1
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Freret ME, Boire A. The anatomic basis of leptomeningeal metastasis. J Exp Med 2024; 221:e20212121. [PMID: 38451255 PMCID: PMC10919154 DOI: 10.1084/jem.20212121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 09/20/2022] [Accepted: 02/08/2024] [Indexed: 03/08/2024] Open
Abstract
Leptomeningeal metastasis (LM), or spread of cancer to the cerebrospinal fluid (CSF)-filled space surrounding the central nervous system, is a fatal complication of cancer. Entry into this space poses an anatomical challenge for cancer cells; movement of cells between the blood and CSF is tightly regulated by the blood-CSF barriers. Anatomical understanding of the leptomeninges provides a roadmap of corridors for cancer entry. This Review describes the anatomy of the leptomeninges and routes of cancer spread to the CSF. Granular understanding of LM by route of entry may inform strategies for novel diagnostic and preventive strategies as well as therapies.
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Affiliation(s)
- Morgan E. Freret
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Adrienne Boire
- Department of Neurology, Human Oncology and Pathogenesis Program, Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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2
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Tewarie IA, Senko AW, Jessurun CAC, Zhang AT, Hulsbergen AFC, Rendon L, McNulty J, Broekman MLD, Peng LC, Smith TR, Phillips JG. Predicting leptomeningeal disease spread after resection of brain metastases using machine learning. J Neurosurg 2023; 138:1561-1569. [PMID: 36272119 DOI: 10.3171/2022.8.jns22744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 08/25/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The incidence of leptomeningeal disease (LMD) has increased as treatments for brain metastases (BMs) have improved and patients with metastatic disease are living longer. Sample sizes of individual studies investigating LMD after surgery for BMs and its risk factors have been limited, ranging from 200 to 400 patients at risk for LMD, which only allows the use of conventional biostatistics. Here, the authors used machine learning techniques to enhance LMD prediction in a cohort of surgically treated BMs. METHODS A conditional survival forest, a Cox proportional hazards model, an extreme gradient boosting (XGBoost) classifier, an extra trees classifier, and logistic regression were trained. A synthetic minority oversampling technique (SMOTE) was used to train the models and handle the inherent class imbalance. Patients were divided into an 80:20 training and test set. Fivefold cross-validation was used on the training set for hyperparameter optimization. Patients eligible for study inclusion were adults who had consecutively undergone neurosurgical BM treatment, had been admitted to Brigham and Women's Hospital from January 2007 through December 2019, and had a minimum of 1 month of follow-up after neurosurgical treatment. RESULTS A total of 1054 surgically treated BM patients were included in this analysis. LMD occurred in 168 patients (15.9%) at a median of 7.05 months after BM diagnosis. The discrimination of LMD occurrence was optimal using an XGboost algorithm (area under the curve = 0.83), and the time to LMD was prognosticated evenly by the random forest algorithm and the Cox proportional hazards model (C-index = 0.76). The most important feature for both LMD classification and regression was the BM proximity to the CSF space, followed by a cerebellar BM location. Lymph node metastasis of the primary tumor at BM diagnosis and a cerebellar BM location were the strongest risk factors for both LMD occurrence and time to LMD. CONCLUSIONS The outcomes of LMD patients in the BM population are predictable using SMOTE and machine learning. Lymph node metastasis of the primary tumor at BM diagnosis and a cerebellar BM location were the strongest LMD risk factors.
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Affiliation(s)
- Ishaan Ashwini Tewarie
- 1Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- 4Department of Neurosurgery, Leiden Medical Center, Leiden, The Netherlands; and
| | - Alexander W Senko
- 1Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Charissa A C Jessurun
- 1Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- 3Department of Neurosurgery, Haaglanden Medical Center, The Hague
- 4Department of Neurosurgery, Leiden Medical Center, Leiden, The Netherlands; and
| | - Abigail Tianai Zhang
- 1Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Alexander F C Hulsbergen
- 1Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- 3Department of Neurosurgery, Haaglanden Medical Center, The Hague
- 4Department of Neurosurgery, Leiden Medical Center, Leiden, The Netherlands; and
| | - Luis Rendon
- 1Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jack McNulty
- 1Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marike L D Broekman
- 1Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- 3Department of Neurosurgery, Haaglanden Medical Center, The Hague
- 4Department of Neurosurgery, Leiden Medical Center, Leiden, The Netherlands; and
| | - Luke C Peng
- 1Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Timothy R Smith
- 1Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - John G Phillips
- 1Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- 5Department of Radiation Oncology, Tennessee Oncology, Nashville, Tennessee
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3
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Byun J, Kim JH. Revisiting the Role of Surgical Resection for Brain Metastasis. Brain Tumor Res Treat 2023; 11:1-7. [PMID: 36762802 PMCID: PMC9911712 DOI: 10.14791/btrt.2022.0028] [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] [Received: 08/11/2022] [Revised: 01/07/2023] [Accepted: 01/09/2023] [Indexed: 02/05/2023] Open
Abstract
Brain metastasis (BM) is the most common type of brain tumor in adults. The contemporary management of BM remains challenging. Advancements in systemic cancer treatment have increased the survival of patients with cancer. Although the treatment of BM is still complicated, advances in radiotherapy, including stereotactic radiosurgery and chemotherapy, have improved treatment outcomes. Surgical resection is the traditional treatment for BM and its role in the surgical resection of BM has been well established. However, refinement of the surgical resection technique and strategy for BM is needed. Herein, we discuss the evolving role of surgery in patients with BM and the future of BM treatment.
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Affiliation(s)
- Joonho Byun
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jong Hyun Kim
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea.
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4
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Kozak MM, Karl J, von Eyben R, Guo F, Gutkin P, Horst K. Incidence of Brain Metastases in Women Treated With Neoadjuvant Chemotherapy for Breast Cancer: Implications for Screening. Clin Breast Cancer 2022; 22:e916-e921. [PMID: 36068116 DOI: 10.1016/j.clbc.2022.08.002] [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] [Received: 06/29/2022] [Accepted: 08/08/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE Patients with metastatic breast cancer may develop brain metastases. Our study identified high-risk patients to refine selection criteria for BM screening approaches. PATIENTS We reviewed breast cancer patients treated with neoadjuvant chemotherapy (NAC) at a single university center between 2005 and 2019. METHODS Competing risks analysis was performed with the Fine and Gray model to analyze the cumulative incidence of BM and loco-regional recurrence. Overall survival (OS) and progression-free survival (PFS) were calculated using Kaplan-Meier and log-rank tests. Multivariable analysis was performed with Cox proportional hazards regression to identify factors predictive for development of BM. Statistical significance was determined as a 2-sided P value of <.05. RESULTS In total, 112 patients experienced distant failure (DF) and 49 patients developed BM. Twenty patients with BM (41%) presented with symptoms requiring craniotomy +/- whole brain radiation treatment. Patients with BM were significantly more likely to have local (P < .01) and regional (P < .01) failure. On multivariable analysis, age <40 years (P = .011), presence of lung metastases (P < .0001), and residual nodal disease with >4 lymph nodes positive after NAC (P = .024) all predicted for increased likelihood of BM. Patients with these criteria had higher likelihoods of having BM (P = .013) and worse PFS (P = .044). On multivariable analysis for OS, presence of lung metastases was the most significant predictor of poor outcome (P < .0001). CONCLUSION We propose a study of screening brain MRI for young (<40 years) patients with breast cancer receiving NAC and patients who develop metastatic disease post-NAC, especially those with lung involvement.
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Affiliation(s)
- Margaret M Kozak
- University of Iowa Hospitals and Clinics, Department of Radiation Oncology, Iowa City, IA
| | - Jamie Karl
- Stanford University, Department of Radiation Oncology, Stanford, CA
| | - Rie von Eyben
- Stanford University, Department of Radiation Oncology, Stanford, CA
| | - Felicia Guo
- Stanford University, Department of Radiation Oncology, Stanford, CA
| | - Paulina Gutkin
- Stanford University, Department of Radiation Oncology, Stanford, CA
| | - Kathleen Horst
- Stanford University, Department of Radiation Oncology, Stanford, CA.
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5
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Smith PD, Bhenderu LS, Kommuri S, Fleener EE, Hoover JM. Treatment of Leptomeningeal Carcinomatosis Following Treatment of Cerebellar Metastasis of HER2+ (Human Epidermal Growth Factor Receptor 2 Positive) Breast Cancer: Case Report and Review of Literature. Cureus 2022; 14:e24008. [PMID: 35547416 PMCID: PMC9090228 DOI: 10.7759/cureus.24008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2022] [Indexed: 11/12/2022] Open
Abstract
Leptomeningeal carcinomatosis (LC) after metastasis of breast cancer is a rare occurrence with potentially devastating complications. Treatment options are limited, and there is a lack of literature on this topic. We report the case of a 38-year-old woman with estrogen/progesterone receptor negative (ER/PR-), human epidermal growth factor receptor 2 positive (HER2+) invasive ductal carcinoma of the left breast who underwent bilateral mastectomies with axillary lymph node dissection and chemotherapy treatment. The patient returned 11 months later with persistent headaches. Imaging and resection found cerebellar metastasis of the breast carcinoma. The brain metastasis was treated with further chemotherapy and stereotactic radiosurgery. Follow-up imaging showed the development of small lesions outside the radiation site. Metabolic studies were performed to determine if the new lesions were due to tumor recurrence or radiation necrosis, but the studies were inconclusive as to the etiology of these lesions. The patient later developed LC that was successfully treated with full resolution of the disease using intrathecal trastuzumab. There are currently no consensuses on treatment guidelines for treating LC. Here, we demonstrate successful treatment of LC from an ER/PR-, HER2+ breast carcinoma with intrathecal trastuzumab.
