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Wilcox JA, Chukwueke UN, Ahn MJ, Aizer AA, Bale TA, Brandsma D, Brastianos PK, Chang S, Daras M, Forsyth P, Garzia L, Glantz M, Oliva ICG, Kumthekar P, Le Rhun E, Nagpal S, O'Brien B, Pentsova E, Lee EQ, Remsik J, Rudà R, Smalley I, Taylor MD, Weller M, Wefel J, Yang JT, Young RJ, Wen PY, Boire AA. Leptomeningeal metastases from solid tumors: A SNO and ASCO consensus review on clinical management and future directions. Neuro Oncol 2024:noae103. [PMID: 38902944 DOI: 10.1093/neuonc/noae103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Indexed: 06/22/2024] Open
Abstract
Leptomeningeal metastases are increasingly becoming recognized as a treatable, yet generally incurable, complication of advanced cancer. As modern cancer therapeutics have prolonged the lives of patients with metastatic cancer, specifically in patients with parenchymal brain metastases, treatment options and clinical research protocols for patients with leptomeningeal metastases from solid tumors have similarly evolved to improve survival within specific populations. Recent expansion in clinical investigation, early diagnosis, and drug development have given rise to new unanswered questions. These include leptomeningeal metastasis biology and preferred animal modeling, epidemiology in the modern cancer population, ensuring validation and accessibility of newer leptomeningeal metastasis diagnostics, best clinical practices with multi-modality treatment options, clinical trial design and standardization of response assessments, and avenues worthy of further research. An international group of multi-disciplinary experts in the research and management of leptomeningeal metastases, supported by the Society for Neuro-Oncology and American Society of Clinical Oncology, were assembled to reach a consensus opinion on these pressing topics and provide a roadmap for future directions. Our hope is that these recommendations will accelerate collaboration and progress in the field of leptomeningeal metastases and serve as a platform for further discussion and patient advocacy.
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Affiliation(s)
- Jessica A Wilcox
- Department of Neurology, Brain Tumor Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ugonma N Chukwueke
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Myung-Ju Ahn
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ayal A Aizer
- Department of Radiation Oncology, Brigham and Women's Hospital / Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Tejus A Bale
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Dieta Brandsma
- Department of Neuro-Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Priscilla K Brastianos
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Susan Chang
- Division of Neuro-Oncology, Department of Neurosurgery, University of San Francisco California, San Francisco, CA, USA
| | - Mariza Daras
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | - Peter Forsyth
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Livia Garzia
- Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Toronto, ON, Canada
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - Michael Glantz
- Department of Neurosurgery, Penn State College of Medicine, Hershey, PA, USA
| | - Isabella C Glitza Oliva
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Priya Kumthekar
- The Lou and Jean Malnati Brain Tumor Institute, Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, USA
| | - Emilie Le Rhun
- Departments of Neurology and Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Seema Nagpal
- Division of Neuro-Oncology, Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Barbara O'Brien
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elena Pentsova
- Department of Neurology, Brain Tumor Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Eudocia Quant Lee
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jan Remsik
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Laboratory for Immunology of Metastatic Ecosystems, Center for Cancer Biology, VIB, Leuven, Belgium
- Department of Oncology, KU Leuven, Leuven, Belgium
| | - Roberta Rudà
- Division of Neuro-Oncology, Department of Neuroscience, University and City of Health and Science Hospital, Turin, Italy
- Department of Neurology, Castelfranco Veneto and Treviso Hospitals, Castelfranco Veneto, Italy
| | - Inna Smalley
- Department of Tumor Biology, The Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Michael D Taylor
- Division of Neurosurgery, Department of Surgery, Texas Children's Hospital, Houston, TX, USA Neuro-oncology Research Program, Department of Pediatrics, Section of Hematology-Oncology, Baylor College of Medicine
| | - Michael Weller
- Department of Neurology, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Jeffrey Wefel
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jonathan T Yang
- Department of Radiation Oncology, Department of Radiation Oncology, New York University School of Medicine, New York, NY, USA
| | - Robert J Young
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Patrick Y Wen
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Adrienne A Boire
- Department of Neurology, Brain Tumor Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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2
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Zhong W, Wu L, Huang L, Wang J, Shi H, Wu S. Double-dose osimertinib combined with intrathecal injection of pemetrexed improves the efficacy of EGFR-mutant non-small cell lung cancer and leptomeningeal metastasis: case report and literature review. Front Oncol 2024; 14:1377451. [PMID: 38711856 PMCID: PMC11070505 DOI: 10.3389/fonc.2024.1377451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 04/08/2024] [Indexed: 05/08/2024] Open
Abstract
Leptomeningeal metastasis (LM) is a complication of non-small cell lung cancer (NSCLC) characterized by poor prognosis and short survival. A variety of therapeutic approaches have been sought to improve the efficacy of LM. Here we present a clinical case and conduct a literature review to investigate the effectiveness and safety of double-dose osimertinib combined with a pemetrexed intrathecal injection. This is an older man who underwent thoracoscopic pneumonectomy and was diagnosed with stage IIA lung adenocarcinoma with EGFR21 L858R mutation. He experienced thoracic vertebral metastases 33 months postoperatively and received first-line treatment with gefitinib combined with radiotherapy for vertebral metastases. However, the patient developed a grade 3 rash with unacceptable toxicity and his CEA levels were significantly increased 22 months later, leading to a targeted treatment adjustment to 80 mg of osimertinib orally once daily. Four months later, the patient developed LM and osimertinib dosage was increased to 160 mg once daily; however, neurological symptoms did not improve, and cerebrospinal fluid (CSF) tumor cells remained detected. Accordingly, the patient received an intrathecal injection of pemetrexed (dose 30 mg) every 2-3 months, 2-3 times per course (4-6 days each time), and continued to receive a double dose of osimertinib. After three courses of intrathecal chemotherapy, CSF tumor cells were eliminated, and neurological symptoms significantly improved. During the treatment, he experienced a one-degree rash, leukopenia, thrombocytopenia, and fatigue. This patient has been alive and well with disease control for 28 months since the diagnosis of meningeal metastases. Combining double-dose osimertinib and an intrathecal injection of pemetrexed demonstrated therapeutic efficacy and manageable adverse effects in this patient with advanced NSCLC with EGFR-mutant and LM.
