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Remsik J, Boire A. The path to leptomeningeal metastasis. Nat Rev Cancer 2024:10.1038/s41568-024-00700-y. [PMID: 38871881 DOI: 10.1038/s41568-024-00700-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/29/2024] [Indexed: 06/15/2024]
Abstract
The leptomeninges, the cerebrospinal-fluid-filled tissues surrounding the central nervous system, play host to various pathologies including infection, neuroinflammation and malignancy. Spread of systemic cancer into this space, termed leptomeningeal metastasis, occurs in 5-10% of patients with solid tumours and portends a bleak clinical prognosis. Previous, predominantly descriptive, clinical studies have provided few insights. Recent development of preclinical leptomeningeal metastasis models, alongside genomic, transcriptomic and proteomic sequencing efforts, has provided groundwork for mechanistic understanding and identification of long-needed therapeutic targets. Although previously understood as an anatomically isolated compartment, the leptomeninges are increasingly appreciated as a major conduit of communication between the systemic circulation and the central nervous system. Despite the unique nature of the leptomeningeal microenvironment, the general principles of metastasis hold true: cells metastasizing to the leptomeninges must gain access to the new environment, survive within the space and evade the immune system. The study of leptomeningeal metastasis has the potential to uncover novel site-specific metastatic principles and illuminate the physiology of the leptomeningeal space. In this Review, we provide a biology-focused overview of how metastatic cells reach the leptomeninges, thrive in this nutritionally sparse environment and evade the detection of the omnipresent immune system.
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Affiliation(s)
- Jan Remsik
- Human Oncology & Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Laboratory for Immunology of Metastatic Ecosystems, Center for Cancer Biology, VIB, Leuven, Belgium
- Department of Oncology, KU Leuven, Leuven, Belgium
| | - Adrienne Boire
- Human Oncology & Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Brain Tumour Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Low SSP, El-Shakankery K, Brown E, Christie A, McCormack S, Stares M. Case report: A rare case of immunotherapy induced isolated left CN VI palsy in a patient with unresectable melanoma. Front Oncol 2024; 14:1330271. [PMID: 38410107 PMCID: PMC10896602 DOI: 10.3389/fonc.2024.1330271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 01/23/2024] [Indexed: 02/28/2024] Open
Abstract
Introduction Immune checkpoint inhibitors are the mainstay of treatment in patients with unresectable or metastatic melanoma. Combination immunotherapy with ipilimumab and nivolumab has shown to improve survival outcomes as compared to single agent immunotherapy in these patients. Neurological immune-related adverse effects (irAEs) are uncommon and cranial nerve palsies are seen even more infrequently. Case presentation A 66-year-old woman with a background of metastatic, unresectable melanoma with supraclavicular and axillary lymph nodal involvement presented with a headache, photophobia and diplopia 3 weeks after her first cycle of ipilimumab and nivolumab. She was subsequently diagnosed with a left-sided cranial nerve VI palsy and treated with high dose oral steroids and steroid eye drops, with complete resolution of symptoms. She also experienced Grade 3 dermatitis requiring topical steroids, Grade 2 hypothyroidism and vitiligo. She continues to have an excellent clinical and radiological response, despite further immunotherapy being suspended. Conclusion This is the first reported UK case of immunotherapy-induced isolated cranial nerve VI palsy. Multiple irAEs are more common with combination immunotherapy and its occurrence is associated with more favourable outcomes in melanoma. Immunotherapy continues to revolutionise oncological care, but clinicians must be cognizant of unpredictable irAEs, which may require prompt assessment and intervention.
