Intrathecal topotecan in adult patients with neoplastic meningitis

Neoplastic meningitis in solid tumours: updated review of diagnosis, prognosis, therapeutic management, and future directions

Neoplastic meningitis (NM) is a relatively frequent metastatic complication of cancer associated with high levels of neurological morbidity and generally poor prognosis. It appears in 5%-15% of patients with solid tumours, the most frequent being breast and lung cancer and melanoma. Symptoms are caused by involvement of the cerebral hemispheres, cranial nerves, spinal cord, and nerve roots, and are often multifocal or present with signs and symptoms of intracranial hypertension. The main diagnostic tools are the neurological examination, brain and spinal cord contrast-enhanced magnetic resonance imaging, and cerebrospinal fluid analysis including cytology, although studies have recently been conducted into the detection of tumour cells and DNA in the cerebrospinal fluid, which increases diagnostic sensitivity. With the currently available therapies, treatment aims not to cure the disease, but to delay and ameliorate the symptoms and to preserve quality of life. Treatment of NM involves a multimodal approach that may include radiotherapy, intrathecal and/or systemic chemotherapy, and surgery. Treatment should be individualised, and is based mainly on clinical practice guidelines and expert opinion. Promising clinical trials are currently being conducted to evaluate drugs with molecular and immunotherapeutic targets. This article is an updated review of NM epidemiology, clinical presentation, diagnosis, prognosis, management, and treatment; it is aimed at general neurologists and particularly at neurologists practicing in hospital settings with oncological patients.

Leptomeningeal Spread in Glioblastoma: Diagnostic and Therapeutic Challenges

BACKGROUND

Glioblastoma (GBM) is the most common and aggressive primary malignant brain tumor. Leptomeningeal spread (LMS) is a severe complication of GBM, raising diagnostic and therapeutic challenges in clinical routine.

METHODS

We performed a review of the literature focused on LMS in GBM. MEDLINE and EMBASE databases were queried from 1989 to 2019 for articles describing diagnosis and therapeutic options in GBM LMS, as well as risk factors and pathogenic mechanisms.

RESULTS

We retrieved 155 articles, including retrospective series, case reports, and early phase clinical trials, as well as preclinical studies. These articles confirmed that LMS in GBM remains (a) a diagnostic challenge with cytological proof of LMS obtained in only 35% of cases and (b) a therapeutic challenge with a median overall survival below 2 months with best supportive care alone. For patients faced with suggestive clinical symptoms, whole neuroaxis magnetic resonance imaging and cerebrospinal fluid analysis are both recommended. Liquid biopsies are under investigation and may help prompt a reliable diagnosis. Based on the literature, a multimodal and personalized therapeutic approach of LMS, including surgery, radiotherapy, systemic cytotoxic chemotherapy, and intrathecal chemotherapies, may provide benefits to selected patients. Interestingly, molecular targeted therapies appear promising in case of actionable molecular target and should be considered.

CONCLUSION

As the prognosis of glioblastoma is improving over time, LMS becomes a more common complication. Our review highlights the need for translational studies and clinical trials dedicated to this challenging condition in order to improve diagnostic and therapeutic strategies.

IMPLICATIONS FOR PRACTICE

This review summarizes the diagnostic tools and applied treatments for leptomeningeal spread, a complication of glioblastoma, as well as their outcomes. The importance of exhaustive molecular testing for molecular targeted therapies is discussed. New diagnostic and therapeutic strategies are outlined, and the need for translational studies and clinical trials dedicated to this challenging condition is highlighted.

Intra-CSF topotecan in treatment of breast cancer patients with leptomeningeal metastases

Background

There are few treatment options for patients with leptomeningeal metastases (LM).

Methods

We report a case series of patients with breast cancer and LM treated with intra‐CSF topotecan (TOPO). Outcome was assessed by clinical exam and MRI at baseline, at end of induction (4‐5 weeks), then every 3 months; CSF cytology was determined at baseline and with each treatment.