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Affiliation(s)
- Wenjuan Zhong
- Department of Oncology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
- Jiangxi Clinical Medical Center for Cancer, Ganzhou, Jiangxi, China
| | - Longqiu Wu
- Department of Oncology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
- Jiangxi Clinical Medical Center for Cancer, Ganzhou, Jiangxi, China
| | - Lixing Huang
- Department of Gastroenterology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
| | - Jianfeng Wang
- Department of Oncology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
- Jiangxi Clinical Medical Center for Cancer, Ganzhou, Jiangxi, China
| | - Huaqiu Shi
- Department of Oncology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
- Jiangxi Clinical Medical Center for Cancer, Ganzhou, Jiangxi, China
| | - Shugui Wu
- Department of Oncology, The Affiliated Ganzhou Hospital of Nanchang University, Ganzhou, Jiangxi, China
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Fan C, Jiang Z, Teng C, Song X, Li L, Shen W, Jiang Q, Huang D, Lv Y, Du L, Wang G, Hu Y, Man S, Zhang Z, Gao N, Wang F, Shi T, Xin T. Efficacy and safety of intrathecal pemetrexed for TKI-failed leptomeningeal metastases from EGFR+ NSCLC: an expanded, single-arm, phase II clinical trial. ESMO Open 2024; 9:102384. [PMID: 38377785 PMCID: PMC11076967 DOI: 10.1016/j.esmoop.2024.102384] [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: 10/26/2023] [Revised: 01/06/2024] [Accepted: 01/19/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND This study aimed to evaluate the efficacy and safety of intrathecal pemetrexed (IP) for treating patients with leptomeningeal metastases (LM) from non-small-cell lung cancer (NSCLC) who progressed from epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitor (TKI) treatment in an expanded, prospective, single-arm, phase II clinical study (ChiCTR1800016615). PATIENTS AND METHODS Patients with confirmed NSCLC-LM who progressed from TKI received IP (50 mg, day 1/day 5 for 1 week, then every 3 weeks for four cycles, and then once monthly) until disease progression or intolerance. Objectives were to assess overall survival (OS), response rate, and safety. Measurable lesions were assessed by investigator according to RECIST version 1.1. LM were assessed according to the Response Assessment in Neuro-Oncology (RANO) criteria. RESULTS The study included 132 patients; 68% were female and median age was 52 years (31-74 years). The median OS was 12 months (95% confidence interval 10.4-13.6 months), RANO-assessed response rate was 80.3% (106/132), and the most common adverse event was myelosuppression (n = 42; 31.8%), which reversed after symptomatic treatment. The results of subgroup analysis showed that absence of brain parenchymal metastasis, good Eastern Cooperative Oncology Group score, good response to IP treatment, negative cytology after treatment, and patients without neck/back pain/difficult defecation had longer survival. Gender, age, previous intrathecal methotrexate/cytarabine, and whole-brain radiotherapy had no significant influence on OS. CONCLUSIONS This study further showed that IP is an effective and safe treatment method for the EGFR-TKI-failed NSCLC-LM, and should be recommended for these patients in clinical practice and guidelines.
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Affiliation(s)
- C Fan
- Department of Oncology, Second Affiliated Hospital of Harbin Medical University, Harbin
| | - Z Jiang
- Department of Oncology, Second Affiliated Hospital of Harbin Medical University, Harbin
| | - C Teng
- Department of Oncology, Second Affiliated Hospital of Harbin Medical University, Harbin
| | - X Song
- Department of Oncology, Second Affiliated Hospital of Harbin Medical University, Harbin
| | - L Li
- Department of Oncology, Second Affiliated Hospital of Harbin Medical University, Harbin
| | - W Shen
- Department of Oncology, Second Affiliated Hospital of Harbin Medical University, Harbin
| | - Q Jiang
- Department of Oncology, Second Affiliated Hospital of Harbin Medical University, Harbin
| | - D Huang
- Department of Oncology, Second Affiliated Hospital of Harbin Medical University, Harbin
| | - Y Lv
- Department of Oncology, Second Affiliated Hospital of Harbin Medical University, Harbin
| | - L Du
- Department of Oncology, Second Affiliated Hospital of Harbin Medical University, Harbin
| | - G Wang
- Department of Oncology, Second Affiliated Hospital of Harbin Medical University, Harbin
| | - Y Hu
- Department of Oncology, Second Affiliated Hospital of Harbin Medical University, Harbin
| | - S Man
- Department of Oncology, Second Affiliated Hospital of Harbin Medical University, Harbin
| | - Z Zhang
- Department of Oncology, Second Affiliated Hospital of Harbin Medical University, Harbin
| | - N Gao
- Department of Oncology, Heilongjiang Sengong General Hospital, Harbin, People's Republic of China
| | - F Wang
- Department of Oncology, Heilongjiang Sengong General Hospital, Harbin, People's Republic of China
| | - T Shi
- Department of Oncology, Heilongjiang Sengong General Hospital, Harbin, People's Republic of China
| | - T Xin
- Department of Oncology, Second Affiliated Hospital of Harbin Medical University, Harbin.