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Affiliation(s)
- Samantha Su Ping Low
- Edinburgh Cancer Centre, Western General Hospital, NHS Lothian, Edinburgh, United Kingdom
| | - Karim El-Shakankery
- Edinburgh Cancer Centre, Western General Hospital, NHS Lothian, Edinburgh, United Kingdom
| | - Ewan Brown
- Edinburgh Cancer Centre, Western General Hospital, NHS Lothian, Edinburgh, United Kingdom
| | - Alan Christie
- Edinburgh Cancer Centre, Western General Hospital, NHS Lothian, Edinburgh, United Kingdom
| | | | - Mark Stares
- Edinburgh Cancer Centre, Western General Hospital, NHS Lothian, Edinburgh, United Kingdom
- Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh, United Kingdom
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Zhou D, Gong Z, Wu D, Ma C, Hou L, Niu X, Xu T. Harnessing immunotherapy for brain metastases: insights into tumor-brain microenvironment interactions and emerging treatment modalities. J Hematol Oncol 2023; 16:121. [PMID: 38104104 PMCID: PMC10725587 DOI: 10.1186/s13045-023-01518-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 12/01/2023] [Indexed: 12/19/2023] Open
Abstract
Brain metastases signify a deleterious milestone in the progression of several advanced cancers, predominantly originating from lung, breast and melanoma malignancies, with a median survival timeframe nearing six months. Existing therapeutic regimens yield suboptimal outcomes; however, burgeoning insights into the tumor microenvironment, particularly the immunosuppressive milieu engendered by tumor-brain interplay, posit immunotherapy as a promising avenue for ameliorating brain metastases. In this review, we meticulously delineate the research advancements concerning the microenvironment of brain metastases, striving to elucidate the panorama of their onset and evolution. We encapsulate three emergent immunotherapeutic strategies, namely immune checkpoint inhibition, chimeric antigen receptor (CAR) T cell transplantation and glial cell-targeted immunoenhancement. We underscore the imperative of aligning immunotherapy development with in-depth understanding of the tumor microenvironment and engendering innovative delivery platforms. Moreover, the integration with established or avant-garde physical methodologies and localized applications warrants consideration in the prevailing therapeutic schema.
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Affiliation(s)
- Dairan Zhou
- Department of Neurosurgery, Changzheng Hospital, Naval Medical University, 415 Fengyang Road, Huangpu District, Shanghai, 200003, People's Republic of China
| | - Zhenyu Gong
- Department of Neurosurgery, Klinikum Rechts Der Isar, Technical University of Munich, Munich, 81675, Germany
| | - Dejun Wu
- Department of Neurosurgery, The Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, Anhui, People's Republic of China
| | - Chao Ma
- Department of Neurosurgery, The Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, Anhui, People's Republic of China
| | - Lijun Hou
- Department of Neurosurgery, Changzheng Hospital, Naval Medical University, 415 Fengyang Road, Huangpu District, Shanghai, 200003, People's Republic of China
| | - Xiaomin Niu
- Department of Shanghai Lung Cancer Center, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, 241 Huaihai West Road, Xuhui District, Shanghai, 200030, People's Republic of China.
| | - Tao Xu
- Department of Neurosurgery, Changzheng Hospital, Naval Medical University, 415 Fengyang Road, Huangpu District, Shanghai, 200003, People's Republic of China.
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Mantica M, Drappatz J. Immunotherapy associated central nervous system complications in primary brain tumors. Front Oncol 2023; 13:1124198. [PMID: 36874119 PMCID: PMC9981156 DOI: 10.3389/fonc.2023.1124198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/23/2023] [Indexed: 02/18/2023] Open
Abstract
Advances clarifying the genetics and function of the immune system within the central nervous system (CNS) and brain tumor microenvironment have led to increasing momentum and number of clinical trials using immunotherapy for primary brain tumors. While neurological complications of immunotherapy in extra-cranial malignancies is well described, the CNS toxicities of immunotherapy in patients with primary brain tumors with their own unique physiology and challenges are burgeoning. This review highlights the emerging and unique CNS complications associated with immunotherapy including checkpoint inhibitors, oncolytic viruses, adoptive cell transfer/chimeric antigen receptor (CAR) T cell and vaccines for primary brain tumors, as well as reviews modalities that have been currently employed or are undergoing investigation for treatment of such toxicities.
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Affiliation(s)
- Megan Mantica
- Department of Neurology, University of Pittsburgh, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, United States
| | - Jan Drappatz
- Department of Neurology, University of Pittsburgh, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, United States
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Sterner RC, Sterner RM. Immune effector cell associated neurotoxicity syndrome in chimeric antigen receptor-T cell therapy. Front Immunol 2022; 13:879608. [PMID: 36081506 PMCID: PMC9445841 DOI: 10.3389/fimmu.2022.879608] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
Chimeric antigen receptor (CAR)-T cell therapy is an emerging staple in the treatment of certain hematological malignancies. While CAR-T cells have produced robust responses in certain hematological malignancies, toxicities associated with the therapy have limited their use. Immune Effector Cell Associated Neurotoxicity Syndrome (ICANS) is a potentially life-threatening neurotoxicity that commonly occurs with CAR-T cell therapy. Here we will discuss ICANS, its treatment, possible mechanisms, and potential solutions to this critical limitation of CAR-T cell therapy. As the field of CAR-T cell therapy evolves, improved treatments and methods to circumvent or overcome ICANS are necessary to improve morbidity, mortality, and decrease the cost of CAR-T cell therapy. This serious, life-threatening side effect needs to be studied to better understand its mechanisms and develop treatments and alternative strategies.
