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Katsin M, Shman T, Migas A, Lutskovich D, Serada Y, Khalankova Y, Kostina Y, Dubovik S. Case report: Rapid resolution of grade IV ICANS after first line intrathecal chemotherapy with methotrexate, cytarabine and dexamethasone. Front Immunol 2024; 15:1380451. [PMID: 38765003 PMCID: PMC11099209 DOI: 10.3389/fimmu.2024.1380451] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 04/22/2024] [Indexed: 05/21/2024] Open
Abstract
Corticosteroid therapy is the mainstay of immune effector cell-associated neurotoxicity syndrome (ICANS) management, although its use has been associated with worse overall survival (OS) and progression-free survival (PFS) after chimeric antigen receptor T-cell (CAR-T cell) therapy. Many options are being investigated for prophylaxis and management. Accumulating evidence supports the use of intrathecal (IT) chemotherapy for the management of high-grade ICANS. Here, we describe a case of a patient with stage IV Primary mediastinal B-cell lymphoma (PMBCL) successfully treated with IT methotrexate, cytarabine, and dexamethasone as first-line therapy for CD19 CAR-T cell-associated grade IV ICANS. The stable and rapid resolution of ICANS to grade 0 allowed us to discontinue systemic corticosteroid use, avoiding CAR-T cells ablation and ensuring preservation of CAR-T cell function. The described patient achieved a complete radiologic and clinical response to CD19 CAR-T cell therapy and remains disease-free after 9 months. This case demonstrates a promising example of how IT chemotherapy could be used as first-line treatment for the management of high-grade ICANS.
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Affiliation(s)
- Mikalai Katsin
- Department of Hematology, Vitebsk Regional Clinical Cancer Centre, Vitebsk, Belarus
| | - Tatsiana Shman
- Laboratory of Genetic Biotechnologies, Belarusian Research Center for Pediatric Oncology, Hematology and Immunology, Minsk, Belarus
| | - Alexandr Migas
- Laboratory of Genetic Biotechnologies, Belarusian Research Center for Pediatric Oncology, Hematology and Immunology, Minsk, Belarus
| | - Dzmitry Lutskovich
- Laboratory of Genetic Biotechnologies, Belarusian Research Center for Pediatric Oncology, Hematology and Immunology, Minsk, Belarus
| | - Yuliya Serada
- Department of Hematology, Vitebsk Regional Clinical Cancer Centre, Vitebsk, Belarus
| | - Yauheniya Khalankova
- Department of Hematology, Vitebsk Regional Clinical Cancer Centre, Vitebsk, Belarus
| | - Yuliya Kostina
- Department of Hematology, Vitebsk Regional Clinical Cancer Centre, Vitebsk, Belarus
| | - Simon Dubovik
- Laboratory of Molecular Diagnostics and Biotechnology, Institute of Bioorganic Chemistry of the National Academy of Sciences of Belarus, Minsk, Belarus
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Zhong W, Wu L, Huang L, Wang J, Shi H, Wu S. Double-dose osimertinib combined with intrathecal injection of pemetrexed improves the efficacy of EGFR-mutant non-small cell lung cancer and leptomeningeal metastasis: case report and literature review. Front Oncol 2024; 14:1377451. [PMID: 38711856 PMCID: PMC11070505 DOI: 10.3389/fonc.2024.1377451] [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: 01/27/2024] [Accepted: 04/08/2024] [Indexed: 05/08/2024] Open
Abstract
Leptomeningeal metastasis (LM) is a complication of non-small cell lung cancer (NSCLC) characterized by poor prognosis and short survival. A variety of therapeutic approaches have been sought to improve the efficacy of LM. Here we present a clinical case and conduct a literature review to investigate the effectiveness and safety of double-dose osimertinib combined with a pemetrexed intrathecal injection. This is an older man who underwent thoracoscopic pneumonectomy and was diagnosed with stage IIA lung adenocarcinoma with EGFR21 L858R mutation. He experienced thoracic vertebral metastases 33 months postoperatively and received first-line treatment with gefitinib combined with radiotherapy for vertebral metastases. However, the patient developed a grade 3 rash with unacceptable toxicity and his CEA levels were significantly increased 22 months later, leading to a targeted treatment adjustment to 80 mg of osimertinib orally once daily. Four months later, the patient developed LM and osimertinib dosage was increased to 160 mg once daily; however, neurological symptoms did not improve, and cerebrospinal fluid (CSF) tumor cells remained detected. Accordingly, the patient received an intrathecal injection of pemetrexed (dose 30 mg) every 2-3 months, 2-3 times per course (4-6 days each time), and continued to receive a double dose of osimertinib. After three courses of intrathecal chemotherapy, CSF tumor cells were eliminated, and neurological symptoms significantly improved. During the treatment, he experienced a one-degree rash, leukopenia, thrombocytopenia, and fatigue. This patient has been alive and well with disease control for 28 months since the diagnosis of meningeal metastases. Combining double-dose osimertinib and an intrathecal injection of pemetrexed demonstrated therapeutic efficacy and manageable adverse effects in this patient with advanced NSCLC with EGFR-mutant and LM.
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Affiliation(s)
- Wenjuan Zhong
- Department of Oncology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
- Jiangxi Clinical Medical Center for Cancer, Ganzhou, Jiangxi, China
| | - Longqiu Wu
- Department of Oncology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
- Jiangxi Clinical Medical Center for Cancer, Ganzhou, Jiangxi, China
| | - Lixing Huang
- Department of Gastroenterology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
| | - Jianfeng Wang
- Department of Oncology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
- Jiangxi Clinical Medical Center for Cancer, Ganzhou, Jiangxi, China
| | - Huaqiu Shi
- Department of Oncology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
- Jiangxi Clinical Medical Center for Cancer, Ganzhou, Jiangxi, China
| | - Shugui Wu
- Department of Oncology, The Affiliated Ganzhou Hospital of Nanchang University, Ganzhou, Jiangxi, China
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Oka K, Futamura S, Harada T. Intrathecal Trastuzumab for HER2-Positive Cancer of Unknown Primary Leptomeningeal Metastasis: A Case Report. Cureus 2024; 16:e57322. [PMID: 38690464 PMCID: PMC11060115 DOI: 10.7759/cureus.57322] [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] [Accepted: 03/27/2024] [Indexed: 05/02/2024] Open
Abstract
Cancer of unknown primary (CUP) and leptomeningeal metastasis are difficult conditions with limited treatment options. We report a case of CUP leptomeningeal metastasis that was refractory to empirical chemotherapy but achieved a favorable response to intrathecal trastuzumab after the identification of human epidermal growth factor receptor-2 (HER2) amplification. A 59-year-old woman was diagnosed with CUP with metastasis of a poorly differentiated carcinoma to the left axillary, anterior mediastinal, peritoneal, and bilateral supraclavicular lymph nodes. Leptomeningeal metastasis was confirmed shortly after she started empiric chemotherapy; empiric therapy with intrathecal methotrexate failed to relieve her symptoms. Meanwhile, the lymph node specimen tested positive for HER2 amplification. She underwent intrathecal trastuzumab, then her neurological symptoms resolved the following day. We suggest that intrathecal trastuzumab is an effective treatment for HER2-positive CUP leptomeningeal metastasis.
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Affiliation(s)
- Kohei Oka
- Department of Medical Oncology, Fukuchiyama City Hospital, Fukuchiyama, JPN
| | - Shun Futamura
- Department of Medical Oncology, Fukuchiyama City Hospital, Fukuchiyama, JPN
| | - Taishi Harada
- Department of Medical Oncology, Fukuchiyama City Hospital, Fukuchiyama, JPN
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Hirakawa Y, Kitao A, Watanabe M, Matsumoto S, Komaki R, Sakai R, Morimoto K, Yakushijin K, Minami H. Irreversible Intrathecal Chemotherapy-induced Myelopathy in a Patient with Diffuse Large B-cell Lymphoma. Intern Med 2024; 63:547-551. [PMID: 37380452 PMCID: PMC10937126 DOI: 10.2169/internalmedicine.2031-23] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 05/17/2023] [Indexed: 06/30/2023] Open
Abstract
Intrathecal chemotherapy is often administered for prophylaxis and treatment of central nervous system involvement in hematological malignancies. However, it may rarely cause neurotoxicity as a side effect. We herein report a 74-year-old woman with diffuse large B-cell lymphoma including a spinal lesion. She received systemic and intrathecal chemotherapy. After five doses of intrathecal chemotherapy, she developed intrathecal chemotherapy-induced myelopathy. Intrathecal treatment was discontinued, and she was administered vitamin B12 and folic acid, along with steroid pulses. However, her symptoms did not improve. Intrathecal chemotherapy-induced myelopathy is rare, but may be irreversible; therefore, clinicians should be aware of this potential complication.
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Affiliation(s)
- Yuri Hirakawa
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Graduate School of Medicine School of Medicine, Japan
| | - Akihito Kitao
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Graduate School of Medicine School of Medicine, Japan
| | - Marika Watanabe
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Graduate School of Medicine School of Medicine, Japan
| | - Sakuya Matsumoto
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Graduate School of Medicine School of Medicine, Japan
| | - Ryohei Komaki
- Division of Neurology, Department of Medicine, Kobe University Graduate School of Medicine School of Medicine, Japan
| | - Rina Sakai
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Graduate School of Medicine School of Medicine, Japan
| | - Kohei Morimoto
- Division of Neurology, Department of Medicine, Kobe University Graduate School of Medicine School of Medicine, Japan
| | - Kimikazu Yakushijin
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Graduate School of Medicine School of Medicine, Japan
| | - Hironobu Minami
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Graduate School of Medicine School of Medicine, Japan
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Sastow D, Tatarian J, Riazat-Kesh YJRA, Farina K, Becker M, Feld J, Kremyanskaya M, Mascarenhas J, Byrd K, Male HJ, Lin TL, Tremblay D. Multi-institutional analysis of outcomes in acute myeloid leukemia patients with central nervous system involvement. Leuk Lymphoma 2023; 64:2002-2007. [PMID: 37590099 DOI: 10.1080/10428194.2023.2248331] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/05/2023] [Accepted: 08/09/2023] [Indexed: 08/19/2023]
Abstract
We evaluated outcomes of AML patients with central nervous system (CNS) involvement at two academic institutions. Fifty-two adult patients were identified. Neurologic symptoms were reported in 69% of patients, with headache the most common (33%). 84% (n = 42) of patients cleared their cerebrospinal fluid (CSF), with a median number of one dose of intrathecal (IT) chemotherapy. Of these patients, 21% (n = 9) had a CSF relapse, with 67% (n = 6) of those experiencing CSF relapse also having concurrent bone marrow relapse. Of the 36 patients with baseline neurologic symptoms, 69% had improvement in symptoms post-IT therapy. The median overall survival was 9.3 months and 3.5 months for patients with CNS involvement diagnosed before/during induction and at relapse, respectively. In this study, IT therapy was rapidly effective in clearing CSF blasts and improving neurologic symptoms in most patients. Few patients experienced CSF relapse, which predominantly occurred in the setting of concomitant bone marrow relapse.