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Wu H, Zhang Q, Zhai W, Chen Y, Yang Y, Xie M, Huang Z, Xu Y, Li H, Gong L, Yu S, Fan Y, Chen K. Effectiveness of high-dose third-generation EGFR-tyrosine kinase inhibitors in treating EGFR-mutated non-small cell lung cancer patients with leptomeningeal metastasis. Lung Cancer 2024; 188:107475. [PMID: 38266613 DOI: 10.1016/j.lungcan.2024.107475] [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: 11/22/2023] [Revised: 01/16/2024] [Accepted: 01/17/2024] [Indexed: 01/26/2024]
Abstract
BACKGROUND Leptomeningeal metastasis (LM) is associated with an extremely poor prognosis in patients with epidermal growth factor receptor (EGFR)-mutated non-small cell lung cancer (NSCLC). The third-generation EGFR-tyrosine kinase inhibitors (TKIs), currently the preferred drug of choice, have significantly improved treatment outcomes in these patients. However, the optimal dose of third-generation EGFR-TKIs for clinical use remains undetermined in NSCLC patients with LM. METHODS We retrospectively analyzed the clinical characteristics and treatment outcomes of 105 patients with EGFR-mutated NSCLC and cytologically confirmed LM who had received third-generation EGFR-TKI treatment after LM diagnosis. Patients were stratified into high- and standard-dose groups based on the treatment dose of third-generation EGFR-TKI. Subsequent treatments for LM were collected, particularly the efficacy of different doses of third-generation EGFR-targeted drugs. RESULTS The median follow-up period was 28.7 months (range 0.6-40.2) at the cut-off date of August 27, 2023. The 105 included patients who received third-generation EGFR-TKI treatment had a clinical response rate (CRR) of 54.3 % (57/105), and the median overall survival (OS) from LM diagnosis was 12.3 months (95 % confidence interval [CI] = 10.0-15.0). Among them, 46 (43.8 %) patients received a high-dose regimen, and the remaining 59 (56.2 %) patients were treated with standard-dose drugs. Patients treated with high-dose third-generation EGFR-TKIs showed a higher CRR and longer OS than those treated with standard-dose therapy (65.2 % vs. 45.8 %, p = 0.047; 15.0 vs. 10.2 months, p = 0.014). Importantly, high-dose third-generation EGFR-TKI showed superior OS than standard-dose treatment in all subgroups (prior first-/second-generation EGFR-TKI resistance group, 19.5 vs. 9.8 months, p = 0.047; third-generation EGFR-TKI resistance group, 10.0 vs. 4.3 months, p = 0.045; EGFR-TKI naive group, not reach vs. 15.6 months, p = 0.031). Multivariate analysis revealed that high-dose third-generation EGFR-TKIs, intrathecal chemotherapy, previous TKI treatment history, and Karnofsky Performance Status score were independent predictors of OS (all p < 0.05). CONCLUSIONS High-dose third-generation EGFR-TKIs are effective treatments for NSCLC patients with EGFR mutations and LM, regardless of previous EGFR-TKI exposure.
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Affiliation(s)
- Haicheng Wu
- Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou 310022, China; Department of Thoracic Medical Oncology, Zhejiang Cancer Hospital, Hangzhou 310022, China; Wenzhou Medical University, Postgraduate Training Base Alliance, Wenzhou 325000, China
| | - Qian Zhang
- Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou 310022, China; Department of Thoracic Medical Oncology, Zhejiang Cancer Hospital, Hangzhou 310022, China; Department of Oncology, The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Wanchen Zhai
- Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou 310022, China; Department of Thoracic Medical Oncology, Zhejiang Cancer Hospital, Hangzhou 310022, China; Department of Oncology, The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Yunfei Chen
- Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou 310022, China; Department of Thoracic Medical Oncology, Zhejiang Cancer Hospital, Hangzhou 310022, China; Wenzhou Medical University, Postgraduate Training Base Alliance, Wenzhou 325000, China
| | - Yehao Yang
- Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou 310022, China; Department of Thoracic Medical Oncology, Zhejiang Cancer Hospital, Hangzhou 310022, China; Wenzhou Medical University, Postgraduate Training Base Alliance, Wenzhou 325000, China
| | - Mingning Xie
- Department of Medical Oncology, Huzhou Central Hospital, Huzhou 313000, China
| | - Zhiyu Huang
- Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou 310022, China; Department of Thoracic Medical Oncology, Zhejiang Cancer Hospital, Hangzhou 310022, China
| | - Yanjun Xu
- Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou 310022, China; Department of Thoracic Medical Oncology, Zhejiang Cancer Hospital, Hangzhou 310022, China
| | - Hui Li
- Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou 310022, China; Department of Thoracic Medical Oncology, Zhejiang Cancer Hospital, Hangzhou 310022, China
| | - Lei Gong
- Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou 310022, China; Department of Thoracic Medical Oncology, Zhejiang Cancer Hospital, Hangzhou 310022, China
| | - Sizhe Yu
- Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou 310022, China; Department of Thoracic Medical Oncology, Zhejiang Cancer Hospital, Hangzhou 310022, China
| | - Yun Fan
- Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou 310022, China; Department of Thoracic Medical Oncology, Zhejiang Cancer Hospital, Hangzhou 310022, China.
| | - Kaiyan Chen
- Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou 310022, China; Department of Thoracic Medical Oncology, Zhejiang Cancer Hospital, Hangzhou 310022, China.
