Advances in the Diagnosis and Treatment of Leptomeningeal Disease

Immunotherapy for leptomeningeal disease from solid tumors: current clinical outcomes and future opportunities

Leptomeningeal disease is a debilitating, late-stage form of metastatic cancer disseminated within the cerebrospinal fluid, subarachnoid space, and leptomeninges, leading to significant neurological morbidity and mortality. As systemic cancer treatments improve, rates of leptomeningeal disease have increased, yet prognosis remains exceedingly poor. A wide range of treatment modalities have been trialed; however, no standard of care has been established. Additionally, many clinical trials exclude patients with leptomeningeal disease, limiting available prospective data. In this review, we discuss the efficacy of immunotherapy for leptomeningeal disease from solid tumors including systemic and intrathecal therapies, as well as combined therapy regimens. Our review indicates a continued deficiency in the current prospective literature and highlights ongoing research regarding the leptomeningeal immune microenvironment, which will be critical in directing future study of leptomeningeal disease treatment. Currently, the efficacy of immunotherapies on leptomeningeal disease appears limited, and further prospective research is needed to draw significant conclusions. However, recent advancement in understanding the leptomeningeal microenvironment points to potential efficacy of novel immunotherapies targeting the innate immune system, and further study is warranted to evaluate the efficacy of these treatments in this subpopulation of patients.

A Rare Cause of Nuchal Rigidity: Metastatic Triple-Negative Breast Cancer Involving the Skull and Upper Cervical Spine

A 48-year-old female presented to the ED with worsening headache and neck pain for the past week. Her medical history is significant for recurrent left-sided triple-negative breast cancer (TNBC) with metastasis to the chest wall, liver, and lungs, initially diagnosed two years ago. She underwent a left-sided mastectomy and received radiation therapy and chemotherapy. Physical examination was remarkable for nuchal rigidity and photophobia. MRI of the brain with contrast was performed, and the results were consistent with the new calvarium, skull, and upper cervical spine osseous metastases without any intracranial metastatic disease. This case report presents a rare cause of nuchal rigidity and photophobia due to an uncommon metastatic pattern in a patient with TNBC.

Leptomeningeal Disease Secondary to Invasive Ductal Carcinoma of the Breast: A Rapidly Progressive and Fatal Complication

Leptomeningeal disease (LMD) is a rare yet serious complication of advanced malignancy, often seen in breast cancer and associated with a poor prognosis.  This case report highlights the rapid progression and diagnostic challenges encountered in a woman in her 40s with advanced breast cancer who presented with severe headaches, absence seizures, and diplopia. The patient's complex past history included invasive ductal carcinoma, prior brain metastasis, and recent craniotomy, which added significant challenges to diagnosis and management.  Clinical investigations included computed tomography (CT) of the head, magnetic resonance imaging (MRI) of the orbit and head, electroencephalography (EEG), and lumbar puncture, which indicated optic nerve sheath enhancement, ventricular prominence, coating of facial and vestibulocochlear nerves, and cerebrospinal fluid abnormalities suggestive of LMD. Although empiric treatment for bacterial and tuberculous meningitis was initiated, the patient's rapid decline necessitated an aggressive multimodal approach. Management included high-dose corticosteroids, broad-spectrum antibiotics, antitubercular drugs, and anticonvulsants, though her seizures persisted. Ultimately, comfort-focused care was prioritized as her condition remained refractory to interventions, and she was transitioned to palliative care.  This case emphasizes the need for early suspicion, prompt multidisciplinary involvement, and the challenges in managing complex oncological cases with atypical neurological manifestations. The poor prognosis associated with LMD reflects the limitations of current therapeutic strategies and the need for a nuanced approach to care.