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Affiliation(s)
- Dahniel Sastow
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Kyle Farina
- Department of Pharmacy Practice, The Mount Sinai Hospital, New York, NY, USA
| | - Michelle Becker
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jonathan Feld
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Marina Kremyanskaya
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kenneth Byrd
- University of Kansas Medical Center, Kansas City, KS, USA
| | - Heather J Male
- University of Kansas Medical Center, Kansas City, KS, USA
| | - Tara L Lin
- University of Kansas Medical Center, Kansas City, KS, USA
| | - Douglas Tremblay
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Lyseight FLS, Dupont COC, Cherubini GB. Intrathecal chemotherapy for the management of lymphoblastic lymphoma in a 4-year-old dog: a case report. Front Vet Sci 2023; 10:1209935. [PMID: 37732143 PMCID: PMC10507905 DOI: 10.3389/fvets.2023.1209935] [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: 04/21/2023] [Accepted: 07/25/2023] [Indexed: 09/22/2023] Open
Abstract
Intrathecal chemotherapy is used in human medicine for the treatment or prophylaxis of CNS hematopoietic neoplasia. However, the clinical benefits in veterinary medicine have been scarcely documented. A 4-year-old male entire cross-breed dog presented with a 24-h history of severe lethargy, pelvic limb weakness, and urinary retention. Examination revealed generalized peripheral lymphadenomegaly, and the neurological findings were suggestive of a myelopathy in the region of T3-L3. Following the diagnosis of multicentric lymphoblastic B-cell lymphoma (stage Vb), a modified L-LOP with cytosine arabinoside was started, and complete clinical remission was achieved. After 4 weeks, there was acute neurological deterioration (spinal pain and proprioceptive deficits) without peripheral lymphadenomegaly. MRI findings and CSF analysis were consistent with meningeal and spinal cord lymphoma infiltration at the level of L3. Intrathecal chemotherapy (cytosine arabinoside and methotrexate) were administered in the cisterna magna with systemic dexamethasone and analgesia. Clinical signs were resolved within 24 h, and the patient remained asymptomatic for 3.5 weeks. After this period, CNS relapse (proprioceptive deficits and severe thoracolumbar pain) was suspected, and repeat intrathecal chemotherapy was declined. The patient was humanely euthanized 9 weeks after the initial diagnosis. This is the first report on the clinical benefit of intrathecal chemotherapy with a combination of methotrexate and cytarabine for the management of CNS lymphoma in dogs. Based on our case, intrathecal chemotherapy with methotrexate and cytarabine can induce a short-lasting CNS clinical remission (3 weeks).
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Affiliation(s)
| | | | - Giunio Bruto Cherubini
- Neurology and Neurosurgery Service, Dick White Referrals, Part of Linnaeus Veterinary Limited, Cambridgeshire, United Kingdom
- Department of Veterinary Sciences, University of Pisa, Pisa, Italy
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Patterson JD, Farach AM, Singh M, Britz GW, Rostomily RC. Leptomeningeal metastasis from neuroendocrine carcinoma of the cervix: illustrative case. J Neurosurg Case Lessons 2023; 5:CASE22457. [PMID: 36718868 PMCID: PMC10550709 DOI: 10.3171/case22457] [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] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 11/21/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Leptomeningeal carcinomatosis is a rare feature of metastasis that is characterized by thickening and increased contrast enhancement throughout the meninges of the central nervous system (CNS). Leptomeningeal disease (LMD) can occur as spread from primary CNS tumors or as a manifestation of metastasis to the CNS from primary tumor sites outside the CNS. Leptomeningeal disease is, however, rare in cervical cancer, in which metastasis occurs typically from local invasion. OBSERVATIONS The authors discuss the case of CNS metastasis with LMD from the rare neuroendocrine carcinoma of the cervix (NECC). Cervical cancer infrequently metastasizes to the CNS, but NECC is an aggressive variant with greater metastatic potential. Many of these patients will have previously received pelvic radiation, limiting their candidacy for craniospinal radiation for LMD treatment due to field overlap. This illustrative case documents the first known case of NECC CNS metastasis accompanied by LMD treated with intrathecal chemotherapy. LESSONS Reported is the first known case of NECC with CNS metastasis accompanied by LMD. The authors highlight the potentially critical role of intrathecal chemotherapy, in addition to radiotherapy, in treating leptomeningeal metastasis from cervical cancer.
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Affiliation(s)
| | | | - Monisha Singh
- Oncology, Houston Methodist Hospital, Houston, Texas
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Asawa P, Vusqa U, Khan C, Samhouri Y, Fazal S. Intrathecal Chemotherapy as a Potential Treatment for Steroid-refractory Immune Effector Cell-associated Neurotoxicity Syndrome. Anticancer Res 2022; 42:3853-3856. [PMID: 35896259 DOI: 10.21873/anticanres.15876] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 05/02/2022] [Revised: 06/15/2022] [Accepted: 06/29/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM Chimeric antigen receptor (CAR) T-cell therapy has revolutionized the treatment of various B-cell malignancies. However, it can cause serious adverse effects like immune effector cell-associated neurotoxicity syndrome (ICANS). ICANS is attributed to disruption of the blood-brain barrier due to inflammatory cytokines and increased levels of immune effector cells (IECs) in the cerebrospinal fluid (CSF). Corticosteroids and supportive management are the mainstays of ICANS treatment. However, no guidelines exist for the treatment of steroid-refractory ICANS. Some reports have shown favorable outcomes with no long-term complications in patients with steroid-refractory ICANS treated with intrathecal (IT) chemotherapy. CASE REPORT We describe the outcomes of two patients with steroid-refractory ICANS treated with IT chemotherapy. Both patients had refractory large B-cell lymphoma and were not candidates for autologous transplant. They developed steroid-refractory ICANS after CAR T-cell infusion. IT chemotherapy with 12 mg methotrexate and 50 mg hydrocortisone resulted in prompt neurological improvement in both patients. One of them passed away due to multiple other comorbidities, and the other patient continues to do well without any complications. CONCLUSION IT chemotherapy could be considered as a potential approach for the management of steroid-refractory ICANS based on our experience. Prospective studies are needed to validate this approach.
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Affiliation(s)
- Palash Asawa
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, PA, U.S.A.;
| | - Urwat Vusqa
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, PA, U.S.A
| | - Cyrus Khan
- Division of Hematology and Cellular Therapy, Allegheny Health Network Cancer Institute, Pittsburgh, PA, U.S.A
| | - Yazan Samhouri
- Division of Hematology and Cellular Therapy, Allegheny Health Network Cancer Institute, Pittsburgh, PA, U.S.A
| | - Salman Fazal
- Division of Hematology and Cellular Therapy, Allegheny Health Network Cancer Institute, Pittsburgh, PA, U.S.A
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Perego G, Longobardo G, Viganò L, Locatelli A, Veneziano C, Fazio M. Stability of a standardized preparation of methotrexate, cytarabine, and methylprednisolone hemisuccinate for intrathecal use. J Oncol Pharm Pract 2022:10781552221117228. [PMID: 35892160 DOI: 10.1177/10781552221117228] [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: 11/15/2022]
Abstract
INTRODUCTION Data about the feasibility or stability of drugs prepared for intrathecal administration are scarce, especially concerning the possibility of mixing two or more compounds in the same syringe. We evaluated the stability of an extemporaneously prepared triple intrathecal therapy containing methotrexate, cytarabine, and methylprednisolone hemisuccinate. MATERIALS AND METHODS Six mixtures containing 12.5 mg methotrexate, 50 mg cytarabine, and 40 mg methylprednisolone hemisuccinate, diluted to a final volume of 5 ml with water for injection, were prepared in polypropylene syringes on six different days. Syringes were stored protected from light either at room temperature (20°C) (n = 3) or refrigerated temperature (4°C) (n = 3). Samples were analyzed immediately after preparation and again at 0.5, 2, 4, 6, 8, and 24 h. The analysis was conducted with a high-performance liquid chromatography instrument equipped with a quaternary pump and diode array detector. pH was also assessed before every sample analysis. RESULTS When mixed in a polypropylene syringe, the three drugs were stable at both temperatures tested. No degradation >10% was observed in any sample and pH remained between 7.0 and 7.5 over time. No precipitation or color change occurred. Among the three compounds, methylprednisolone hemisuccinate was the most labile as a slight temperature- and time-dependent degradation was observed. CONCLUSION Triple intrathecal solution of methotrexate, cytarabine, and methylprednisolone hemisuccinate is stable for up to 24 h when stored in polypropylene syringes protected from light at 4°C and 20°C.
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Affiliation(s)
- Gianluca Perego
- Pharmacy Unit, 9372IRCCS San Raffaele Hospital, Milan, Italy
| | | | - Lucia Viganò
- Department of Medical Oncology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Alberta Locatelli
- Department of Medical Oncology, IRCCS San Raffaele Hospital, Milan, Italy
| | | | - Maria Fazio
- Pharmacy Unit, 9372IRCCS San Raffaele Hospital, Milan, Italy
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Takahara K, Katayama M, Tamura R. Prolonged Survival and Restored Useful Life by Early Induction of Intrathecal Chemotherapy in a Patient with Leptomeningeal Carcinomatosis from Ovarian Cancer. Brain Sci 2022; 12:748. [PMID: 35741633 DOI: 10.3390/brainsci12060748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 04/24/2022] [Revised: 05/09/2022] [Accepted: 06/04/2022] [Indexed: 11/17/2022] Open
Abstract
Leptomeningeal carcinomatosis (LMC) is a rare but devastating complication of advanced cancer. Breast cancer, lung cancer, and melanoma are the three most common causes of LMC, whereas it is rare in ovarian cancer. Here, we report the case of a 59-year-old woman who was diagnosed with LMC from ovarian cancer and was successfully treated with intrathecal chemotherapy via Ommaya reservoir and radiation therapy. The patient had an amelioration of symptoms and prolonged survival. Though LMC from ovarian cancer is thought to be rare, it is not going to remain a rare entity because the incidence of LMC in general is thought to be increasing, which is also the case with ovarian cancer. According to 31 cases whose treatment course is reported in literature, despite the absence of an established treatment for LMC, intrathecal (IT) chemotherapy whose survival benefit has been suggested in past studies might also prolong survival in patients with LMC from ovarian cancer. IT chemotherapy via Ommaya reservoir may be preferred to the lumbar puncture route. The presentation of non-specific symptoms of LMC in patients may hinder its diagnosis; however, early diagnosis and treatment induction is the key for patients' prolonged survival and restored useful life.
