGuire
- Department of Physical Medicine and Rehabilitation, Medical College of Wisconsin, Milwaukee, WI, USA
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18
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Eisengart JB, Pierpont EI, Kaizer AM, Rudser KD, King KE, Pasquali M, Polgreen LE, Dickson PI, Le SQ, Miller WP, Tolar J, Orchard PJ, Lund TC. Intrathecal enzyme replacement for Hurler syndrome: biomarker association with neurocognitive outcomes. Genet Med 2019; 21:2552-60. [PMID: 31019279 DOI: 10.1038/s41436-019-0522-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 04/15/2019] [Indexed: 11/08/2022] Open
Abstract
PURPOSE Abnormalities in cerebrospinal fluid (CSF) have been reported in Hurler syndrome, a fatal neurodegenerative lysosomal disorder. While no biomarker has predicted neurocognitive response to treatment, one of these abnormalities, glycosaminoglycan nonreducing ends (NREs), holds promise to monitor therapeutic efficacy. A trial of intrathecal enzyme replacement therapy (ERT) added to standard treatment enabled tracking of CSF abnormalities, including NREs. We evaluated safety, biomarker response, and neurocognitive correlates of change. METHODS In addition to intravenous ERT and hematopoietic cell transplantation, patients (N = 24) received intrathecal ERT at four peritransplant time points; CSF was evaluated at each point. Neurocognitive functioning was quantified at baseline, 1 year, and 2 years posttransplant. Changes in CSF biomarkers and neurocognitive function were evaluated for an association. RESULTS Over treatment, there were significant decreases in CSF opening pressure, biomarkers of disease activity, and markers of inflammation. Percent decrease in NRE from pretreatment to final intrathecal dose posttransplant was positively associated with percent change in neurocognitive score from pretreatment to 2 years posttransplant. CONCLUSION Intrathecal ERT was safe and, in combination with standard treatment, was associated with reductions in CSF abnormalities. Critically, we report evidence of a link between a biomarker treatment response and neurocognitive outcome in Hurler syndrome.
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19
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Abstract
Surgical-site infection, spinal cord abscess, and catheter tip granuloma are known but rare complications of intrathecal drug delivery systems (IDDS). To date, there are no published cases of brain abscess in a patient with an IDDS. In this study, we report a case of a cancer patient with an IDDS for management of cancer pain who developed a brain abscess with profound mental status changes and clinical management challenges.
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Affiliation(s)
- David R Walega
- Department of Anesthesiology, Feinberg School of Medicine, Northwestern University , Chicago, Illinois
| | - Marc Korn
- Department of Anesthesiology, Feinberg School of Medicine, Northwestern University , Chicago, Illinois
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20
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Glitza IC, Rohlfs M, Guha-Thakurta N, Bassett RL, Bernatchez C, Diab A, Woodman SE, Yee C, Amaria RN, Patel SP, Tawbi H, Wong M, Hwu WJ, Hwu P, Heimberger A, McCutcheon IE, Papadopoulos N, Davies MA. Retrospective review of metastatic melanoma patients with leptomeningeal disease treated with intrathecal interleukin-2. ESMO Open 2018; 3:e000283. [PMID: 29387478 PMCID: PMC5786950 DOI: 10.1136/esmoopen-2017-000283] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 12/01/2017] [Accepted: 12/06/2017] [Indexed: 01/01/2023] Open
Abstract
Objectives Metastatic melanoma patients with leptomeningeal disease (LMD) have an extremely poor prognosis, with a median survival measured in weeks, and few treatment options. Outcomes of a retrospective cohort of patients with LMD that were treated with intrathecal interleukin-2 (IT IL-2) were reviewed to assess the long-term efficacy of this therapy. Methods The records of metastatic melanoma patients with LMD who were treated with IT IL-2 from 2006 to 2014 in a Compassionate Investigational New Drug study were reviewed. IL-2 (1.2 mIU) was administered intrathecally via Ommaya reservoir up to five times per week in the inpatient setting for 4 weeks; patients with good tolerance and clinical benefit received maintenance IT IL-2 every 1–3 months thereafter. Results The cohort included 43 patients. The median age of the patients was 47 years (range 18–71), and 32 (74%) were male. 23 patients (53%) had positive cerebrospinal fluid (CSF) cytology and radiographic evidence of LMD, 8 (19%) had positive CSF cytology only, 9 (21%) had radiographic evidence only and 3 (7%) were diagnosed based on pathology review after