Results

Thirty‐one women [median age, 58 (37‐81); median KPS 60 (40‐100)] received treatment. At baseline, 68% had positive CSF cytology, and 90%, leptomeningeal enhancement on MRI. 84% of patients also received focal RT (not during TOPO) and 77% received concomitant systemic hormonal or chemotherapy. Median number of TOPO treatments was 14.5 (range, 3‐71); median duration of treatment, 11 weeks (1‐176); and median OS, 6.9 months (range, 0.9‐48.8). Patients remaining progression‐free during 4‐6 weeks of induction (81%) had a median OS of 11.5 months (range, 1.8‐48.8). Overall neurologic PFS at 6, 12, and 24 months was 39%, 26%, and 6%, respectively. Clearing of CSF malignant cells for >3 consecutive samples occurred in 10/21 (48%) patients with positive CSF cytology at baseline, remaining clear for a median duration of 15.9 months (range, 1.4‐34.5). Grade 3 adverse events included headache or vomiting (3pts), T2 hyperintensity surrounding the ventricular catheter (2 pts), and meningitis (2 pts).

Conclusions

Intra‐CSF TOPO, with focal RT as needed for symptomatic areas of enhancement produced durable clearing of CSF malignant cells in 48% of patients positive at baseline, with promising median PFS and OS.

Neoplastic meningitis in solid tumours: Updated review of diagnosis, prognosis, therapeutic management, and future directions

Neoplastic meningitis (NM) is a relatively frequent metastatic complication of cancer associated with high levels of neurological morbidity and generally poor prognosis. It appears in 5%-15% of patients with solid tumours, the most frequent being breast and lung cancer and melanoma. Symptoms are caused by involvement of the cerebral hemispheres, cranial nerves, spinal cord, and nerve roots, and are often multifocal or present with signs and symptoms of intracranial hypertension. The main diagnostic tools are the neurological examination, brain and spinal cord contrast-enhanced magnetic resonance imaging, and cerebrospinal fluid analysis including cytology, although studies have recently been conducted into the detection of tumour cells and DNA in the cerebrospinal fluid, which increases diagnostic sensitivity. With the currently available therapies, treatment aims not to cure the disease, but to delay and ameliorate the symptoms and to preserve quality of life. Treatment of NM involves a multimodal approach that may include radiotherapy, intrathecal and/or systemic chemotherapy, and surgery. Treatment should be individualised, and is based mainly on clinical practice guidelines and expert opinion. Promising clinical trials are currently being conducted to evaluate drugs with molecular and immunotherapeutic targets. This article is an updated review of NM epidemiology, clinical presentation, diagnosis, prognosis, management, and treatment; it is aimed at general neurologists and particularly at neurologists practicing in hospital settings with oncological patients.

A Pilot Phase 1 Study of Intrathecal Pemetrexed for Refractory Leptomeningeal Metastases From Non-small-cell Lung Cancer

Objectives: We aim to determine the feasibility, safety, maximally tolerated dose (MTD), recommended dose and potential anti-tumor activity of intrathecal pemetrexed (IP).

Materials and Methods: Lung adenocarcinoma patients with recurrent or progressive leptomeningeal metastases (LM) after intrathecal chemotherapy were recruited. IP dose was escalated from 10 mg. A minimum of three patients and a maximum of six were enrolled in each cohort. Schedule protocol was IP twice per week for 2 weeks in induction therapy, followed by once per week for 4 weeks in consolidation therapy. Serial samples of plasma and cerebrospinal fluid (CSF) were obtained for pharmacokinetic studies.

Results: Thirteen patients were enrolled between March 2017 and July 2018. EGFR driver oncogene was identified in most of the patients. Severe adverse events (AEs) were encountered in 31% (4/13) of the cases, including myelosuppression, radiculitis, and elevation of hepatic aminotransferases (EHA). Study protocol was revised due to lethal myelosuppression. Following protocol revision, vitamin B12 and folic acid supplementation was given at the beginning of treatment, and myelosuppression was well-controlled. Dose-limiting toxicities (DLT) were myelosuppression, radiculitis, and EHA. Two patients (2/2) developed dose-limiting myelosuppression at 15 mg level. One patient (1/6) experienced dose-limiting radiculitis and EHA at 10 mg level. MTD was 10 mg. Response rate was 31% (4/13) and disease control rate was 54% (7/13). The drug concentration showed a decreasing trend in serial CSF samples following each IP. After IP, the peak plasma concentration was reached at 4 h in two cases, 6 h in two cases, 9 h in one case, and 12 h in one case, respectively.

Conclusion: Pemetrexed was appropriate for intrathecal administration. IP at 10 mg dose in combination with vitamin supplementation on the schedule of 1–2 times per week showed controllable toxicity and good efficacy. This regimen paves the way for subsequent clinical trial.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier NCT03101579.