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Jafari F, Nodeh MM, Hosseinjani H, Baharara H, Azad S, Arasteh O, Johnston TP, Sahebkar A. A Review on the Efficacy and Safety of Intrathecal Administration of Novel Medications for Leptomeningeal Metastases in Solid Cancers. Curr Med Chem 2024; 31:2732-2750. [PMID: 37157199 DOI: 10.2174/0929867330666230508142657] [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: 10/30/2022] [Revised: 02/27/2023] [Accepted: 03/31/2023] [Indexed: 05/10/2023]
Abstract
Leptomeningeal disease (LMD) is a rare and lethal manifestation that may occur in the advanced stages of solid tumors and hematological malignancies. With advances in diagnostic techniques, the detection and confirmation of the presence of LMD have increased. Although its optimal treatment remains a challenge, the use of the intrathecal route for the delivery of novel therapeutics is now considered a promising drug delivery strategy to complement radiation and systemic-based therapies. Although methotrexate, cytarabine, and thiotepa have a long history in the treatment of LMD, other medications have also been shown to be beneficial. In this article, we have reviewed the effects of novel medications administered via the intrathecal route for the treatment of solid tumors. We have searched PubMed, Scopus, and Google Scholar databases till the end of September 2021 using the following keywords: "leptomeningeal disease", "leptomeningeal carcinomatosis", "leptomeningeal metastases", "solid tumors", "solid cancers", and "intrathecal". Our literature findings have uncovered that most studies on LMD, which occurs secondary to solid cancers, are available as 'case reports', and few clinical trials have been conducted to date. Single-drug (monotherapy) or combination drug therapy, administered via the intrathecal route, especially in metastatic breast and lung cancer, has been shown to improve patients' symptoms and overall lifespan, while exhibiting a low and acceptable prevalence of side effects. However, judgments/conclusions about the effectiveness and safety of these drugs still require further clinical evaluation.
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Affiliation(s)
- Fatemeh Jafari
- Department of Clinical Pharmacy, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad Moeini Nodeh
- Division of Hematology and Oncology, Department of Internal Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hesamoddin Hosseinjani
- Department of Clinical Pharmacy, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hamed Baharara
- Department of Clinical Pharmacy, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Sajad Azad
- Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Omid Arasteh
- Department of Clinical Pharmacy, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Thomas P Johnston
- Division of Pharmacology and Pharmaceutical Sciences, School of Pharmacy, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Amirhossein Sahebkar
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
- Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Biotechnology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
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6
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Hong Y, Miao Q, Zheng X, Xu Y, Huang Y, Chen S, Huang Z, Xu H, Jiang K, Zhong Q, Zhang L, Zheng X, Zeng H, Yang S, Li Y, Li S, Zhuang W, Lin G. Effects of intrathecal pemetrexed on the survival of patients with leptomeningeal metastasis from lung adenocarcinoma: a propensity score matching analysis. J Neurooncol 2023; 165:301-312. [PMID: 37995007 DOI: 10.1007/s11060-023-04483-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 10/17/2023] [Indexed: 11/24/2023]
Abstract
PURPOSE To explore the impact of intrathecal pemetrexed (IP) on the survival of lung adenocarcinoma (LUAC) patients with leptomeningeal metastasis (LM). METHODS We analyzed patients with LUAC and LM who received systemic therapy after LM diagnosis at the Fujian Cancer Hospital between July 2018 and March 2022. Patients who underwent IP were assigned to the IP group; those without IP treatment were designated as the non-IP group. Propensity score matching (PSM) was performed between the two groups. RESULTS 165 patients were enrolled: 83 and 82 in the IP and non-IP groups, respectively. After 1:1 PSM, we included 114 patients in the matched cohort. Median overall survival (OS) was 13.2 months (95% CI 10.8-15.6 months) in the IP group versus 10.1 months (95% CI 5.3-14.9 months) in the non-IP group (P = 0.488). Only Eastern Cooperative Oncology Group Performance Status (ECOG PS) was confirmed as an independent predictor for OS in the matched cohort (hazard ratio (HR) 2.03; P = 0.023). Multivariate competing-risks analysis showed that IP significantly correlated with central nervous system-related death (HR 0.31; P = 0.046). When stratified by ECOG PS, IP improved survival in patients with poor ECOG PS (PS = 2) (14.3 months vs. 1.6 months; P = 0.003). CONCLUSIONS Intrathecal pemetrexed did not enhance OS for the entire LUAC patient with LM compared to non-intrathecal chemotherapy. However, it exhibited the potential to reduce the risk of central nervous system-related mortality and improve survival in patients with poor ECOG PS.
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Affiliation(s)
- Yaping Hong
- Department of Thoracic Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014, China
- Fujian Key Laboratory of Advanced Technology for Cancer Screening and Early Diagnosis, Fuzhou, 350014, China
| | - Qian Miao
- Department of Thoracic Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014, China
- Fujian Key Laboratory of Advanced Technology for Cancer Screening and Early Diagnosis, Fuzhou, 350014, China
| | - Xinlong Zheng
- Department of Thoracic Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014, China
- Fujian Key Laboratory of Advanced Technology for Cancer Screening and Early Diagnosis, Fuzhou, 350014, China
| | - Yiquan Xu
- Department of Thoracic Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014, China
- Fujian Key Laboratory of Advanced Technology for Cancer Screening and Early Diagnosis, Fuzhou, 350014, China
| | - Yunjian Huang
- Department of Thoracic Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014, China
- Fujian Key Laboratory of Advanced Technology for Cancer Screening and Early Diagnosis, Fuzhou, 350014, China
| | - Shengjia Chen
- Department of Thoracic Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014, China
- Fujian Key Laboratory of Advanced Technology for Cancer Screening and Early Diagnosis, Fuzhou, 350014, China
| | - Zhangzhou Huang
- Department of Thoracic Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014, China
- Fujian Key Laboratory of Advanced Technology for Cancer Screening and Early Diagnosis, Fuzhou, 350014, China
| | - Haipeng Xu
- Department of Thoracic Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014, China
- Fujian Key Laboratory of Advanced Technology for Cancer Screening and Early Diagnosis, Fuzhou, 350014, China
| | - Kan Jiang
- Department of Thoracic Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014, China
- Fujian Key Laboratory of Advanced Technology for Cancer Screening and Early Diagnosis, Fuzhou, 350014, China
| | - Qiaofeng Zhong
- Department of Thoracic Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014, China
- Fujian Key Laboratory of Advanced Technology for Cancer Screening and Early Diagnosis, Fuzhou, 350014, China
| | - Longfeng Zhang
- Department of Thoracic Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014, China
- Fujian Key Laboratory of Advanced Technology for Cancer Screening and Early Diagnosis, Fuzhou, 350014, China
| | - Xiaobin Zheng
- Department of Thoracic Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014, China
- Fujian Key Laboratory of Advanced Technology for Cancer Screening and Early Diagnosis, Fuzhou, 350014, China
| | - Hongfu Zeng
- Department of Thoracic Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014, China
- Fujian Key Laboratory of Advanced Technology for Cancer Screening and Early Diagnosis, Fuzhou, 350014, China
| | - Shanshan Yang
- Department of Thoracic Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014, China
- Fujian Key Laboratory of Advanced Technology for Cancer Screening and Early Diagnosis, Fuzhou, 350014, China
| | - Yujing Li
- Department of Thoracic Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014, China
- Fujian Key Laboratory of Advanced Technology for Cancer Screening and Early Diagnosis, Fuzhou, 350014, China
| | - Shihui Li
- Department of Thoracic Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014, China
- Fujian Key Laboratory of Advanced Technology for Cancer Screening and Early Diagnosis, Fuzhou, 350014, China
| | - Wu Zhuang
- Department of Thoracic Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014, China.
