1
|
Roy-O'Reilly MA, Lanman T, Ruiz A, Rogawski D, Stocksdale B, Nagpal S. Diagnostic and Therapeutic Updates in Leptomeningeal Disease. Curr Oncol Rep 2023; 25:937-950. [PMID: 37256537 PMCID: PMC10326117 DOI: 10.1007/s11912-023-01432-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2023] [Indexed: 06/01/2023]
Abstract
PURPOSE OF REVIEW Leptomeningeal disease (LMD) is a devastating complication of advanced metastatic cancer associated with a poor prognosis and limited treatment options. This study reviews the current understanding of the clinical presentation, pathogenesis, diagnosis, and treatment of LMD. We highlight opportunities for advances in this disease. RECENT FINDINGS In recent years, the use of soluble CSF biomarkers has expanded, suggesting improved sensitivity over traditional cytology, identification of targetable mutations, and potential utility for monitoring disease burden. Recent studies of targeted small molecules and intrathecal based therapies have demonstrated an increase in overall and progression-free survival. In addition, there are several ongoing trials evaluating immunotherapy in LMD. Though overall prognosis of LMD remains poor, studies suggest a potential role for soluble CSF biomarkers in diagnosis and management and demonstrate promising findings in patient outcomes with targeted therapies for specific solid tumors. Despite these advances, there continues to be a gap of knowledge in this disease, emphasizing the importance of inclusion of LMD patients in clinical trials.
Collapse
Affiliation(s)
| | - Tyler Lanman
- Department of Neurology, Stanford Medicine, Palo Alto, CA, 94305, USA
| | - Amber Ruiz
- Department of Neurology, Stanford Medicine, Palo Alto, CA, 94305, USA
| | - David Rogawski
- Department of Neurology, Stanford Medicine, Palo Alto, CA, 94305, USA
| | - Brian Stocksdale
- Department of Neurology, Stanford Medicine, Palo Alto, CA, 94305, USA
| | - Seema Nagpal
- Department of Neurology, Stanford Medicine, Palo Alto, CA, 94305, USA.
| |
Collapse
|
2
|
Leptomeningeal disease in glioblastoma: endgame or opportunity? J Neurooncol 2021; 155:107-115. [PMID: 34623599 DOI: 10.1007/s11060-021-03864-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 09/30/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Glioblastoma is an aggressive cancer with a notoriously poor prognosis. Recent advances in treatment have increased overall survival, though this may be accompanied by an increased incidence of leptomeningeal disease (LMD). LMD carries a particularly severe prognosis and remains a late stage manifestation of glioblastoma without satisfactory treatment. The objective of this review is to survey the literature on treatment of LMD in glioblastoma and to more fully characterize the current therapeutic strategies. METHODS The authors performed a systematic review following PRISMA criteria on PubMed and OVID databases. Articles that included adult patients with LMD from glioblastoma were retrieved and reviewed. RESULTS LMD in glioblastoma patients is increasing in incidence, with reports of up to 21%. The overall survival without treatment is alarmingly brief, with patients surviving between 1.6-3.8 months. All studies showed that treatment does improve overall survival significantly, increasing to 11.7 months in one study. However, no one adjuvant or surgical therapy has been shown to improve survival in LMD significantly over another. Direct treatment methods include chemotherapy (standard, anti-angiogenic, intrathecal, immunotherapy), and radiation. Hydrocephalus is a complication in LMD that can be treated with ventriculoperitoneal shunt placement, however treating hydrocephalus and delivering intrathecal chemotherapy is a challenge. CONCLUSION Though evidence remains lacking and there is no consensus, treatments show a trend towards improving survival and should be considered on a case-by-case basis. Further studies are necessary in the pursuit of a standard of care.
Collapse
|
3
|
Engelhard HH, Willis AJ, Hussain SI, Papavasiliou G, Banner DJ, Kwasnicki A, Lakka SS, Hwang S, Shokuhfar T, Morris SC, Liu B. Etoposide-Bound Magnetic Nanoparticles Designed for Remote Targeting of Cancer Cells Disseminated Within Cerebrospinal Fluid Pathways. Front Neurol 2020; 11:596632. [PMID: 33329349 PMCID: PMC7729165 DOI: 10.3389/fneur.2020.596632] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 11/03/2020] [Indexed: 12/26/2022] Open
Abstract
Magnetic nanoparticles (MNPs) have potential for enhancing drug delivery in selected cancer patients, including those which have cells that have disseminated within cerebrospinal fluid (CSF) pathways. Here, we present data related to the creation and in vitro use of new two-part MNPs consisting of magnetic gold-iron alloy cores which have streptavidin binding sites, and are coated with biotinylated etoposide. Etoposide was chosen due to its previous use in the CSF and ease of biotinylation. Etoposide magnetic nanoparticles (“Etop-MNPs”) were characterized by several different methods, and moved at a distance by surface-walking of MNP clusters, which occurs in response to a rotating permanent magnet. Human cell lines including D283 (medulloblastoma), U138 (glioblastoma), and H2122 (lung adenocarcinoma) were treated with direct application of Etop-MNPs (and control particles), and after remote particle movement. Cell viability was determined by MTT assay and trypan blue exclusion. Results indicated that the biotinylated etoposide was successfully bound to the base MNPs, with the hybrid particle attaining a maximum velocity of 0.13 ± 0.018 cm/sec. Etop-MNPs killed cancer cells in a dose-dependent fashion, with 50 ± 6.8% cell killing of D283 cells (for example) with 24 h of treatment after remote targeting. U138 and H2122 cells were found to be even more susceptible to the killing effect of Etop-MNPs than D283 cells. These findings indicate that the novel Etop-MNPs have a cytotoxic effect, and can be moved relatively rapidly at physiologic distances, using a rotating magnet. While further testing is needed, intrathecal administration of Etop-MNPs holds promise for magnetically-enhanced eradication of cancer cells distributed within CSF pathways, particularly if given early in the course of the disease.