craniotomy. The median overall survival (OS) from initiation of IT IL-2 was 7.8 months (range, 0.4–90.8 months), with 1-year, 2-year and 5-year OS rates of 36%, 26% and 13%. The presence of neurological symptoms (HR 2.1, P=0.03), positive baseline CSF cytology (HR 4.1, P=0.001) and concomitant use of targeted therapy (HR 3.0, P=0.02) was associated with shorter OS on univariate analysis. All patients developed symptoms due to increased intracranial pressure which was managed with supportive medications and/or CSF removal, and there were no treatment-related deaths. Conclusion These results demonstrate that despite their historically dismal prognosis a subset of metastatic melanoma patients with LMD treated with IT IL-2 can achieve long-term survival, but these data need to be verified in a prospective trial setting.
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Affiliation(s)
- Isabella C Glitza
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michelle Rohlfs
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nandita Guha-Thakurta
- Department of Diagnostic Radiology/ Neuro Imaging, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Roland L Bassett
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Chantale Bernatchez
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Adi Diab
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Scott E Woodman
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Cassian Yee
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Rodabe N Amaria
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sapna P Patel
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Hussein Tawbi
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael Wong
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Wen-Jen Hwu
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Patrick Hwu
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Amy Heimberger
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ian E McCutcheon
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nicholas Papadopoulos
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael A Davies
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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21
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Kramer K, Pandit-Taskar N, Humm JL, Zanzonico PB, Haque S, Dunkel IJ, Wolden SL, Donzelli M, Goldman DA, Lewis JS, Lyashchenko SK, Khakoo Y, Carrasquillo JA, Souweidane MM, Greenfield JP, Lyden D, De Braganca KD, Gilheeney SW, Larson SM, Cheung NKV. A phase II study of radioimmunotherapy with intraventricular 131 I-3F8 for medulloblastoma. Pediatr Blood Cancer 2018; 65:10.1002/pbc.26754. [PMID: 28940863 PMCID: PMC6692907 DOI: 10.1002/pbc.26754] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 07/12/2017] [Accepted: 07/18/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND High-risk and recurrent medulloblastoma (MB) is associated with significant mortality. The murine monoclonal antibody 3F8 targets the cell-surface disialoganglioside GD2 on MB. We tested the efficacy, toxicity, and dosimetry of compartmental radioimmunotherapy (cRIT) with intraventricular 131 I-labeled 3F8 in patients with MB on a phase II clinical trial. METHODS Patients with histopathologically confirmed high-risk or recurrent MB were eligible for cRIT. After determining adequate cerebrospinal fluid (CSF) flow, patients received 2 mCi (where Ci is Curie) 124 I-3F8 or 131 I-3F8 with nuclear imaging for dosimetry, followed by up to four therapeutic (10 mCi/dose) 131 I-3F8 injections. Dosimetry estimates were based on serial CSF and blood samplings over 48 hr plus region-of-interest analyses on serial imaging scans. Disease evaluation included pre- and posttherapy brain/spine magnetic resonance imaging approximately every 3 months for the first year after treatment, and every 6-12 months thereafter. RESULTS Forty-three patients received a total of 167 injections; 42 patients were evaluable for outcome. No treatment-related deaths occurred. Toxicities related to drug administration included acute bradycardia with somnolence, headache, fatigue, and CSF pleocytosis consistent with chemical meningitis and dystonic reaction. Total CSF absorbed dose was 1,453 cGy (where Gy is Gray; 350.0-2,784). Median overall survival from first dose of cRIT was 24.9 months (95% confidence interval [CI]:16.3-55.8). Patients treated in radiographic and cytologic remission were at a lower risk of death compared to patients with radiographically measurable disease (hazard ratio: 0.40, 95% CI: 0.18-0.88, P = 0.024). CONCLUSIONS cRIT with 131 I-3F8 is safe, has favorable dosimetry to CSF, and when added to salvage therapy using conventional modalities, may have clinical utility in maintaining remission in high-risk or recurrent MB.