- Fujian Key Laboratory of Advanced Technology for Cancer Screening and Early Diagnosis, Fuzhou, 350014, China.
| | - Gen Lin
- Department of Thoracic Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014, China.
- Fujian Key Laboratory of Advanced Technology for Cancer Screening and Early Diagnosis, Fuzhou, 350014, China.
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Zhao Y, Yu L, Wang L, Wu Y, Chen H, Wang Q, Wu Y. The Riddle of the Sphinx: Progress in Leptomeningeal Metastasis of Non-Small Cell Lung Cancer. Clin Med Insights Oncol 2023; 17:11795549231205206. [PMID: 37915530 PMCID: PMC10617270 DOI: 10.1177/11795549231205206] [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: 06/02/2023] [Accepted: 09/15/2023] [Indexed: 11/03/2023] Open
Abstract
Leptomeningeal metastasis (LM) is a serious complication of advanced non-small cell lung cancer (NSCLC), and the incidence of LM has been increasing yearly in recent times. There is no consensus on the best treatment modality for LM, which underscores a difficult problem in the management of advanced NSCLC patients. The existing treatments include molecular targeted therapy, systemic chemotherapy, local radiotherapy, antivascular tumor therapy, intrathecal chemotherapy, and immunotherapy, but their efficacy is not satisfactory. In this article, we briefly describe the clinical manifestations, diagnosis, and treatment of NSCLC-LM and discuss progress regarding evaluation of the efficacy of LM treatment to better provide a necessary reference for clinical practice and clinical trial evaluation.
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Affiliation(s)
| | | | | | | | | | | | - Yufeng Wu
- Yufeng Wu, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou 450008, China.
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8
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Holdaway M, Ablyazova F, Huda S, D'Amico RS, Wong T, Shani D, Ben-Shalom N, Boockvar JA. First in-human intrathecal delivery of bevacizumab for leptomeningeal spread from recurrent glioblastoma: rationale for a dose escalation trial. J Neurooncol 2023; 164:231-237. [PMID: 37548850 DOI: 10.1007/s11060-023-04412-5] [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: 06/27/2023] [Accepted: 07/28/2023] [Indexed: 08/08/2023]
Abstract
PURPOSE To outline the dose rationale for the first in-human intrathecal delivery of bevacizumab for LMS of GBM. METHODS A 19-year-old female patient presented to Lenox Hill Hospital following thalamic GBM recurrence. She subsequently underwent two infusions of intra-arterial BEV (NCT01269853) and experienced a period of relative disease stability until progression in 2022. One month later, MRI disclosed diffuse enhancement representative of LMS of GBM. The patient subsequently underwent five cycles of IT BEV in mid-2022 (IND 162119). Doses of 25 mg, 37.5 mg, 50 mg, 50 mg, and 37.8 mg were delivered at two-week intervals between doses 1-4. The final 37.8 mg dose was given one day following her fourth dose, given that the patient was to be discharged, traveled several hours to our center, and was tolerating therapy well. Dosage was decreased due to the short interval between the final two treatments. Shortly after IT BEV completion, she received a third dose of IA BEV. RESULTS Our patient did not show any signs of serious adverse effects or dose limiting toxicities following any of the treatments. It is difficult to determine PFS due to the rapid progression associated with LMS of GBM and rapid timeframe of treatment. CONCLUSION LMS continues to be a devastating progression in many types of cancer, including GBM, and novel ways to deliver therapeutics may offer patients symptomatic and therapeutic benefits.
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Affiliation(s)
- Matthew Holdaway
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Lenox Hill Hospital, 130 East 77th Street, New York, NY, 10065, USA.
