Diagnosis and outcome measures in trials for neoplastic meningitis: a review of the literature and clinical experience

Ovarian Adenocarcinoma With Leptomeningeal Metastases

Leptomeningeal carcinomatosis (LMC) is an uncommon disease that unfortunately has a rapid deterioration and a very poor prognosis with a devastating outcome. There has been an associated increase in the incidence of the leptomeningeal disease recently. There is a low percentage of LMC, around five percent of patients with metastatic disease. LMC has been presented in solid tumors such as breast cancer, lung cancer, melanoma, and GI malignancies. LMC is less likely reported in ovarian cancers. The clinical presentation of LMC is variable and will express according to where the cancer cells infiltrate. The malignant cells can travel with the cerebrospinal fluid (CSF) and deposit on the brain, cerebellum, spinal cord, cranial nerves, and spinal roots. We report this case as a clinical anatomical exercise for healthcare professionals.

Characteristics of Patients with Meningeal Carcinomatosis Combined with Myelopathy

OBJECTIVE

To explore the disease manifestations and radiological characteristics of patients with meningeal carcinomatosis (MC) combined with myelopathy.

PATIENTS AND METHODS

The detailed medical information of patients who suffered from MC with myelopathy in record system were collected and reviewed.

RESULTS

In these patients, five cases were male and two cases were female. The age was from fifteen to fifty-seven years. In the course of disease, tumor cells were discovered in cerebrospinal fluid of three patients and in biopsy samples of four patients. Cerebrospinal fluid (CSF) test results showed white blood cell counts increased in seven patients, protein increased in six patients and glucose reduced in five patients. In addition, MRI revealed that the white matter abnormalities showed in all cases and pia mater was enhanced in four patients, meningeal enhanced was observed in three patients. All patients were given appropriate therapy during hospitalization. Follow-up result showed that all patients passed away two to five months after diagnosis.

CONCLUSION

MC causes spinal membrane, spinal nerve root to be involved besides, also can produce the matter of myelopathy. Early detection of intramedullary lesion is conducive to strengthening the awareness of the diagnosis of MC.

A case report of endometrial adenocarcinoma with leptomeningeal metastases

In patients with a history of solid tumors, any new onset of neurological symptoms should be assessed for central nervous system involvement even in rare cases such as gynecological malignancies that nervous system involvement is a rare event.

Leptomeningeal Carcinomatosis in Urothelial Carcinoma of the Urinary Bladder: A Report of a Patient with a Fulminant Course Who Died of Cancer after Definitive Therapies

A 45-year-old Japanese man visited a community hospital with the chief complaint of asymptomatic macrohematuria. He was diagnosed with muscle-invasive bladder cancer (MIBC), and he received intra-arterial chemotherapy followed by radiation therapy at another institution. Twenty-eight months after chemoradiotherapy, magnetic resonance imaging (MRI) revealed MIBC recurrence. After neoadjuvant chemotherapy, robot-assisted radical cystectomy was performed. Pathological examination indicated high-grade urothelial carcinoma with lymphovascular invasion, a positive surgical margin, and skip lesions of cancer cells in the perivesical adipose tissue. Three months after surgery, he was brought to our hospital in an ambulance with the chief complaint of rotatory vertigo and was speaking inarticulately. Head and whole spine MRI revealed meningeal metastasis along both the vestibulocochlear nerves and cauda equina. Analysis of the cerebrospinal fluid revealed malignant cells. The patient was diagnosed with leptomeningeal carcinomatosis originating from the MIBC. He received whole-brain radiotherapy followed by the administration of pembrolizumab. Unfortunately, the patient's condition quickly deteriorated, and he died of cancer 4 months after surgery.

Survival following Ommaya reservoir placement for neoplastic meningitis

The objective of this study was to evaluate the outcomes of patients with neoplastic meningitis (NM) following Ommaya reservoir placement in order to determine whether any patient factors are associated with longer survival. NM is a devastating late manifestation of cancer, and given its dismal prognosis, identifying appropriate patients for Ommaya reservoir placement is difficult. The authors performed a retrospective review of 80 patients who underwent Ommaya reservoir placement at three medical centers from September 2001 through September 2012. The primary outcome was death. Differences in survival were assessed with Kaplan-Meier survival analyses. The Cox proportional hazards and logistic regression modeling were performed to identify factors associated with survival. The primary diagnoses were solid organ, hematologic, and primary central nervous system tumors in 53.8%, 41.3%, and 5%, respectively. The median overall survival was 72.5 days (95% confidence interval 36-122) with 30% expiring within 30 days and only 13.8% surviving more than 1 year. There were no differences in median overall survival between sites (p=0.37) despite differences in time from diagnosis of NM to Ommaya reservoir placement (p<0.001). Diagnosis of hematologic malignancy was inversely associated with death within 90 days (p=0.04; odds ratio 0.34), older age was associated with death within 90 days (p=0.05; odds ratio 1.5, per 10 year increase in age). The prognosis of NM remains poor despite the available treatment with intraventricular chemotherapy. There exists significant variability in treatment algorithms among medical centers and consideration of this variability is crucial when interpreting existing series of Ommaya reservoir use in the treatment of patients with NM.