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Lowe SR, Wang CP, Brisco A, Whiting J, Arrington J, Ahmed K, Yu M, Robinson T, Oliver D, Etame A, Tran N, Beer Furlan A, Sahebjam S, Mokhtari S, Piña Y, Macaulay R, Forsyth P, Vogelbaum MA, Liu JKC. Surgical and anatomic factors predict development of leptomeningeal disease in patients with melanoma brain metastases. Neuro Oncol 2022; 24:1307-1317. [PMID: 35092434 PMCID: PMC9340645 DOI: 10.1093/neuonc/noac023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Leptomeningeal disease (LMD) is a devastating complication of systemic malignancy, of which there is an unclear etiology. The aim of this study is to determine if surgical or anatomic factors can predict LMD in patients with metastatic melanoma. METHODS A retrospective chart review was performed of 1162 patients treated at single institution for melanoma brain metastases (MBM). Patients with fewer than 3 months follow-up or lacking appropriate imaging were excluded. Demographic information, surgical, and anatomic data were collected. RESULTS Eight hundred and twenty-seven patients were included in the final review. On multivariate analysis for the entire cohort, female gender, dural-based and intraventricular metastasis, and tumor bordering CSF spaces were associated with increased risk of LMD. Surgical resection was not significant for risk of LMD. On multivariate analysis of patients who have undergone surgical resection of a metastatic tumor, dural-based and intraventricular metastasis, ventricular entry during surgery, and metastasis in the infratentorial space were associated with increased risk of LMD. On multivariate analysis of patients who did not undergo surgery, chemotherapy after initial diagnosis and metastasis bordering CSF spaces were associated with increased risk of LMD. CONCLUSION In a single-institution cohort of MBM, we found that surgical resection alone did not result in an increased risk of LMD. Anatomical factors such as dural-based and intraventricular metastasis were significant for developing LMD, as well as entry into a CSF space during surgical resection. These data suggest a strong correlation between anatomic location and tumor cell seeding in relation to the development of LMD.
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Affiliation(s)
- Stephen R Lowe
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Christopher P Wang
- University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Amanda Brisco
- University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Junmin Whiting
- Department of Biostatistics & Bioinformatics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - John Arrington
- Department of Radiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Kamran Ahmed
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Michael Yu
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Timothy Robinson
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Daniel Oliver
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Arnold Etame
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Nam Tran
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Andre Beer Furlan
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Solmaz Sahebjam
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Sepideh Mokhtari
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Yolanda Piña
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Robert Macaulay
- Department of Pathology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Peter Forsyth
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Michael A Vogelbaum
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - James K C Liu
- Corresponding Author: James K. C. Liu, MD, Department of Neuro-Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA ()
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Roshchina KE, Bekyashev AK, Gasparyan TG, Aleshin VA, Osinov IK, Savateev AN, Khalafyan DA. Modern possibilities of neurosurgical treatment of brain metastases. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2022; 86:119-125. [PMID: 36252202 DOI: 10.17116/neiro202286051119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Despite significant progress in neuroimaging and introduction of new combined treatments for solid tumors, brain metastases are still adverse factor for overall survival. Brain metastases are diagnosed in 8-10% of patients and associated with extremely poor prognosis. These lesions result focal and general cerebral symptoms. Literature review highlights the current principles of surgical treatment of metastatic brain lesions in patients with solid tumors.
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Affiliation(s)
- K E Roshchina
- Blokhin National Medical Research Center of Oncology, Moscow, Russia
| | - A Kh Bekyashev
- Blokhin National Medical Research Center of Oncology, Moscow, Russia
- Russian Medical Academy for Continuous Professional Education, Moscow, Russia
| | - T G Gasparyan
- Blokhin National Medical Research Center of Oncology, Moscow, Russia
- Scientific Center of Neurology, Moscow, Russia
| | - V A Aleshin
- Blokhin National Medical Research Center of Oncology, Moscow, Russia
| | - I K Osinov
- Burdenko Neurosurgical Center, Moscow, Russia
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8
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Leptomeningeal Disease. Hematol Oncol Clin North Am 2021; 36:189-215. [PMID: 34756800 DOI: 10.1016/j.hoc.2021.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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9
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Hartanto RA, Tamba DA, Setyawan NH, Ekaputra E, Malueka RG, Harahap ISK, Dwianingsih EK. Extraventricular Choroid Plexus Carcinoma with Spinal Metastasis: A Case Report. Open Access Maced J Med Sci 2021. [DOI: 10.3889/oamjms.2021.6240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
We report a case of extraventricular choroid plexus carcinoma (CPC) accompanied by spinal metastasis in a pediatric patient. A 15-year-old female patient presented with chronic progressive headache and blurry vision. Magnetic resonance imaging (MRI) revealed an intra-axial mass in the left frontal lobe. A gross total resection was performed, and the histopathological examination revealed the diagnosis of CPC, confirmed with immunohistochemical (IHC) analysis of GFAP, S100, EM, P53 and Ki67. Eleven months later, MRI result identified another mass in the left frontal lobe. Spinal MRI showed drop metastasis to the spine, accompanied by leptomeningeal seeding. This case demonstrated the importance of IHC and spinal MRI in the management of CPC. This case report may provide more insight into extraventricular CPC cases, which is important for the adequate management of patients with CPC in the future.
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Dankner M, Lam S, Degenhard T, Garzia L, Guiot MC, Petrecca K, Siegel PM. The Underlying Biology and Therapeutic Vulnerabilities of Leptomeningeal Metastases in Adult Solid Cancers. Cancers (Basel) 2021; 13:cancers13040732. [PMID: 33578853 PMCID: PMC7916586 DOI: 10.3390/cancers13040732] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/03/2021] [Accepted: 02/06/2021] [Indexed: 01/18/2023] Open
Abstract
Metastasis to the central nervous system occurs in approximately 20% of patients with advanced solid cancers such as lung cancer, breast cancer, and melanoma. While central nervous system metastases most commonly form in the brain parenchyma, metastatic cancer cells may also reside in the subarachnoid space surrounding the brain and spinal cord to form tumors called leptomeningeal metastases. Leptomeningeal metastasis involves cancer cells that reach the subarachnoid space and proliferate in the cerebrospinal fluid compartment within the leptomeninges, a sequela associated with a myriad of symptoms and poor prognosis. Cancer cells exposed to cerebrospinal fluid in the leptomeninges must contend with a unique microenvironment from those that establish within the brain or other organs. Leptomeningeal lesions provide a formidable clinical challenge due to their often-diffuse infiltration within the subarachnoid space. The molecular mechanisms that promote the establishment of leptomeningeal metastases have begun to be elucidated, demonstrating that it is a biological entity distinct from parenchymal brain metastases and is associated with specific molecular drivers. In this review, we outline the current state of knowledge pertaining to the diagnosis, treatment, and molecular underpinnings of leptomeningeal metastasis.
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Affiliation(s)
- Matthew Dankner
- Goodman Cancer Research Centre, Faculty of Medicine, McGill University, Montreal, QC H3A 1A3, Canada; (M.D.); (M.-C.G.)
| | - Stephanie Lam
- Department of Diagnostic Radiology, Faculty of Medicine, Research Institute of the McGill University Health Centre, Montreal, QC H3T 1E2, Canada;
- Research Institute of the McGill University Health Centre, Montreal, QC H4A 3J1, Canada;
| | - Theresa Degenhard
- Department of Neurology and Neurosurgery, Montreal Neurological Institute-Hospital, Goodman Cancer Research Centre, McGill University, Montreal, QC H3A 2B4, Canada; (T.D.); (K.P.)
- Department of Neurology and Neurosurgery, Montreal Neurological Institute-Hospital, McGill University, Montreal, QC H3A 2B4, Canada
| | - Livia Garzia
- Research Institute of the McGill University Health Centre, Montreal, QC H4A 3J1, Canada;
| | - Marie-Christine Guiot
- Goodman Cancer Research Centre, Faculty of Medicine, McGill University, Montreal, QC H3A 1A3, Canada; (M.D.); (M.-C.G.)
- Department of Neurology and Neurosurgery, Montreal Neurological Institute-Hospital, Goodman Cancer Research Centre, McGill University, Montreal, QC H3A 2B4, Canada; (T.D.); (K.P.)
- Department of Neurology and Neurosurgery, Montreal Neurological Institute-Hospital, McGill University, Montreal, QC H3A 2B4, Canada
- Department of Pathology, McGill University, Montreal, QC H3A 1A3, Canada
| | - Kevin Petrecca
- Department of Neurology and Neurosurgery, Montreal Neurological Institute-Hospital, Goodman Cancer Research Centre, McGill University, Montreal, QC H3A 2B4, Canada; (T.D.); (K.P.)
- Department of Neurology and Neurosurgery, Montreal Neurological Institute-Hospital, McGill University, Montreal, QC H3A 2B4, Canada
| | - Peter M. Siegel
- Goodman Cancer Research Centre, Faculty of Medicine, McGill University, Montreal, QC H3A 1A3, Canada; (M.D.); (M.-C.G.)
- Department of Diagnostic Radiology, Faculty of Medicine, Research Institute of the McGill University Health Centre, Montreal, QC H3T 1E2, Canada;
- Department of Neurology and Neurosurgery, Montreal Neurological Institute-Hospital, Goodman Cancer Research Centre, McGill University, Montreal, QC H3A 2B4, Canada; (T.D.); (K.P.)
- Department of Biochemistry, McGill University, Montreal, QC H3A 1A3, Canada
- Department of Anatomy & Cell Biology, McGill University, Montreal, QC H3A 1A3, Canada
- Department of Oncology, McGill University, Montreal, QC H3A 1A3, Canada
- Correspondence: ; Tel.: +1-514-398-4259; Fax: +1-514-398-6769
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Scharl S, Kessel KA, Diehl C, Gempt J, Meyer B, Zimmer C, Straube C, Combs SE. Is local radiotherapy a viable option for patients with an opening of the ventricles during surgical resection of brain metastases? Radiat Oncol 2020; 15:276. [PMID: 33303000 PMCID: PMC7730779 DOI: 10.1186/s13014-020-01725-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 12/06/2020] [Indexed: 11/10/2022] Open
Abstract
Background Local hypofractionated stereotactic radiotherapy (HFSRT) of the resection cavity is emerging as the standard of care in the treatment of patients with a limited number of brain metastases as it warrants less neurological impairment compared to whole brain radiotherapy. In periventricular metastases surgical resection can lead to an opening of the ventricles and subsequently carries a potential risk of cerebrospinal tumour cell dissemination. The aim of this study was to assess whether local radiotherapy of the resection cavity is viable in these cases. Methods From our institutional database we analyzed the data of 125 consecutive patients with resected brain metastases treated in our institution with HFSRT between 2009 and 2017. The incidence of LMD, overall survival (OS), local recurrence (LC) and distant recurrence were evaluated depending on ventricular opening (VO) during surgery. Results From all 125 patients, the ventricles were opened during surgery in 14 cases (11.2%). None of the patients with VO and 7 patients without VO during surgery developed LMD (p = 0.371). OS (p = 0.817), LC (p = 0.524) and distant recurrence (p = 0.488) did not differ in relation to VO during surgical resection. However, the incidence of distant intraventricular recurrence was slightly increased in patients with VO (14.3% vs. 2.7%, p < 0.01). Conclusion VO during neurosurgical resection did not affect the outcome after HFSRT of the resection cavity in patients with brain metastases. Particularly, the incidence of LMD was not increased in patients receiving local HFSRT after VO. HFSRT can therefore be offered independently of VO as a local treatment of tumor bed after resection of brain metastases.