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Affiliation(s)
- Robert C. Sterner
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
| | - Rosalie M. Sterner
- Department of Surgery, Mayo Clinic, Rochester, MN, United States
- *Correspondence: Rosalie M. Sterner,
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Brummer AB, Yang X, Ma E, Gutova M, Brown CE, Rockne RC. Dose-dependent thresholds of dexamethasone destabilize CAR T-cell treatment efficacy. PLoS Comput Biol 2022; 18:e1009504. [PMID: 35081104 PMCID: PMC8820647 DOI: 10.1371/journal.pcbi.1009504] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 02/07/2022] [Accepted: 01/12/2022] [Indexed: 12/14/2022] Open
Abstract
Chimeric antigen receptor (CAR) T-cell therapy is potentially an effective targeted immunotherapy for glioblastoma, yet there is presently little known about the efficacy of CAR T-cell treatment when combined with the widely used anti-inflammatory and immunosuppressant glucocorticoid, dexamethasone. Here we present a mathematical model-based analysis of three patient-derived glioblastoma cell lines treated in vitro with CAR T-cells and dexamethasone. Advanced in vitro experimental cell killing assay technologies allow for highly resolved temporal dynamics of tumor cells treated with CAR T-cells and dexamethasone, making this a valuable model system for studying the rich dynamics of nonlinear biological processes with translational applications. We model the system as a nonautonomous, two-species predator-prey interaction of tumor cells and CAR T-cells, with explicit time-dependence in the clearance rate of dexamethasone. Using time as a bifurcation parameter, we show that (1) dexamethasone destabilizes coexistence equilibria between CAR T-cells and tumor cells in a dose-dependent manner and (2) as dexamethasone is cleared from the system, a stable coexistence equilibrium returns in the form of a Hopf bifurcation. With the model fit to experimental data, we demonstrate that high concentrations of dexamethasone antagonizes CAR T-cell efficacy by exhausting, or reducing the activity of CAR T-cells, and by promoting tumor cell growth. Finally, we identify a critical threshold in the ratio of CAR T-cell death to CAR T-cell proliferation rates that predicts eventual treatment success or failure that may be used to guide the dose and timing of CAR T-cell therapy in the presence of dexamethasone in patients. Bioengineering and gene-editing technologies have paved the way for advance immunotherapies that can target patient-specific tumor cells. One of these therapies, chimeric antigen receptor (CAR) T-cell therapy has recently shown promise in treating glioblastoma, an aggressive brain cancer often with poor patient prognosis. Dexamethasone is a commonly prescribed anti-inflammatory medication due to the health complications of tumor associated swelling in the brain. However, the immunosuppressant effects of dexamethasone on the immunotherapeutic CAR T-cells are not well understood. To address this issue, we use mathematical modeling to study in vitro dynamics of dexamethasone and CAR T-cells in three patient-derived glioblastoma cell lines. We find that in each cell line studied there is a threshold of tolerable dexamethasone concentration. Below this threshold, CAR T-cells are successful at eliminating the cancer cells, while above this threshold, dexamethasone critically inhibits CAR T-cell efficacy. Our modeling suggests that in the presence of high dexamethasone reduced CAR T-cell efficacy, or increased exhaustion, can occur and result in CAR T-cell treatment failure.
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Affiliation(s)
- Alexander B. Brummer
- Department of Computational and Quantitative Medicine, Division of Mathematical Oncology, Beckman Research Institute, City of Hope National Medical Center, Duarte, California, United States of America
- * E-mail: (ABB); (CEB); (RCR)
| | - Xin Yang
- Department of Hematology and Hematopoietic Cell Translation and Immuno-Oncology, Beckman Research Institute, City of Hope National Medical Center, Duarte, California, United States of America
| | - Eric Ma
- Department of Hematology and Hematopoietic Cell Translation and Immuno-Oncology, Beckman Research Institute, City of Hope National Medical Center, Duarte, California, United States of America
| | - Margarita Gutova
- Department of Stem Cell Biology and Regenerative Medicine, Beckman Research Institute, City of Hope National Medical Center, Duarte, California, United States of America
| | - Christine E. Brown
- Department of Hematology and Hematopoietic Cell Translation and Immuno-Oncology, Beckman Research Institute, City of Hope National Medical Center, Duarte, California, United States of America
- * E-mail: (ABB); (CEB); (RCR)
| | - Russell C. Rockne
- Department of Computational and Quantitative Medicine, Division of Mathematical Oncology, Beckman Research Institute, City of Hope National Medical Center, Duarte, California, United States of America
- * E-mail: (ABB); (CEB); (RCR)
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