Collapse
Affiliation(s)
- Herbert H Engelhard
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, United States.,Department of Bioengineering University of Illinois at Chicago, Chicago, IL, United States
| | - Alexander J Willis
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, United States.,Department of Medicine, University of Illinois at Chicago, Chicago, IL, United States
| | - Syed I Hussain
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, United States.,Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL, United States
| | - Georgia Papavasiliou
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL, United States
| | - David J Banner
- Department of Bioengineering University of Illinois at Chicago, Chicago, IL, United States
| | - Amanda Kwasnicki
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, United States
| | - Sajani S Lakka
- Department of Medicine, University of Illinois at Chicago, Chicago, IL, United States
| | | | - Tolou Shokuhfar
- Department of Bioengineering University of Illinois at Chicago, Chicago, IL, United States
| | - Sean C Morris
- Pulse Therapeutics, Inc., St. Louis, MO, United States
| | - Bing Liu
- IMRA America, Inc., Ann Arbor, MI, United States
| |
Collapse
|
4
|
Zima LA, Tulpule S, Samson K, Shonka N. Seizure prevalence, contributing factors, and prognostic factors in patients with leptomeningeal disease. J Neurol Sci 2019; 403:19-23. [PMID: 31176194 DOI: 10.1016/j.jns.2019.05.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 05/06/2019] [Accepted: 05/28/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND To determine seizure prevalence and contributing factors in patients with leptomeningeal disease (LMD). METHODS Authors performed a retrospective review of 79 consecutive patients with a diagnosis of LMD. Associations between categorical variables were assessed using Chi-Square tests or Fisher's Exact tests. Survival was plotted with Kaplan Meier curves. Variables with a log-rank p-value of <0.20 were entered into a Cox Proportional Hazard regression analysis. RESULTS Seizure prevalence in those with and without brain metastases was 22%. Of those who seized, 65% were admitted for this at least once while only one patient required intubation. Primary malignancy, type or route of chemotherapy administration, form of radiation therapy (craniospinal, focal, or whole brain), surgical treatment, location of LMD, and number of brain metastases did not influence seizure development. Only 13% of patients who never had seizures were on a prophylactic AED (anti-epileptic drug). In patients who had brain metastasis, there was no significant difference in prevalence of seizure before versus after LMD diagnosis suggesting that LMD does not significantly increase the risk of seizure compared to brain metastasis alone. A multivariate analysis revealed that while males trended toward inferior survival, only performance status and treatment with systemic chemotherapy showed a significant association with survival. Median survival time of patients after LMD diagnosis was four months. CONCLUSION The prevalence of seizure in LMD patients is 22%. There were no statistically significant predisposing factors to seizure development. ECOG and use of systemic chemotherapy were found to be significant prognostic factors.
Collapse
Affiliation(s)
- Laura Ann Zima
- University of Nebraska Medical Center, S 42nd St & Emile St, Omaha, NE 68198, United States of America.
| | - Sunil Tulpule
- University of Nebraska Medical Center, S 42nd St & Emile St, Omaha, NE 68198, United States of America
| | - Kaeli Samson
- University of Nebraska Medical Center, S 42nd St & Emile St, Omaha, NE 68198, United States of America
| | - Nicole Shonka
- University of Nebraska Medical Center, S 42nd St & Emile St, Omaha, NE 68198, United States of America; Fred & Pamela Buffett Cancer Center, University of Nebraska Medical Center, United States of America
| |
Collapse
|
5
|
Kirkman MA, Hayward R, Phipps K, Aquilina K. Outcomes in children with central nervous system tumors disseminated at presentation: a large single-center experience. Childs Nerv Syst 2018; 34:2259-2267. [PMID: 29938304 DOI: 10.1007/s00381-018-3871-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 06/18/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE Children with disseminated central nervous system (CNS) tumors have worse outcomes than those with solitary disease, but outcomes of disease dissemination at initial presentation have not been systematically studied and compared across tumor groups to date. We evaluated the impact of tumor dissemination at presentation on management and clinical outcomes in a cohort of consecutively treated children in a single neurosurgical unit over a 14-year period. METHODS Method used was a retrospective review of data on children presenting to Great Ormond Street Hospital, London, UK, with medulloblastoma, primitive neuroectodermal tumor, atypical teratoid rhabdoid tumor, pilocytic astrocytoma, and ependymoma between 2003 and 2016 inclusive. Uni- and multi-variate analyses were performed to evaluate a range of outcome measures. RESULTS Three-hundred sixty-one children were identified in total, 53 with disease dissemination at presentation (M:F = 34:19, median age = 3.8 years, range = 7 days-15.6 years) and 308 with solitary tumors (M:F = 161:147, median age = 5.8 years, range = 1 day-16.9 years). Median follow-up was similar irrespective of dissemination status (disseminated tumor 64.0 months, range = 5.2-152.0 months; solitary tumor 74.5 months, range = 4.7-170.1 months; P > 0.05). In multivariate analyses, tumor type and dissemination status at presentation were significantly associated with overall survival (P < 0.0001), risk of recurrence/disease progression (P < 0.01), and event-free survival (P < 0.0001). Subtotal resection was associated with shorter time to recurrence/disease progression (P < 0.01) and worse event-free (P < 0.0001) but not overall survival, whereas treatment with chemotherapy and radiotherapy were associated with improved overall (Ps < 0.0001) and event-free survival (Ps < 0.05). Differences between tumor groups were evident. CONCLUSIONS Dissemination status at initial presentation significantly affects outcomes in children with CNS tumors.