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Affiliation(s)
- Kim Kramer
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York
| | - Neeta Pandit-Taskar
- Department of Radiology (Molecular Imaging and Therapy Service), Memorial Sloan Kettering Cancer Center, New York
| | - John L. Humm
- Department of Radiology (Molecular Imaging and Therapy Service), Memorial Sloan Kettering Cancer Center, New York
| | - Pat B. Zanzonico
- Department of Radiology (Molecular Imaging and Therapy Service), Memorial Sloan Kettering Cancer Center, New York
| | - Sofia Haque
- Department of Radiology (Molecular Imaging and Therapy Service), Memorial Sloan Kettering Cancer Center, New York
| | - Ira J. Dunkel
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York
| | - Suzanne L. Wolden
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York
| | - Maria Donzelli
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York
| | - Debra A. Goldman
- Department of Epidemiology & Biostatistics, Weill Cornell Medical College, New York
| | - Jason S. Lewis
- Department of Radiology (Molecular Imaging and Therapy Service), Memorial Sloan Kettering Cancer Center, New York
| | - Serge K. Lyashchenko
- Department of Radiology (Molecular Imaging and Therapy Service), Memorial Sloan Kettering Cancer Center, New York
| | - Yasmin Khakoo
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York
| | - Jorge A. Carrasquillo
- Department of Radiology (Molecular Imaging and Therapy Service), Memorial Sloan Kettering Cancer Center, New York
| | | | | | - David Lyden
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York
| | | | | | - Steven M. Larson
- Department of Radiology (Molecular Imaging and Therapy Service), Memorial Sloan Kettering Cancer Center, New York
| | - Nai-Kong V. Cheung
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York
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22
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Abstract
The central nervous system (CNS) is an important site of involvement by acute lymphoblastic leukemia (ALL) in adults. The prevalence is sufficiently high that prophylactic treatment is routinely given to this sanctuary site in order to eradicate occult disease that might otherwise lead to a relapse. A lumbar puncture should be routinely performed in all newly diagnosed patients with ALL. The risks of CNS leukemia vary by phenotype and genotype. Preventive treatment of the CNS during post-remission therapy has become an integral part of all current ALL treatment protocols. Most treatment regimens combine multiple doses of intrathecal chemotherapy with high-dose systemic methotrexate and/or cytarabine. Cranial irradiation is less commonly used for prophylaxis but is still the most effective treatment for overt CNS leukemia. Recurrences within the CNS usually coincide with or predict soon afterwards for systemic relapse in the marrow and blood.
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Affiliation(s)
- Richard A Larson
- a Department of Medicine, Section of Hematology/Oncology, and Comprehensive Cancer Center , The University of Chicago , Chicago , IL , USA
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Ho J, Fowler P, Heidari A, Johnson RH. Intrathecal Amphotericin B: A 60-Year Experience in Treating Coccidioidal Meningitis. Clin Infect Dis 2017; 64:519-524. [PMID: 27927853 DOI: 10.1093/cid/ciw794] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 11/22/2016] [Indexed: 12/14/2022] Open
Abstract
Coccidioidal meningitis (CM) is a devastating complication of coccidioidomycosis. Since the late 1950s, intrathecal (IT) amphotericin B deoxycholate (AmBd) has been successfully used to treat and often cure this disease, reducing mortality rates from 100% to approximately 30%. The introduction of azoles further revolutionized the treatment of coccidioidal infections. However, IT AmBd remains the only known curative option in the management of CM. While the use of IT AmBd is well described in many articles, few discuss the actual methods behind preparation, titration, and dosing strategies utilized. The practitioners at Kern Medical (Bakersfield, California) have >60 years of experience in the utilization of IT AmBd and the treatment of CM. This article describes the practice experience in the treatment of CM, preparation of IT AmBd, and the different dosing strategies used in regard to route of administration (ie, cisternal, lumbar, ventricular).