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Hou L, Han W, Jin J, Chen X, Zou Y, Yan L, He J, Bu H. Clinical efficacy and safety of different doses of intrathecal methotrexate in the treatment of leptomeningeal carcinomatosis: a prospective and single-arm study. Jpn J Clin Oncol 2021; 51:1715-1722. [PMID: 34585252 DOI: 10.1093/jjco/hyab155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 04/16/2021] [Accepted: 09/14/2021] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To investigate the clinical efficacy and safety of different doses of intrathecal methotrexate in the treatment of leptomeningeal carcinomatosis. METHODS 53 patients admitted to the Second Hospital of Hebei Medical University with leptomeningeal carcinomatosis were recruited. They were divided into two groups: 15-mg-group received 15 mg methotrexate intrathecally, while the other received 10 mg methotrexate. All patients were followed up to 31 December 2020 or until death. Primary endpoint was the response rate. Secondary endpoints were survival and safety. Treatment-related adverse events were recorded. RESULTS The intrathecal chemotherapy was regularly maintained in 42 cases. Most primary cancers were lung (60.4%), stomach (18.9%) or breast (5.7%). The clinical response rate was higher in the 15 mg group than the 10 mg group (62.5 vs. 34.5%, P = 0.042). In the 15 mg group, two cases showed myelosuppression and one case showed seizures. In the 10 mg group, one patient appeared fever, three patients appeared myelosuppression and one showed leukoencephalopathy. However, there were no serious irreversible adverse reactions in neither of the two groups. In terms of survival, the median survival was 15.7 weeks in the 15 mg group and 27.1 weeks in the 10 mg group (P = 0.116). Multivariate analysis showed that only targeted therapy improved the survival (P < 0.0001, HR = 5.386). CONCLUSION Increased dose of methotrexate did not prolong the overall survival, but it was more effective in relieving clinical symptoms with no increased adverse reactions. Targeted therapy might improve the survival.
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Affiliation(s)
- Lan Hou
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China.,Department of Neurology, Baoding No.1 Central Hospital, Baoding, China
| | - Weixin Han
- Department of Neurology, Hebei Chest Hospital, Shijiazhuang, China
| | - Jie Jin
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China.,Department of Neurology, Baoding No.1 Central Hospital, Baoding, China
| | - Xin Chen
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China.,Department of Neurology, Baoding No.1 Central Hospital, Baoding, China
| | - Yueli Zou
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China.,Department of Neurology, Baoding No.1 Central Hospital, Baoding, China
| | - Litian Yan
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China.,Department of Neurology, Baoding No.1 Central Hospital, Baoding, China
| | - Junying He
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China.,Department of Neurology, Baoding No.1 Central Hospital, Baoding, China
| | - Hui Bu
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China.,Department of Neurology, Baoding No.1 Central Hospital, Baoding, China
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Abstract
Malignant meningitis (MM) is the diffuse involvement of the leptomeninges by infiltrating cancer cells, most frequently from lung and breast cancers. This review is aimed to discuss the current advances in the diagnosis and management of MM, along with management of MM-associated hydrocephalus. We reviewed the literature using PubMed and Google Scholar search engines, focusing on various recent randomized controlled trials and clinical trials on MM. Given the hallmark multifocal involvement, the clinical symptoms and signs are also random and asymmetric. There are three important pillars for establishing a diagnosis of MM: clinical examination, neuroimaging, and CSF cytological findings. Several factors should be considered in decision-making, including performance status, neurological findings (clinical, MRI, and CSF flow dynamic), and evaluation of the primary tumor (nature and systemic dissemination). Response Assessment in Neuro-Oncology (RANO) working group recommended the objective assessment of disease for evaluating the progression and response to therapy. Pillars of current management are mainly focal irradiation and intrathecal or systemic chemotherapy. Symptomatic hydrocephalus is managed with a ventriculoperitoneal shunt, lumboperitoneal shunt, or endoscopic third ventriculostomy as palliative procedures, providing significant improvement in performance scores in the limited survival time of patients with MM. Studies using novel therapeutic approaches, such as new biological or cytotoxic compounds, are ongoing. Despite the use of all the combinations, the overall prognosis remains grim; therefore, decision-making for treatment should predominantly be based on attaining an optimal quality of life.
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Affiliation(s)
- Ashutosh Kumar
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Jayesh C Sardhara
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Guramritpal Singh
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Soumen Kanjilal
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ved P Maurya
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sanjay Behari
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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13
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Abstract
Leptomeningeal metastasis (LM) is a devastating complication of cancer with variable clinical presentation and limited benefit from existing treatment options. In this review, we discuss advances in LM diagnostics and therapeutics with the potential to reverse this grim course. Emerging cerebrospinal fluid circulating tumor cell and cell-free tumor DNA analysis technologies will improve diagnosis of LM, while providing crucial genetic information, capturing tumor heterogeneity, and quantifying disease burden. Circulating tumor cells and cell-free tumor DNA have utility as biomarkers to track disease progression and treatment response. Treatment options for LM include ventriculoperitoneal shunting for symptomatic relief, radiation therapy including whole-brain radiation and focal radiation for bulky leptomeningeal involvement, and systemic and intrathecal medical therapies, including targeted and immunotherapies based on tumor mutational profiling. While existing treatments for LM have limited efficacy, recent advances in liquid biopsy together with increasing availability of targeted treatments will lead to rational multimodal individualized treatments and improved patient outcomes.
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Affiliation(s)
- Ugur Sener
- Department of Neurology, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Priya Kumthekar
- Department of Neurology, Malnati Brain Tumor Institute at the Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Adrienne Boire
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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14
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Ma'koseh M, Tamimi F, Abufara A, Abusalem L, Salama O, Saleh Y, Khader R, Faiyoumi BA, Al-Rwashdeh M, Halahleh K. Impact of Central Nervous System International Prognostic Index on the Treatment of Diffuse Large B Cell Lymphoma. Cureus 2021; 13:e16802. [PMID: 34513408 PMCID: PMC8407468 DOI: 10.7759/cureus.16802] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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] [Accepted: 07/31/2021] [Indexed: 11/07/2022] Open
Abstract
Background The central nervous system international prognostic index (CNS-IPI) is being used widely for the identification of patients with diffuse large B cell lymphoma (DLBCL) with a high risk of central nervous system (CNS) relapse. The aim of our study is to confirm the value of the CNS-IPI in predicting CNS relapse in our young study population and to evaluate its impact on the selection of patients for CNS prophylaxis. Methods We retrospectively reviewed patients diagnosed with DLBCL who were treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (RCHOP) regimen from January 2010 till December 2018. Correlation between CNS-IPI and cumulative incidence of CNS relapse and time to CNS relapse was examined through Kaplan-Meier plots. Median time to CNS relapse and median overall survival after CNS relapse were also estimated using the Kaplan-Meier plots. Results A total of 354 patients were included. The median age was 46 years. Overall, 5% of the patients developed CNS relapse. Median survival after CNS relapse was seven months. Two-year CNS relapse rates according to CNS-IPI were 0.7%, 5.1%, and 26% for low, intermediate, and high-risk, groups respectively. On multivariate analysis, poor performance status (p=0.045), involvement of two or more extranodal sites (p= 0.021), involvement of bone marrow (p= 0.029), and renal or adrenal glands (p= 0.006) significantly correlated with CNS relapse. Considering the CNS-IPI and high-risk anatomical sites (breast, uterus, testis, and epidural space), 26% of our patients with DLBCL would have needed prophylaxis. Conclusion Although CNS-IPI helps in better selection of DLBCL patients for CNS prophylaxis, it can possibly increase the number of patients exposed to unnecessary prophylaxis. More investigational biomarkers are needed to better refining high-risk patients.
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Affiliation(s)
| | - Faris Tamimi
- Medical Oncology, King Hussein Cancer Center, Amman, JOR
| | - Alaa Abufara
- Medical Oncology, King Hussein Cancer Center, Amman, JOR
| | - Lana Abusalem
- Medical Oncology, King Hussein Cancer Center, Amman, JOR
| | - Osama Salama
- Medical Oncology, King Hussein Cancer Center, Amman, JOR
| | - Yacob Saleh
- Medical Oncology, King Hussein Cancer Center, Amman, JOR
| | - Rnad Khader
- Medical Oncology, King Hussein Cancer Center, Amman, JOR
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15
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Dietrich C, Salzmann M, Steinbrecher A, Herbst R, Hassel JC. Durable complete remission of leptomeningeal melanoma by intrathecal methotrexate maintained with systemic ipilimumab. Immunotherapy 2021; 13:1079-1083. [PMID: 34259028 DOI: 10.2217/imt-2021-0031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Leptomeningeal disease (LMD) is a complication of metastasized melanoma, with poor prognosis even in the era of immunotherapy. We present the case of a 37-year-old man who was diagnosed with stage IV melanoma with lymphonodular, splenic and pulmonary metastases. Treatment with dabrafenib and trametinib led to a complete remission, but subsequent symptomatic LMD. Treatment was changed to intrathecal methotrexate, leading to aseptic meningitis, but also a remission of LMD. Followed by ipilimumab monotherapy, a durable, complete remission was observed. Symptomatic LMD may not be amenable to immunotherapy alone, as quick responses may be needed. With little evidence and few retrospective trials demonstrating the challenging treatment of LMD, intrathecal chemotherapy, potentially in combination, may still be considered a viable option.
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Affiliation(s)
- Carmen Dietrich
- Department of Dermatology & National Center for Tumor Diseases, University Hospital Heidelberg, Im Neuenheimer Feld 460, Heidelberg, 69120, Germany
| | - Martin Salzmann
- Department of Dermatology & National Center for Tumor Diseases, University Hospital Heidelberg, Im Neuenheimer Feld 460, Heidelberg, 69120, Germany
| | - Andreas Steinbrecher
- Department of Neurology, Helios Clinic, Nordhäuser Straße 74, Erfurt, 99089, Germany
| | - Rudolf Herbst
- Department of Dermatology, Helios Clinic, Nordhäuser Straße 74, Erfurt, 99089, Germany
| | - Jessica C Hassel
- Department of Dermatology & National Center for Tumor Diseases, University Hospital Heidelberg, Im Neuenheimer Feld 460, Heidelberg, 69120, Germany
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16
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Hotta M, Ito T, Konishi A, Yoshimura H, Nakanishi T, Fujita S, Satake A, Nomura S. Multiple Myeloma with Central Nervous System Relapse Early after Autologous Stem Cell Transplantation: A Case Report and Literature Review. Intern Med 2021; 60:463-468. [PMID: 33518613 PMCID: PMC7925288 DOI: 10.2169/internalmedicine.5646-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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] [Indexed: 11/06/2022] Open
Abstract
Few reports have so far described central nervous system (CNS) involvement in multiple myeloma (MM), which shows a poor prognosis owing to its resistance to several treatments. We herein describe a 45-year-old woman who had MM (diagnosed with IgA-κ type) with CNS relapse early after undergoing autologous hematopoietic stem cell transplantation. Because no standard treatment for CNS lesions of MM has been established, we conducted a literature review on the cerebrospinal fluid (CSF) transferability of drugs for MM, since it was considered to be a useful tool for CNS involvement. Immunomodulatory-drugs including pomalidomide exhibit a good CSF transfer ability, and, therefore, may be beneficial against the CNS involvement of MM.