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Affiliation(s)
- Sophia Scharl
- Department of Radiation Oncology, Technische Universität München (TUM), Ismaninger Straße 22, Munich, Germany
| | - Kerstin A Kessel
- Department of Radiation Oncology, Technische Universität München (TUM), Ismaninger Straße 22, Munich, Germany.,Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, Ingolstädter Landstraße 1, Neuherberg, Germany.,Deutsches Konsortium Für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
| | - Christian Diehl
- Department of Radiation Oncology, Technische Universität München (TUM), Ismaninger Straße 22, Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, Technische Universität München (TUM), Ismaninger Straße 22, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Technische Universität München (TUM), Ismaninger Straße 22, Munich, Germany
| | - Claus Zimmer
- Department of Diagnostic and Interventional Neuroradiology, Technische Universität München (TUM), Ismaninger Straße 22, Munich, Germany
| | - Christoph Straube
- Department of Radiation Oncology, Technische Universität München (TUM), Ismaninger Straße 22, Munich, Germany.,Deutsches Konsortium Für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Technische Universität München (TUM), Ismaninger Straße 22, Munich, Germany. .,Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, Ingolstädter Landstraße 1, Neuherberg, Germany. .,Deutsches Konsortium Für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany.
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12
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Zhang M, Li G. Commentary: The Effects of Postoperative Neurological Deficits on Survival in Patients With Single Brain Metastasis. Oper Neurosurg (Hagerstown) 2020; 19:E552-E554. [PMID: 32860056 DOI: 10.1093/ons/opaa267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 06/27/2020] [Indexed: 11/12/2022] Open
Affiliation(s)
- Michael Zhang
- Department of Neurosurgery, Stanford Medical Center, Palo Alto, California
| | - Gordon Li
- Department of Neurosurgery, Stanford Medical Center, Palo Alto, California
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13
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Spinal Drop Metastasis of Glioblastoma-Two Case Reports, Clinicopathologic Features, Current Modalities of Evaluation, and Treatment with a Review of the Literature. World Neurosurg 2020; 146:261-269. [PMID: 33161132 DOI: 10.1016/j.wneu.2020.10.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 10/03/2020] [Accepted: 10/05/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Glioblastomas (World Health Organization grade IV) are aggressive primary neoplasms of the central nervous system. Spinal metastasis occurs supposedly in 2%-5% of patients. This percentage may be only the tip of iceberg because most succumb to the disease before clinical detection and few documented cases are reported. CASE DESCRIPTIONS A 45-year-old man presented with history of diplopia and gait disturbance. Magnetic resonance imaging showed a left cerebellar space-occupying lesion. The histopathology was consistent with glioblastoma. The patient underwent adjuvant chemoradiation. A year later, he presented with seizures, worsening headache, neck stiffness, and low back pain. Imaging showed metastasis to the S1/S2 region of the spinal canal. A 29-year-old man presented with episodic headaches associated with nausea, vomiting, neck stiffness, and imbalance while walking. Computed tomography of the brain showed a hypodense lesion involving the left midbrain, pons, and left middle cerebellar peduncle, causing fourth ventricular pressure with obstructive hydrocephalus. A navigation-guided biopsy of the brainstem lesion confirmed the diagnosis of glioblastoma World Health Organization grade IV, isocitrate dehydrogenase 1 (R132 H) and H3K27M negative. Isocitrate dehydrogenase gene sequencing was suggested. The patient was referred for chemoradiation. During treatment, he worsened neurologically and developed axial neck and back pain. Neuraxis screening showed disseminated leptomeningeal spread, which was confirmed on dural biopsy. CONCLUSIONS Spinal and dural metastasis should always be suspected in patients with glioblastoma with signs and symptoms not explained by primary lesion. A regular protocol with postcontrast magnetic resonance imaging before and after initial surgery is mandatory to detect spinal metastasis before it becomes clinically apparent, thereby improving the prognosis and quality of life in patients.
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Acute Management of Gamma Knife Radiosurgery for Asymptomatic Obstructive Hydrocephalus Associated with Posterior Fossa Metastases. World Neurosurg 2020; 144:e714-e722. [PMID: 32949796 DOI: 10.1016/j.wneu.2020.09.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 09/11/2020] [Accepted: 09/11/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We retrospectively assessed the effectiveness and safety of Gamma Knife radiosurgery (GKRS) for asymptomatic obstructive hydrocephalus associated with posterior fossa metastases, which was known empirically but not well discussed. METHODS We reviewed the medical records of 27 patients who underwent GKRS for asymptomatic obstructive hydrocephalus related to posterior fossa metastases. RESULTS Cumulative control rates of hydrocephalus were 11.1%, 51.9%, 70.4%, and 74.6% at 1, 2, 3, and 6 months after GKRS. Primary gastrointestinal tract cancer (P = 0.001) was significantly correlated with unfavorable management. Evans ratio at GKRS (median 0.31) improved significantly compared with that at 1-3 months after GKRS (median 0.26) (P < 0.0001) and maintained at 6 to 12 months. Cumulative local tumor control rates were 91.7%, 70.8%, and 64.4% at 3, 6, and 12 months after GKRS. Primary gastrointestinal tract cancer (P = 0.018) and no conventional systemic agents (P = 0.027) were significantly correlated with unfavorable control. Cumulative incidence rates of adverse radiation effects were 0.0%, 16.7%, and 24.2% at 6, 9, and 12 months after GKRS. Primary gastrointestinal tract cancer (P < 0.0001) and single and 2- or 3-fraction GKRS (P < 0.0001) were significantly correlated with unfavorable outcomes. All but 1 patient avoided surgical procedure for hydrocephalus after GKRS. CONCLUSIONS The present findings suggest that GKRS is an effective and safe treatment for asymptomatic obstructive hydrocephalus caused by posterior fossa metastases, and all but 1 could avoid invasive surgical procedures for hydrocephalus. Posterior fossa metastases from gastrointestinal tract cancer resulted in unsatisfactory outcomes for control of hydrocephalus, tumor progression, and adverse radiation effects.
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Umezawa Y, Shirotake S, Kaneko G, Nishimoto K, Okada Y, Uchino A, Yasuda M, Oyama M. Meningeal carcinomatosis from bladder cancer: A case report and review of the literature. Mol Clin Oncol 2019; 10:506-510. [PMID: 31007911 DOI: 10.3892/mco.2019.1820] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 02/04/2019] [Indexed: 11/06/2022] Open
Abstract
A 66-year-old Japanese male patient was referred to Saitama Medical University International Medical Center for treatment of bladder cancer (clinical stage T2 or higher without metastasis), and underwent radical cystectomy with pelvic lymphadenectomy. The histopathological diagnosis was high-grade urothelial carcinoma (pathological stage T2bN2, ly1, v0) and 2 cycles of adjuvant systemic chemotherapy (gemcitabine plus cisplatin) were administered. At 15 months after the operation, mediastinal and lung hilar lymph nodes and multiple bone metastases were identified on computed tomography imaging. After 3 cycles of the previous regimen as salvage systemic chemotherapy, the lymph node metastases had shrunk and the bone metastases were stable; therefore, further chemotherapy was planned. At 26 days after the initiation of the 4th cycle, the patient felt nausea and lower limb weakness. Spinal and brain magnetic resonance imaging with contrast medium revealed diffuse enhancement at the surface of the spinal cord and brain. In addition, abnormal signal intensity in the subarachnoid space was observed on fluid-attenuated inversion recovery imaging; therefore, the patient was diagnosed with meningeal carcinomatosis (MC). Treatment, including whole-brain radiotherapy, was planned for MC; however, the patient's condition rapidly worsened and he succumbed to the disease 14 days after the diagnosis of MC. The definitive diagnosis of MC was confirmed at autopsy.
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Affiliation(s)
- Yuta Umezawa
- Department of Uro-Oncology, Saitama Medical University International Medical Center, Hidaka, Saitama 350-1298, Japan
| | - Suguru Shirotake
- Department of Uro-Oncology, Saitama Medical University International Medical Center, Hidaka, Saitama 350-1298, Japan
| | - Go Kaneko
- Department of Uro-Oncology, Saitama Medical University International Medical Center, Hidaka, Saitama 350-1298, Japan
| | - Koshiro Nishimoto
- Department of Uro-Oncology, Saitama Medical University International Medical Center, Hidaka, Saitama 350-1298, Japan
| | - Yoshitaka Okada
- Department of Diagnostic Radiology, Saitama Medical University International Medical Center, Hidaka, Saitama 350-1298, Japan
| | - Akira Uchino
- Department of Diagnostic Radiology, Saitama Medical University International Medical Center, Hidaka, Saitama 350-1298, Japan
| | - Masanori Yasuda
- Department of Diagnostic Pathology, Saitama Medical University International Medical Center, Hidaka, Saitama 350-1298, Japan
| | - Masafumi Oyama
- Department of Uro-Oncology, Saitama Medical University International Medical Center, Hidaka, Saitama 350-1298, Japan
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Abstract
Leptomeningeal metastasis (LM) results from dissemination of cancer cells to both the leptomeninges (pia and arachnoid) and cerebrospinal fluid (CSF) compartment. Breast cancer, lung cancer, and melanoma are the most common solid tumors that cause LM. Recent approval of more active anticancer therapies has resulted in improvement in survival that is partly responsible for an increased incidence of LM. Neurologic deficits, once manifest, are mostly irreversible, and often have a significant impact on patient quality of life. LM-directed therapy is based on symptom palliation, circumscribed use of neurosurgery, limited field radiotherapy, intra-CSF and systemic therapies. Novel methods of detecting LM include detection of CSF circulating tumor cells and tumor cell-free DNA. A recent international guideline for a standardization of response assessment in LM may improve cross-trial comparisons as well as within-trial evaluation of treatment. An increasing number of retrospective studies suggest that molecular-targeted therapy, such as EGFR and ALK inhibitors in lung cancer, trastuzumab in HER2+ breast cancer, and BRAF inhibitors in melanoma, may be effective as part of the multidisciplinary management of LM. Prospective randomized trials with standardized response assessment are needed to further validate these preliminary findings.