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Affiliation(s)
- Jackie Ho
- Department of Pharmacy, Kern Medical, Bakersfield, California, USA
| | - Pete Fowler
- Department of Pharmacy, Kern Medical, Bakersfield, California, USA
| | - Arash Heidari
- Department of Medicine, Kern Medical, Bakersfield, California, USA.,David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Royce H Johnson
- Department of Medicine, Kern Medical, Bakersfield, California, USA.,David Geffen School of Medicine, University of California, Los Angeles, California, USA
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Abou Al-Shaar H, Alkhani A. Intrathecal baclofen therapy for spasticity: A compliance-based study to indicate effectiveness. Surg Neurol Int 2016; 7:S539-41. [PMID: 27602250 PMCID: PMC4982341 DOI: 10.4103/2152-7806.187529] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Accepted: 05/06/2016] [Indexed: 11/06/2022] Open
Abstract
Background: Intrathecal baclofen (ITB) therapy using a programmable battery-based pump is a well-recognized option in the treatment of patients with refractory spasticity. Improvements in clinical scale scores for muscle spasticity among this heterogeneous group of patients may not reflect the functional benefits of this therapeutic option. The aim of our study is to report the efficacy of ITB therapy by setting the patient's compliance at the 2-year follow-up after pump implantation as an indicator of treatment efficacy, as appreciated by the patients or their caregivers. Methods: A cohort of 31 patients admitted for ITB therapy was studied. Treatment and follow-up expenses were supported by national health services. Compliance to follow-up visits 2 years after implantation was used as an indicator of treatment efficacy. Results: Twenty-seven patients (mean age: 28.8 ± 19.3 years) were included in the study. At the 2-year post-implantation set point, 20 patients continued to comply with the treatment program. Those 20 patients reported at least moderate improvements in their symptoms, which justified treatment compliance. Conclusion: At the 2-year follow-up post-implantation set point, nearly 3 of 4 patients (74.1%) continued to comply with the treatment, indicating treatment efficacy.
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Affiliation(s)
- Hussam Abou Al-Shaar
- Department of Neurosciences, Division of Neurosurgery, King Faisal Specialist Hospital and Research Centre, Alfaisal University, Riyadh, Saudi Arabia; College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Ahmed Alkhani
- Department of Neurosciences, Division of Neurosurgery, King Faisal Specialist Hospital and Research Centre, Alfaisal University, Riyadh, Saudi Arabia; College of Medicine, Alfaisal University, Riyadh, Saudi Arabia; Department of Neurosurgery, Mohammed Bin Abdulaziz Hospital, Riyadh, Saudi Arabia
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25
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Saulino MF, Patel T, Fisher SP. The Application of Failure Modes and Effects Analysis Methodology to Intrathecal Drug Delivery for Pain Management. Neuromodulation 2016; 20:177-186. [PMID: 27477689 PMCID: PMC5324639 DOI: 10.1111/ner.12475] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 05/27/2016] [Accepted: 06/13/2016] [Indexed: 11/30/2022]
Abstract
Objective This study aimed to utilize failure modes and effects analysis (FMEA) to transform clinical insights into a risk mitigation plan for intrathecal (IT) drug delivery in pain management. Methods The FMEA methodology, which has been used for quality improvement, was adapted to assess risks (i.e., failure modes) associated with IT therapy. Ten experienced pain physicians scored 37 failure modes in the following categories: patient selection for therapy initiation (efficacy and safety concerns), patient safety during IT therapy, and product selection for IT therapy. Participants assigned severity, probability, and detection scores for each failure mode, from which a risk priority number (RPN) was calculated. Failure modes with the highest RPNs (i.e., most problematic) were discussed, and strategies were proposed to mitigate risks. Results Strategic discussions focused on 17 failure modes with the most severe outcomes, the highest probabilities of occurrence, and the most challenging detection. The topic of the highest‐ranked failure mode (RPN = 144) was manufactured monotherapy versus compounded combination products. Addressing failure modes associated with appropriate patient and product selection was predicted to be clinically important for the success of IT therapy. Conclusions The methodology of FMEA offers a systematic approach to prioritizing risks in a complex environment such as IT therapy. Unmet needs and information gaps are highlighted through the process. Risk mitigation and strategic planning to prevent and manage critical failure modes can contribute to therapeutic success.
