Leptomeningeal spread of breast cancer: report of case and review of the literature

Optimal Management of Leptomeningeal Carcinomatosis in Breast Cancer Patients-A Systematic Review

The incidence of leptomeningeal carcinomatosis in breast cancer patients (LC-BC) is increasing. Despite significantly affecting patient quality of life (QoL) and overall survival (OS), little is known about its optimal management. A systematic review of treatment strategies for LC-BC was performed. EMBASE, Ovid Medline, Pubmed, and the Cochrane Central Register of Controlled Trials were searched from 1946 to 2015 for trials reporting on treatments for LC-BC. All treatment modalities and study types were considered. The outcome measures of interest included OS, time to neurologic progression (TTNP), QoL, and treatment toxicity. Of 718 unique citations, 173 studies met the prespecified eligibility criteria. Most were not specific to LC-BC patients. Of 4 identified randomized controlled trials (RCTs), 1 was specific to LC-BC patients and compared systemic therapy and involved-field radiotherapy with or without intrathecal (IT) methotrexate (35 patients), and the remaining 3 had compared different IT chemotherapy regimens (58 of 157 with LC-BC). Of the remaining studies, 19 were nonrandomized interventional studies (225 LC-BC patients), 148 were observational studies (3230 LC-BC patients), and 2 systematic reviews. Minimal prospective data were available on OS, TTNP, QoL, and toxicity. Owing to study heterogeneity, meta-analyses of the endpoint data could not be performed. Limited high-quality evidence exists regarding optimal treatment of LC-BC. The identified studies were heterogeneous and often methodologically poor. The only RCT that specifically assessed the role of IT chemotherapy showed no benefit, and, if anything, harm. Further prospective, tumor-specific trials with improved interstudy methodologic consistency and transparently reported data on OS, TTNP, QoL, and toxicity are urgently needed.

Atypical presentation of a cervical breast-cancer metastasis mimicking a dumbbell-shaped neurinoma

INTRODUCTION

Spinal metastases are frequently encountered in patients with breast cancer. Because of recent improvements in oncologic therapies a growing incidence of symptomatic leptomeningeal metastases (LM) should be expected. The differential diagnosis of LM comprises a wide range of conditions, including neurinoma. The radiologic discrimination between metastases and neurinomas is primarily based on distinct neuroimaging features, particularly number, size and growth pattern.

PRESENTATION OF CASE

We report the first case of a solitary leptomeningeal metastasis of a cervical nerve-root, which mimicked a benign dumbbell-shaped neurinoma, using neuroimaging and visualized intraoperatively. The tumor was successfully treated with surgery followed by adjuvant radiochemotherapy (RCT).

DISCUSSION

While the patient history directs towards a metastasis, the localization, growth pattern and MRI signal were concordant with a cervical neurinoma. The current literature is not conclusive concerning the optimal choice of treatment; the therapy is strictly palliative and indications for surgery remain individual decisions. However, due to recent improvements in survival of patients with LM require reconsideration of established strategies.

CONCLUSION

The present case report and the reviewed literature point towards a growing clinical relevance of symptomatic LM in cancer patients and their possible atypical presentations and locations.

Central nervous system metastases in breast cancer patients administered trastuzumab

Amplification or over-expression of the HER2/neu receptor is present in 20-30% of invasive breast cancers and in 60% of intraductal breast carcinomas. Patients with HER2/neu gene aberrations have more aggressive disease, frequent disease recurrence and a shorter survival. Trastuzumab (herceptin) is a monoclonal antibody selectively directed against the HER2/neu receptor. The addition of trastuzumab to chemotherapy in HER2/neu-positive advanced breast cancer patients has increased complete and partial response rates, and prolonged time to progression and overall survival. However, a relatively common failure site in patients administered trastuzumab is the central nervous system (CNS). CNS metastases in these patients seem to develop despite responses achieved in extracerebral sites. This pattern of failure has mainly been attributed to the lack of trastuzumab penetration to the CNS owing to the high molecular weight (145 kDa) of this molecule. Additionally, increased risk of CNS relapse may be associated with improved systemic control of extracerebral metastases and prolonged survival without brain protection (a sanctuary site). Finally, it was postulated that HER2/neu over-expression and/or amplification might predispose to brain metastases. The aim of this article is to discuss the pathophysiology of this phenomenon and its clinical implications.