- Albany Medical College, Albany, NY, USA.
| | - Faina Ablyazova
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Lenox Hill Hospital, 130 East 77th Street, New York, NY, 10065, USA
| | - Shayan Huda
- CUNY School of Medicine, New York City, NY, USA
| | - Randy S D'Amico
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Lenox Hill Hospital, 130 East 77th Street, New York, NY, 10065, USA
| | - Tamika Wong
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Lenox Hill Hospital, 130 East 77th Street, New York, NY, 10065, USA
| | - Dana Shani
- Department of Hematology, Medical Oncology, Internal Medicine, Lenox Hill Hospital, New York City, NY, USA
- Northwell Health Cancer Institute, New Hyde Park, New York, NY, USA
| | - Netanel Ben-Shalom
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Lenox Hill Hospital, 130 East 77th Street, New York, NY, 10065, USA
| | - John A Boockvar
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Lenox Hill Hospital, 130 East 77th Street, New York, NY, 10065, USA
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Roy-O'Reilly MA, Lanman T, Ruiz A, Rogawski D, Stocksdale B, Nagpal S. Diagnostic and Therapeutic Updates in Leptomeningeal Disease. Curr Oncol Rep 2023; 25:937-950. [PMID: 37256537 PMCID: PMC10326117 DOI: 10.1007/s11912-023-01432-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2023] [Indexed: 06/01/2023]
Abstract
PURPOSE OF REVIEW Leptomeningeal disease (LMD) is a devastating complication of advanced metastatic cancer associated with a poor prognosis and limited treatment options. This study reviews the current understanding of the clinical presentation, pathogenesis, diagnosis, and treatment of LMD. We highlight opportunities for advances in this disease. RECENT FINDINGS In recent years, the use of soluble CSF biomarkers has expanded, suggesting improved sensitivity over traditional cytology, identification of targetable mutations, and potential utility for monitoring disease burden. Recent studies of targeted small molecules and intrathecal based therapies have demonstrated an increase in overall and progression-free survival. In addition, there are several ongoing trials evaluating immunotherapy in LMD. Though overall prognosis of LMD remains poor, studies suggest a potential role for soluble CSF biomarkers in diagnosis and management and demonstrate promising findings in patient outcomes with targeted therapies for specific solid tumors. Despite these advances, there continues to be a gap of knowledge in this disease, emphasizing the importance of inclusion of LMD patients in clinical trials.
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Affiliation(s)
| | - Tyler Lanman
- Department of Neurology, Stanford Medicine, Palo Alto, CA, 94305, USA
| | - Amber Ruiz
- Department of Neurology, Stanford Medicine, Palo Alto, CA, 94305, USA
| | - David Rogawski
- Department of Neurology, Stanford Medicine, Palo Alto, CA, 94305, USA
| | - Brian Stocksdale
- Department of Neurology, Stanford Medicine, Palo Alto, CA, 94305, USA
| | - Seema Nagpal
- Department of Neurology, Stanford Medicine, Palo Alto, CA, 94305, USA.
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10
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Zhou T, Zhu S, Xiong Q, Gan J, Wei J, Cai J, Liu A. Intrathecal chemotherapy combined with systemic therapy in patients with refractory leptomeningeal metastasis of non-small cell lung cancer: a retrospective study. BMC Cancer 2023; 23:333. [PMID: 37041504 PMCID: PMC10088274 DOI: 10.1186/s12885-023-10806-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 04/03/2023] [Indexed: 04/13/2023] Open
Abstract
BACKGROUND Leptomeningeal metastasis (LM) is the most devastating complication of non-small cell lung cancer (NSCLC), and its incidence is increasing. There is currently no standard treatment for LM, and the efficacy of traditional intravenous drug treatment is low, making refractory LM a difficult problem. In this study, we evaluated the efficacy and safety of intrathecal chemotherapy (IC)-based regimens in patients with refractory LM. METHODS We retrospectively enrolled NSCLC patients with confirmed LM who received IC and systemic therapy at the Second Affiliated Hospital of Nanchang University from December 2017 to July 2022. We analysed overall survival (OS), intracranial progression-free survival (iPFS), clinical response, and safety in these patients. RESULTS A total of 41 patients were enrolled. The median number of IC treatments was seven (range: 2-22). Seven patients received intrathecal methotrexate, and 34 patients received intrathecal pemetrexed. Clinical manifestations related to LM improved after IC and systemic therapy in 28 (68.3%) patients. The median iPFS in the whole cohort was 8 months (95% confidence interval [CI]: 6.4-9.7 months), and the median OS was 10.1 months (95% CI: 6.8-13.4 months). Multivariate analysis of the 41 patients with LM using a Cox proportional risk model showed that bevacizumab was an independent prognostic factor in patients treated with combination therapy (p = 0.002; hazard ratio [HR] 0.240; 95% CI: 0.097-0.595). Poor ECOG performance status remained a significant predictor of poor prognosis for survival (p = 0.048; HR 2.560; 95% CI: 1.010-6.484). Myelosuppression was the major adverse event over all IC dose levels. There were 18 cases of myelosuppression, 15 cases of leukopenia, and nine cases of thrombocytopenia. Eleven patients had myelosuppression above grade 3, including four with thrombocytopenia and seven with leukopenia. CONCLUSIONS Combination therapy based on IC had good curative effects, was safe to use, and was associated with prolonged survival in NSCLC patients with LM. The use of bevacizumab is a good prognostic factor for NSCLC LM patients with combination therapy.
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Affiliation(s)
- Tao Zhou
- Department of Oncology, The Second Affiliated Hospital of Nanchang University, No.1 Minde Street, Nanchang, Jiangxi Province, 330000, People's Republic of China
| | - Shaofeng Zhu
- Department of Oncology, The Second Affiliated Hospital of Nanchang University, No.1 Minde Street, Nanchang, Jiangxi Province, 330000, People's Republic of China
| | - Qiang Xiong
- Department of Oncology, The Second Affiliated Hospital of Nanchang University, No.1 Minde Street, Nanchang, Jiangxi Province, 330000, People's Republic of China
- Jiangxi Key Laboratory of Clinical Translational Cancer Research, Nanchang, Jiangxi Province, 330000, People's Republic of China
| | - Jiongli Gan
- Department of Oncology, The Second Affiliated Hospital of Nanchang University, No.1 Minde Street, Nanchang, Jiangxi Province, 330000, People's Republic of China
| | - Jianping Wei
- Department of Oncology, The Second Affiliated Hospital of Nanchang University, No.1 Minde Street, Nanchang, Jiangxi Province, 330000, People's Republic of China
- Jiangxi Key Laboratory of Clinical Translational Cancer Research, Nanchang, Jiangxi Province, 330000, People's Republic of China
| | - Jing Cai
- Department of Oncology, The Second Affiliated Hospital of Nanchang University, No.1 Minde Street, Nanchang, Jiangxi Province, 330000, People's Republic of China.