Collapse
Affiliation(s)
- Matthew A Kirkman
- Department of Neurosurgery, Great Ormond Street Hospital for Children NHS Trust, London, WC1N 3JH, UK
- Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Richard Hayward
- Department of Neurosurgery, Great Ormond Street Hospital for Children NHS Trust, London, WC1N 3JH, UK
| | - Kim Phipps
- Department of Neurosurgery, Great Ormond Street Hospital for Children NHS Trust, London, WC1N 3JH, UK
| | - Kristian Aquilina
- Department of Neurosurgery, Great Ormond Street Hospital for Children NHS Trust, London, WC1N 3JH, UK.
| |
Collapse
|
6
|
Kirkman MA, Hayward R, Phipps K, Aquilina K. Surgical decision-making in the management of childhood tumors of the CNS disseminated at presentation. J Neurosurg Pediatr 2018; 21:563-573. [PMID: 29624145 DOI: 10.3171/2018.1.peds17456] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE It is relatively unusual for pediatric CNS tumors to be disseminated at presentation, and the literature on the clinical features, management, and outcomes of this specific group is scarce. Surgical management in this population is often challenging, particularly in the presence of hydrocephalus. The authors present their recent experience of treating pediatric CNS tumors that were disseminated at presentation, and they compare these lesions with focal tumors. METHODS The authors performed a retrospective review of prospectively collected data on children presenting to a tertiary center between 2003 and 2016 inclusive. RESULTS Of 361 children with CNS tumors, the authors identified 53 patients with disease dissemination at presentation (male/female ratio 34:19, median age 3.8 years, age range 7 days to 15.6 years) and 308 without dissemination at presentation (male/female ratio 161:147, median age 5.8 years, age range 1 day to 16.9 years). Five tumor groups were studied: medulloblastoma (disseminated n = 29, focal n = 74), other primitive neuroectodermal tumor (n = 8, n = 17), atypical teratoid rhabdoid tumor (n = 8, n = 22), pilocytic astrocytoma (n = 6, n = 138), and ependymoma (n = 2, n = 57). The median follow-up duration in survivors was not significantly different between those with disease dissemination at presentation (64.0 months, range 5.2-152.0 months) and those without it (74.5 months, range 4.7-170.1 months) (p > 0.05). When combining data from all 5 tumor groups, dissemination status at presentation was significantly associated with a higher risk of requiring CSF diversion, a higher surgical complication rate, and a reduced likelihood of achieving gross-total resection of the targeted lesion (all variables p < 0.05). Differences between the 5 tumor groups were evident. No factors that predicted the need for permanent CSF diversion following temporary external ventricular drainage were identified on multivariate analysis, and there was no clear superiority of either ventriculoperitoneal shunt surgery or endoscopic third ventriculostomy as a permanent CSF diversion procedure. CONCLUSIONS Tumor type and dissemination status at initial presentation significantly affect outcomes across a range of measures. The management of hydrocephalus in patients with CNS tumors is challenging, and further prospective studies are required to identify the optimal CSF diversion strategy in this population.