An unusual case of headache

We report an unusual case of carcinomatous meningitis presenting as a headache in a previously well woman. It occurs in only 3-5% of solid tumours and is an unusual form of presentation for underlying primary malignancy. This 44-year-old woman initially presented with subacute headache of 3 weeks duration and was treated as migraine, and later thought to have viral meningitis. The diagnosis was made from cytology examination on repeated lumbar puncture of cerebrospinal fluid (CSF). Within a month of onset of symptoms, the patient developed gradually worsening headache, right 6th cranial nerve palsy with associated diplopia as well as refractory generalised tonic-clonic seizures. Treatment included CSF drainage through insertion of Ommaya reservoir, and palliative systemic chemotherapy. Further palliative chemotherapy was withheld upon patient's and family's request. The patient died shortly after initial treatment; 7 weeks after her initial presentation to her general practitioner with headache.

Central nervous system metastases in women who receive trastuzumab-based therapy for metastatic breast carcinoma

BACKGROUND

Women with HER-2 overexpressing metastatic breast carcinoma benefit from trastuzumab-based therapy, but trastuzumab does not cross the blood-brain barrier. The authors characterized central nervous system (CNS) disease in these women.

METHODS

Using pharmacy records, the authors retrospectively identified 153 women treated with trastuzumab alone or with chemotherapy for HER-2-positive metastatic breast carcinoma at Dana-Farber Partners Cancer Care from June 1998 to December 2000. A study cohort of 122 patients was identified after excluding patients without adequate clinical follow-up or who had CNS disease before trastuzumab treatment. Central nervous system disease was defined as one or more brain metastases or as leptomeningeal carcinomatosis. The median follow-up of this cohort was 23 months.

RESULTS

Central nervous system metastases were identified in 34% of patients (95% confidence interval, 26-44%) at a median of 16 months after diagnosis of metastatic breast carcinoma and 6 months from the beginning of trastuzumab therapy. Ninety-three percent of patients with CNS disease presented with clinical symptoms. Five percent of patients with CNS disease had leptomeningeal involvement alone, although 14% had leptomeningeal involvement and parenchymal brain metastases. Fifty percent of patients were responding or had stable disease while receiving trastuzumab at other disease sites at the time of diagnosis of CNS metastasis. The median survival period after CNS metastases was 13 months. Fifty percent of patients died of progressive CNS disease. Patients receiving trastuzumab as first-line therapy for metastatic disease frequently developed brain metastases while responding to or stable on trastuzumab at other disease sites.

CONCLUSIONS

Metastatic breast carcinoma to the CNS is common among patients receiving trastuzumab-based therapy, including patients responding to therapy outside the CNS. This may be due either to predilection for the CNS by HER-2-positive tumor cells and/or poor penetration of the CNS by trastuzumab or to improved visceral disease control leading to a longer life and onset of late tumor spread to the CNS. Efforts to characterize other risk factors for development of CNS disease, optimal screening algorithms, and new treatment strategies may be warranted.

Intraventricular immunotoxin therapy for leptomeningeal neoplasia

OBJECTIVE

The goals of this clinical trial of intraventricular 454A12-rRA therapy were to identify dose-limiting toxicities, to evaluate the pharmacokinetics of single-dose intraventricular 454A12-rRA, and to detect antitumor activity.

METHODS

We performed a pilot study of intraventricular therapy with the immunotoxin 454A12-rRA in eight patients with leptomeningeal spread of systemic neoplasia. The immunotoxin 454A12-rRA is a conjugate of a monoclonal antibody against the human transferrin receptor and recombinant ricin A chain, the enzymatically active subunit of the protein toxin ricin. Patients were treated with single doses of 454A12-rRA ranging from 1.2 to 1200 micrograms.

RESULTS

The early phase half-life of 454A12-rRA in ventricular cerebrospinal fluid (CSF) averaged 44 +/- 21 minutes, and the late phase half-life averaged 237 +/- 86 minutes. The clearance of the immunotoxin was faster than the clearance of coinjected technetium-99m-diethylenetriamine penta-acetic acid, averaging approximately 2.4-fold greater. No 454A12-rRA degradation was detected by Western blot analysis of ventricular CSF for a period of 24 hours, and bioactivity was retained in CSF paralleling the concentration of immunotoxin. No acute or chronic drug toxicity was identified in patients who received less than or equal to 38 micrograms of 454A12-rRA by intraventricular injection. Doses more than or equal to 120 micrograms caused a CSF inflammatory response that was associated with transient headache, vomiting, and altered mental status. This acute syndrome was responsive to steroids and CSF drainage. No systemic toxicity was detected. In four of the eight patients, a greater than 50% reduction of tumor cell counts in the lumbar CSF occurred within 5 to 7 days after the intraventricular dose of 454A12-rRA; however, no patient had their CSF cleared of tumor, and clinical or magnetic resonance imaging evidence of tumor progression was demonstrated in seven of the eight patients after treatment.