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17
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Churilla TM, Handorf E, Collette S, Collette L, Dong Y, Aizer AA, Kocher M, Soffietti R, Alexander BM, Weiss SE. Whole brain radiotherapy after stereotactic radiosurgery or surgical resection among patients with one to three brain metastases and favorable prognoses: a secondary analysis of EORTC 22952-26001. Ann Oncol 2018; 28:2588-2594. [PMID: 28961826 DOI: 10.1093/annonc/mdx332] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background The absence of a survival benefit for whole brain radiotherapy (WBRT) among randomized trials has been attributed to a competing risk of death from extracranial disease. We re-analyzed EORTC 22952 to assess the impact of WBRT on survival for patients with controlled extracranial disease or favorable prognoses. Patients and methods We utilized Cox regression, landmark analysis, and the Kaplan-Meier method to evaluate the impact of WBRT on survival accounting for (i) extracranial progression as a time-dependent covariate in all patients and (ii) diagnosis-specific graded prognostic assessment (GPA) score in patients with primary non-small-cell lung cancer (NSCLC). Results A total of 329 patients treated per-protocol were included for analysis with a median follow up of 26 months. One hundred and fifteen (35%) patients had no extracranial progression; 70 (21%) patients had progression <90 days, 65 (20%) between 90 and 180 days, and 79 (24%) patients >180 days from randomization. There was no difference in the model-based risk of death in the WBRT group before [hazard ratio (HR) (95% CI)=0.70 (0.45-1.11), P = 0.133), or after [HR (95% CI)=1.20 (0.89-1.61), P = 0.214] extracranial progression. Among 177 patients with NSCLC, 175 had data available for GPA calculation. There was no significant survival benefit to WBRT among NSCLC patients with favorable GPA scores [HR (95% CI)=1.10 (0.68-1.79)] or unfavorable GPA scores [HR (95% CI)=1.11 (0.71-1.76)]. Conclusions Among patients with limited extracranial disease and one to three brain metastases at enrollment, we found no significant survival benefit to WBRT among NSCLC patients with favorable GPA scores or patients with any histology and controlled extracranial disease status. This exploratory analysis of phase III data supports the practice of omitting WBRT for patients with limited brain metastases undergoing SRS and close surveillance. Clinical Trials Number NCT00002899.
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Affiliation(s)
- T M Churilla
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, USA
| | - E Handorf
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, USA
| | | | | | - Y Dong
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, USA
| | - A A Aizer
- Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, USA
| | - M Kocher
- Department of Radiation Oncology, University of Cologne, Cologne, Germany
| | - R Soffietti
- Department of Neuro-oncology, University of Turin and City of Health and Science Hospital, Torino, Italy
| | - B M Alexander
- Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, USA
| | - S E Weiss
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, USA;.
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18
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Sinclair G, Benmakhlouf H, Martin H, Brigui M, Maeurer M, Dodoo E. The role of radiosurgery in the acute management of fourth ventricle compression due to brain metastases. Surg Neurol Int 2018; 9:112. [PMID: 29930878 PMCID: PMC5991270 DOI: 10.4103/sni.sni_387_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 12/26/2017] [Indexed: 11/16/2022] Open
Abstract
Background: Approximately 20–30% of all intracranial metastases are located in the posterior fossa. The clinical evolution hinges on factors such as tumor growth dynamics, local topographic conditions, performance status, and prompt intervention. Fourth ventricle (V4) compression with secondary life-threatening obstructive hydrocephalus remains a major concern, often requiring acute surgical intervention. We have previously reported on the application of adaptive hypofractionated Gamma Knife Radiosurgery in the acute management of critically located metastases, a technique known to us as rapid rescue radiosurgery (3R). We report the results of 3R in the management of posterior fossa lesions and ensuing V4 decompression. Case Descriptions: Four patients with V4 compression due to posterior fossa metastases were treated with 3R by three separate gamma knife radiosurgical sessions (GKRS) over a period of seven days. Mean V4 volume was 1.02 cm3 at GKRS 1, 1.13 cm3 at GKRS 2, and 1.12 cm3 at GKRS 3. Mean tumor volume during the week of treatment was 10 cm3 at both GKRS 1 and 2 and 9 cm3 at GKRS 3. On average, we achieved a tumor volume reduction of 52% and a V4 size increase of 64% at the first follow-up (4 weeks after GKRS 3). Long-term follow-up showed continued local tumor control, stable V4 volume, and absence of hydrocephalus. Conclusion: For this series, 3R was effective in terms of rapid tumor ablation, V4 decompression, and limited radiation-induced toxicity. This surgical procedure may become an additional tool in the management of intractable posterior fossa metastasis with V4 compression.
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Affiliation(s)
- G Sinclair
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - H Benmakhlouf
- Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - H Martin
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - M Brigui
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - M Maeurer
- Division of Therapeutic Immunology, Department of Laboratory Medicine, Karolinska Institute, Centre for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden
| | - E Dodoo
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
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Le Rhun E, Taillibert S, Chamberlain MC. Neoplastic Meningitis Due to Lung, Breast, and Melanoma Metastases. Cancer Control 2018; 24:22-32. [DOI: 10.1177/107327481702400104] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Emilie Le Rhun
- Division of Neuro-Oncology, Departments of Neurology and
Neurological Surgery, University of Washington School of Medicine, Seattle,
Washington
- Department of Neurosurgery, University Hospital, the Breast
Unit, Departments of Neurology and Neurological Surgery, University of Washington School of
Medicine, Seattle, Washington
| | - Sophie Taillibert
- Department of Medical Oncology, Oscar Lambret Center, Lille
Cedex, France, the Division of Neuro-Oncology, Departments of Neurology and Neurological
Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Marc C. Chamberlain
- Departments of Neurology, and Radiation Oncology,
Pitié-Salpétrière Hospital, Assistance Publique des Hôpitaux de Paris, Université Pierre et
Marie Curie, Paris, France, and the Department of Neurology, Fred Hutchinson Cancer Research
Center, Seattle Cancer Care Alliance, and Division of Neuro-Oncology, Departments of
Neurology and Neurological Surgery, University of Washington School of Medicine, Seattle,
Washington
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20
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Pellerino A, Bertero L, Rudà R, Soffietti R. Neoplastic meningitis in solid tumors: from diagnosis to personalized treatments. Ther Adv Neurol Disord 2018. [PMID: 29535794 PMCID: PMC5844521 DOI: 10.1177/1756286418759618] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Neoplastic meningitis (NM) is a devastating complication of solid tumors with poor outcome. Some randomized clinical trials have been conducted with heterogeneous inclusion criteria, diagnostic parameters, response evaluation and primary endpoints. Recently, the Leptomeningeal Assessment in Neuro-Oncology (LANO) Group and the European Society for Medical Oncology/European Association for Neuro-Oncology have proposed some recommendations in order to provide diagnostic criteria and response evaluation scores for NM. The aim of these guidelines is to integrate the neurological examination with magnetic resonance imaging and cerebrospinal fluid findings as well as to provide a framework for use in clinical trials. However, this composite assessment needs further validation. Since intrathecal therapy represents a treatment with limited efficacy in NM, many studies have been conducted on systemic therapies, including target therapies, with some encouraging results in terms of disease control. In this review, we have analyzed the clinical aspects and the most recent diagnostic tools and therapeutic options in NM.
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Affiliation(s)
- Alessia Pellerino
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Via Cherasco 15, Turin, 10126 Italy
| | - Luca Bertero
- Section of Pathology, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Roberta Rudà
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
| | - Riccardo Soffietti
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
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21
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Thon N, Kreth FW, Tonn JC. The role of surgery for brain metastases from solid tumors. HANDBOOK OF CLINICAL NEUROLOGY 2018; 149:113-121. [PMID: 29307348 DOI: 10.1016/b978-0-12-811161-1.00008-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Surgery, stereotactic radiosurgery, radiotherapy, and chemotherapy including novel targeted therapy strategies and any combination thereof as well as supportive care are the key elements for treatment of brain metastases. Goals of microsurgery are to obtain tissue samples for histologic diagnosis (particularly in case of uncertainty about the unknown primary tumor but also in the context of future targeted therapies), to relieve burden from space-occupying effects, to improve local tumor control, and to prolong overall survival. Complete surgical resection improves local tumor control and may even affect overall survival. Stereotactic radiosurgery is an equal effective alternative for metastases up to 3 cm in diameter, especially in highly eloquent or deep seated location. Gross total resection (as defined by immediate postoperative MRI) does not necessarily have to be combined with whole brain radiotherapy (WBRT), at least for patients with good performance status and controlled systemic disease. Particularly in cases of incomplete resections, focal irradiation or radiosurgery of the resection cavity or tumor remnant rather than WBRT may be attempted.
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Affiliation(s)
- Niklas Thon
- Department of Neurosurgery, University of Munich LMU, Munich, Germany
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22
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Ma R, Levy M, Gui B, Lu SE, Narra V, Goyal S, Danish S, Hanft S, Khan AJ, Malhotra J, Motwani S, Jabbour SK. Risk of leptomeningeal carcinomatosis in patients with brain metastases treated with stereotactic radiosurgery. J Neurooncol 2018; 136:395-401. [PMID: 29159778 DOI: 10.1007/s11060-017-2666-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 11/04/2017] [Indexed: 11/27/2022]
Abstract
There is limited available literature examining factors that predispose patients to the development of LMC after stereotactic radiosurgery (SRS) for brain metastases. We sought to evaluate risk factors that may predispose patients to LMC after SRS treatment in this case-control study of patients with brain metastases who underwent single-fraction SRS between 2011 and 2016. Demographic and clinical information were collected retrospectively for 19 LMC cases and 30 controls out of 413 screened patients with brain metastases. Risk factors of interest were evaluated by univariate and multivariate logistic regression analyses and overall survival rates were evaluated by Kaplan-Meier survival analysis. About 5% of patients with brain metastases treated with SRS developed LMC. Patients with LMC (median 154 days, 95% CI 33-203 days) demonstrated a poorer overall survival than matched controls (median 417 days, 95% CI 121-512 days, p = 0.002). The most common primary tumor histologies that lead to the development of LMC were non-small cell lung cancer (36.8%), breast cancer (26.3%), and melanoma (21.1%). No association was found between the risk of LMC and the location of the brain lesion or total volume of brain metastases. Prior surgical resection of brain metastases before SRS was associated with a 6.5 times higher odds (95% CI 1.45-29.35, p = 0.01) of developing LMC post-radiosurgery compared to those with no prior resections of brain metastases. Additionally, adjuvant WBRT may help to reduce the risk of LMC and can be considered in decision-making for patients who have had brain metastasectomy.