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Affiliation(s)
- Masaaki Hotta
- First Department of Internal Medicine, Kansai Medical University, Japan
| | - Tomoki Ito
- First Department of Internal Medicine, Kansai Medical University, Japan
| | - Akiko Konishi
- First Department of Internal Medicine, Kansai Medical University, Japan
| | - Hideaki Yoshimura
- First Department of Internal Medicine, Kansai Medical University, Japan
| | | | - Shinya Fujita
- First Department of Internal Medicine, Kansai Medical University, Japan
| | - Atsushi Satake
- First Department of Internal Medicine, Kansai Medical University, Japan
| | - Shosaku Nomura
- First Department of Internal Medicine, Kansai Medical University, Japan
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17
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Pan Z, Yang G, He H, Cui J, Li W, Yuan T, Chen K, Jiang T, Gao P, Sun Y, Cong X, Li Z, Wang Y, Pang X, Song Y, Zhao G. Intrathecal pemetrexed combined with involved-field radiotherapy as a first-line intra-CSF therapy for leptomeningeal metastases from solid tumors: a phase I/II study. Ther Adv Med Oncol 2020; 12:1758835920937953. [PMID: 32733606 PMCID: PMC7370561 DOI: 10.1177/1758835920937953] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [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: 12/31/2019] [Accepted: 05/21/2020] [Indexed: 12/22/2022] Open
Abstract
Purpose: A phase I/II study of intrathecal pemetrexed (IP) combined with involved-field radiotherapy (IFRT) was performed to determine feasibility, safety, and antitumor activity for leptomeningeal metastases (LM) from solid tumors. Methods: Participants first received induction IP administration, followed by concomitant radiotherapy within 3 days. The concomitant regimen consisted of IP (pemetrexed 10 mg, dexamethasone 5 mg, once per week, 4 times in 4 weeks) and IFRT (40 Gy in 20 fractions). Six participants were recruited to assess feasibility in phase I, and then 28 patients were recruited further. All patients were assessed to investigate safety, efficacy, and outcomes. Results: Between April 2018 and December 2018, 34 patients (male: 15; female: 19; median age: 56 years) were enrolled, including non-small-cell lung cancer (21), small-cell lung cancer (5), breast cancer (4), and others (4). Thirty-two patients received concurrent therapy and 25 (74%) patients completed the treatment. Major adverse events (AEs) consisted of myelosuppression, the elevation of hepatic aminotransferases, and radiculitis. Total AEs rate was 53% (18/34), including 6 (18%) patients with grade 3 and 1 (3%) with grade 4 AEs. The response rate was 68% (23/34). The median overall survival was 5.5 (0.3–16.6) months. Median neurological progression-free survival (NPFS) was 3.5 (0.3–15.2) months. Six-month NPFS rate was 47%. One-year survival rate was 21.6%. Conclusion: IP at a 10 mg dose on a schedule of 1–2 times per week presented good efficacy and safety in CSF. The concomitant regimen is an efficacious therapeutic option for LM patients with solid tumors. Trial Registration: This study (IPLM) was registered at https://register.clinicaltrials.gov [ClinicalTrials.gov identifier: NCT03507244].
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Affiliation(s)
- Zhenyu Pan
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, China
| | - Guozi Yang
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, China
| | - Hua He
- Cancer Center, The First Hospital of Jilin University, Changchun, China
| | - Jiuwei Cui
- Cancer Center, The First Hospital of Jilin University, Changchun, China
| | - Wei Li
- Cancer Center, The First Hospital of Jilin University, Changchun, China
| | - Tingting Yuan
- Department of Radiology, The First Hospital of Jilin University, Changchun, China
| | - Kunzhi Chen
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, China
| | - Tongchao Jiang
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, China
| | - Pengxiang Gao
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, China
| | - Yanan Sun
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, China
| | - Xiaofeng Cong
- Cancer Center, The First Hospital of Jilin University, Changchun, China
| | - Zhi Li
- Cancer Center, The First Hospital of Jilin University, Changchun, China
| | - Yongxiang Wang
- Department of Clinical Laboratory, The First Hospital of Jilin University, Changchun, China
| | - Xiaochuan Pang
- Department of Clinical Laboratory, The First Hospital of Jilin University, Changchun, China
| | - Yuanyuan Song
- Department of Clinical Laboratory, The First Hospital of Jilin University, 71 Xinmin Street, Changchun, 130021, China
| | - Gang Zhao
- Department of Neuro-Oncological Surgery, The First Hospital of Jilin University, 71 Xinmin Street, Changchun, 130021, China
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18
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Kamoda H, Kinoshita H, Yonemoto T, Iuchi T, Tsukanishi T, Hagiwara Y, Ohtori S, Yamazaki M, Ishii T. Factors Linked to Prognosis in Patients with Leptomeningeal Metastasis Diagnosed by Spinal Magnetic Resonance Imaging. Spine Surg Relat Res 2020; 4:64-68. [PMID: 32039299 PMCID: PMC7002071 DOI: 10.22603/ssrr.2019-0064] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 09/26/2019] [Indexed: 11/26/2022] Open
Abstract
Introduction Leptomeningeal metastasis (LM) is known to demonstrate a very poor prognosis. The purpose of this study was to evaluate the prognostic factors in LM cases diagnosed by spinal magnetic resonance imaging (MRI). Methods We retrospectively analyzed 19 patients with LM detected by spinal MRI between 2010 and 2017. Results The primary tumors were breast carcinoma (n = 7), lung carcinoma (n = 6), lymphoma (n = 3), colorectal carcinoma (n = 2), and gastric carcinoma (n = 1). Thirteen patients exhibited preceding brain metastasis, and 11 of these exhibited metastasis in the posterior fossa. Ten patients exhibited limb paralysis. Performance status at diagnosis was 0-1 in 6 patients, 2 in 9 patients, and 3-4 in 4 patients. Testing of cerebrospinal fluid revealed malignant cells in 9 patients. On MRI, 11 patients demonstrated disseminated tumor lesions at the cervical cord level, 15 patients at the thoracic cord level, and 11 patients below the conus level. Eleven patients received radiation therapy, while intrathecal chemotherapy was performed in 9 patients. Univariate analysis revealed cervical cord level lesions, intrathecal chemotherapy, paralysis, and performance status as prognostic factors. Multivariate analysis identified existence of a cervical cord lesion as associated with a poor prognosis (hazards ratio (HR) 3.46, 95% confidence interval (CI) 1.12-12.2), while administration of intrathecal chemotherapy was associated with a good prognosis (HR 0.15, 95% CI 0.026-0.67). Conclusions In LM patients, cervical cord level lesions are a negative factor for prognosis, and performance of intrathecal chemotherapy is a positive factor for prognosis.
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Affiliation(s)
- Hiroto Kamoda
- Division of Orthopedic Surgery, Chiba Cancer Center, Chiba, Japan
| | | | - Tsukasa Yonemoto
- Division of Orthopedic Surgery, Chiba Cancer Center, Chiba, Japan
| | - Toshihiko Iuchi
- Division of Neurological Surgery, Chiba Cancer Center, Chiba, Japan
| | - Toshinori Tsukanishi
- Division of Orthopedic Surgery, Chiba Cancer Center, Chiba, Japan.,Department of Orthopedic Surgery, Tsukuba University, Ibaraki, Japan
| | - Yoko Hagiwara
- Division of Orthopedic Surgery, Chiba Cancer Center, Chiba, Japan
| | - Seiji Ohtori
- Department of Orthopedic Surgery, Chiba University, Chiba, Japan
| | - Masashi Yamazaki
- Department of Orthopedic Surgery, Tsukuba University, Ibaraki, Japan
| | - Takeshi Ishii
- Division of Orthopedic Surgery, Chiba Cancer Center, Chiba, Japan
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19
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Reid JH, Perissinotti AJ, Benitez L, Bixby DL, Burke P, Pettit K, Marini BL. Impact of prophylactic intrathecal chemotherapy on CNS relapse rates in AML patients presenting with hyperleukocytosis. Leuk Lymphoma 2019; 61:862-868. [PMID: 31739707 DOI: 10.1080/10428194.2019.1691199] [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] [Indexed: 10/25/2022]
Abstract
Central nervous system (CNS) relapse in acute myeloid leukemia (AML) confers a poor prognosis. Despite the identification of risk factors for CNS relapse (e.g. hyperleukocytosis), there is no standard practice for CNS relapse risk reduction with intrathecal (IT) chemotherapy in patients. We compared outcomes of 50 patients who did not receive IT chemotherapy with 18 patients who did receive IT chemotherapy with a hyperleukocytosis at diagnosis (defined as white blood cell count ≥100,000 cells/mcL). There were three occurrences of CNS relapse, all within patients who did not receive prophylaxis. There was no difference in the incidence of CNS relapse between the patient cohorts (p = .560). These results highlight the low incidence of CNS relapse in our patient population that received and survived induction chemotherapy despite selecting for a high risk cohort. Furthermore, there is a need for a CNS relapse registry to standardize treatment approaches in this high-risk patient population.
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Affiliation(s)
- Justin H Reid
- Department of Pharmacy Services and Clinical Pharmacy, Michigan Medicine, Ann Arbor, MI, USA.,University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Anthony J Perissinotti
- Department of Pharmacy Services and Clinical Pharmacy, Michigan Medicine, Ann Arbor, MI, USA.,University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Lydia Benitez
- Department of Pharmacy Services and Clinical Pharmacy, Michigan Medicine, Ann Arbor, MI, USA.,University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Dale L Bixby
- Department of Internal Medicine and Division of Hematology and Oncology, Michigan Medicine and University of Michigan Medical School, Ann Arbor, MI, USA
| | - Patrick Burke
- Department of Internal Medicine and Division of Hematology and Oncology, Michigan Medicine and University of Michigan Medical School, Ann Arbor, MI, USA
| | - Kristen Pettit
- Department of Internal Medicine and Division of Hematology and Oncology, Michigan Medicine and University of Michigan Medical School, Ann Arbor, MI, USA
| | - Bernard L Marini
- Department of Pharmacy Services and Clinical Pharmacy, Michigan Medicine, Ann Arbor, MI, USA.,University of Michigan College of Pharmacy, Ann Arbor, MI, USA
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20
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Oka S, Ono K, Nohgawa M. Successful treatment with pomalidomide and intrathecal injections for central nervous system plasmacytoma in a patient under haemodialysis. J Clin Pharm Ther 2019; 45:221-225. [PMID: 31602676 DOI: 10.1111/jcpt.13054] [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: 07/18/2019] [Revised: 08/13/2019] [Accepted: 08/23/2019] [Indexed: 11/29/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVES The involvement of the central nervous system (CNS) in multiple myeloma (MM) is uncommon and has an extremely poor prognosis, and optimal treatment strategies for the CNS MM patients have not yet been established. CASE SUMMARY A 71-year-old MM patient with severe renal impairment exhibited extramedullary relapse in the CNS and progression while being treated with lenalidomide and dexamethasone. However, she achieved very good partial remission after a treatment with pomalidomide, cyclophosphamide and dexamethasone (PCD) in combination with intrathecal chemotherapy. WHAT IS NEW AND CONCLUSION This is the first case report to describe MM with CNS involvement in a patient who had responded to PCD under haemodialysis. The combined intrathecal administration of cytotoxic agents and PCD may prolong survival and is tolerated well by patients with severe renal impairment.