Meningeal carcinomatosis in solid tumors

The involvement of the leptomeninges by metastatic tumors can be observed in solid tumors, in which case it is termed meningeal carcinomatosis (MC), and in lymphoproliferative malignant disease. It is more common in breast and lung cancer, as well as melanoma, with adenocarcinoma being the most frequent histological type. MC is usually a late event, with disseminated and progressive disease already present and, it is characterized by multifocal neurological signs and symptoms. Diagnosis is based on the evaluation of clinical presentation, cerebrospinal fluid and neuroimaging studies. The better systemic disease control is observed with new therapeutic agents, and the development of neuroimaging methods is responsible for the increasing incidence of such metastatic evolution. Intrathecal chemotherapy is generally the treatment of choice, although frequently palliative. Prognosis is guarded, although a higher performance status may indicate a subgroup of patients with a more favorable outcome.

Leptomeningeal metastases

OPINION STATEMENT

Leptomeningeal cancer dissemination is a metastatic complication with growing impact in clinical oncology. Advances in treatment have been hampered by difficulties in diagnosis and response assessment, and nihilistic attitudes of physicians due to the poor prognosis, even when treating patients. However, relevant advances in therapeutic management have been achieved. In selected patients, survival and time to neurological progression can be improved with therapy, although an early diagnosis is critical (hence the importance of a high suspicion index). It is mandatory to perform an MRI of the entire neuraxis and cerebrospinal fluid (CSF) examination of up to two samples if the first lumbar puncture is negative, with appropriate volume and processing methods. It is advisable to supplement CSF analysis using flow cytometry techniques and new biomarker determinations (not yet validated) to improve diagnostic yield sensitivity. Currently, patients with good performance status and the option to receive effective systemic treatment must be treated with added intrathecal chemotherapy through Ommaya reservoirs and focal radiotherapy to bulky lesions or refractory painful areas. However, a standard treatment approach is not well-established due to the lack of well-designed randomized clinical trials and the mix of different cancer subtypes treated with the same drug in most studies. Liposomal cytarabine offers some advantages over methotrexate, both being first-line treatments for intrathecal administration. Recently, new agents have proven safe and feasible, broadening the available treatment options. The individualized choice of intrathecal agent based on the primary malignancy and appropriate treatment of underlying systemic disease are critical to improved outcomes in these patients.

Leptomeningeal seeding in patients with brain metastases treated by gamma knife radiosurgery

To characterize the development of leptomeningeal seeding (LMS) in patients with brain metastases after gamma knife radiosurgery (GKRS). Eight hundred and twenty-seven patients that underwent GKRS as a part of an initial treatment plan for brain metastases between January 2002 and December 2010 were included in the study. Six hundred and fifty patients were treated with GKRS alone and 177 patients received GKRS combined with upfront whole brain radiation therapy (WBRT). Actuarial curves for overall survival (OS) and the development of LMS were plotted using the Kaplan-Meier method. Median overall survival for all patients was 55 weeks (95 % CI, 47.8-62.2), and the overall incidence of LMS was 5.3 %. The actuarial rates for LMS at 6 and 12 months were 3.1 and 5.8, respectively. Uni- and multivariate analysis suggested that breast cancer and a large number of metastases (n ≥ 4) are significant risk factors of LMS (P < 0.05). Regarding treatment modalities, the addition of WBRT was found to have a significant impact on lowering the risk of LMS by multivariate analysis (P = 0.045). LMS is an important pattern of CNS failure. The risk of LMS following GKRS may be associated with multiple lesions, breast cancer, and the omission of WBRT. Additional data from large-scale, randomized controlled trials are required to identify risk factors associated with the LMS more accurately.