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Affiliation(s)
- Rosaline Ma
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, 195 Little Albany Street, New Brunswick, NJ, 08901, USA
| | - Morgan Levy
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, 195 Little Albany Street, New Brunswick, NJ, 08901, USA
| | - Bin Gui
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, 195 Little Albany Street, New Brunswick, NJ, 08901, USA
| | - Shou-En Lu
- Department of Biostatistics, Rutgers School of Public Health, Piscataway, NJ, USA
| | | | - Sharad Goyal
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, 195 Little Albany Street, New Brunswick, NJ, 08901, USA
| | - Shabbar Danish
- Department of Neurosurgery, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Simon Hanft
- Department of Neurosurgery, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Atif J Khan
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, 195 Little Albany Street, New Brunswick, NJ, 08901, USA
| | - Jyoti Malhotra
- Department of Medical Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Sabin Motwani
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, 195 Little Albany Street, New Brunswick, NJ, 08901, USA
| | - Salma K Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, 195 Little Albany Street, New Brunswick, NJ, 08901, USA.
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23
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Foreman PM, Jackson BE, Singh KP, Romeo AK, Guthrie BL, Fisher WS, Riley KO, Markert JM, Willey CD, Bredel M, Fiveash JB. Postoperative radiosurgery for the treatment of metastatic brain tumor: Evaluation of local failure and leptomeningeal disease. J Clin Neurosci 2017; 49:48-55. [PMID: 29248376 DOI: 10.1016/j.jocn.2017.12.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 10/23/2017] [Accepted: 12/03/2017] [Indexed: 11/18/2022]
Abstract
In patients undergoing surgical resection of a metastatic brain tumor, whole brain radiation therapy reduces the risk of recurrence and neurologic death. Focal radiation has the potential to mitigate neurocognitive side effects. We present an institutional experience of postoperative radiosurgery for the treatment of brain metastases. A retrospective review of a prospectively maintained institutional radiosurgery database was performed for the years 2005-2015 identifying all adult patients treated with postoperative radiosurgery to the tumor bed. Primary endpoints include local recurrence and postoperative LMD. Kaplan-Meier curves and Cox regression were used to evaluate time to local recurrence and postoperative LMD. Ninety-one patients received adjuvant focal radiation for a brain metastasis. Median radiographic follow-up among patients who had not developed a local failure was 9 months. Of the 91 patients, 20 (22%) developed local recurrence and 32 (35%) experienced postoperative LMD. Freedom from local recurrence and LMD at 1 year was 84% and 69%, respectively. In multivariable models, predictors of local failure included the presence of more than one brain metastasis (HR = 2.65, p = .04) with a preoperative tumor diameter of >3 cm (HR = 4.16, p = .06) trending toward significance. There was a trend to a higher risk of LMD with >1 tumor (HR 2.07, p = .06) and breast cancer (HR 2.37, p = .07). More than one metastasis is an independent predictor of local and leptomeningeal failure following postoperative radiosurgery. The high rate of LMD was likely related to the liberal definition of LMD to include focal dural recurrences.
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Affiliation(s)
- Paul M Foreman
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States.
| | - Bradford E Jackson
- Division of Preventative Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Karan P Singh
- Division of Preventative Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Andrew K Romeo
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Barton L Guthrie
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Winfield S Fisher
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Kristen O Riley
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - James M Markert
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Christopher D Willey
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Markus Bredel
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - John B Fiveash
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, United States
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24
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Le Rhun E, Bertrand N, Dumont A, Tresch E, Le Deley MC, Mailliez A, Preusser M, Weller M, Revillion F, Bonneterre J. Identification of single nucleotide polymorphisms of the PI3K-AKT-mTOR pathway as a risk factor of central nervous system metastasis in metastatic breast cancer. Eur J Cancer 2017; 87:189-198. [PMID: 29103666 DOI: 10.1016/j.ejca.2017.10.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 09/29/2017] [Accepted: 10/03/2017] [Indexed: 12/13/2022]
Abstract
INTRODUCTION The PI3K-AKT-mTOR pathway may be involved in the development of central nervous system (CNS) metastasis from breast cancer. Accordingly, herein we explored whether single nucleotide polymorphisms (SNPs) of this pathway are associated with altered risk of CNS metastasis formation in metastatic breast cancer patients. METHODS The GENEOM study (NCT00959556) included blood sample collection from breast cancer patients treated in the neoadjuvant, adjuvant or metastatic setting. We identified patients with CNS metastases for comparison with patients without CNS metastasis, defined as either absence of neurological symptoms or normal brain magnetic resonance imaging (MRI) before death or during 5-year follow-up. Eighty-eight SNPs of phosphoinositide 3-kinase (PI3K)/protein kinase B (AKT)/mammalian (or mechanistic) target of rapamycin (mTOR) pathway genes were selected for analysis: AKT1 (17 SNPs), AKT2 (4), FGFR1 (2), mTOR (7), PDK1 (4), PI3KR1 (11), PI3KCA (20), PTEN (17), RPS6KB1 (6). RESULTS Of 342 patients with metastases, 207 fulfilled the inclusion criteria: One-hundred-and-seven patients remained free of CNS metastases at last follow-up or date of death whereas 100 patients developed CNS metastases. Among clinical parameters, hormonal and human epidermal growth factor receptor-2 (HER2) status as well as vascular tumour emboli was associated with risk of CNS metastasis. Only PI3KR1-rs706716 was associated with CNS metastasis in univariate analysis after Bonferroni correction (p < 0.00085). Multivariate analysis showed associations between AKT1-rs3803304, AKT2-rs3730050, PDK1-rs11686903 and PI3KR1-rs706716 and CNS metastasis . CONCLUSION PI3KR1-rs706716 may be associated with CNS metastasis in metastatic breast cancer patients and could be included in a predictive composite score to detect early CNS metastasis irrespective of breast cancer subtype.
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Affiliation(s)
- Emilie Le Rhun
- Univ. Lille, F-59000 Lille, France; Inserm, U-1192, F-59000 Lille, France; CHU Lille, General and Stereotaxic Neurosurgery service, F-59000 Lille, France; Oscar Lambret Center, Medical Oncology Department, F-59000 Lille, France.
| | - Nicolas Bertrand
- Univ. Lille, F-59000 Lille, France; Oscar Lambret Center, Medical Oncology Department, F-59000 Lille, France.
| | - Aurélie Dumont
- Oscar Lambret Center, Human Molecular Oncology Unit, Lille, France; Clinical Division of Oncology, Department of Medicine 1, CNS Unit Comprehensive Cancer Center Vienna (CCC-CNS), Vienna, Austria.
| | - Emmanuelle Tresch
- Oscar Lambret Center, Biostatistic Unit, Lille, France; Medical University of Vienna, Vienna, Austria.
| | - Marie-Cécile Le Deley
- Univ. Lille, F-59000 Lille, France; Oscar Lambret Center, Biostatistic Unit, Lille, France; Medical University of Vienna, Vienna, Austria.
| | - Audrey Mailliez
- Oscar Lambret Center, Medical Oncology Department, F-59000 Lille, France.
| | - Matthias Preusser
- Oscar Lambret Center, Human Molecular Oncology Unit, Lille, France; Clinical Division of Oncology, Department of Medicine 1, CNS Unit Comprehensive Cancer Center Vienna (CCC-CNS), Vienna, Austria; Oscar Lambret Center, Biostatistic Unit, Lille, France; Medical University of Vienna, Vienna, Austria.
| | - Michael Weller
- Department of Neurology & Brain Tumor Center, University Hospital, Switzerland; University of Zurich, Switzerland.
| | - Françoise Revillion
- Oscar Lambret Center, Human Molecular Oncology Unit, Lille, France; Clinical Division of Oncology, Department of Medicine 1, CNS Unit Comprehensive Cancer Center Vienna (CCC-CNS), Vienna, Austria.
| | - Jacques Bonneterre
- Univ. Lille, F-59000 Lille, France; Oscar Lambret Center, Medical Oncology Department, F-59000 Lille, France.
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25
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Solomou AG. Magnetic resonance imaging of pineal tumors and drop metastases: a review approach. Rare Tumors 2017; 9:6715. [PMID: 29142658 PMCID: PMC5661140 DOI: 10.4081/rt.2017.6715] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 09/26/2016] [Accepted: 10/01/2016] [Indexed: 11/24/2022] Open
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Yagi R, Kawabata S, Ikeda N, Nonoguchi N, Furuse M, Katayama Y, Kajimoto Y, Kuroiwa T. Intraoperative 5-aminolevulinic acid-induced photodynamic diagnosis of metastatic brain tumors with histopathological analysis. World J Surg Oncol 2017; 15:179. [PMID: 28962578 PMCID: PMC5622438 DOI: 10.1186/s12957-017-1239-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 08/20/2017] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Fluorescence-guided surgery using 5-aminolevulinic acid (5-ALA) is a promising real-time navigation method in the surgical resection of malignant gliomas. In order to determine whether this method is applicable to metastatic brain tumors, we evaluated the usefulness of intraoperative fluorescence patterns and histopathological features in patients with metastatic brain tumors. METHODS We retrospectively reviewed the cases of 16 patients with metastatic brain tumors who underwent intraoperative 5-ALA fluorescence-guided resection. Patients were given 20 mg/kg of 5-ALA orally 2 h prior to the surgery. High-powered excitation illumination and a low-pass filter (420, 450, or 500 nm) were used to visualize the fluorescence of protoporphyrin IX (PpIX), the 5-ALA metabolite. We evaluated the relationships between the fluorescence and histopathological findings in both tumoral and peritumoral brain tissue. RESULTS Tumoral PpIX fluorescence was seen in only 5 patients (31%); in the remaining 11 patients (69%), there was no fluorescence in the tumor bulk itself. In 14 patients (86%), vague fluorescence was seen in peritumoral brain tissue, at a thickness of 2-6 mm. The histopathological examination found cancer cell invasion of adjacent brain tissue in 75% of patients (12/16), at a mean ± SD depth of 1.4 ± 1.0 mm (range 0.2-3.4 mm) from the microscopic border of the tumor. There was a moderate correlation between vague fluorescence in adjacent brain tissue and the depth of cancer cell invasion (P = 0.004). CONCLUSION Peritumoral fluorescence may be a good intraoperative indicator of tumor extent, preceding more complete microscopic gross total resection. TRIAL REGISTRATION Institutional Review Board of Osaka Medical College No. 42, registered February 17, 1998, and No. 300, registered April 1, 2008. They were retrospectively registered.