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Affiliation(s)
| | - Teresa Patel
- Senior Medical Science Liaison, Northeast, Mallinckrodt Pharmaceuticals, Hazelwood, MO, USA
| | - Stanley P Fisher
- Co-Director, Saint Luke's Marion Bloch Neuroscience Institute, Kansas City, MO, USA
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Abstract
Leptomeningeal dissemination of tumor cells, also referred to as neoplastic meningitis, is most frequently seen in patients with late-stage cancer and mostly associated with a poor prognosis. Basically, neoplastic meningitis may affect all patients with a malignant tumor but is most common in patients affected by lung cancer, breast carcinoma, melanoma or hematologic neoplasms such as lymphoma and leukemia. Controlled clinical trials are largely lacking which results in various non-standardized treatment regimens. The presence of solid tumor manifestations in the CNS as well as the extracranial tumor load defines the most appropriate treatment approach. Radiation therapy, systemic chemotherapy and intrathecal treatment must be considered. For each patient, the individual situation needs to be carefully evaluated to determine the potential benefit as well as putative side effects associated with any therapy. A moderate survival benefit and particularly relief from pain and neurological deficits are the main treatment goals. Here, we summarize the management of patients with neoplastic meningitis and review the available treatment options.
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Affiliation(s)
- Patrick Roth
- Department of Neurology, University Hospital Zurich, Frauenklinikstrasse 26, CH-8091 Zurich, Switzerland.
| | - Michael Weller
- Department of Neurology, Brain Tumor Center Zurich, University Hospital Zurich and University of Zurich, Zurich, Switzerland
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Abstract
Intrathecal infusion of medications allows for a direct delivery of agents to the receptors in which they act. This method of treatment is indicated in severe chronic pain of cancer or noncancer origin. In recent years, the use of these devices has increased and the general pain physician, referring doctor and concerned parties such as insurers, needs a better understanding of safety and efficacy. This article is an overview of this therapeutic option and also provides an update on new innovations and forward thinking approaches at improving patient selection and appropriateness of use.
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Affiliation(s)
- Jason E Pope
- Summit Pain Alliance, 392 Tesconi Court, Santa Rosa, CA 95401 USA
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Hodge G, Cohen SH, Thompson GR. In vitro interactions between amphotericin B and hydrocortisone: potential implications for intrathecal therapy. Med Mycol 2015; 53:749-53. [PMID: 26162473 DOI: 10.1093/mmy/myv047] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 05/17/2015] [Indexed: 12/19/2022] Open
Abstract
Fungal meningitis remains a severe and often lethal infection requiring aggressive antifungal therapy and in refractory cases the use of intrathecal amphotericin B (AmB). Administration of amphotericin B by this method may result in clinically apparent adverse reactions such as paresthesias, radiculitis, or myelopathy. Coadministration of hydrocortisone is therefore often given in an attempt to avoid these effects; however, the potential consequences of this approach on fungal growth or on drug synergy/antagonism had not previously been assessed. We used the checkerboard titration broth microdilution method to analyze interactions by fractional inhibitory concentration indices (FICIs). The combination of amphotericin B and hydrocortisone resulted in synergy or indifference against all isolates (Candida, Cryptococcus, and Coccidioides) during in vitro testing at low concentrations. Antagonism was observed using higher hydrocortisone concentrations (those not observed in vivo) suggesting possible steric hindrance or binding to AmB may occur at doses unlikely to be present during clinical care. Concurrent hydrocortisone and AmB administration should not be avoided due to in vitro antagonism concerns.