Collapse
|
7
|
Kondo N, Barth RF, Miyatake SI, Kawabata S, Suzuki M, Ono K, Lehman NL. Cerebrospinal fluid dissemination of high-grade gliomas following boron neutron capture therapy occurs more frequently in the small cell subtype of IDH1 R132H mutation-negative glioblastoma. J Neurooncol 2017; 133:107-118. [PMID: 28534152 DOI: 10.1007/s11060-017-2408-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 04/01/2017] [Indexed: 11/29/2022]
Abstract
We have used boron neutron capture therapy (BNCT) to treat patients in Japan with newly diagnosed or recurrent high-grade gliomas and have observed a significant increase in median survival time following BNCT. Although cerebrospinal fluid dissemination (CSFD) is not usually seen with the current standard therapy of patients with glioblastoma (GBM), here we report that subarachnoid or intraventricular CSFD was the most frequent cause of death for a cohort of our patients with high-grade gliomas who had been treated with BNCT. The study population consisted of 87 patients with supratentorial high-grade gliomas; 41 had newly diagnosed tumors and 46 had recurrent tumors. Thirty of 87 patients who were treated between January 2002 and July 2013 developed CSFD. Tumor histology before BNCT and immunohistochemical staining for two molecular markers, Ki-67 and IDH1R132H, were evaluated for 20 of the 30 patients for whom pathology slides were available. Fluorescence in situ hybridization (FISH) was performed on 3 IDH1R132H-positive and 1 control IDH1R132H-negative tumors in order to determine chromosome 1p and 19q status. Histopathologic evaluation revealed that 10 of the 20 patients' tumors were IDH1R132H-negative small cell GBMs. The remaining patients had tumors consisting of other IDH1R132H-negative GBM variants, an IDH1R132H-positive GBM and two anaplastic oligodendrogliomas. Ki-67 immunopositivity ranged from 2 to 75%. In summary, IDH1R132H-negative GBMs, especially small cell GBMs, accounted for a disproportionately large number of patients who had CSF dissemination. This suggests that these tumor types had an increased propensity to disseminate via the CSF following BNCT and that these patients are at high risk for this clinically serious event.
Collapse
Affiliation(s)
- Natsuko Kondo
- Particle Radiation Oncology Research Center, Kyoto University Research Reactor Institute, Sennan-gun, Osaka, Japan.
| | - Rolf F Barth
- Department of Pathology, The Ohio State University Medical Center, Columbus, OH, USA
| | - Shin-Ichi Miyatake
- Department of Neurosurgery, Osaka Medical College, Takatsuki City, Osaka, Japan
| | - Shinji Kawabata
- Department of Neurosurgery, Osaka Medical College, Takatsuki City, Osaka, Japan
| | - Minoru Suzuki
- Particle Radiation Oncology Research Center, Kyoto University Research Reactor Institute, Sennan-gun, Osaka, Japan
| | - Koji Ono
- Particle Radiation Oncology Research Center, Kyoto University Research Reactor Institute, Sennan-gun, Osaka, Japan
| | - Norman L Lehman
- Department of Pathology, The Ohio State University Medical Center, Columbus, OH, USA.
| |
Collapse
|
8
|
Elsharkawy AE, Salem S, Abuamona R, Bergmann M. Primary spinal glioblastoma multiforme presenting with leptomeningeal gliomatosis and subarachnoid hemorrhage: A case report. INTERDISCIPLINARY NEUROSURGERY 2016. [DOI: 10.1016/j.inat.2016.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
|
9
|
Rieken S, Rieber J, Brons S, Habermehl D, Rief H, Orschiedt L, Lindel K, Weber KJ, Debus J, Combs SE. Radiation-induced motility alterations in medulloblastoma cells. JOURNAL OF RADIATION RESEARCH 2015; 56:430-436. [PMID: 25736470 PMCID: PMC4426914 DOI: 10.1093/jrr/rru120] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Revised: 11/09/2014] [Accepted: 11/21/2014] [Indexed: 05/28/2023]
Abstract
Photon irradiation has been repeatedly suspected of increasing tumor cell motility and promoting locoregional recurrence of disease. This study was set up to analyse possible mechanisms underlying the potentially radiation-altered motility in medulloblastoma cells. Medulloblastoma cell lines D425 and Med8A were analyzed in migration and adhesion experiments with and without photon and carbon ion irradiation. Expression of integrins was determined by quantitative FACS analysis. Matrix metalloproteinase concentrations within cell culture supernatants were investigated by enzyme-linked immunosorbent assay (ELISA). Statistical analysis was performed using Student's t-test. Both photon and carbon ion irradiation significantly reduced chemotactic medulloblastoma cell transmigration through 8-μm pore size membranes, while simultaneously increasing adherence to fibronectin- and collagen I- and IV-coated surfaces. Correspondingly, both photon and carbon ion irradiation downregulate soluble MMP9 concentrations, while upregulating cell surface expression of proadhesive extracellular matrix protein-binding integrin α5. The observed phenotype of radiation-altered motility is more pronounced following carbon ion than photon irradiation. Both photon and (even more so) carbon ion irradiation are effective in inhibiting medulloblastoma cell migration through downregulation of matrix metalloproteinase 9 and upregulation of proadhesive cell surface integrin α5, which lead to increased cell adherence to extracellular matrix proteins.