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Affiliation(s)
- R Yagi
- Department of Neurosurgery, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
| | - S Kawabata
- Department of Neurosurgery, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan.
| | - N Ikeda
- Department of Neurosurgery, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
| | - N Nonoguchi
- Department of Neurosurgery, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
| | - M Furuse
- Department of Neurosurgery, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
| | - Y Katayama
- Department of Neurosurgery, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
| | - Y Kajimoto
- Department of Neurosurgery, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
| | - T Kuroiwa
- Department of Neurosurgery, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
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Le Rhun E, Weller M, Brandsma D, Van den Bent M, de Azambuja E, Henriksson R, Boulanger T, Peters S, Watts C, Wick W, Wesseling P, Rudà R, Preusser M. EANO-ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up of patients with leptomeningeal metastasis from solid tumours. Ann Oncol 2017; 28:iv84-iv99. [PMID: 28881917 DOI: 10.1093/annonc/mdx221] [Citation(s) in RCA: 221] [Impact Index Per Article: 31.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Affiliation(s)
- E Le Rhun
- Neuro-Oncology, Department of Neurosurgery, Lille University Hospital, Lille
- Neurology, Medical Oncology Department, Oscar Lambret Center, Lille
- Lille University, Inserm U-1192, Villeneuve d'Ascq, France
| | - M Weller
- Department of Neurology and Brain Tumour Center, University Hospital, Zurich, Switzerland
| | - D Brandsma
- Department of Neuro-Oncology, Netherlands Cancer Institute, Amsterdam
| | - M Van den Bent
- The Brain Tumour Center at the Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - E de Azambuja
- Medical Oncology Department, Institut Jules Bordet and L'Université Libre de Bruxelles (U.L.B), Brussels, Belgium
| | - R Henriksson
- Regional Cancer Center, Stockholm
- Department of Radiation Sciences and Oncology, University, Umea, Sweden
| | - T Boulanger
- Neuroradiology, Imaging Department, Oscar Lambret Center, Lille, France
| | - S Peters
- Department of Oncology, University Hospital, Lausanne, Switzerland
| | - C Watts
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - W Wick
- Neurology Clinic, Heidelberg University Hospital, Heidelberg
- Clinical Cooperation Unit Neuro-Oncology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Centre (DKFZ), Heidelberg, Germany
| | - P Wesseling
- Department of Pathology, VU University Medical Centre and Brain Tumour Center, Amsterdam
- Department of Pathology, Princess Máxima Center for Paediatric Oncology and University Medical Centre Utrecht, Utrecht, The Netherlands
| | - R Rudà
- Department of Neuro-Oncology, City of Health and Science Hospital, University of Turin, Turin, Italy
| | - M Preusser
- Clinical Division of Oncology, Department of Medicine 1, CNS Unit Comprehensive Cancer Centre (CCC-CNS), Medical University, Vienna, Austria
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28
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Munzone E, Casali C, Del Bene M, Di Meco F. Treatment of Central Nervous System Involvement. Breast Cancer 2017. [DOI: 10.1007/978-3-319-48848-6_64] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Inserra A, Narciso A, Paolantonio G, Messina R, Crocoli A. Palliative care and pediatric surgical oncology. Semin Pediatr Surg 2016; 25:323-332. [PMID: 27955737 DOI: 10.1053/j.sempedsurg.2016.08.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Survival rate for childhood cancer has increased in recent years, reaching as high as 70% in developed countries compared with 54% for all cancers diagnosed in the 1980s. In the remaining 30%, progression or metastatic disease leads to death and in this framework palliative care has an outstanding role though not well settled in all its facets. In this landscape, surgery has a supportive actor role integrated with other welfare aspects from which are not severable. The definition of surgical palliation has moved from the ancient definition of noncurative surgery to a group of practices performed not to cure but to alleviate an organ dysfunction offering the best quality of life possible in all the aspects of life (pain, dysfunctions, caregivers, psychosocial, etc.). To emphasize this aspect a more modern definition has been introduced: palliative therapy in whose context is comprised not only the care assistance but also the plans of care since the onset of illness, teaching the matter to surgeons in training and share paths. Literature is very poor regarding surgical aspects specifically dedicated and all researches (PubMed, Google Scholar, and Cochrane) with various meshing terms result in a more oncologic and psychosocial effort.
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Affiliation(s)
- Alessandro Inserra
- General Pediatric and Thoracic Surgery, Bambino Gesù Children׳s Hospital-Research Institute, Rome, Italy.
| | - Alessandra Narciso
- General Pediatric and Thoracic Surgery, Bambino Gesù Children׳s Hospital-Research Institute, Rome, Italy
| | - Guglielmo Paolantonio
- Interventional Radiology Unit, Bambino Gesù Children׳s Hospital-Research Institute, Rome, Italy
| | - Raffaella Messina
- Neurosurgery Unit, Bambino Gesù Children׳s Hospital-Research Institute, Rome, Italy
| | - Alessandro Crocoli
- General Pediatric and Thoracic Surgery, Bambino Gesù Children׳s Hospital-Research Institute, Rome, Italy
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Abstract
Brain metastases (BMs) occur in 10% to 20% of adult patients with cancer, and with increased surveillance and improved systemic control, the incidence is likely to grow. Despite multimodal treatment, prognosis remains poor. Current evidence supports use of whole-brain radiation therapy when patients present with multiple BMs. However, its associated cognitive impairment is a major deterrent in patients likely to live longer than 6 months. In patients with oligometastases (one to three metastases) and even some with multiple lesions less than 3 to 4 cm, especially if the primary tumor is considered radiotherapy resistant, stereotactic radiosurgery is recommended; if the BMs are greater than 4 cm, surgical resection with or without postoperative whole-brain radiation therapy should be considered. There is increasing evidence that systemic therapy, including targeted therapy and immunotherapy, is effective against BM and may be an early choice, especially in patients with sensitive primary tumors. In patients with progressive systemic disease, limited treatment options, and poor performance status, best supportive care may be appropriate. Regardless of treatment goals, use of corticosteroids or antiepileptic medications is helpful in symptomatic patients. In this review, we provide a summary of current therapy, as well as developments in the treatment of BM from solid tumors.
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Affiliation(s)
- Xuling Lin
- All authors: Memorial Sloan Kettering Cancer Center, New York, NY
| | - Lisa M DeAngelis
- All authors: Memorial Sloan Kettering Cancer Center, New York, NY.
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31
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Ahluwalia MS, Vogelbaum MV, Chao ST, Mehta MM. Brain metastasis and treatment. F1000PRIME REPORTS 2014; 6:114. [PMID: 25580268 PMCID: PMC4251415 DOI: 10.12703/p6-114] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Despite major therapeutic advances in the management of patients with systemic malignancies, management of brain metastases remains a significant challenge. These patients often require multidisciplinary care that includes surgical resection, radiation therapy, chemotherapy, and targeted therapies. Complex decisions about the sequencing of therapies to control extracranial and intracranial disease require input from neurosurgeons, radiation oncologists, and medical/neuro-oncologists. With advances in understanding of the biology of brain metastases, molecularly defined disease subsets and the advent of targeted therapy as well as immunotherapeutic agents offer promise. Future care of these patients will entail tailoring treatment based on host (performance status and age) and tumor (molecular cytogenetic characteristics, number of metastases, and extracranial disease status) factors. Considerable work involving preclinical models and better clinical trial designs that focus not only on effective control of tumor but also on quality of life and neurocognition needs to be done to improve the outcome of these patients.
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Affiliation(s)
- Manmeet S. Ahluwalia
- Burkhardt Brain Tumor Neuro-Oncology Center, Neurological InstituteCleveland Clinic, 9500 Euclid Avenue, Cleveland, OHUSA
| | - Michael V. Vogelbaum
- Burkhardt Brain Tumor Neuro-Oncology Center, Neurological InstituteCleveland Clinic, 9500 Euclid Avenue, Cleveland, OHUSA
| | - Samuel T. Chao
- Burkhardt Brain Tumor Neuro-Oncology Center, Neurological InstituteCleveland Clinic, 9500 Euclid Avenue, Cleveland, OHUSA
| | - Minesh M. Mehta
- Department of Radiation Oncology, University of Maryland School of MedicineBaltimore, MD 21201USA
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Huang AJ, Huang KE, Page BR, Ayala-Peacock DN, Lucas JT, Lesser GJ, Laxton AW, Tatter SB, Chan MD. Risk factors for leptomeningeal carcinomatosis in patients with brain metastases who have previously undergone stereotactic radiosurgery. J Neurooncol 2014; 120:163-9. [PMID: 25048529 DOI: 10.1007/s11060-014-1539-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 07/06/2014] [Indexed: 10/25/2022]
Abstract
Our objective was to explore the hypothesis that the risk of leptomeningeal dissemination (LMD) in patients who underwent stereotactic radiosurgery (SRS) for brain metastases is influenced by the site of the primary cancer, the addition of whole brain radiation therapy (WBRT), surgical resection, and control over their systemic disease. We conducted a retrospective cohort analysis of 805 patients who were treated with SRS for brain metastases between 1999 and 2012 at the Wake Forest Baptist Medical Center, and excluded all patients with evidence of LMD before SRS. The primary outcome was LMD. Forty-nine of 795 patients developed LMD with a cumulative incidence of 6.2% (95% Confidence Interval (CI), 4.7-8.0). Median time from SRS to LMD was 7.4 months (Interquartile Range (IQR), 3.3-15.4). A colorectal primary site (Hazard Ratio (HR), 4.5; 95% CI 2.5-8.0; p < 0.0001), distant brain failure (HR, 2.0; 95% CI 1.2-3.2; p = 0.007), breast primary site (HR, 1.6; 95% CI 1.0-2.7; p = 0.05), the number of intracranial metastases at time of initial SRS (HR, 1.1; 95% CI 1.0-1.2; p = 0.02), and age (by 5-year interval) (HR, 0.9; 95% CI 0.8, 0.9; p = 0.0006) were independent factors associated with LMD. There was no evidence that surgical resection before SRS altered the risk of LMD (HR, 1.1; 95 % CI 0.6-2.0, p = 0.78). In patients who underwent SRS for brain metastases, a colorectal or breast primary site, distant brain failure, younger age, and an increased number of intracranial metastases were independently associated with LMD. Given its relative rarity as an outcome, multi-institutional prospective studies will likely be necessary to validate and quantify these relationships.