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Affiliation(s)
- Greg Hodge
- Department of Medical Microbiology and Immunology, University of California-Davis
| | - Stuart H Cohen
- Department of Internal Medicine, Division of Infectious Diseases, University of California Davis Medical Center
| | - George R Thompson
- Department of Medical Microbiology and Immunology, University of California-Davis Department of Internal Medicine, Division of Infectious Diseases, University of California Davis Medical Center
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Pope JE, Deer TR. Intrathecal Pharmacology Update: Novel Dosing Strategy for Intrathecal Monotherapy Ziconotide on Efficacy and Sustainability. Neuromodulation 2015; 18:414-20. [PMID: 25708382 DOI: 10.1111/ner.12274] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 12/29/2014] [Accepted: 12/30/2014] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Intrathecal drug delivery is a well-defined strategy to treat malignant and nonmalignant pain. Ziconotide is a well-studied intrathecal medicine option that has many attractive qualities, as it is non-granulomagenic, overdose or underdose is not associated with cardiopulmonary compromise or death, and is a non-opoid analgesic. However, it has had slow adoption into pain care algorithms because it has been historically plagued with the connotation of having a narrow therapeutic window and a low sustainability rate. We introduce a novel dosing strategy to improve patient outcomes and sustainability. METHODS Patients were identified as being an intrathecal candidate and trialed with ziconotide based on the current standard of care. Patient demographics, diagnosis, previous treatment failures, and pre-implant visual analog scale (VAS) scores were recorded. Once the trial was deemed successful, based on the dual bolusing strategy, the patient underwent device implantation. Consecutive patients were prospectively followed. Ziconotide was then initiated with a flex dosing strategy, weighted during nocturnal dosing. Outcome endpoints included: reduction in VAS, side effects, durability of therapy, and systemic opioid use prior to implant and at last visit were noted (calculated to daily morphine equivalents). Primary endpoint was tolerability of ziconotide at three months following new dosing strategy. No industry support or funding was obtained for this project. RESULTS All enrolled patients met the endpoint of the study of tolerability of ziconotide at three months. Numbers declined to 75% of patients at four months, and 70% of patients at six months. The discontinuing side-effects were most commonly urinary retention and visual hallucinations. There were no serious adverse events and no unresolved complications reported. Numerical rating scale (NRS) decreased on average from 9.06 to 1.8. Opioid reduction in morphine equivalents averaged 91.5% DISCUSSION The efficacy and tolerability of monotherapy ziconotide may be improved by using a weighted bolus flex dosing strategy as compared with slow continuous infusions. CONCLUSION We present a novel strategy to deliver ziconotide using a unique continuous infusion flex dosing strategy. Further randomized, prospective, higher-powered studies are needed to critically evaluate the conclusions suggested by this limited prospective case series.