Collapse
Affiliation(s)
- Stefan Rieken
- University Hospital of Heidelberg, Department of Radiation Oncology, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Juliane Rieber
- University Hospital of Heidelberg, Department of Radiation Oncology, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Stephan Brons
- Heidelberg Ion Treatment Facility (HIT), Im Neuenheimer Feld 450, 69120 Heidelberg, Germany
| | - Daniel Habermehl
- Klinikum rechts der Isar, Technische Universität München, Klinik für Radioonkologie und Strahlentherapie, Ismaninger Straße 22, 81675 München, Germany
| | - Harald Rief
- University Hospital of Heidelberg, Department of Radiation Oncology, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Lena Orschiedt
- University Hospital of Heidelberg, Department of Radiation Oncology, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Katja Lindel
- University Hospital of Heidelberg, Department of Radiation Oncology, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Klaus J Weber
- University Hospital of Heidelberg, Department of Radiation Oncology, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Jürgen Debus
- University Hospital of Heidelberg, Department of Radiation Oncology, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Stephanie E Combs
- Klinikum rechts der Isar, Technische Universität München, Klinik für Radioonkologie und Strahlentherapie, Ismaninger Straße 22, 81675 München, Germany
| |
Collapse
|
10
|
Harreld JH, Mohammed N, Goldsberry G, Li X, Li Y, Boop F, Patay Z. Postoperative intraspinal subdural collections after pediatric posterior fossa tumor resection: incidence, imaging, and clinical features. AJNR Am J Neuroradiol 2015; 36:993-9. [PMID: 25614472 DOI: 10.3174/ajnr.a4221] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 11/01/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Postoperative intraspinal subdural collections in children after posterior fossa tumor resection may temporarily hinder metastasis detection by MR imaging or CSF analysis, potentially impacting therapy. We investigated the incidence, imaging and clinical features, predisposing factors, and time course of these collections after posterior fossa tumor resection. MATERIALS AND METHODS Retrospective review of postoperative spine MRI in 243 children (5.5 ± 4.6 years of age) from our clinical data base postresection of posterior fossa tumors from October 1994 to August 2010 yielded 37 (6.0 ± 4.8 years of age) subjects positive for postoperative intraspinal subdural collections. Their extent and signal properties were recorded for postoperative (37/37), preoperative (15/37), and follow-up spine (35/37) MRI. Risk factors were compared with age-matched internal controls (n = 37, 5.9 ± 4.5 years of age). Associations of histology, hydrocephalus and cerebellar tonsillar herniation, and postoperative intracranial subdural collections with postoperative intraspinal subdural collections were assessed by the Fisher exact test or χ(2) test. The association between preoperative tumor volume and postoperative intraspinal subdural collections was assessed by the Wilcoxon rank sum test. RESULTS The overall incidence of postoperative intraspinal subdural collections was 37/243 (15.2%), greatest ≤7 days postoperatively (36%); 97% were seen 0-41 days postoperatively (12.9 ± 11.0 days). They were T2 hyperintense and isointense to CSF on T1WI, homogeneously enhanced, and resolved on follow-up MR imaging (35/35). None were symptomatic. They were associated with intracranial subdural collections (P = .0011) and preoperative tonsillar herniation (P = .0228). CONCLUSIONS Postoperative intraspinal subdural collections are infrequent and clinically silent, resolve spontaneously, and have a distinctive appearance. Preoperative tonsillar herniation appears to be a predisposing factor. In this series, repeat MR imaging by 4 weeks documented improvement or resolution of these collections in 88%.
Collapse
Affiliation(s)
- J H Harreld
- From the Departments of Radiological Sciences (J.H.H., Z.P.)
| | - N Mohammed
- Department of Imaging Diagnostic (N.M.), Institute of Paediatric, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia
| | - G Goldsberry
- Department of Radiology (G.G.), McFarland Clinic, Ames, Iowa
| | - X Li
- Biostatistics (X.L., Y.L.)
| | - Y Li
- Biostatistics (X.L., Y.L.)
| | - F Boop
- Surgery (F.B.), St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Z Patay
- From the Departments of Radiological Sciences (J.H.H., Z.P.)
| |
Collapse
|
11
|
Mandel JJ, Yust-Katz S, Cachia D, Wu J, Liu D, de Groot JF, Yung AWK, Gilbert MR. Leptomeningeal dissemination in glioblastoma; an inspection of risk factors, treatment, and outcomes at a single institution. J Neurooncol 2014; 120:597-605. [PMID: 25168214 DOI: 10.1007/s11060-014-1592-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 08/17/2014] [Indexed: 02/03/2023]
Abstract
There are few studies reporting the incidence of leptomeningeal dissemination (LMD) in patients with glioblastoma; only small case series have been published. Consequently, there are no established standards of care for these patients. Therefore, we undertook this retrospective review to evaluate a large series of patients with glioblastoma treated at MD Anderson Cancer Center to estimate the incidence of LMD and assess the impact of a variety of treatment modalities. Analysis was performed on 595 patients with glioblastoma treated on clinical trials from 2006 to 2012. The diagnosis of LMD was made by imaging or positive cerebrospinal fluid cytology in 24 patients. An additional 12 patients with known LMD diagnosed during this same period were included to evaluate the impact of treatment on outcome for a total of 36 patients. LMD developed in 4.0 % (24/595 patients) of the clinical trial cohort. Median survival from glioblastoma diagnosis was 16.0 months. Estimated median time of glioblastoma diagnosis to LMD was 11.9 months. Median overall survival from the time of LMD diagnosis was 3.5 months. Patients treated for LMD with chemotherapy/targeted therapy and radiation had a significantly prolonged survival (7.7 months) compared to chemotherapy/targeted therapy alone, radiation alone or palliative care. LMD remains an uncommon event in patients with glioblastoma. Patients treated aggressively with chemotherapy/targeted therapy and radiation had the longest median survival following diagnosis of LMD. However, patients receiving chemotherapy/targeted therapy and radiation were younger and this may have influenced survival. Given the overall poor outcomes, improved therapeutic approaches are needed for glioblastoma patients with LMD.