Top Ten Tips Palliative Care Clinicians Should Know About Caring for People with Leptomeningeal Disease

Leptomeningeal disease (LMD), spread of cancer to the lining of the brain and its protective coverings, is a feared complication of many different types of cancer. LMD negatively affects prognosis across tumor types. Palliative care (PC) clinicians caring for patients with advanced cancer may be faced with discussing limited prognosis, assisting with symptom management, and helping with medical decision making for patients with LMD. An understanding of pathophysiology, symptomatology, prognosis, and treatment options is essential in providing optimal care. This article, written by clinicians who work across the cancer spectrum, uses an accessible "ten tips" format to help increase PC providers' confidence and competence around caring for people with LMD.

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

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.

Outcomes, responses, and prognostic analyses of intrathecal combined treatment for leptomeningeal metastasis from lung adenocarcinoma

BACKGROUND

Leptomeningeal metastasis (LM) is a severe lung cancer complication, with potentially fatal consequences. The use of intrathecal therapy (IT) combined with systemic therapy has shown promise as a treatment approach for LM. Thus, this study aimed to evaluate the features and responses to IT combined therapy and identify determinants affecting patients with leptomeningeal metastasis resulting from lung adenocarcinoma (LM-LA).

METHODS

A retrospective analysis of medical records from our hospital database was performed, covering from April 2018 to August 2022, for 37 patients diagnosed with LM-LA and treated with IT combined therapy. Patients who received IT combined therapy for LM-LA were evaluated for demographic characteristics, treatment efficacy, survival, and variables that impacted them.

RESULTS

The median overall survival (mOS) of 37 patients was 16.0 months, and the survival rates at 6 and 12 months were 75.7% and 35.1%, respectively. Among the 21 patients with LM-LA who received IT combined with tyrosine kinase inhibitors (TKIs), the mOS was 17.0 months, which was significantly longer than that of patients treated with IT combined with chemotherapy (7.0 months, P = 0.010) and the best supportive care (6.0 months, P = 0.001). However, no significant survival benefit was observed in patients treated with IT combined with TKIs when compared with those treated with IT combined with PD-1 (5.0 months, P = 0.249). Multivariate analysis indicated that the combination of TKIs was an independent favorable prognostic factor for patients with LM-LA.

CONCLUSION

Combination treatment is regarded as an additional option for patients with LM-LA. Compared with other combination therapies in our study, IT combined with TKI therapy provided a better survival outcome for patients with LM-LA.

Lung cancer tumor markers in serous effusions and other body fluids

From its onset and during its progression, lung cancer may affect various extrapulmonary structures. These include the serous membranes, the pleura and pericardium, and less frequently the central nervous system, with leptomeningeal involvement. In these cases, fluid accumulates in the serous membranes which may contain substances secreted by the tumor. Measuring the concentrations of these substances can provide useful information for elucidating the origin of the fluid accumulation, either in pleural and pericardial effusions or in cerebrospinal fluid. This paper describes the histological types of lung cancer that most frequently affect the serosa and leptomeninges. It also reviews the literature on tumor markers in different fluids and makes recommendations for their interpretation.

Brain Metastases and Leptomeningeal Disease

OBJECTIVE

Central nervous system (CNS) metastases include brain parenchymal, spinal cord, and leptomeningeal metastases. This article discusses the diagnostic and therapeutic advances of the last decade that have improved outcomes for patients with these CNS metastases.

LATEST DEVELOPMENTS

The diagnostic tools for CNS metastases, particularly leptomeningeal disease, have evolved over the past decade with respect to advancements in CSF analysis. Multiple medical therapies are now available for brain metastasis treatment that have shown CNS efficacy, including targeted therapies and antibody-drug conjugates. Molecular testing for CNS metastases has become more common and the repertoire of molecularly targeted therapies continues to expand. Advancements in radiation therapy, including improvements in stereotactic radiation techniques, whole-brain radiation with hippocampal avoidance, and proton beam radiation, have changed the radiation management of patients with CNS metastases. New intrathecal agents are currently being tested for the management of leptomeningeal metastases.

ESSENTIAL POINTS

CNS metastases are far more common than primary brain tumors and are increasing in prevalence in the setting of improved treatments and prolonged survival in patients with systemic cancers. There have been many changes in the diagnostics and treatment of CNS metastases, yielding subsequent improvements in patient outcomes with further advancements on the horizon.