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Affiliation(s)
- Satoko Oka
- Division of Hematology, Japanese Red Cross Society Wakayama Medical Center, Wakayama, Japan
| | - Kazuo Ono
- Division of Pathology, Japanese Red Cross Society Wakayama Medical Center, Wakayama, Japan
| | - Masaharu Nohgawa
- Division of Hematology, Japanese Red Cross Society Wakayama Medical Center, Wakayama, Japan
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21
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Pan Z, Yang G, Cui J, Li W, Li Y, Gao P, Jiang T, Sun Y, Dong L, Song Y, Zhao G. A Pilot Phase 1 Study of Intrathecal Pemetrexed for Refractory Leptomeningeal Metastases From Non-small-cell Lung Cancer. Front Oncol 2019; 9:838. [PMID: 31544065 PMCID: PMC6730526 DOI: 10.3389/fonc.2019.00838] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [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: 06/21/2019] [Accepted: 08/14/2019] [Indexed: 12/29/2022] Open
Abstract
Objectives: We aim to determine the feasibility, safety, maximally tolerated dose (MTD), recommended dose and potential anti-tumor activity of intrathecal pemetrexed (IP). Materials and Methods: Lung adenocarcinoma patients with recurrent or progressive leptomeningeal metastases (LM) after intrathecal chemotherapy were recruited. IP dose was escalated from 10 mg. A minimum of three patients and a maximum of six were enrolled in each cohort. Schedule protocol was IP twice per week for 2 weeks in induction therapy, followed by once per week for 4 weeks in consolidation therapy. Serial samples of plasma and cerebrospinal fluid (CSF) were obtained for pharmacokinetic studies. Results: Thirteen patients were enrolled between March 2017 and July 2018. EGFR driver oncogene was identified in most of the patients. Severe adverse events (AEs) were encountered in 31% (4/13) of the cases, including myelosuppression, radiculitis, and elevation of hepatic aminotransferases (EHA). Study protocol was revised due to lethal myelosuppression. Following protocol revision, vitamin B12 and folic acid supplementation was given at the beginning of treatment, and myelosuppression was well-controlled. Dose-limiting toxicities (DLT) were myelosuppression, radiculitis, and EHA. Two patients (2/2) developed dose-limiting myelosuppression at 15 mg level. One patient (1/6) experienced dose-limiting radiculitis and EHA at 10 mg level. MTD was 10 mg. Response rate was 31% (4/13) and disease control rate was 54% (7/13). The drug concentration showed a decreasing trend in serial CSF samples following each IP. After IP, the peak plasma concentration was reached at 4 h in two cases, 6 h in two cases, 9 h in one case, and 12 h in one case, respectively. Conclusion: Pemetrexed was appropriate for intrathecal administration. IP at 10 mg dose in combination with vitamin supplementation on the schedule of 1–2 times per week showed controllable toxicity and good efficacy. This regimen paves the way for subsequent clinical trial. Clinical Trial Registration:www.ClinicalTrials.gov, identifier NCT03101579.
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Affiliation(s)
- Zhenyu Pan
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, China.,Department of Neuro-Oncological Surgery, The First Hospital of Jilin University, Changchun, China
| | - Guozi Yang
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, China
| | - Jiuwei Cui
- Cancer Center, The First Hospital of Jilin University, Changchun, China
| | - Wei Li
- Cancer Center, The First Hospital of Jilin University, Changchun, China
| | - Yu Li
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, China
| | - Pengxiang Gao
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, China
| | - Tongchao Jiang
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, China
| | - Yanan Sun
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, China
| | - Lihua Dong
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, China
| | - Yuanyuan Song
- Department of Clinical Laboratory, The First Hospital of Jilin University, Changchun, China
| | - Gang Zhao
- Department of Neuro-Oncological Surgery, The First Hospital of Jilin University, Changchun, China
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22
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Jastaniah W, Elimam N, Abdalla K, AlAzmi AA, Algamal A, Felimban S. Intrathecal dose intensification by CNS status at diagnosis in the treatment of children with acute lymphoblastic leukemia. ACTA ACUST UNITED AC 2019; 24:369-377. [PMID: 30885098 DOI: 10.1080/16078454.2019.1590962] [Citation(s) in RCA: 4] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Acute lymphoblastic leukemia (ALL) with CNS2 status predicts inferior outcome and a high rate of CNS relapse, similar to overt CNS leukemia (CNS3). The purpose of this study was to determine if intrathecal (IT) dose intensification during induction would improve outcomes and reduce CNS relapse for CNS2 disease. METHODS From January 2001 to December 2014, children (1-14 years) with newly diagnosed ALL were treated at the Princess Noorah Oncology Centre (PNOC) following modifications of the Children's Oncology Group (COG) protocols. We intensified IT methotrexate (ITM) during induction for patients with CNS2 disease. Patients were evaluated for overall survival (OS), disease-free survival (DFS), and cumulative incidence of relapse (CIR). RESULTS 449 children with T-cell (14.3%) or B-cell (85.7%) ALL were treated using PNOC-SR or PNOC-HR regimens (Jan 2001- Dec 2007) or CALL08 regimens (Arm A [SR], Arm B [IR], and Arm C [HR]) (Jan 2008 - Dec 2014). The 5-year OS, DFS, and CIR were 87.2 ± 1.6%, 81.7 ± 1.9%, and 13.0 ± 1.7%, respectively. The OS and DFS of patients with CNS2 were significantly superior to that of patients with CNS3 (P = 0.025 and P = 0.019, respectively). Patients with CNS2 had similar OS and DFS to those with CNS1. None of the patients with CNS2 at initial diagnosis experienced CNS relapse. CONCLUSIONS ITM intensification during induction was associated with elimination of CNS recurrence in patients with CNS2 disease and childhood ALL. Controlled studies are needed to confirm this observation.
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Affiliation(s)
- Wasil Jastaniah
- a Department of Pediatrics, Faculty of Medicine , Umm AlQura University , Makkah , Saudi Arabia.,b Princess Noorah Oncology Center , King Saud Bin Abdulaziz University for Health Sceinces and King Abdulaziz Medical City, Ministry of National Guard Health Affairs , Jeddah , Saudi Arabia
| | - Naglla Elimam
- b Princess Noorah Oncology Center , King Saud Bin Abdulaziz University for Health Sceinces and King Abdulaziz Medical City, Ministry of National Guard Health Affairs , Jeddah , Saudi Arabia
| | - Khalid Abdalla
- b Princess Noorah Oncology Center , King Saud Bin Abdulaziz University for Health Sceinces and King Abdulaziz Medical City, Ministry of National Guard Health Affairs , Jeddah , Saudi Arabia
| | - Aeshah A AlAzmi
- c Department of Pharmaceutical Care, Clinical Pharmacy, Pediatric Hematology/Oncology , King Saud Bin Abdulaziz University for Health Sciences and King Abdulaziz Medical City, Ministry of National Guard Health Affairs , Jeddah , Saudi Arabia
| | - Amal Algamal
- b Princess Noorah Oncology Center , King Saud Bin Abdulaziz University for Health Sceinces and King Abdulaziz Medical City, Ministry of National Guard Health Affairs , Jeddah , Saudi Arabia
| | - Sami Felimban
- b Princess Noorah Oncology Center , King Saud Bin Abdulaziz University for Health Sceinces and King Abdulaziz Medical City, Ministry of National Guard Health Affairs , Jeddah , Saudi Arabia
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23
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Lewis FM, Bohan JK. Early adolescent language development following intrathecal chemotherapy for acute lymphoblastic leukaemia. Int J Speech Lang Pathol 2018; 20:485-493. [PMID: 28394186 DOI: 10.1080/17549507.2017.1309066] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 03/14/2017] [Accepted: 03/16/2017] [Indexed: 06/07/2023]
Abstract
PURPOSE Central nervous system (CNS) prophylaxis in the treatment of childhood acute lymphoblastic leukaemia (ALL) is routinely achieved through intrathecal chemotherapy (ITC). The presence of high level language deficits in older children who received CNS-directed ITC for ALL in early childhood is yet to be elucidated, with previous research suggesting that high level language deficits may appear later in ALL survivors' development at an age when these skills typically emerge. METHOD A test battery covering foundational language skills and higher-order language skills was administered to five participants (aged 10-15 years) with a history of ITC for ALL. Conversion of each child's language performance scores to z scores allowed for clinical interpretation of data across the language areas tested. RESULT Foundational language skills were, in general, of no clinical concern. Three of the five children presented with clinically impaired language skills in areas including resolving ambiguity, making inferences and composing novel sentences. Performance variation between the participants and within the individual participants was noted. CONCLUSION Given the importance of early adolescent language abilities to academic and social development in late primary and secondary schooling, these preliminary findings suggest further research into emerging adolescent language abilities following ITC for ALL is warranted.
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Affiliation(s)
- Fiona M Lewis
- a School of Health and Rehabilitation Sciences , The University of Queensland , Brisbane , Australia
| | - Jaycie K Bohan
- a School of Health and Rehabilitation Sciences , The University of Queensland , Brisbane , Australia
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Ludmir EB, Milgrom SA, Pinnix CC, Gunther JR, Westin J, Oki Y, Fayad LE, Medeiros LJ, Dabaja BS, Nastoupil LJ. Primary breast diffuse large B-cell lymphoma: treatment strategies and patterns of failure<sup/>. Leuk Lymphoma 2018; 59:2896-2903. [PMID: 29697005 DOI: 10.1080/10428194.2018.1460825] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Treatment strategies and outcomes were assessed in 25 patients with primary breast diffuse large B-cell lymphoma (PB-DLBCL) treated between 1995 and 2016. We specifically investigated the timing of recurrence, and the roles of radiotherapy (RT) and central nervous system prophylaxis (CNS PPX). Fifty-two percent of patients received RT, and 28% received CNS PPX. Fourteen patients (56%) experienced recurrence, with 76% of relapses occurring ≥24 months after diagnosis, in contrast to reports supporting the use of 24-month event-free survival as a surrogate endpoint in the general DLBCL population. Use of RT was associated with a trend toward improved progression-free survival (PFS). Twenty percent of patients experienced CNS relapse, with no clear benefit to CNS PPX. These data emphasize the importance of long-term follow-up for PB-DLBCL patients, suggest a PFS benefit with the addition of RT, and highlight high rates of CNS relapse.
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Affiliation(s)
- Ethan B Ludmir
- a Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Sarah A Milgrom
- a Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Chelsea C Pinnix
- a Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Jillian R Gunther
- a Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Jason Westin
- b Department of Lymphoma/Myeloma , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Yasuhiro Oki
- b Department of Lymphoma/Myeloma , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Luis E Fayad
- b Department of Lymphoma/Myeloma , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - L Jeffrey Medeiros
- c Department of Hematopathology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Bouthaina S Dabaja
- a Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Loretta J Nastoupil
- b Department of Lymphoma/Myeloma , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
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25
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Elhassadi E, Murphy M, Hacking D, Farrell M. Durable treatment response of relapsing CNS plasmacytoma using intrathecal chemotherapy, radiotherapy, and Daratumumab. Clin Case Rep 2018; 6:723-728. [PMID: 29636948 PMCID: PMC5889271 DOI: 10.1002/ccr3.1451] [Citation(s) in RCA: 20] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 01/22/2018] [Accepted: 02/01/2018] [Indexed: 12/19/2022] Open
Abstract
CNS myelomatous involvement is a rare complication of multiple myeloma with dismal outcome. This disease's optimal treatment is unclear. Combined approach of systemic therapy, radiotherapy, and intrathecal injections chemotherapy should be considered and autologous stem cell transplant consolidation is offered to eligible patients. The role of Daratumumab in this disease deserves further evaluation.