Treatment of Leptomeningeal Carcinomatosis in a Patient with Metastatic Pancreatic Cancer: A Case Report and Review of the Literature

Pancreatic cancer is the fourth leading cause of cancer-related death with a median survival of 3–11 months when metastatic. We present a patient with metastatic pancreatic cancer and an exceptional response to initial systemic chemotherapy with FOLFIRINOX (fluorouracil, leucovorin, irinotecan, and oxaliplatin). Despite evidence of disease control on body imaging, he developed symptomatic leptomeningeal disease and brain metastases 29 months into treatment. He received aggressive treatment with capecitabine and irinotecan, intrathecal topotecan, and eventually bevacizumab. He did well for 36 weeks on this regimen until developing sepsis. This patient significantly outlived his expected survival and, moreover, did so with very good quality of life. This case demonstrates the natural history of pancreatic cancer progressing to involve the central nervous system when systemic disease is otherwise responsive to chemotherapy. It is the first case to demonstrate the potential effectiveness of intrathecal topotecan in combination with systemic chemotherapy for the treatment of leptomeningeal metastases of pancreatic cancer.

Principles of pharmacotherapy

This chapter will review the challenges in pharmacotherapy in primary brain tumors that include the presence of the blood-brain barrier, a blood-tumor barrier, active drug efflux pumps, and high plasma protein binding of agents. The approaches to improve the delivery of drugs to the brain will be discussed. Often the management of brain tumors involves the use of corticosteroids and enzyme-inducing antiseizure medications that can have significant drug interactions that may impact the efficacy or toxicity of drugs used to treat these patients. Various techniques used to assess drug distribution to the brain will be reviewed.

Topoisomerase inhibitors unsilence the dormant allele of Ube3a in neurons

Angelman syndrome is a severe neurodevelopmental disorder caused by deletion or mutation of the maternal allele of the ubiquitin protein ligase E3A (Ube3a)^1–3. In neurons, the paternal allele of Ube3a is intact but epigenetically silenced^4–6, raising the possibility that Angelman syndrome could be treated by activating this silenced allele to restore functional UBE3A protein^7,8. Using an unbiased, high-content screen in primary cortical neurons from mice, we identified twelve topoisomerase I inhibitors and four topoisomerase II inhibitors that unsilence the paternal Ube3a allele. These drugs included topotecan, irinotecan, etoposide, and dexrazoxane (ICRF-187). At nanomolar concentrations, topotecan upregulated catalytically active UBE3A in neurons from maternal Ube3a-null mice. Topotecan concomitantly downregulated expression of the Ube3a antisense transcript that overlaps the paternal copy of Ube3a^9–11. These results suggest that topotecan unsilences Ube3a in cis by reducing transcription of an imprinted antisense RNA. When administered in vivo, topotecan unsilenced the paternal Ube3a allele in several regions of the nervous system, including neurons in the hippocampus, neocortex, striatum, cerebellum and spinal cord. Paternal expression of Ube3a remained elevated in a subset of spinal cord neurons for at least twelve weeks after cessation of topotecan treatment, suggesting transient topoisomerase inhibition can have enduring effects on gene expression. While potential off-target effects remain to be investigated, our findings suggest a therapeutic strategy for reactivating the functional but dormant allele of Ube3a in patients with Angelman syndrome.

Intrathecal chemotherapy for treatment of leptomeningeal dissemination of metastatic tumours

Neoplastic meningitis consists of diffuse involvement of the leptomeninges by infiltrating cancer cells, and can be caused by systemic or primary CNS tumours, such as solid cancers or lymphoproliferative malignant disease. Neoplastic meningitis is characterised by multifocal neurological signs and symptoms. Thus, careful neurological examination is needed for diagnosis of secondary diffuse involvement. Survival of patients with neoplastic meningitis is short (3-4 months), although some patients have long-lasting remission. Because most patients with neoplastic meningitis have diffuse systemic disease, treatment is typically palliative. However, more aggressive treatments are available to low-risk patients, which could increase survival. Therefore, identification of low-risk patients is important. Intrathecal chemotherapy is currently the main treatment for patients with neoplastic meningitis, but optimum anticancer chemotherapy is being studied.