Leptomeningeal Metastasis: A Review of the Pathophysiology, Diagnostic Methodology, and Therapeutic Landscape

The present review aimed to establish an understanding of the pathophysiology of leptomeningeal disease as it relates to late-stage development among different cancer types. For our purposes, the focused metastatic malignancies include breast cancer, lung cancer, melanoma, primary central nervous system tumors, and hematologic cancers (lymphoma, leukemia, and multiple myeloma). Of note, our discussion was limited to cancer-specific leptomeningeal metastases secondary to the aforementioned primary cancers. LMD mechanisms secondary to non-cancerous pathologies, such as infection or inflammation of the leptomeningeal layer, were excluded from our scope of review. Furthermore, we intended to characterize general leptomeningeal disease, including the specific anatomical infiltration process/area, CSF dissemination, manifesting clinical symptoms in patients afflicted with the disease, detection mechanisms, imaging modalities, and treatment therapies (both preclinical and clinical). Of these parameters, leptomeningeal disease across different primary cancers shares several features. Pathophysiology regarding the development of CNS involvement within the mentioned cancer subtypes is similar in nature and progression of disease. Consequently, detection of leptomeningeal disease, regardless of cancer type, employs several of the same techniques. Cerebrospinal fluid analysis in combination with varied imaging (CT, MRI, and PET-CT) has been noted in the current literature as the gold standard in the diagnosis of leptomeningeal metastasis. Treatment options for the disease are both varied and currently in development, given the rarity of these cases. Our review details the differences in leptomeningeal disease as they pertain through the lens of several different cancer subtypes in an effort to highlight the current state of targeted therapy, the potential shortcomings in treatment, and the direction of preclinical and clinical treatments in the future. As there is a lack of comprehensive reviews that seek to characterize leptomeningeal metastasis from various solid and hematologic cancers altogether, the authors intended to highlight not only the overlapping mechanisms but also the distinct patterning of disease detection and progression as a means to uniquely treat each metastasis type. The scarcity of LMD cases poses a barrier to more robust evaluations of this pathology. However, as treatments for primary cancers have improved over time, so has the incidence of LMD. The increase in diagnosed cases only represents a small fraction of LMD-afflicted patients. More often than not, LMD is determined upon autopsy. The motivation behind this review stems from the increased capacity to study LMD in spite of scarcity or poor patient prognosis. In vitro analysis of leptomeningeal cancer cells has allowed researchers to approach this disease at the level of cancer subtypes and markers. We ultimately hope to facilitate the clinical translation of LMD research through our discourse.

Leptomeningeal metastases in non-small cell lung cancer: Diagnosis and treatment

Leptomeningeal metastasis (LM) is a rare complication of non-small cell lung cancer (NSCLC) with highly mortality. LM will occur once tumor cells spread to the cerebrospinal fluid (CSF) space. Patients may suffer blindness, paralysis, and mental disorders that seriously affect their quality of life. There is a clear unmet need to improve the efficacy of diagnosis and treatment of LM. To better solve this problem, it is helpful to clarify the potential mechanisms of LM. Clinical manifestations, magnetic resonance imaging, and CSF biopsy are the key components in the diagnosis of NSCLC with LM. CSF cytology is insufficient and should be combined with liquid biology. The application of radiotherapy, intrathecal treatment, targeted therapy and immunotherapy provides more options for LM patients. Each treatment has a particular level of efficacy and can be used alone or in combination for individual patients. New technologies in radiotherapy, drug repositioning in intrathecal treatment, and the higher CSF permeability in TKIs have brought new breakthroughs in the treatment of LM. This review focused on clarifying the potential mechanisms, discussing the major clinical challenges, and summarizing recent advances in the diagnosis and treatment of LM from NSCLC. Future research is essential to improve the efficiency of diagnosis, to optimize therapy and to enhance patient prognosis.