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Affiliation(s)
- Ezzat Elhassadi
- Department of Haematology University Hospital Waterford Waterford Ireland
| | - Maurice Murphy
- Department of Pathology University Hospital Waterford Waterford Ireland
| | - Dayle Hacking
- Department of Radiotherapy UPMC Whitefield Cancer Centre Waterford Ireland
| | - Michael Farrell
- Department of Radiology University Hospital Waterford Waterford Ireland
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26
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Nayar G, Ejikeme T, Chongsathidkiet P, Elsamadicy AA, Blackwell KL, Clarke JM, Lad SP, Fecci PE. Leptomeningeal disease: current diagnostic and therapeutic strategies. Oncotarget 2017; 8:73312-73328. [PMID: 29069871 PMCID: PMC5641214 DOI: 10.18632/oncotarget.20272] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [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: 05/10/2017] [Accepted: 07/20/2017] [Indexed: 12/28/2022] Open
Abstract
Leptomeningeal disease has become increasingly prevalent as novel therapeutic interventions extend the survival of cancer patients. Although a majority of leptomeningeal spread occurs secondary to breast cancer, lung cancer, and melanoma, a wide variety of malignancies have been reported as primary sources. Symptoms on presentation are equally diverse, often involving a combination of neurological deficits with the possibility of obstructive hydrocephalus. Diagnosis is definitively made via cerebrospinal fluid cytology for malignant cells, but neuro-imaging with high quality T1-weighted magnetic resonance imaging can aid diagnosis and localization. While leptomeningeal disease is still a terminal, late-stage complication, a variety of treatment modalities, such as intrathecal chemotherapeutics and radiation therapy, have improved median survival from 4–6 weeks to 3–6 months. Positive prognosticative factors for survival include younger age, high performance scores, and controlled systemic disease. In looking to the future, diagnostics that improve early detection and chemotherapeutics tailored to the primary malignancy will likely be the most significant advances in improving survival.
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Affiliation(s)
- Gautam Nayar
- Duke Brain Tumor Immunotherapy Program, Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.,The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA.,Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Tiffany Ejikeme
- Duke Brain Tumor Immunotherapy Program, Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.,The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA.,Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Pakawat Chongsathidkiet
- Duke Brain Tumor Immunotherapy Program, Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.,The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA.,Department of Pathology, Duke University Medical Center, Durham, NC, USA
| | - Aladine A Elsamadicy
- Duke Brain Tumor Immunotherapy Program, Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.,The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA.,Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Kimberly L Blackwell
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey M Clarke
- Division of Medical Oncology, Duke University Medical Center, Durham, NC, USA
| | - Shivanand P Lad
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Peter E Fecci
- Duke Brain Tumor Immunotherapy Program, Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.,The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA.,Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.,Department of Pathology, Duke University Medical Center, Durham, NC, USA
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27
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Abstract
The authors present the history of two patients. The first patient, a 69-year-old woman was diagnosed with locally invasive triple negative breast cancer with pulmonary and cerebral metastases. Complete radiological remission of the clinically asymptomatic cerebral metastases was detected under systemic chemotherapy with carboplatin-docetaxel (75 mg/m2). Later, the patient received whole brain radiotherapy and a second line of chemotherapy. The overall survival was 20 months from the diagnosis of cerebral metastases with conservation of partial autonomy. The second patient, a 57-year-old woman was diagnosed as having hormone sensitive lobular breast cancer with leptomeningeal, lymphonodular and multiple osseal metastases. Before the appearance of the lymphonodular metastasis the patient received intrathecal methotrexate chemotherapy for the leptomeningeal carcinomatosis. Her neurological symptoms completely disappeared. At the onset of the lymphonodular metastasis systemic chemotherapy with ifosfamide (1000 mg/m2, D1-3) - etoposide (100 mg/m2, D1-3) was started allowing complete clinical remission of the lymphadenomegaly and stability of the asymptomatic neurological status. The overall survival was 13 months from the diagnosis of leptomeningeal carcinomatosis with conservation of autonomy. The two cases support potential efficacy of systemic chemotherapy for intracranial metastases of breast cancer. Orv. Hetil., 2016, 157(45), 1809-1813.
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Affiliation(s)
- István Sipőcz
- Onkoradiológiai Osztály, Petz Aladár Megyei Oktató Kórház Győr, Vasvári Pál u. 2-4, 9024
| | - Tamás Pintér
- Onkoradiológiai Osztály, Petz Aladár Megyei Oktató Kórház Győr, Vasvári Pál u. 2-4, 9024
| | | | - Tamás Kullmann
- Onkoradiológiai Osztály, Petz Aladár Megyei Oktató Kórház Győr, Vasvári Pál u. 2-4, 9024
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28
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Ho JC, Dabaja BS, Milgrom SA, Smith GL, Reddy JP, Mazloom A, Young KH, Deng L, Medeiros LJ, Dong W, Allen PK, Andraos TY, Fowler NH, Nastoupil LJ, Oki Y, Fayad LE, Turturro F, Neelapu SS, Westin J, Hagemeister FB, Rodriguez MA, Pinnix CC. Radiation therapy improves survival in patients with testicular diffuse large B-cell lymphoma<sup/>. Leuk Lymphoma 2017; 58:2833-2844. [PMID: 28482717 DOI: 10.1080/10428194.2017.1312381] [Citation(s) in RCA: 7] [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] [Indexed: 10/19/2022]
Abstract
In 120 Stage I-IV testicular diffuse large B-cell lymphoma (DLBCL) patients treated from 1964 to 2015, we assessed the benefits of prophylactic contralateral testicular radiation (RT) and prophylactic central nervous system (CNS) therapy on overall, progression free, testicular relapse free, and CNS relapse free survival (OS, PFS, TRFS, and CRFS, respectively). Seventy percent of patients received RT, 53% received anthracyclines and rituximab (modern therapy), and 61% received CNS prophylaxis. On univariate analysis RT was associated with improved TRFS, PFS, and trended toward improved OS. On multivariate analysis (MVA), RT was significantly associated with improved OS and PFS; the PFS benefit persisted among patients receiving modern therapy. CNS prophylaxis was associated with improved OS, PFS, and TRFS, but not CRFS on univariate analysis, and was not significant on MVA. RT is associated with improved survival, and should be considered for all testicular DLBCL patients, but additional strategies are needed to prevent CNS relapse.
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Affiliation(s)
- Jennifer C Ho
- a Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Bouthaina S Dabaja
- a Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Sarah A Milgrom
- a Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Grace L Smith
- a Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Jay P Reddy
- a Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Ali Mazloom
- b Tacoma Valley Radiation Oncology , Tacoma , WA , USA
| | - Ken H Young
- c Department of Hematopathology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Lijuan Deng
- c Department of Hematopathology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - L Jeffrey Medeiros
- c Department of Hematopathology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Wenli Dong
- d Department of Biostatistics , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Pamela K Allen
- a Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Therese Y Andraos
- a Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Nathan H Fowler
- e Department of Lymphoma/Myeloma , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Loretta J Nastoupil
- e Department of Lymphoma/Myeloma , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Yasuhiro Oki
- e Department of Lymphoma/Myeloma , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Luis E Fayad
- e Department of Lymphoma/Myeloma , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Francesco Turturro
- e Department of Lymphoma/Myeloma , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Sattva S Neelapu
- e Department of Lymphoma/Myeloma , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Jason Westin
- e Department of Lymphoma/Myeloma , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Fredrick B Hagemeister
- e Department of Lymphoma/Myeloma , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Maria Alma Rodriguez
- e Department of Lymphoma/Myeloma , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Chelsea C Pinnix
- a Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
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29
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Abstract
Background There is limited data on the impact of specific patient characteristics, tumor subtypes or treatment interventions on survival in breast cancer LM. Methods A systematic review was conducted to assess the impact of hormone receptor and HER-2 status on survival in breast cancer LM. A search for clinical studies published between 1/1/2007 and 7/1/2012 and all randomized-controlled trials was performed. Survival data from all studies are reported by study design (prospective trials, retrospective cohort studies, case studies). Results A total of 36 studies with 851 LM breast cancer subjects were identified. The majority (87%) were treated with intrathecal chemotherapy. Pooled median overall survival ranged from 14.9-18.1 weeks depending on study type. Breast cancer LM survival (15 weeks) was longer than other solid tumor LM 8.3 weeks and lung cancer LM 8.7 weeks, but shorter than LM lymphoma (15.4 versus 24.2 weeks). The impact of hormone receptor and HER-2 status on survival could not be determined. Conclusions A median overall survival of 15 weeks in prospective studies of breast cancer LM provides a historical comparison for future LM breast cancer trials. Other outcomes including the impact of molecular status on survival could not be determined based on available studies.
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Affiliation(s)
- Brian J Scott
- Department of Neurology, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | | | - Santosh Kesari
- Translational Neuro-Oncology Laboratories and Department of Neurosciences, Moores UCSD Cancer Center, La Jolla, California, USA
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30
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Wu YL, Zhou L, Lu Y. Intrathecal chemotherapy as a treatment for leptomeningeal metastasis of non-small cell lung cancer: A pooled analysis. Oncol Lett 2016; 12:1301-1314. [PMID: 27446430 PMCID: PMC4950629 DOI: 10.3892/ol.2016.4783] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [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: 03/27/2015] [Accepted: 04/22/2016] [Indexed: 02/05/2023] Open
Abstract
Leptomeningeal metastasis (LM) is increasingly common in patients with non-small cell lung cancer (NSCLC) due to improved treatment, and ultimately, prolonged patient survival. The current study is a pooled analysis that evaluated intrathecal chemotherapy (ITC) as a treatment for NSCLC patients with LM. The PUBMED, OVID, EBSCO and Cochrane Library databases were searched for published studies involving ITC in NSCLC patients with LM. The primary outcomes of interest included response (symptomatic, radiographic and cytological) and survival. Overall, 4 prospective studies and 5 retrospective studies were included. In total, 37 patients received ITC only, and 552 patients received multiple interventions (ITC, whole-brain radiotherapy, epidermal growth factor receptor tyrosine kinase inhibitors, systemic chemotherapy and support care). In patients with available individual information, the reevaluated cytological, clinical and radiographic rates of response to ITC were 55% (53-60%; n=49), 64% (53-79%; n=58), and 53% (n=32), respectively, and the reevaluated median survival time (from the onset of treatment, n=50) was 6.0 months (95% CI, 5.2-6.8). In patients without available individual information, the reported cytological and clinical rates of response to ITC are 14-52% and 13-50%, respectively, and the reported median survival time (from the diagnosis of LM) was 3.0-4.3 months. The clinical response rates of patients only receiving ITC varied from 71 to 79% (100% if including stable disease). The median survival time of patients who only received ITC (7.5 months) was much longer than that of patients who received multiple interventions (3.0-5.0 months). Accordingly, in NSCLC patients with LM, ITC may offer a promising response rate and survival benefits under a suitable regimen. In addition, a suitable combination strategy of multidisciplinary therapy is extremely important for these particular patients.