- Jiangxi Key Laboratory of Clinical Translational Cancer Research, Nanchang, Jiangxi Province, 330000, People's Republic of China.
- Radiation Induced Heart Damage Institute of Nanchang University, Nanchang, Jiangxi Province, 330000, People's Republic of China.
| | - Anwen Liu
- Department of Oncology, The Second Affiliated Hospital of Nanchang University, No.1 Minde Street, Nanchang, Jiangxi Province, 330000, People's Republic of China.
- Jiangxi Key Laboratory of Clinical Translational Cancer Research, Nanchang, Jiangxi Province, 330000, People's Republic of China.
- Radiation Induced Heart Damage Institute of Nanchang University, Nanchang, Jiangxi Province, 330000, People's Republic of China.
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Li H, Zheng S, Lin Y, Yu T, Xie Y, Jiang C, Liu X, Qian X, Yin Z. Safety, Pharmacokinetic and Clinical Activity of Intrathecal Chemotherapy With Pemetrexed via the Ommaya Reservoir for Leptomeningeal Metastases From Lung Adenocarcinoma: A Prospective Phase I Study. Clin Lung Cancer 2023; 24:e94-e104. [PMID: 36588048 DOI: 10.1016/j.cllc.2022.11.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/17/2022] [Accepted: 11/26/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Leptomeningeal metastasis (LM) is a highly fatal and debilitating complication of lung adenocarcinoma (LUAD) with limited therapeutic options. This study aimed to evaluate the efficacy and toxicities of intrathecal chemotherapy (IC) with pemetrexed via Ommaya reservoir in LUAD with refractory LM. METHODS In this prospective, single-arm, phase I trial (ChiCTR2000028936), LUAD-LM patients who had progressed after at least two prior treatments were recruited. Pemetrexed from 30 mg to 50 mg was administered on Days 1 and 8 every 3 weeks via Ommaya reservoir. Serial samples of cerebrospinal fluid (CSF) and plasma were obtained for pharmacokinetic studies. The primary endpoint was progression-free survival (PFS), and the secondary endpoints included overall survival (OS), objective response rate (ORR), disease control rate (DCR), and therapeutic toxicities. RESULTS Twenty-three patients were enrolled and analyzed, revealing an ORR of 43.5% (95% CI, 23.2%-63.8%) and DCR of 82.6% (95% CI, 61.2%-95.0%). The median PFS and OS were 6.3 and 9.5 months, respectively. Dose-limiting toxicity was only observed in 2 patients (2/23, 8.7%), and 30 mg pemetrexed was considered as the recommended dose for IC. Pharmacokinetic analysis showed that using Ommaya reservoirs, higher pemetrexed concentrations and prolonged half-lives were achieved in the CSF compared with lumbar puncture (LP). CONCLUSIONS Intrathecal pemetrexed at a dose of 30 mg via Ommaya reservoirs on Days 1 and 8 every 21 days achieved promising disease control and satisfactory survival with moderate toxicities in resistant LUAD-LM, providing a feasible and effective option, especially for the patients who cannot tolerate LP.
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Affiliation(s)
- Huiying Li
- The Comprehensive Cancer Center, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Shengnan Zheng
- Department of Pharmacy, Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Yongjuan Lin
- Department of Geriatric Oncology, Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Tingting Yu
- Department of Geriatric Oncology, Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Yu Xie
- Department of Geriatric Oncology, Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Cheng Jiang
- Department of Geriatric Oncology, Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Xiangyu Liu
- Department of Neurosurgery, Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Xiaoping Qian
- The Comprehensive Cancer Center, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China.
| | - Zhenyu Yin
- Department of Geriatric Oncology, Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China.
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Zhang C, Jiang D, Luo C, Yuan D, Shang G. Perioperative Effect of Single-Port Thoracoscopic Segmentectomy and Three-Port Thoracoscopic Segmentectomy in the Treatment of Early Non-Small-Cell Lung Cancer. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2023; 2023:7550317. [PMID: 36873790 PMCID: PMC9981298 DOI: 10.1155/2023/7550317] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/19/2022] [Accepted: 09/27/2022] [Indexed: 02/25/2023]
Abstract
Background Clinically, there were few reports on single-hole thoracoscopic segmental resection in non-small-cell lung cancer (NSCLC), and no report on the comparison of single-hole and three-hole thoracoscopic segmental resection. Hence, the purpose of the study was to explore the perioperative role of single-port thoracoscopic segmentectomy and three-port thoracoscopic segmentectomy for early-stage NSCLC. Methods The clinical data of 80 patients with early-stage NSCLC who were treated in our hospital from January 2021 to June 2022 were selected as the retrospective research subjects and divided into a comparison/research group with 40 cases in each group according to different surgical methods. Among them, the comparison group was received three-port thoracoscopic segmentectomy, and the research group was received single-port thoracoscopic segmentectomy. The surgical indicators, immune and tumor marker levels, as well as prognostic complications between two groups were compared. Results There was no remarkable diversity between the two groups in terms of operation time and the number of lymph nodes dissected during the operation (P > 0.05). The surgical blood loss in research group was lower than comparison group (P < 0.05). After treatment, the levels of CYFRA21-1, CA125, as well as VGEF in the research group were markedly lower than comparison group (P < 0.05). The differences in CD4+, CD3+, and CD4+/CD8+ after treatment were prominent, and the research group was higher than comparison group (P < 0.05). There was no statistical difference in postoperative complications between the two groups (P > 0.05). Conclusions Single-hole thoracoscopic lobectomy has obvious advantages in the treatment of NSCLC, which can reduce intraoperative bleeding, enhance the recovery of patients' immune function, and promote postoperative recovery.