CONCLUSION

Tumoricidal concentrations of the immunotoxin 454A12-rRA can be attained safely in the CSF of patients with leptomeningeal tumor spread.

Diffuse spinal leptomeningeal metastases from prostatic cancer. A case report

A patient with a spinal form of diffuse metastatic leptomeningeal carcinoma from prostatic cancer is reported. The clinical manifestations and diagnosis are discussed, and the literature reviewed.

Spinal cord compression in breast cancer

Myelography was performed on 78 patients with breast cancer who had signs or symptoms compatible with spinal cord compression. Of 42 patients (54%) with extradural defects, 21 (50%) had a complete block. All patients with positive myelograms (M+) had a positive bone scan and 41 of 42 (97%) had positive skeletal x-rays. Except for paraplegia, paraparesis, or a sensory level abnormality, signs and symptoms were usually not precise enough to accurately predict patients with cord lesions; however, back pain, paresthesias, and bladder or bowel dysfunction were significantly more common in M+ patients. Cerebrospinal fluid (CSF) protein was elevated in almost all M+ patients but also in approximately half of the M- group. Cytology and glucose analysis of CSF were not of value in predicting cord involvement. Response to treatment was better for patients with fewer sites of metastatic disease and a shorter time from diagnosis to treatment. There was no notable difference in survival between M+ and M- patients. Myelography remains the most precise tool for diagnosing spinal cord lesions. Unfortunately, the prognosis of patients with metastatic breast cancer is poor regardless of whether spinal cord compression is present.

Patterns of metastasis and natural courses of breast carcinoma

Breast carcinoma is known to metastatize to all organs. In order to understand the patterns of spread and natural courses, this review summarizes detailed studies of patients with various stages of the disease. After treatment of early breast carcinoma (stage I, II, and some III), the recurrent lesion can be classified as local, regional, distant, or combinations thereof. The sites of dissemination of patients presenting with stage IV disease and of those who had autopsy after diagnosis of breast cancer are presented for comparison. Clinicopathological factors that influence the relative incidence, specific site, subsequent event, and prognosis of recurrent and metastatic breast cancers are discussed.

Central nervous system metastasis from breast carcinoma. Autopsy study

Central nervous system (CNS) metastasis was noted in 309 patients of 1044 autopsy cases of breast carcinoma. The brain was involved in 193 cases, and cranial dura in 167 cases. In 82 cases, the cranial dura was the sole site of CNS involvement. Metastasis to the leptomeninges was found in 59 cases, and to the spinal cord and dura in 32 cases. Metastases to the infratentorial portion of the brain was almost as frequent as to the cerebrum. Forty-two percent of the brain metastasis were single lesions, which is similar to the frequency of solitary metastasis to the brain from malignant tumors as a whole. CNS metastasis occurred more frequently in younger patients than older patients, and the clinical course of these patients was shorter than for those patients without CNS metastasis. CNS metastasis developed in the late stage of the disease, and often was not recognized clinically. Only 31% of the cases were clinically diagnosed or suspected before death. A median survival of these patients after clinical diagnosis of CNS metastasis was 33 days. However, a significant improvement was noted in the clinical diagnosis and median survival in the latter half of the study period. Eleven patients lived for more than 1 year after diagnosis of CNS metastasis. Only 14% of the 309 patients died from CNS failure.

Breast carcinoma: pattern of metastasis at autopsy

Breast cancer is known to metastasize to all organs of the human body, and its manifestations are protean. It is almost impossible to predict which organ system will be invaded. Since 1950, there are seven autopsy series of patients with breast carcinoma published in the English literature. All data came from American hospitals (total of 2,147 patients), and each report studied more than 100 patients with breast cancer. The reported incidence of involvement of different organ sites are presented in Table I. Although the data came from different institutions and spanned over 35 years (1943-1977), the findings regarding metastatic involvement of specific organs are fairly similar.