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Affiliation(s)
- Ya-Lan Wu
- Department of Oncology, Chengdu Shang Jin Nan Fu Hospital, Chengdu, Sichuan 610041, P.R. China
- Department of Thoracic Oncology, Cancer Center, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan 610041, P.R. China
- State Key Laboratory of Biotherapy, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Lin Zhou
- Department of Thoracic Oncology, Cancer Center, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan 610041, P.R. China
- State Key Laboratory of Biotherapy, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - You Lu
- Department of Thoracic Oncology, Cancer Center, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan 610041, P.R. China
- State Key Laboratory of Biotherapy, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan 610041, P.R. China
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31
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Pan Z, Yang G, He H, Zhao G, Yuan T, Li Y, Shi W, Gao P, Dong L, Li Y. Concurrent radiotherapy and intrathecal methotrexate for treating leptomeningeal metastasis from solid tumors with adverse prognostic factors: A prospective and single-arm study. Int J Cancer 2016; 139:1864-72. [PMID: 27243238 PMCID: PMC5096248 DOI: 10.1002/ijc.30214] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [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: 03/11/2016] [Revised: 05/17/2016] [Accepted: 05/20/2016] [Indexed: 12/15/2022]
Abstract
The prognosis of leptomeningeal metastasis (LM) from solid tumors is extremely poor, especially for patients with adverse prognostic factors. In this phase II clinical trial, we evaluated the efficacy and safety of intrathecal chemotherapy (IC) combined with concomitant involved‐field radiotherapy (IF‐RT) for treating LM from solid tumors with adverse prognostic factors. Fifty‐nine patients with LM from various solid tumors were enrolled between May 2010 and December 2014. Concurrent therapy consisted of concomitant IC (methotrexate 12.5–15 mg and dexamethasone 5 mg, weekly) and IF‐RT (whole brain and/or spinal canal RT, 40 Gy/20f). For patients with low Karnofsky performance status (KPS) score and radiotherapy intolerance, induction IC (1–3 times) was given before concurrent therapy. Thirty‐eight patients (64.4%) received subsequent treatments. All patients were followed up at least 6 months after LM diagnosis or until death. Primary endpoint evaluated was clinical response rate. Secondary endpoints were overall survival (OS) and safety. The pathological types included lung cancer (n = 42), breast cancer (n = 11) and others (n = 6). Median KPS score was 40 (range 20–70). Fifty‐one patients (86.4%) completed concurrent therapy. The overall response rate was 86.4% (51/59). OS ranged from 0.4 to 36.7 months (median 6.5 months), and 1‐year‐survival rate was 21.3%. Treatment‐related adverse events mainly included acute meningitis, chronic‐delayed encephalopathy, radiculitis, myelosuppression and mucositis. Twelve patients (20.3%) had grade III–V toxic reactions. We concluded that IC combined with concomitant IF‐RT, with significant efficacy and acceptable toxicity, may be an optimal therapeutic option for treatment of LM from solid tumors with adverse prognostic factors. LM, in which cancer cells spread to membranes enveloping the brain and spinal cord, is a devastating complication of solid cancers. Existing LM therapies center on IC. In this prospective clinical study, the authors combined intrathecal methotrexate with involved‐field radiotherapy in a concomitant regimen, showing that the approach can potentially improve quality of life for patients with adverse prognostic factors. Concurrent radiotherapy‐bolstered IC by contributing to prolonged remission of neurological symptoms and increasing OS. The findings suggest that the concomitant regimen could be an optimal treatment option for LM. What's new? Leptomeningeal metastasis (LM), in which cancer cells spread to membranes enveloping the brain and spinal cord, is a devastating complication of solid cancers. Existing LM therapies center on intrathecal chemotherapy (IC). In this prospective clinical study, the authors combined intrathecal methotrexate with involved‐field radiotherapy in a concomitant regimen, showing that the approach can potentially improve quality of life for patients with adverse prognostic factors. Concurrent radiotherapy bolstered IC by contributing to prolonged remission of neurological symptoms and increasing overall survival. The findings suggest that the concomitant regimen could be an optimal treatment option for LM.
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Affiliation(s)
- Zhenyu Pan
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, 130021, China
| | - Guozi Yang
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, 130021, China
| | - Hua He
- Cancer Center, The First Hospital of Jilin University, Changchun, 130021, China
| | - Gang Zhao
- Department of Neuro-Oncological Surgery, The First Hospital of Jilin University, Changchun, 130021, China
| | - Tingting Yuan
- Department of Radiology, The First Hospital of Jilin University, Changchun, 130021, China
| | - Yu Li
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, 130021, China
| | - Weiyan Shi
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, 130021, China
| | - Pengxiang Gao
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, 130021, China
| | - Lihua Dong
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, 130021, China
| | - Yunqian Li
- Department of Neuro-Oncological Surgery, The First Hospital of Jilin University, Changchun, 130021, China
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32
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Abstract
Breast cancer metastatic to the brain and/or leptomeningeal spread of disease is a frequently encountered clinical situation, especially given the extended course of disease in these patients. Systemic therapies can often effectively prolong extracranial disease control, making effective strategies to control central nervous system-based disease even more critical. We present a case of bulky leptomeningeal relapse of breast cancer in the setting of prior whole brain radiation therapy. In order to treat the patient’s bulky disease and leptomeningeal spread while avoiding the potential toxicities of repeat whole brain radiation, the patient was treated with frameless stereotactic radiosurgery and intrathecal chemotherapy. This is the first report of this treatment approach for leptomeningeal relapse of breast cancer. The patient had an excellent response to treatment and durable intracranial control.
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33
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Lekovic G, Drazin D, Mak AC, Schwartz MS. Cyberknife Radiosurgery and Concurrent Intrathecal Chemotherapy for Leptomeningeal Metastases: Case Report of Prolonged Survival of a HER-2+ Breast Cancer Patient Status-Post Craniospinal Irradiation. Cureus 2016; 8:e453. [PMID: 26918221 PMCID: PMC4744073 DOI: 10.7759/cureus.453] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [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] [Indexed: 11/05/2022] Open
Abstract
Leptomeningeal disease (LMD) from breast cancer is usually a rapidly fatal condition, with median overall survival reported to be 15 weeks. Conventional treatment for LMD includes craniospinal irradiation and intrathecal (IT) methotrexate. However, the role of stereotactic radiation for leptomeningeal disease remains poorly defined. This case report describes our experience using Cyberknife radiosurgery to treat a 49-year-old female with HER-2+ breast cancer and focal/nodular leptomeningeal metastases that were refractory to craniospinal irradiation and concurrent IT chemotherapy. This combined approach--i.e., craniospinal irradiation, IT chemotherapy, and Cyberknife Radiosurgery for local, recurrent metastases--resulted in survival of 46 months with controlled disease. Based on our experience with this patient, we believe further consideration of radiosurgery for LMD is warranted.
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Affiliation(s)
| | | | - Albert C Mak
- Medical Director, Pasadena Cyberknife Center, Glendale Adventist Medical Center
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34
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Alsdorf WH, Schmitz M, Schieferdecker A, Dierlamm J, Bokemeyer C, Binder M. Severe and irreversible myelopathy after concurrent systemic and intrathecal nucleoside analogue treatment for refractory diffuse large B-cell lymphoma: A case report and review of the literature. J Oncol Pharm Pract 2015; 22:523-7. [PMID: 25655468 DOI: 10.1177/1078155214562268] [Citation(s) in RCA: 7] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We report a patient with refractory diffuse large B-cell lymphoma who developed irreversible, severe spinal neurotoxicity after concurrent treatment with intrathecal and systemic cytarabine. Shortly after concomitant administration of intrathecal triple therapy (MTX, dexamethasone and cytarabine) and high-dose systemic cytarabin (R-DHAP protocol) the patient lost control of bowel and bladder function and developed an ascending, irreversible paraplegia. Infectious or neoplastic diseases of the spinal cord were ruled out. A magnetic resonance imaging scan of the spine resulted in a diagnosis of toxic myelitis. Previously observed cases of spinal neurotoxicity after cytarabine treatment are reviewed as well as current guidelines for the use of intrathecal chemotherapy in high-grade non-Hodgkin lymphoma. In summary, severe spinal neurotoxicity of intrathecal chemotherapy is a rare side-effect, however several studies suggest that the neurotoxicity of cytarabine is significantly enhanced by concurrent intrathecal and high-dose systemic administration. Simultaneous high-dose systemic and intrathecal chemotherapy with cytarabine should therefore be avoided.
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Affiliation(s)
- Winfried H Alsdorf
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section Pneumology, Hubertus Wald-Tumor Zentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Schmitz
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section Pneumology, Hubertus Wald-Tumor Zentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Aneta Schieferdecker
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section Pneumology, Hubertus Wald-Tumor Zentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Judith Dierlamm
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section Pneumology, Hubertus Wald-Tumor Zentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Carsten Bokemeyer
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section Pneumology, Hubertus Wald-Tumor Zentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mascha Binder
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section Pneumology, Hubertus Wald-Tumor Zentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Ferreri AJM, Bruno-Ventre M, Donadoni G, Ponzoni M, Citterio G, Foppoli M, Vignati A, Scarfò L, Sassone M, Govi S, Caligaris-Cappio F. Risk-tailored CNS prophylaxis in a mono-institutional series of 200 patients with diffuse large B-cell lymphoma treated in the rituximab era. Br J Haematol 2014; 168:654-62. [PMID: 25312994 DOI: 10.1111/bjh.13194] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [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: 07/30/2014] [Accepted: 09/12/2014] [Indexed: 11/30/2022]
Abstract
The most effective strategy to prevent central nervous system (CNS) dissemination in diffuse large B-cell lymphoma (DLBCL) remains an important, unmet clinical need. Herein, we report a retrospective analysis of risk-tailored CNS prophylaxis in 200 human immunodeficiency virus-negative adults with DLBCL treated with rituximab-CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) or similar. High risk of CNS relapse was defined by involvement of specific extranodal organs, or simultaneous presence of advanced stage and high serum lactate dehydrogenase level; CNS prophylaxis with high-dose methotrexate ± intrathecal chemotherapy (IT) was routinely used in high-risk patients diagnosed after 2007. CNS relapse risk was low in 93 patients and high in 107; 40 high-risk patients received prophylaxis, which consisted of IT alone in 7. At a median follow-up of 60 months, one low-risk and nine high-risk patients (1% vs. 8%; P = 0·01) experienced CNS relapse. In the high-risk group, CNS relapses occurred in 8/67 (12%) patients who did not receive prophylaxis and in 1/40 (2·5%) patients who did; the latter occurred in a patient managed with IT alone. CNS relapse rate was 12% (9/74) for patients treated with "inadequate" prophylaxis (none or IT only) and 0% (0/33) for patients managed with intravenous prophylaxis (P = 0·03). In conclusion, high-dose methotrexate-based prophylaxis significantly reduces CNS failures in high-risk patients stratified by involvement of specific extranodal sites and International Prognostic Index.