Need for a new treatment strategy: leptomeningeal carcinomatosis from gastric cancer

Leptomeningeal carcinomatosis (LMC) is an extremely rare manifestation of gastric cancer. The treatment options are very limited for LMC; despite standard treatment with intrathecal chemotherapy, the prognosis is grim and the median overall survival is 3-4 months. Here we report on a patient with LMC from metastatic gastric cancer who was treated with a novel approach of high-dose systemic irinotecan, comparable with the dose utilized in treating primary brain tumors such as gliomas. Our patient not only had an excellent tumor response to this novel approach, but also had a prolonged overall survival of 13 months, which is unusual for LMC from gastric cancer.

Intrathecal chemotherapy delivered by a lumbar-thecal catheter in metastatic medulloblastoma: a case illustration

BACKGROUND

Medulloblastoma is the most common malignant brain tumour in children. Despite recent advances, the prognosis in high risk patients remains poor. Further improvement in survival is dependent upon the development of strategies to attack the tumour more effectively, but with less toxicity. Intrathecal chemotherapy, is an ideal but currently underused method of directly targeting residual tumour within the area of resection and the leptomeningeal disease commonly associated with this tumour.

METHOD

We describe the case of a 12 yr old child with metastatic medulloblastoma, who received intrathecal topotecan via a spinal catheter.

CONCLUSION

This method represents a simple, safe and effective method of delivering an even and widespread distribution of drug within the cerebrospinal fluid (CSF) of the neuroaxis. With new agents being identified and others in the early stages of development, intrathecal chemotherapy may emerge as an important therapeutic option to consider when faced with such challenging cases.

Leptomeningeal neoplasms

Leptomeningeal metastasis is becoming an increasingly important late complication of cancer as survival from systemic disease increases, and due to the fact that many novel cancer drugs fail to achieve therapeutic concentrations in the central nervous system. It occurs when neoplastic cells enter cerebrospinal fluid (CSF) pathways, causing diffuse infiltration of the subarachnoid space of the brain and spinal cord. Definitive diagnosis is established by the demonstration of malignant cells in the CSF. However, in certain circumstances the presence of leptomeningeal enhancement on brain or spinal MRI may be sufficient to make the diagnosis. Early diagnosis and aggressive treatment may delay neurologic progression and can lead to prolonged survival and improvement of neurologic function in certain patients. The prognosis depends on the underlying malignancy but is often poor, with a median survival of 4 months, and most treatment interventions are palliative. Nevertheless, some patients respond to treatment, and some survive beyond 1 or 2 years after diagnosis. Areas of radiographic bulky disease or symptomatic tumor should receive radiotherapy. Intrathecal chemotherapy is most effective in patients with lymphoma, leukemia, or breast cancer and without evidence of bulky disease on neuroimaging. Intrathecal chemotherapy requires normal CSF flow, and the most commonly used agents are methotrexate, cytarabine, and thiotepa. In lieu of intrathecal therapy, systemic chemotherapy may occasionally be indicated in select patients in part based on its ability to penetrate into bulky disease. When hydrocephalus occurs, ventriculoperitoneal shunting frequently leads to rapid clinical improvement. There is hope that progress in diagnostic modalities and the development of more effective intrathecal antineoplastic drugs may decrease neurologic morbidity and improve quality of life and survival.

Continuous intrathecal treatment with methotrexate via subcutaneous port: implication for leptomeningeal dissemination of malignant tumors

Use of intrathecal (IT) chemotherapy combined with radiotherapy can extend survival of patients with untreated leptomeningeal dissemination of malignant tumors from one month to two to six months. The goal of the present study was to determine the effect of continuous IT (CIT) via a subcutaneous port that was placed using a neuronavigation system. Twenty patients with leptomeningeal dissemination (primary disease: 10 cancers, 6 gliomas and 4 lymphomas) were given 2-7 cycles of continuous IT (CIT) with methotrexate (MTX; 10 mg) administered into the lateral ventricle for 5 consecutive days biweekly. The concentration of MTX in the lateral ventricle was 7 to 10 x 10(-6 )M from Day 1 to 4. Response to this therapy included 6 patients with complete remission, 7 with progressive disease, and 7 with stable disease. Kaplan-Meier analysis revealed a median overall survival of 8 months while the overall survival rate for leptomeningeal specific death or for metastasis from cancer was 13 or 5 months, respectively. Complications of CIT with MTX were relatively low (<0.5%), and nausea and vomiting did not occur in any of the patients. In conclusion, CIT with 10 mg MTX via subcutaneous port for 5 days may improve the therapeutic effect and reduce the complications associated with treatment of leptomeningeal dissemination from malignant tumors. This would be a safe technique with possible implications that bear repeating more patients.