Collapse
Affiliation(s)
- Jacob J Mandel
- Department of Neurology, Baylor College of Medicine, One Baylor Plaza, MS Nb302, Houston, TX, 77030, USA,
| | | | | | | | | | | | | | | |
Collapse
|
12
|
Harreld JH, Sabin ND, Rossi MG, Awwad R, Reddick WE, Yuan Y, Glass JO, Ji Q, Gajjar A, Patay Z. Elevated cerebral blood volume contributes to increased FLAIR signal in the cerebral sulci of propofol-sedated children. AJNR Am J Neuroradiol 2014; 35:1574-9. [PMID: 24699094 DOI: 10.3174/ajnr.a3911] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND PURPOSE Hyperintense FLAIR signal in the cerebral sulci of anesthetized children is attributed to supplemental oxygen (fraction of inspired oxygen) but resembles FLAIR hypersignal associated with perfusion abnormalities in Moyamoya disease and carotid stenosis. We investigated whether cerebral perfusion, known to be altered by anesthesia, contributes to diffuse signal intensity in sulci in children and explored the relative contributions of supplemental oxygen, cerebral perfusion, and anesthesia to signal intensity in sulci. MATERIALS AND METHODS Supraventricular signal intensity in sulci on pre- and postcontrast T2 FLAIR images of 24 propofol-sedated children (6.20 ± 3.28 years) breathing supplemental oxygen and 18 nonsedated children (14.28 ± 2.08 years) breathing room air was graded from 0 to 3. The Spearman correlation of signal intensity in sulci with the fraction of inspired oxygen and age in 42 subjects, and with dynamic susceptibility contrast measures of cortical CBF, CBV, and MTT available in 25 subjects, were evaluated overall and compared between subgroups. Factors most influential on signal intensity in sulci were identified by stepwise logistic regression. RESULTS CBV was more influential on noncontrast FLAIR signal intensity in sulci than the fraction of inspired oxygen or age in propofol-sedated children (CBV: r = 0.612, P = .026; fraction of inspired oxygen: r = -0.418, P = .042; age: r = 0.523, P = .009) and overall (CBV: r = 0.671, P = .0002; fraction of inspired oxygen: r = 0.442, P = .003; age: r = -0.374, P = .015). MTT (CBV/CBF) was influential in the overall cohort (r = 0.461, P = .020). Signal intensity in sulci increased with contrast in 45% of subjects, decreased in none, and was greater (P < .0001) in younger propofol-sedated subjects, in whom the signal intensity in sulci increased with age postcontrast (r = .600, P = .002). CONCLUSIONS Elevated cortical CBV appears to contribute to increased signal intensity in sulci on noncontrast FLAIR in propofol-sedated children. The effects of propofol on age-related cerebral perfusion and vascular permeability may play a role.
Collapse
Affiliation(s)
- J H Harreld
- From the Departments of Radiological Sciences (J.H.H., N.D.S., R.A., W.E.R., J.O.G., Q.J., Z.P.)
| | - N D Sabin
- From the Departments of Radiological Sciences (J.H.H., N.D.S., R.A., W.E.R., J.O.G., Q.J., Z.P.)
| | | | - R Awwad
- From the Departments of Radiological Sciences (J.H.H., N.D.S., R.A., W.E.R., J.O.G., Q.J., Z.P.)
| | - W E Reddick
- From the Departments of Radiological Sciences (J.H.H., N.D.S., R.A., W.E.R., J.O.G., Q.J., Z.P.)
| | | | - J O Glass
- From the Departments of Radiological Sciences (J.H.H., N.D.S., R.A., W.E.R., J.O.G., Q.J., Z.P.)
| | - Q Ji
- From the Departments of Radiological Sciences (J.H.H., N.D.S., R.A., W.E.R., J.O.G., Q.J., Z.P.)
| | - A Gajjar
- Oncology (A.G.), St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Z Patay
- From the Departments of Radiological Sciences (J.H.H., N.D.S., R.A., W.E.R., J.O.G., Q.J., Z.P.)
| |
Collapse
|
13
|
Ko JH, Lu PH, Tang TC, Hsu YH. Metastasis of primary CNS lymphoma along a ventriculoperitoneal shunt. J Clin Oncol 2011; 29:e823-4. [PMID: 22025153 DOI: 10.1200/jco.2011.37.3233] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Jui-Hung Ko
- Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital, 5 Fu-Shin St, Kwei-Shan, Tao-Yuan County 333, Taiwan
| | | | | | | |
Collapse
|
14
|
Bone morphogenetic protein-7 is a MYC target with prosurvival functions in childhood medulloblastoma. Oncogene 2011; 30:2823-35. [PMID: 21317922 DOI: 10.1038/onc.2011.10] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Medulloblastoma (MB) is the most common malignant brain tumor in children. It is known that overexpression and/or amplification of the MYC oncogene is associated with poor clinical outcome, but the molecular mechanisms and the MYC downstream effectors in MB remain still elusive. Besides contributing to elucidate how progression of MB takes place, most importantly, the identification of novel MYC-target genes will suggest novel candidates for targeted therapy in MB. A group of 209 MYC-responsive genes was obtained from a complementary DNA microarray analysis of a MB-derived cell line, following MYC overexpression and silencing. Among the MYC-responsive genes, we identified the members of the bone morphogenetic protein (BMP) signaling pathway, which have a crucial role during the development of the cerebellum. In particular, the gene BMP7 was identified as a direct target of MYC. A positive correlation between MYC and BMP7 expression was documented by analyzing two distinct sets of primary MB samples. Functional studies in vitro using a small-molecule inhibitor of the BMP/SMAD signaling pathway reproduced the effect of the small interfering RNA-mediated silencing of BMP7. Both approaches led to a block of proliferation in a panel of MB cells and to inhibition of SMAD phosphorylation. Altogether, our findings indicate that high MYC levels drive BMP7 overexpression, promoting cell survival in MB cells. This observation suggests the potential relevance of targeting the BMP/SMAD pathway as a novel therapeutic approach for the treatment of childhood MB.