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Affiliation(s)
- Andrés J M Ferreri
- Division of Onco-Haematological Medicine, Department of Onco-Haematology, Unit of Lymphoid Malignancies, Milan, Italy
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Fukano R, Nishimura M, Ito N, Nakashima K, Kodama Y, Okamura J, Inagaki J. Efficacy of prophylactic additional cranial irradiation and intrathecal chemotherapy for the prevention of CNS relapse after allogeneic hematopoietic SCT for childhood ALL. Pediatr Transplant 2014; 18:518-23. [PMID: 24815062 DOI: 10.1111/petr.12276] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [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] [Accepted: 03/25/2014] [Indexed: 11/30/2022]
Abstract
We evaluated the efficacy of CRT and IT chemotherapy, in addition to conditioning including TBI, for the prevention of CNS relapse, in allogeneic HSCT for childhood ALL. From January 1999 to December 2009, a total of 48 patients, without previous or presenting CNS involvement, underwent HSCT for ALL. All patients received myeloablative conditioning including TBI of 12 or 13.2 Gy and IT chemotherapy twice between days -10 and -2 prior to HSCT. Twenty-five patients received CRT prior to TBI (CRT+), and 23 patients did not (CRT-). CRT+ and CRT- patients had a seven-yr EFS rate of 40.0 ± 9.8% and 41.7 ± 10.6%, respectively (p = 0.8252). The seven-yr relapse rates for CRT+ and CRT- patients were 45.0 ± 11.2% and 38.4 ± 11.6%, respectively (p = 0.7460). CNS relapses were evident in 1 (4.0%) CRT+ patient and 1 (4.4%) CRT- patient (p = 1.000). There were no significant differences in EFS and the probability of CNS relapse between CRT+ and CRT- patients. These results demonstrate that CRT and IT chemotherapy, in addition to conditioning chemotherapy, may not be necessary in childhood ALL patients without previous or presenting CNS involvement.
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Affiliation(s)
- Reiji Fukano
- Department of Pediatrics, National Kyushu Cancer Center, Fukuoka, Japan
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McLaughlin CA, Hockenberry MJ, Kurtzberg J, Hueckel R, Martin PL, Docherty SL. Standardization of health care provider competencies for intrathecal access procedures. J Pediatr Oncol Nurs 2014; 31:304-16. [PMID: 25057001 DOI: 10.1177/1043454214543019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION This quality improvement (QI) project addresses a method for experienced health care providers to maintain skill-based competence for intrathecal access procedures. METHODS A prospective QI design using intrathecal access simulation to assess, educate, and evaluate skill competency. Simulation was used as a strategy to promote patient safety and standardize practice patterns. Pretest and posttest methodology using paired t tests were performed to assess anxiety, confidence, and knowledge. RESULTS Fourteen pediatric providers participated in this QI project. There was a statistically significant improvement in confidence measuring intracranial pressure (ICP; t = -2.92, P = .013), performance-related overall anxiety (t = -2.132, P = .05) and administering intrathecal chemotherapy (t = -2.144, P = .053). Fifty percent of participants missed a medication error demonstrating confirmation bias. CONCLUSION This simulation strategy resulted in improved confidence in measuring ICP, performance-related overall anxiety, and confidence in administering chemotherapy. Confirmation bias occurred during simulation testing for a medication error. We propose this method for maintaining clinical competencies in health care providers and introducing new skills to existing practices.
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Affiliation(s)
| | | | | | - Rémi Hueckel
- Duke University School of Nursing, Durham, NC, USA
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Kumar DS, Noronha V, Joshi A, Jain H, Prabhash K. Carcinomatous meningitis in non-small cell lung cancer: Palliation with intrathecal treatment. Indian J Med Paediatr Oncol 2014; 35:75-8. [PMID: 25006289 PMCID: PMC4080668 DOI: 10.4103/0971-5851.133726] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Carcinomatous meningitis or meningeal carcinomatosis is seen in up to 5% of patients of metastatic non-small cell lung cancer. However, isolated carcinomatous meningitis without brain parenchymal metastasis is less common. Patients with carcinomatous meningitis have limited treatment options. However, intrathecal therapy if used optimally along with targeted therapy when indicated result in good palliation with improvement in survival.
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Affiliation(s)
- D Santhosh Kumar
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Vanita Noronha
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Amit Joshi
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Hasmukh Jain
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Kumar Prabhash
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
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Scott BJ, Kesari S. Leptomeningeal metastases in breast cancer. Am J Cancer Res 2013; 3:117-126. [PMID: 23593536 PMCID: PMC3623833] [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] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 03/02/2013] [Indexed: 06/02/2023] Open
Abstract
Central nervous system (CNS) metastasis from breast cancer may be characterized as either parenchymal brain metastasis (BM) or leptomeningeal (LM) metastasis. BM are much more common (about 80% of all CNS metastases), and have been more extensively studied than LM. CNS metastasis in breast cancer has been associated with reduced overall survival, with the shortest survival generally observed in cases of LM. Here, we review the epidemiology, prognostic factors, diagnostic tools, currently available treatments, and potential future therapies for LM from breast cancer.
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Affiliation(s)
- Brian J Scott
- Department of Neurology, UC San FranciscoSan Francisco, CA
| | - Santosh Kesari
- Department of Neurosciences, Moores Cancer Center, UC San DiegoLa Jolla, CA
- Translational Neuro-Oncology Laboratories, Moores Cancer Center, UC San DiegoLa Jolla, CA, USA
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Hu R, Miao M, Zhang R, Li Y, Li J, Zhu K, Yang Y, Liu Z, Yang W. Ovary involvement of diffuse large B-cell lymphoma. Am J Case Rep 2012; 13:96-8. [PMID: 23569499 PMCID: PMC3616171 DOI: 10.12659/ajcr.882997] [Citation(s) in RCA: 11] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2012] [Accepted: 05/10/2012] [Indexed: 11/09/2022]
Abstract
BACKGROUND Primary ovarian non-Hodgkin's lymphoma (PONHL) is an uncommon entity; its pathology is usually diffuse large B cell lymphoma (DLBCL). CASE REPORTS We report 3 cases of ovary involvement of DLBCL, 1 of which rapidly developed to central nervous system involvement. Diagnosis and subsequent treatment are discussed and the literature on the origin, epidemiology, clinical presentation, diagnosis, treatment and prognosis of ovary lymphoma are reviewed. All patients were diagnosed as having DLBCL after ovary biopsy, and were subsequently given regular chemotherapy. Two of them obtained remission and 1 of them had central nervous system involvement. CONCLUSIONS Ovary involvement of DLBCL is rare; prognosis is related to the overall clinical manifestation and some serum biomarkers. Diagnosis is established by ovary biopsy. Inaccurate or delayed diagnosis is often due to the lesions presenting as a mass resembling ovary cancer and may lead to poor outcome. Treatment regimen mainly consists of chemotherapy (CHOP) associated with rituximab. Intrathecal chemotherapy may play an important role in prevention of central nervous system involvement.
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Affiliation(s)
- Rong Hu
- Department of Hematology, Shengjing Hospital, China Medical University, China
| | - Miao Miao
- Department of Hematology, Shengjing Hospital, China Medical University, China
| | - Rong Zhang
- Department of Hematology, Shengjing Hospital, China Medical University, China
| | - Yingchun Li
- Department of Hematology, Shengjing Hospital, China Medical University, China
| | - Jia Li
- Department of Hematology, Shengjing Hospital, China Medical University, China
| | - Ke Zhu
- Department of Hematology, Shengjing Hospital, China Medical University, China
| | - Ying Yang
- Department of Hematology, Shengjing Hospital, China Medical University, China
| | - Zhuogang Liu
- Department of Hematology, Shengjing Hospital, China Medical University, China
| | - Wei Yang
- Department of Hematology, Shengjing Hospital, China Medical University, China
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Abstract
Primary central nervous system lymphoma (PCNSL) accounts for only 3% of brain tumors. It can involve the brain parenchyma, leptomeninges, eyes and the spinal cord. Unlike systemic lymphoma, durable remissions remain uncommon. Although phase III trials in this rare disease are difficult to perform, many phase II trials have attempted to define standards of care. Treatment modalities for patients with newly diagnosed PCNSL include radiation and/or chemotherapy. While the role of radiation therapy for initial management of PCNSL is controversial, clinical trials will attempt to improve the therapeutic index of this modality. Routes of chemotherapy administration include intravenous, intraocular, intraventricular or intra-arterial. Multiple trials have outlined different methotrexate-based chemotherapy regimens and have used local techniques to improve drug delivery. A major challenge in the management of patients with PCNSL remains the delivery of aggressive treatment with preservation of neurocognitive function. Because PCNSL is rare, it is important to perform multicenter clinical trials and to incorporate detailed measurements of long-term toxicities. In this review we focus on different chemotherapeutic approaches for immunocompetent patients with newly diagnosed PCNSL and discuss the role of local drug delivery in addition to systemic therapy. We also address the neurocognitive toxicity of treatment.
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Lee HY, Im SI, Kang MH, Kim KM, Kim SH, Kim HG, Kang JH, Lee GW. Irreversible paraplegia following one time prophylactic intrathecal chemotherapy in an adult patient with acute lymphoblastic leukemia. Yonsei Med J 2008; 49:151-4. [PMID: 18306482 PMCID: PMC2615263 DOI: 10.3349/ymj.2008.49.1.151] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [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] [Indexed: 11/27/2022] Open
Abstract
We present an adult female patient who developed irreversible paraplegia and areflexia four days post intrathecal chemotherapy with methotrexate, cytosine arabinoside and hydrocortisone. On magnetic resonance imaging (MRI) of the lumbar spine, diffuse gadolinium enhancement of the anterior spinal nerve roots (ventral roots) was detected. Methylprednisolone was intravenously administered at a daily dose of 30mg/kg for three days. Despite this treatment, flaccid weakness in the lower extremities and urinary retention persisted. Following consolidation chemotherapy, no improvement in neurologic status was noted. Six months later, a follow-up MRI revealed severe atrophy of the thoracic spinal cord.
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Affiliation(s)
- Hea Yong Lee
- Division of Hematology and Oncology, Department of Internal Medicine, College of Medicine, Gyeong-Sang National University, Jinju, Korea
| | - Sung-il Im
- Division of Hematology and Oncology, Department of Internal Medicine, College of Medicine, Gyeong-Sang National University, Jinju, Korea
| | - Myoung-Hee Kang
- Division of Hematology and Oncology, Department of Internal Medicine, College of Medicine, Gyeong-Sang National University, Jinju, Korea
| | - Kwang Min Kim
- Division of Hematology and Oncology, Department of Internal Medicine, College of Medicine, Gyeong-Sang National University, Jinju, Korea
| | - Seok Hyun Kim
- Division of Hematology and Oncology, Department of Internal Medicine, College of Medicine, Gyeong-Sang National University, Jinju, Korea
| | - Hun-Gu Kim
- Division of Hematology and Oncology, Department of Internal Medicine, College of Medicine, Gyeong-Sang National University, Jinju, Korea
- Gyeongsang Institute of Health Science, Jinju, Korea
- Gyeongnam Regional Cancer Center, Jinju, Korea
| | - Jung Hun Kang
- Division of Hematology and Oncology, Department of Internal Medicine, College of Medicine, Gyeong-Sang National University, Jinju, Korea
- Gyeongsang Institute of Health Science, Jinju, Korea
- Gyeongnam Regional Cancer Center, Jinju, Korea
| | - Gyeong-Won Lee
- Division of Hematology and Oncology, Department of Internal Medicine, College of Medicine, Gyeong-Sang National University, Jinju, Korea
- Gyeongsang Institute of Health Science, Jinju, Korea
- Gyeongnam Regional Cancer Center, Jinju, Korea
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