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Affiliation(s)
- Andrew J Huang
- Department of Radiation Oncology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA,
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Petterwood J, Lim K, Gonzalvo A, Quan G. Intradural extramedullary colorectal adenocarcinoma metastasis to the cervical spine. ANZ J Surg 2013; 85:582-3. [DOI: 10.1111/ans.12452] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Joshua Petterwood
- Department of Spinal Surgery and Orthopaedics; University of Melbourne; Austin Health; Melbourne Victoria Australia
| | - Kelvin Lim
- Departments of Radiology; Austin Health; Heidelberg Victoria Australia
| | | | - Gerald Quan
- Department of Spinal Surgery and Orthopaedics; University of Melbourne; Austin Health; Melbourne Victoria Australia
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Risk factors for early death after surgery in patients with brain metastases: reevaluation of the indications for and role of surgery. J Neurooncol 2013; 116:145-52. [DOI: 10.1007/s11060-013-1273-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Accepted: 10/09/2013] [Indexed: 10/26/2022]
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35
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Le Rhun E, Taillibert S, Chamberlain MC. Carcinomatous meningitis: Leptomeningeal metastases in solid tumors. Surg Neurol Int 2013; 4:S265-88. [PMID: 23717798 PMCID: PMC3656567 DOI: 10.4103/2152-7806.111304] [Citation(s) in RCA: 180] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 04/11/2013] [Indexed: 11/04/2022] Open
Abstract
Leptomeningeal metastasis (LM) results from metastatic spread of cancer to the leptomeninges, giving rise to central nervous system dysfunction. Breast cancer, lung cancer, and melanoma are the most frequent causes of LM among solid tumors in adults. An early diagnosis of LM, before fixed neurologic deficits are manifest, permits earlier and potentially more effective treatment, thus leading to a better quality of life in patients so affected. Apart from a clinical suspicion of LM, diagnosis is dependent upon demonstration of cancer in cerebrospinal fluid (CSF) or radiographic manifestations as revealed by neuraxis imaging. Potentially of use, though not commonly employed, today are use of biomarkers and protein profiling in the CSF. Symptomatic treatment is directed at pain including headache, nausea, and vomiting, whereas more specific LM-directed therapies include intra-CSF chemotherapy, systemic chemotherapy, and site-specific radiotherapy. A special emphasis in the review discusses novel agents including targeted therapies, that may be promising in the future management of LM. These new therapies include anti-epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors erlotinib and gefitinib in nonsmall cell lung cancer, anti-HER2 monoclonal antibody trastuzumab in breast cancer, anti-CTLA4 ipilimumab and anti-BRAF tyrosine kinase inhibitors such as vermurafenib in melanoma, and the antivascular endothelial growth factor monoclonal antibody bevacizumab are currently under investigation in patients with LM. Challenges of managing patients with LM are manifold and include determining the appropriate patients for treatment as well as the optimal route of administration of intra-CSF drug therapy.
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Affiliation(s)
- Emilie Le Rhun
- Breast Unit, Department of Medical Oncology, Centre Oscar Lambret and Department of Neuro Oncology, Roger Salengro Hospital, University Hospital, Lille, France
| | - Sophie Taillibert
- Neurology, Mazarin and Radiation Oncology, Pitié Salpétrière Hospital, University Pierre et Marie Curie, Paris VI, Paris, France
| | - Marc C. Chamberlain
- Neurology and Neurological Surgery, University of Washington, Fred Hutchinson Research Cancer Center, Seattle, WA, USA
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Jung JM, Kim S, Joo J, Shin KH, Gwak HS, Lee SH. Incidence and risk factors for leptomeningeal carcinomatosis in breast cancer patients with parenchymal brain metastases. J Korean Neurosurg Soc 2012; 52:193-9. [PMID: 23115660 PMCID: PMC3483318 DOI: 10.3340/jkns.2012.52.3.193] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Revised: 06/14/2012] [Accepted: 09/17/2012] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE The objective of study is to evaluate the incidence of leptomeningeal carcinomatosis (LMC) in breast cancer patients with parenchymal brain metastases (PBM) and clinical risk factors for the development of LMC. METHODS We retrospectively analyzed 27 patients who had undergone surgical resection (SR) and 156 patients with whole brain radiation therapy (WBRT) as an initial treatment for their PBM from breast cancer in our institution and compared the difference of incidence of LMC according to clinical factors. The diagnosis of LMC was made by cerebrospinal fluid cytology and/or magnetic resonance imaging. RESULTS A total of 27 patients (14%) in the study population developed LMC at a median of 6.0 months (range, 1.0-50). Ten of 27 patients (37%) developed LMC after SR, whereas 17 of 156 (11%) patients who received WBRT were diagnosed with LMC after the index procedure. The incidence of LMC was significantly higher in the SR group compared with the WBRT group and the hazard ratio was 2.95 (95% confidence interval; 1.33-6.54, p<0.01). Three additional factors were identified in the multivariable analysis : the younger age group (<40 years old), the progressing systemic disease showed significantly increased incidence of LMC, whereas the adjuvant chemotherapy reduce the incidence. CONCLUSION There is an increased risk of LMC after SR for PBM from breast cancer compared with WBRT. The young age (<40) and systemic burden of cancer in terms of progressing systemic disease without adjuvant chemotherapy could be additional risk factors for the development of LMC.
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Affiliation(s)
- Jong-Myung Jung
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
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Zhang M, Ou Y, Zhang H, Zhang J, Xia L, Qu Y, Wang H, Zhan Q, Song Y, Yu C. Leptomeningeal metastasis from central nervous system tumors: A study of classification and stage in the spinal canal of 58 patients. CHINESE SCIENCE BULLETIN-CHINESE 2012. [DOI: 10.1007/s11434-012-5262-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Ahn JH, Lee SH, Kim S, Joo J, Yoo H, Lee SH, Shin SH, Gwak HS. Risk for leptomeningeal seeding after resection for brain metastases: implication of tumor location with mode of resection. J Neurosurg 2012; 116:984-93. [DOI: 10.3171/2012.1.jns111560] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Surgical spillage has been one of the causative factors for the development of leptomeningeal seeding (LMS) after resection of brain metastases. In this paper, the authors' goal was to define the factors related to the development of LMS and to evaluate the difference according to tumor location.
Methods
The authors retrospectively analyzed 242 patients who had undergone resection for brain metastases. The factors investigated included tumor location with proximity to the CSF pathway (that is, contacting, involved with, or separated from the CSF pathway), the method of resection, and the use of the Cavitron Ultrasonic Surgical Aspirator (CUSA).
Results
A total of 39 patients (16%) developed LMS at a median of 6.0 months (range 1–42 months) after resection. The risk of developing LMS was significantly higher in patients whose tumors were resected piecemeal than in those whose tumors were removed en bloc, with a hazard ratio (HR) of 4.08 (p < 0.01). The incidence of LMS was significantly higher in patients in whom the CUSA was used, and the HR was 2.64 (p < 0.01). The proximity of tumor to the CSF pathway in the involved group conferred an increased risk of LMS compared with the separated group (HR 11.36, p < 0.01). The risk of piecemeal resection for LMS was significant only in involved lesions (p < 0.01), and the use of the CUSA in both contact and involved lesions increased the incidence of LMS (p < 0.01 and p < 0.03, respectively).
Conclusions
The authors suggest that piecemeal resection using the CUSA should be limited because of the risk of postsurgical LMS, especially when the tumor is in contact with the CSF pathway.
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Affiliation(s)
- Jun Hyong Ahn
- 1Department of Neurosurgery, Seoul National University College of Medicine; and
| | | | | | | | - Heon Yoo
- 4Neuro-oncology Clinic, National Cancer Center, Goyang, Korea
| | - Seung Hoon Lee
- 4Neuro-oncology Clinic, National Cancer Center, Goyang, Korea
| | - Sang Hoon Shin
- 4Neuro-oncology Clinic, National Cancer Center, Goyang, Korea
| | - Ho-Shin Gwak
- 4Neuro-oncology Clinic, National Cancer Center, Goyang, Korea
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Lombardi G, Zustovich F, Farina P, Della Puppa A, Manara R, Cecchin D, Brunello A, Cappetta A, Zagonel V. Neoplastic meningitis from solid tumors: new diagnostic and therapeutic approaches. Oncologist 2011; 16:1175-88. [PMID: 21795431 PMCID: PMC3228160 DOI: 10.1634/theoncologist.2011-0101] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Accepted: 05/17/2011] [Indexed: 01/19/2023] Open
Abstract
Neoplastic meningitis is a result of the spread of malignant cells to the leptomeninges and subarachnoid space and their dissemination within the cerebrospinal fluid. This event occurs in 4%-15% of all patients with solid tumors and represents an important prognostic factor for poor survival. Neoplastic meningitis should be diagnosed in the early stages of disease to prevent important neurological deficits and to provide the most appropriate treatment. Despite new diagnostic approaches developed in recent years, such as positron emission tomography-computed tomography and new biological markers, the combination of magnetic resonance imaging without and with gadolinium enhancement and cytology still has the greatest diagnostic sensitivity. Recently, no new randomized studies comparing intrathecal (i.t.) with systemic treatment have been performed, yet there have been a few small phase II studies and case reports about new molecularly targeted substances whose successful i.t. or systemic application has been reported. Trastuzumab, gefitinib, and sorafenib are examples of possible future treatments for neoplastic meningitis, in order to better individualize therapy thus allowing better outcomes. In this review, we analyze the most recent and interesting developments on diagnostic and therapeutic approaches.
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Affiliation(s)
- Giuseppe Lombardi
- Medical Oncology 1 Unit, Istituto Oncologico Veneto–IRCCS, Padova, Italy.
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Abstract
Neurological complications of systemic cancer-those arising outside the nervous system-can be distressing, disabling, and sometimes fatal. Diagnosis is often difficult because different neurological disorders may present with similar signs and symptoms. Furthermore, comorbid neurological illnesses, common in elderly patients with cancer, can complicate diagnosis. Early diagnosis and aggressive treatment can improve neurological symptoms and can substantially enhance a patient's quality of life. We approach the problem of neurological complications of systemic cancer as would a neurologist: first by identifying the anatomical area or areas that are affected (ie, brain, spinal cord, peripheral nerve), then by evaluating the diagnostic approach, considering the symptoms and signs and including appropriate laboratory tests, and finally, by recommending treatment. We focus on disorders that are difficult to diagnose, need neurological consultation, and for which effective treatments exist.
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Affiliation(s)
- Mustafa Khasraw
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, USA.
| | - Jerome B Posner
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, USA
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41
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Moyano MS, Gutiérrez-Gutiérrez G, Rodríguez-Esteban I, Crespo GS, Casado E. Melanoma leptomeningeal dissemination following frontoparietal metastasis surgery: Case report and review of the literature. Oncol Lett 2010; 1:1101-1104. [PMID: 22870120 DOI: 10.3892/ol.2010.194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2010] [Accepted: 09/20/2010] [Indexed: 11/05/2022] Open
Abstract
We present the case of a patient with a solitary left frontoparietal brain metastasis of melanoma previously treated with surgery. Three months later, the patient was admitted to the emergency room in a confusional state with meningeal signs. A cerebrospinal fluid (CSF) test and magnetic resonance imaging findings suggested a subarachnoid haemorrhage (SAH) and/or meningeal carcinomatosis. The results of a cytological examination of the CSF showed neoplastic epithelial cells consistent with metastatic melanoma cells. Resection of metastatic posterior fossa lesions is often cited as a risk factor for leptomeningeal dissemination, however, when the resection is limited to the anterior fossa, this complication is relatively rare. In contrast, SAH may be a complication of leptomeningeal dissemination and responsible for acute meningeal syndrome. Treatment with high doses of corticoids did not show any improvement, and intrathecal chemotherapy was not possible due to the patient's poor functional status. She succumbed 1 week after admission.