Headache attributed to infections nosography and differential diagnosis

Headache is a very frequent symptom of infection. It has many possible underlying mechanisms, of which two or more can coexist in a single patient. It can be caused by direct stimulation of intracranial pain-producing structures, as in the case of brain abscesses, by irritation of the pachy- and leptomeninges, as in cases of bacterial or viral meningitis, or by a state of intracranial hypertension, as seen in obstructive hydrocephalus. There is no doubt that headache is often the first or the predominant symptom of serious, sometimes life-threatening, infectious diseases; certainly, it is a condition frequently encountered in all epidemiological studies. Indeed, it is estimated that over 60% of people have, at some point in their lives, experienced headache during an infection. This evidence leads to the need for a systematic approach to headache secondary to infection. This chapter provides some elements on pain mechanisms in systemic and intracranial infections and on the possible role of antimicrobial agents in the genesis of headache. The first section provides a detailed "etiology-based" description of the International Classification of Headache Disorders, 2nd edition (ICHD-II: Headache Classification Subcommittee of the International Headache Society, 2004), while the second section presents a "symptom-based" algorithm applicable in the first diagnostic assessment, according to the headache features and to the most frequently associated clinical manifestations during infections of the central nervous system (CNS).

Diagnostic tools for neoplastic meningitis: detecting disease, identifying patient risk, and determining benefit of treatment

Three methods are routinely used to diagnose neoplastic meningitis (NM): clinical signs and symptoms, cerebrospinal fluid (CSF) cytology, and magnetic resonance imaging (MRI) of the brain and spine. Clinical manifestations are often subtle or may be ascribed to other cancer complications, eg, treatment-related disorders or brain parenchymal metastases. CSF cytology has a high specificity (>95%), but its sensitivity is generally less than 50%. MRI sensitivity and specificity vary with the type of primary cancer; overall, MRI findings consistent with leptomeningeal disease are detected in fewer than 50% of NM patients. While most clinicians evaluate CSF cytology along with MRI and the clinical examination, underdiagnosis is a major problem, since many patients are both cytologically and radiographically negative. Failure to consider NM in the differential diagnosis magnifies the problem of underdiagnosis. CSF flow cytometry is particularly promising for evaluating NM from hematologic cancers, with a diagnostic sensitivity many fold greater than conventional cytology. Research has focused on identifying biochemical markers of tumor cells in the CSF. For example, molecules involved in CNS penetration (eg, matrix metalloproteinases and cathepsins), tumor cell tropism (eg, chemokines CXCL8 and CCL18), and angiogenesis (eg, vascular endothelial growth factor) are elevated in the CSF of patients with NM. Evidence that some tumor types are more likely to infiltrate the CNS also has stimulated research into primary tumor markers predictive of CNS metastases. At present, there is no tumor marker or patient characteristic that reliably predicts the development of NM, and diagnosis still relies on suggestive signs and symptoms, positive CSF cytology, or a consistent MRI-all late manifestations of NM. Until techniques capable of detecting NM early are developed, increased awareness of the disease and standardized evaluation are likely to have the greatest impact on improving diagnosis and implementing earlier treatment.

Neoplastic meningitis from breast carcinoma with complete response to liposomal cytarabine: case report

Neoplastic meningitis from breast cancer often leads to a progressive neurologic deterioration followed by fatal outcome. The therapy is based on the administration of high dose systemic chemotherapy with drugs able to pass through the blood-brain barrier, such as methotrexate (MTX) and cytarabine, cranial or craniospinal irradiation, and intrathecal (IT) administration of MTX and/or cytarabine. However, these approaches only have modest efficacy and are associated with side effects for the patients. A depot formulation of liposomal cytarabine (DepoCyte) has proven to be useful in clinical trials. We describe the case of a woman with a diagnosis of leptomeningeal carcinomatosis from breast carcinoma who presented cerebrospinal fluid normalization and prolonged complete MRI response to intrathecal chemotherapy with liposomal cytarabine (DepoCyte).

Current treatment of leptomeningeal metastases: systemic chemotherapy, intrathecal chemotherapy and symptom management

Treatment of leptomeningeal metastases is multifaceted and includes symptomatic therapy, intrathecal and systemic chemotherapy, and radiotherapy. As the majority of patients have widespread incurable systemic tumor, treatment is predominantly palliative; however, some patients with leukemia, lymphoma or breast cancer may have prolonged remissions and the possibility of cure.