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Affiliation(s)
- Jason E Pope
- Center for Pain Relief, Teays Valley, WV, USA
- Center for Pain Relief, Charleston, WV, USA
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Saulino M, Gofeld M. "Sonology" of programmable intrathecal pumps. Neuromodulation 2014; 17:696-8; discussion 698. [PMID: 24528931 DOI: 10.1111/ner.12159] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2013] [Revised: 11/27/2013] [Accepted: 12/14/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The study aims to demonstrate the unique sonographic features of the commercially available intrathecal drug delivery systems. METHODS "Not-for-human-use" pumps were obtained, placed in a tray, and covered with an ultrasound phantom gel. The anterior surface of each pump was scanned and the sonographic features were observed and recorded. RESULTS All systems have a centrally located reservoir port (RP) and a peripherally located catheter access port (CAP) that are observable on ultrasound. The RP of the SynchroMed II system (Medtronic, Minneapolis, MN, USA) appears as an anechoic depression and a break in the bright echogenic line of the superior pump surface. The CAP appears as smaller diameter conical depression outside the circular perimeter of the pump. The RP of the MedStream system (Codman & Shurtleff, Inc., Raynham, MA, USA) has a dome-shaped appearance. The CAP appears as a smaller dome-shaped object that is off center but still contained within the circular perimeter of the pump. Similarly, the RP of the Prometra system (Flowonix Medical Inc, Mt. Olive, NJ, USA) is a dome-shaped object. The CAP visually appears similar to the reservoir access port of the SynchroMed II system, namely a small depression and a break in the bright echogenic line of the pump surface, outside the perimeter of the pump. CONCLUSION In all programmable intrathecal pumps, the RP can be readily identified sonographically. Potentially, the dome-shaped configuration of RP for the Prometra and MedStream systems make the access easier, when compared with SynchroMed II system. Ultrasound could potentially be utilized to localize the RP and CAP for all the systems as each of the three systems has a unique sonographic appearance.
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Affiliation(s)
- Michael Saulino
- Department of Rehabilitation Medicine, Thomas Jefferson University, Philadelphia, PA, USA
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Abstract
A majority of pancreatic cancer patients present with pain at the time of diagnosis. Pain management can be challenging in light of the aggressive nature of this cancer. Apart from conventional pharmacotherapy, timely treatment with neurolytic celiac plexus block (NCPB) has been shown to be of benefit. NCPB has demonstrated efficacious pain control in high quality studies with analgesic effects lasting one to two months. NCPB has also shown to decrease the requirements of narcotics, and thus decrease opioid related side effects. Another option for the control of moderate to severe pain is intrathecal therapy (IT). Delivery of analgesic medications intrathecally allows for lower dosages of medications and thus reduced toxicity. Both of the above mentioned interventional procedures have been shown to have low complication rates, and be safe and effective. Ultimately, comprehensive pancreatic cancer pain management necessitates understanding of pain mechanisms and delivery of sequential validated therapeutic interventions within a multidisciplinary patient care model.
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Affiliation(s)
- Mariam Hameed
- Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, 600 N. Wolfe St., Phipps 160, Baltimore, MD 21287, USA; E-Mails: (M.H.); (H.H.)
| | - Haroon Hameed
- Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, 600 N. Wolfe St., Phipps 160, Baltimore, MD 21287, USA; E-Mails: (M.H.); (H.H.)
| | - Michael Erdek
- Division of Pain Medicine, Department of Anesthesia and Critical Care Medicine, Johns Hopkins University, School of Medicine, 550 North Broadway St., Suite 301, Baltimore, MD 21205, USA
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Brugnoletti F, Morris EB, Laningham FH, Patay Z, Pauley JL, Pui CH, Jeha S, Inaba H. Recurrent intrathecal methotrexate induced neurotoxicity in an adolescent with acute lymphoblastic leukemia: Serial clinical and radiologic findings. Pediatr Blood Cancer 2009; 52:293-5. [PMID: 18831032 PMCID: PMC2605174 DOI: 10.1002/pbc.21764] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Systemic and intrathecal methotrexate (MTX) are integral components of acute lymphoblastic leukemia (ALL) therapy, but can be associated with neurotoxicity. We describe here the case of an adolescent male with T-cell ALL who developed recurrent episodes of subacute neurotoxicity characterized by slurred speech, emotional lability, and hemiparesis after intrathecal MTX administration. Serial magnetic resonance imaging with diffusion-weighted imaging showed recurrent areas of restricted diffusion within cerebral hemispheric white matter, which correlated chronologically with the administration of intrathecal therapy and severity of clinical symptoms. Resolution of diffusion abnormalities did not preclude further toxicity and a large lesion could cause persisting symptoms.