Collapse
|
15
|
Damek DM. Cerebral edema, altered mental status, seizures, acute stroke, leptomeningeal metastases, and paraneoplastic syndrome. Hematol Oncol Clin North Am 2010; 24:515-35. [PMID: 20488351 DOI: 10.1016/j.hoc.2010.03.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Neurologic symptoms commonly occur in oncology patients, and in some cases they may be the presenting symptom of malignancy. Cancer-related neurologic syndromes are rarely pathognomonic and must be differentiated from other benign or serious conditions. This article reviews common neuro-oncologic syndromes that may lead to urgent evaluation in the emergency department, including cerebral edema, altered mental status, seizures, acute stroke, leptomeningeal metastases, and paraneoplastic neurologic syndromes.
Collapse
Affiliation(s)
- Denise M Damek
- Neuro-Oncology, University of Colorado Denver School of Medicine, 12631 East 17th Avenue, MS# B-185, Aurora, CO 80045, USA.
| |
Collapse
|
16
|
Abstract
Inflammatory processes as well as primary and secondary tumorous changes may involve cranial nerves causing neurological deficits. In addition to neurologists, ENT physicians, ophthalmologists and maxillofacial surgeons, radiologists play an important role in the investigation of patients with cranial nerve symptoms. Multidetector computed tomography (MDCT) and particularly magnetic resonance imaging (MRI) allow the depiction of the cranial nerve anatomy and pathological neural changes. This article briefly describes the imaging techniques in MDCT and MRI and is dedicated to the radiological presentation of inflammatory and tumorous cranial nerve pathologies.
Collapse
|
17
|
Cerebral Edema, Altered Mental Status, Seizures, Acute Stroke, Leptomeningeal Metastases, and Paraneoplastic Syndrome. Emerg Med Clin North Am 2009; 27:209-29. [DOI: 10.1016/j.emc.2009.02.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
18
|
Hsieh PC, Wu CT, Lin KL, Jaing TH, Tseng CK, Lui TN, Jung SM. The clinical experience of medulloblastoma treatment and the significance of time sequence for development of leptomeningeal metastasis. Childs Nerv Syst 2008; 24:1463-7. [PMID: 18802711 DOI: 10.1007/s00381-008-0697-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2008] [Indexed: 10/21/2022]
Abstract
OBJECTS Among patients with medulloblastoma, an unrare aggressive central nervous system (CNS) tumor found mostly in the posterior fossa, drop metastasis from primary location to anatomically lower sites including whole spinal cord is known as a potential way for tumor to spread. There were already lots of extensive discussions regarding diagnosis and treatment for such common neurologic complication in systemic cancer; however, fewer were found about medulloblastoma. This study aimed to reexamine the possible known prognostic factors, especially drop metastasis, and defined the influence of them. MATERIALS AND METHODS We retrospectively review a series of 36 patients who suffered from posterior fossa medulloblastoma and found leptomeningeal metastasis in 12 of them. Incidence, diagnosis, prognostic factors, and treatments for this common complication are discussed. The magnetic resonance images (MRI) of these patients were reviewed. The time sequence between primary surgical procedure and development of MRI evidences of drop metastasis was used for subgrouping. Log-rank test was used for survival analysis. CONCLUSIONS By survival analysis, patients with late drop metastasis, defined as new radiologic evidence of leptomeningeal involvement after primary CNS procedures, were found to have significant survival difference to those with early metastasis defined as drop metastasis found at the time of diagnosis (log-rank test, p = 0.0047). Further stratification of patients within this group may help in evaluation of prognosis and development of different treatment strategies.