Systemic chemotherapy, intrathecal chemotherapy, and symptom management in the treatment of leptomeningeal metastasis

Metastasis to the leptomeninges occurs in many common cancers, including leukemia; lung, breast, and gastrointestinal cancers; and tumors of the brain. By way of the flow of cerebrospinal fluid, leptomeningeal metastasis spreads throughout the neuraxis. Consequently, therapy for leptomeningeal metastasis must be directed to the entire central nervous system (CNS). Treatment often consists of involved-field radiotherapy, systemic chemotherapy, and intrathecal chemotherapy. However, because meningeal spread occurs most often in advanced disease, treatment is mainly palliative, except in childhood leukemia, where durable remission has been reported. This article outlines the role of systemic and intrathecal chemotherapy in patients with leptomeningeal metastases. Strategies for symptom management in these patients are also described.

Neoplastic meningitis

Neoplastic meningitis is recognized clinically in 4% to 7% of patients with extraneural cancer, but it remains dramatically under-diagnosed. The frequency of neoplastic meningitis is increasing because of heightened clinical suspicion, improved neuroimaging techniques, and longer survival in patients with extraneural cancer Longer survival allows residual tumor cells within central nervous system sanctuary sites time to become symptomatic. Affected patients may present with cerebral, cranial nerve, or spinal signs and symptoms, depending on the specific sites of central nervous system (CNS) involvement. Magnetic Resonance Imaging (MRI) seems to be sensitive for detecting metastatic deposits along the neuraxis. However, metastases at a microscopic level are below the resolution of MRI scanning. As a result, the standard diagnostic test for neoplastic meningitis remains the cytologic identification of malignant cells in cerebrospinal fluid (CSF). Although CSF cytology is useful, malignant cells are not detected in as many as one third of patients who have compelling clinical or radiographic evidence of neoplastic meningitis. Novel assays are being tested that may enhance the early identification of malignant cells in CSF. Currently, the diagnosis occurs generally after the onset of neurologic manifestations and heralds a rapidly fatal course for most patients. By the time symptoms appear, most tumors have disseminated widely within the CNS, due to cortical irritation, compression of nervous system structures, or obstruction of CSF flow. At this stage surgery, cranial irradiation, and chemotherapy are rarely, if ever, curative. The goals of treatment are to improve or to stabilize the neurologic status of patients and to prolong survival. A major problem in treating neoplastic meningitis is that the entire neuraxis must be treated. If only symptomatic areas are treated, reseeding of the neuraxis with tumor cells will occur. Therefore, intrathecal chemotherapy remains a mainstay of therapy. Currently, four therapeutic agents are available for intrathecal treatment: methotrexate, ara-C, sustained-release ara-C (DepoCyt; Chiron Therapeutics, San Francisco, CA), and thiotepa. Unfortunately, intrathecal chemotherapy does not treat bulky disease in the subarachnoid space, and often is slow to stabilize progressive neurologic deficits. For these reasons, radiation therapy to sites of symptomatic disease and sites of bulky disease on imaging studies is recommended. High dose intravenous methotrexate may be as effective as intrathecal methotrexate. Alternative approaches (which offer less toxicity, enhanced therapeutic effect, and prolonged survival) are being investigated.

Lipid-associated sialoprotein in the cerebrospinal fluid: association with brain malignancies

BACKGROUND

Changes in the glycosylation process by tumor cells result in larger amounts of sialoproteins on their surface compared with normal cells. Sialoproteins then are released into the surrounding environment primarily by shedding or cell lysis. In the current study, the authors attempted to evaluate whether lipid-associated sialoprotein (LSP) in the cerebrospinal fluid (CSF) can distinguish patients with primary and metastatic brain tumors from those without brain tumors as well as determine response to treatment.

METHODS

CSF samples were obtained from a tissue bank. The concentration of LSP was determined after chloroform:methanol extraction followed by protein precipitation. One-way analysis of variance and Scheffe pairwise comparisons were used for statistical analysis.

RESULTS

The CSF of neurologically normal controls, patients with a normal leukocyte count (< or = 5/microl), and patients with various neurologic disorders or systemic tumors without central nervous system (CNS) malignancies contained similar levels of LSP. The CSF from patients with a normal leukocyte count and newly diagnosed primary or metastatic brain tumors contained on average 3.7-fold higher levels of LSP compared with CSF from patients without CNS tumors (P = 0.0001). The CSF from patients with brain tumors with progressive disease not responding to treatment contained high levels of LSP comparable to the levels found in newly diagnosed patients. The CSF from treatment-responsive patients contained decreased levels of LSP similar to that found in control patients.

CONCLUSIONS

The LSP in CSF may be a useful marker with which to determine the presence of intracranial malignancies and assess response to treatment.