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Affiliation(s)
- Fulvia Brugnoletti
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN
| | - E. Brannon Morris
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN,Department of Pediatrics, College of Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Fred H. Laningham
- Department of Radiological Sciences, St. Jude Children's Research Hospital, Memphis, TN,Department of Radiology, College of Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Zoltán Patay
- Department of Radiological Sciences, St. Jude Children's Research Hospital, Memphis, TN,Department of Radiology, College of Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Jennifer L Pauley
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN,College of Pharmacy, University of Tennessee Health Science Center, Memphis, TN
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN,Department of Pediatrics, College of Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Sima Jeha
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN,Department of Pediatrics, College of Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Hiroto Inaba
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN,Department of Pediatrics, College of Medicine, University of Tennessee Health Science Center, Memphis, TN
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Abstract
Intrathecal therapy represents an effective and well established treatment of nonmalignant as well as malignant pain. Devices available include mechanical constant flow pumps as well as electronic variable flow pumps with patient-controlled bolus release. The latter provide faster dose finding, individual pain control, and good acceptance by patients. New technologies such as membrane pumps and rechargeable devices are expected to be developed to clinical perfection. The available drugs for intrathecal therapy are listed according to the polyanalgesic consensus on intrathecal therapy. The integration of remote patient-controlled analgesia into electronic implantable devices, and the peptide analgesic ziconotide, have significantly improved intrathecal therapy. Complications include infections, catheter ruptures or disconnections, catheter granulomas, and technical dysfunctions. Further possibilities for optimizing intrathecal therapy include development of new drugs, drug side effects, catheter and pump technologies, and surgical techniques.
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Affiliation(s)
- Wilfried Ilias
- Dept Anesthesiology, Intensive Care Medicine and Pain Therapy, Academic Teaching Hospital St. John of God, Vienna, Austria
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Jacob E, Scorsone K, Blaney SM, D'Argenio DZ, Berg SL. Synergy of karenitecin and mafosfamide in pediatric leukemia, medulloblastoma, and neuroblastoma cell lines. Pediatr Blood Cancer 2008; 50:757-60. [PMID: 17849472 PMCID: PMC2975705 DOI: 10.1002/pbc.21330] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND A major barrier to treatment of leptomeningeal disease is the lack of proven combination chemotherapy regimens for intrathecal administration. The purpose of this study was to determine the cytotoxic effects of karenitecin and mafosfamide in vitro against leukemia, medulloblastoma, and neuroblastoma cell lines. PROCEDURE A modified methyl tetrazolium (MTT) assay was used to determine the sensitivity of the cells to karenitecin and mafosfamide. Cells were exposed to drug for 72 hr, after which the number of surviving cells was quantitated. For drug combination experiments, cells were exposed to medium alone (controls), single drugs alone (mafosfamide only, karenitecin only) or to different concentrations of the combination of the two drugs (karenitecin + mafosfamide), for a total of 36 concentration pairs per plate. The universal response surface approach (URSA) was used to analyze the cytotoxic effects of the combination of karenitecin and mafosfamide. RESULTS The IC(50)s of karenitecin and mafosfamide for the various cell lines were similar. For both drugs nearly complete inhibition of cell growth was demonstrated at higher concentrations in all cell lines. In the neuroblastoma cell lines (SK-N-DZ; SK-N-SH) and the DAOY medulloblastoma cell line, the combination of karenitecin and mafosfamide were synergistic. In the D283 medulloblastoma and both the leukemia cell lines (JM1 and Molt-4), the drug interaction was additive. Antagonism was not seen in any cell line. CONCLUSIONS Karenitecin and mafosfamide are additive or synergistic in vitro against tumor types that disseminate to the leptomeninges. These results provide guidance for the choice of potential combination intrathecal regimens.
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Affiliation(s)
- Eufemia Jacob
- Texas Children's Cancer Center, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA.
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