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Affiliation(s)
- María Sereno Moyano
- Department of Medical Oncology, Infanta Sofía Hospital, San Sebastián de los Reyes, Madrid, Spain
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Soffietti R, Akerley W, Jensen RL, Bischoff J, Regierer AC. The role of intra-cerebrospinal fluid treatment and prophylaxis in patients with solid tumors. Semin Oncol 2009; 36:S55-68. [PMID: 19660684 DOI: 10.1053/j.seminoncol.2009.05.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Metastasis to the central nervous system (CNS), including neoplastic meningitis (NM), is a devastating complication of systemic cancer. With the improved survival of cancer patients, the incidence of CNS metastasis is rising, especially among those with breast or lung carcinoma. New therapies that effectively treat these primary tumors outside of the CNS have underscored the significance of CNS metastases; they have become a significant clinical issue and a therapeutic challenge. This review discusses clinical situations in which treatment or chemoprophylaxis of CNS metastases and NM from breast or lung cancer may play an important role. Potential clinical trials to assess these assumptions also will be proposed.
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Affiliation(s)
- Riccardo Soffietti
- Department of Neuroscience, University and San Giovanni Battista Hospital, Torino, Italy.
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Suki D, Hatiboglu MA, Patel AJ, Weinberg JS, Groves MD, Mahajan A, Sawaya R. Comparative risk of leptomeningeal dissemination of cancer after surgery or stereotactic radiosurgery for a single supratentorial solid tumor metastasis. Neurosurgery 2009; 64:664-74; discussion 674-6. [PMID: 19197219 DOI: 10.1227/01.neu.0000341535.53720.3e] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To test the hypothesis that differential risks of developing leptomeningeal disease (LMD) exist in patients having a single supratentorial brain metastasis resected via a piecemeal or en bloc approach or treated with stereotactic radiosurgery (SRS). METHODS Between 1993 and 2006, 827 patients with a supratentorial brain metastasis underwent resection or SRS at The University of Texas M.D. Anderson Cancer Center. The primary outcome was the incidence of LMD. RESULTS Resection was performed piecemeal in 191 patients and en bloc in 351 patients; 285 patients received SRS. LMD occurred in 33 patients, 29 in the resection group and 4 in the SRS group. Risk of LMD was significantly higher with piecemeal tumor resection than with other procedures (SRS: hazard ratio [HR] for piecemeal, 5.8; 95% confidence interval [CI], 1.9-17.2; P = 0.002; en bloc, HR for piecemeal, 2.7; 95% CI, 1.3-5.6; P = 0.009). The difference between piecemeal and en bloc was particularly pronounced in patients with a melanoma primary (HR, 8.4; 95% CI, 1.8-39.2; P = 0.007). The risk of LMD was not significantly different between en bloc resection and SRS (HR for en bloc, 2.1; 95% CI, 0.7-6.4; P = 0.21). Similar results were obtained when comparing effects of SRS and both resection approaches after limiting the sample to patients with tumors in a specific volume range. CONCLUSION Piecemeal resection of a supratentorial brain metastasis carries a higher risk of LMD than en bloc resection or SRS. Further assessment of the role of the 2 surgical resection approaches and SRS in a controlled prospective setting with large numbers of patients is warranted.
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Affiliation(s)
- Dima Suki
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA.
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Huang K, Sneed PK, Kunwar S, Kragten A, Larson DA, Berger MS, Chan A, Pouliot J, McDermott MW. Surgical resection and permanent iodine-125 brachytherapy for brain metastases. J Neurooncol 2008; 91:83-93. [PMID: 18719856 DOI: 10.1007/s11060-008-9686-2] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2008] [Accepted: 08/11/2008] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate the efficacy and toxicity of surgical resection and permanent iodine-125 brachytherapy without adjuvant whole brain radiation therapy (WBRT) for brain metastases. METHODS AND MATERIALS Forty patients were treated with permanent iodine-125 brachytherapy at the time of resection of brain metastases from 1997 to 2003. Actuarial freedom from progression (FFP) and survival were measured from the date of surgery and estimated using the Kaplan-Meier method, with censoring at last imaging for FFP endpoints. RESULTS The median survival was 11.3 months overall, 12.0 months in 19 patients with newly diagnosed brain metastases and 7.3 months in 21 patients with recurrent brain metastases. Twenty-two patients (55%) remained free of progression of brain metastases, three failed at the resection cavity (including one with leptomeningeal dissemination), two failed with leptomeningeal spread only, and 13 failed elsewhere in the brain including two who also had leptomeningeal disease. The 1-year resection cavity FFP probabilities were 92%, 86% and 88%; and brain FFP probabilities were 29%, 43% and 37% for the newly diagnosed, recurrent and all patients, respectively. Symptomatic necrosis developed 7.4-40.0 months (median, 19.5 months) after brachytherapy in 9 patients (23%), confirmed by resection in 6 patients. CONCLUSIONS Excellent local control was achieved using permanent iodine-125 brachytherapy for brain metastasis resection cavities, although there is a high risk of radiation necrosis over time. These data support consideration of permanent brachytherapy without adjuvant WBRT as a treatment option in patients with symptomatic or large newly diagnosed or recurrent brain metastases.
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Affiliation(s)
- Kim Huang
- Department of Radiation Oncology, University of California San Francisco, 505 Parnassus Avenue, Room L-08, San Francisco, CA, 94143-0226, USA.
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Affiliation(s)
- William P O'Meara
- Department Radiation Oncology, National Naval Medical Center, Bethesda, Maryland, USA
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Suki D, Abouassi H, Patel AJ, Sawaya R, Weinberg JS, Groves MD. Comparative risk of leptomeningeal disease after resection or stereotactic radiosurgery for solid tumor metastasis to the posterior fossa. J Neurosurg 2008; 108:248-57. [DOI: 10.3171/jns/2008/108/2/0248] [Citation(s) in RCA: 123] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The authors tested the hypothesis that patients with metastatic posterior fossa lesions (MPFLs) treated with resection have a higher risk of leptomeningeal disease (LMD) than those with MPFLs treated with stereotactic radiosurgery (SRS).
Methods
Between 1993 and 2004, 379 patients with MPFLs were treated with resection or SRS at The University of Texas M. D. Anderson Cancer Center. The authors' primary study outcome was the incidence of LMD, as diagnosed with cerebrospinal fluid cytological analysis and/or neuroimaging.
Results
Resection was performed in 260 patients, whereas 119 patients underwent SRS. The median patient age was 56 years, 51% of patients were male, and 93% had a Karnofsky Performance Scale score $ 70. The most common primary cancers were those of the lung, breast, and kidney, as well as melanoma. Leptomeningeal dissemination of cancer occurred in 33 patients: 26 in the resection group and 7 in the SRS group (resection group: rate ratio [RR] 2.06, 95% confidence interval [CI] 0.89–4.75, p = 0.09). Piecemeal tumor resection (137 cases) was associated with a significantly higher risk of LMD than en bloc resection (123 cases; RR 3.4, 95% CI 1.43–8.12, p = 0.006) or SRS (RR 3.37, 95% CI 1.41–8.04, p = 0.006), and there was no significant difference in the risk for LMD between en bloc resection and SRS (en bloc resection: RR 0.98, 95% CI 0.34–2.81, p = 0.98). The multivariate RR and significance associated with piecemeal resection, however, were consistent, with a strong effect (RR 2.45, 95% CI 1.19–5.02, p = 0.02) and no indication of biases associated with tumor size, location, or cystic/necrotic appearance.
Conclusions
There is an increased risk of LMD after piecemeal resection of an MPFL. This increase, although clinically and statistically significant, is not as alarming as previously reported and is absent when en bloc removal is achieved. Further assessment of the role of resection in a controlled prospective setting is warranted.
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Affiliation(s)
| | | | | | | | | | - Morris D. Groves
- 2Neuro-Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
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Béjot Y, Catteau A, Hervieu M, Giré P, Caillier M, Bénatru I, Osseby GV, Soichot P, Moreau T, Giroud M. [Leptomeningeal dissemination after ethmoidal sinus adenocarcinoma surgery: a rare complication]. Rev Neurol (Paris) 2008; 164:189-93. [PMID: 18358880 DOI: 10.1016/j.neurol.2007.09.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2007] [Revised: 07/16/2007] [Accepted: 09/25/2007] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Although rare, adenocarcinoma is the most frequent neoplasm of the ethmoid sinus and must be regarded as an occupational disease secondary to chronic wood dust exposure. Few cases with neurological metastasis have been reported. CASE REPORT We report the cases of two patients who developed a multiple cranial nerve disorder for the first case and a cauda equina syndrome for the second, after ethmoid adenocarcinoma surgery. CONCLUSION Diagnosis of carcinomatous meningitis is difficult and is based on clinical data, CSF analysis and gadolinium-enhanced T1-weighted brain and spinal cord MRI. The implication of surgery is discussed. Prognosis of such a disorder is poor.
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Affiliation(s)
- Y Béjot
- Service de neurologie, CHU, 21000 Dijon, France.
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Boogerd W. Leptomeningeal metastasis in solid tumours: Is there a role for intrathecal therapy? EJC Suppl 2007. [DOI: 10.1016/s1359-6349(07)70022-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Abstract
Brain metastases are the most common brain tumors seen in clinical practice, comprising well over half of all brain tumors. For many years, surgical resection of brain metastases was considered a form of palliative therapy only, but more recently it has been shown to have a more important role in extending survival in appropriately selected patients. Newer surgical techniques have helped to reduce the morbidity associated with tumor resection. Although randomized studies have demonstrated the need for postoperative whole-brain radiotherapy, there remains interest in the use of other surgical adjuncts to delay or eliminate the need for fractionated radiotherapy. The use of various treatment modalities, particularly image-guided surgery and stereotactic radiosurgery, allows clinicians who are focused on the treatment of brain metastases to achieve superior levels of tumor control within the brain. As a result, overall survival is much more dependent on the status of the patient's systemic disease.
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Affiliation(s)
- Michael A Vogelbaum
- Brain Tumor Institute/ND40, Cleveland Clinic Foundation, Cleveland, OH, USA.
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