Collapse
Affiliation(s)
- Po-Chuan Hsieh
- Department of Neurosurgery, Chang Gung Memorial Hospital, No. 5, Fu-Shin Street, Kwei-Shan, Taoyuan, 333, Taiwan, Republic of China.
| | | | | | | | | | | | | |
Collapse
|
19
|
Abstract
Leptomeningeal metastasis is becoming an increasingly important late complication of cancer as survival from systemic disease increases, and due to the fact that many novel cancer drugs fail to achieve therapeutic concentrations in the central nervous system. It occurs when neoplastic cells enter cerebrospinal fluid (CSF) pathways, causing diffuse infiltration of the subarachnoid space of the brain and spinal cord. Definitive diagnosis is established by the demonstration of malignant cells in the CSF. However, in certain circumstances the presence of leptomeningeal enhancement on brain or spinal MRI may be sufficient to make the diagnosis. Early diagnosis and aggressive treatment may delay neurologic progression and can lead to prolonged survival and improvement of neurologic function in certain patients. The prognosis depends on the underlying malignancy but is often poor, with a median survival of 4 months, and most treatment interventions are palliative. Nevertheless, some patients respond to treatment, and some survive beyond 1 or 2 years after diagnosis. Areas of radiographic bulky disease or symptomatic tumor should receive radiotherapy. Intrathecal chemotherapy is most effective in patients with lymphoma, leukemia, or breast cancer and without evidence of bulky disease on neuroimaging. Intrathecal chemotherapy requires normal CSF flow, and the most commonly used agents are methotrexate, cytarabine, and thiotepa. In lieu of intrathecal therapy, systemic chemotherapy may occasionally be indicated in select patients in part based on its ability to penetrate into bulky disease. When hydrocephalus occurs, ventriculoperitoneal shunting frequently leads to rapid clinical improvement. There is hope that progress in diagnostic modalities and the development of more effective intrathecal antineoplastic drugs may decrease neurologic morbidity and improve quality of life and survival.
Collapse
Affiliation(s)
- Jan Drappatz
- Jan Drappatz, MD Harvard Medical School, Department of Neurology, Brigham and Women’s Hospital and Dana-Farber/Brigham and Women’s Cancer Center, Center for Neuro-Oncology, 44 Binney Street SW 430, Boston, MA 02115, USA.
| | | |
Collapse
|
20
|
Zacharoulis S, Ji L, Pollack IF, Duffner P, Geyer R, Grill J, Schild S, Jaing TH, Massimino M, Finlay J, Sposto R. Metastatic ependymoma: a multi-institutional retrospective analysis of prognostic factors. Pediatr Blood Cancer 2008; 50:231-5. [PMID: 17610266 DOI: 10.1002/pbc.21276] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
PURPOSE Metastatic ependymoma is exceedingly rare at diagnosis with variable prognosis reported in the literature. The purpose of this study was to identify prognostic factors in children with metastatic ependymoma. PROCEDURE Data regarding diagnosis, treatment and follow-up for 40 patients from eight institutional cohorts were collected. RESULTS Twenty-nine (72%) patients were less than 36 months of age at the time of diagnosis, 28% were females, and 90% of the patients had posterior fossa tumors. Gross total resection (GTR) of the primary tumor was achieved in 16 patients (40%). Adjuvant therapy was variable and included craniospinal irradiation (CSRT), chemotherapy, and chemotherapy with focal irradiation. The 5-year event free survival (EFS) and overall survival (OS) from the time of diagnosis were 29% (+/-7%) and 43% (+/-8%), respectively. Age at diagnosis was associated significantly with both EFS and OS (P < 0.001 for EFS, and P = 0.01 for OS). Patients who were 24-35 months of age at diagnosis had a 5-year EFS of 66% and a 5-year OS of 73%; both survival rates were superior to those of patients younger than 24 months of age or older than 36 months. Patients with GTR achieved a 5-year EFS of 35% and OS of 59%, compared to a 5-year EFS of 25% and OS of 32% for patients who did not achieve GTR (P = 0.12 for EFS, P = 0.03 for OS). CONCLUSIONS GTR should be attempted in patients with metastatic ependymoma. A subgroup of patients between 24 and 35 months might have a favorable outcome.
Collapse
|
21
|
Kinebuchi Y, Ishikawa M, Ishizuka O, Nishizawa O, Hongo K. Leptomeningeal metastases in a patient with an extragonadal germ cell tumor. Clin Med Oncol 2008; 2:371-4. [PMID: 21892301 PMCID: PMC3161680 DOI: 10.4137/cmo.s687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
We present a case of leptomeningeal metastases in a 30-year-old man with an extragonadal germ cell tumor. The patient was referred to our hospital for treatment of an occipital brain metastasis. This lesion was resected, followed by whole brain radiotherapy and further chemotherapy, and a temporary complete remission was achieved. However, leptomeningeal recurrence developed, and despite salvage chemotherapy, the patient died of disease. Although multidisciplinary treatment is given to treat brain metastases of germ cell tumors, the patients’ prognosis has been unsatisfactory. The identification of a standard/effective treatment is required.
Collapse
Affiliation(s)
- Yoshiaki Kinebuchi
- Department of Urology, Shinshu University School of Medicine, Matsumoto, Japan
| | | | | | | | | |
Collapse
|
22
|
Narin O, Drappatz J, Doherty LM, Wen PY, Kesari S. Cerebrospinal Fluid Spread of Anaplastic Glioma. J Clin Oncol 2007; 25:596-7. [PMID: 17290068 DOI: 10.1200/jco.2006.09.3096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Ozden Narin
- Dana-Farber/Brigham and Women's Cancer Center, Center for Neuro-Oncology, Boston, MA, USA
| | | | | | | | | |
Collapse
|