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Affiliation(s)
- Cong Zhang
- Department of Thoracic Surgery, Chengdu Seventh People's Hospital, Chengdu, 610200 Sichuan, China
| | - Dexiong Jiang
- Department of Thoracic Surgery, Chengdu Seventh People's Hospital, Chengdu, 610200 Sichuan, China
| | - Cuilian Luo
- Department of Oncology, Chengdu Seventh People's Hospital, Chengdu, 610200 Sichuan, China
| | - Dongdong Yuan
- Department of Thoracic Surgery, Chengdu Seventh People's Hospital, Chengdu, 610200 Sichuan, China
| | - Guansheng Shang
- Department of Thoracic Surgery, Chengdu Seventh People's Hospital, Chengdu, 610200 Sichuan, China
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The Evolving Landscape of Leptomeningeal Cancer from Solid Tumors: A Systematic Review of Clinical Trials. Cancers (Basel) 2023; 15:cancers15030685. [PMID: 36765643 PMCID: PMC9913452 DOI: 10.3390/cancers15030685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/10/2023] [Accepted: 01/18/2023] [Indexed: 01/25/2023] Open
Abstract
Leptomeningeal carcinomatosis (LMC) is a fatal but uncommon complication occurring in 5-15% of patients with stage IV cancer. Current treatment options are ineffective at managing leptomeningeal spread, with a median overall survival (mOS) of 2-6 months. We aimed to conduct a systematic review of the literature to identify past and future therapies for LMC from solid tumors. Forty-three clinical trials (CTs) published between 1982-2022 were identified. Of these, 35 (81.4%) were non-randomized CTs and 8 (18.6%) were randomized CTs. The majority consisted of phase I (16.3%) and phase II CTs (65.1%). Trials enrolled patients with LMC from various primary histology (n = 23, 57.5%), with one CT evaluating LCM from melanoma (2.4%). A total of 21 trials evaluated a single modality treatment. Among CTs, 23.7% closed due to low accrual. Intraventricular (ITV)/intrathecal (IT) drug delivery was the most common route of administration (n = 22, 51.2%) vs. systemic drug delivery (n = 13, 30.3%). Two clinical trials evaluated the use of craniospinal irradiation for LMC with favorable results. LMC continues to carry a dismal prognosis, and over the years, increments in survival have remained stagnant. A paradigm shift towards targeted systemic therapy with continued standardization of efficacy endpoints will help to shed light on promising treatments.
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Ozcan G, Singh M, Vredenburgh JJ. Leptomeningeal Metastasis from Non-Small Cell Lung Cancer and Current Landscape of Treatments. Clin Cancer Res 2023; 29:11-29. [PMID: 35972437 DOI: 10.1158/1078-0432.ccr-22-1585] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/06/2022] [Accepted: 08/11/2022] [Indexed: 02/06/2023]
Abstract
Leptomeningeal metastasis (LM), also known as leptomeningeal carcinomatosis (LC), is a devastating complication of metastatic cancer that occurs when neoplastic cells invade the meningeal space. Diagnosis of LM remains challenging given the heterogeneous signs and symptoms at presentation and requires thorough neurological examination, cerebrospinal fluid (CSF) analysis, and MRI of the brain and spine with gadolinium. Detecting neoplastic cells in the CSF is the gold standard for diagnosing leptomeningeal metastases; however, it has low sensitivity and may require multiple CSF samples. New emerging technologies, such as liquid biopsy of CSF, have increased sensitivity and specificity for detecting circulating tumor cells in CSF. The management of LM in patients with NSCLC requires an individualized multidisciplinary approach. Treatment options include surgery for ventricular shunt placement, radiation therapy to bulky or symptomatic disease sites, systemic or intrathecal chemotherapy, molecularly targeted agents, and, more recently, immunotherapy. Targeting actionable mutations in LM from NSCLC, such as EGFR tyrosine kinase inhibitors or anaplastic lymphoma kinase gene rearrangement inhibitors, has shown encouraging results in terms of disease control and survival. Although there are limited data regarding the use of immunotherapy in LM, immunotherapy has produced promising results in several case reports. In this review, we focused on the epidemiology, pathophysiology, clinical presentation, diagnosis, and current treatment strategies, with a special emphasis on novel agents, including targeted therapies and immunotherapy of LM in patients with NSCLC.
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Affiliation(s)
- Gonca Ozcan
- Department of Medicine, University of Connecticut Health Center, Farmington, Connecticut
| | - Meghana Singh
- Department of Medicine, University of Connecticut Health Center, Farmington, Connecticut
| | - James J Vredenburgh
- Department of Medicine, Division of Hematology-Oncology, Saint Francis Hospital, Hartford, Connecticut
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15
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Leptomeningeal metastases in non-small cell lung cancer: Diagnosis and treatment. Lung Cancer 2022; 174:1-13. [PMID: 36206679 DOI: 10.1016/j.lungcan.2022.09.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 09/08/2022] [Accepted: 09/27/2022] [Indexed: 02/01/2023]
Abstract
Leptomeningeal metastasis (LM) is a rare complication of non-small cell lung cancer (NSCLC) with highly mortality. LM will occur once tumor cells spread to the cerebrospinal fluid (CSF) space. Patients may suffer blindness, paralysis, and mental disorders that seriously affect their quality of life. There is a clear unmet need to improve the efficacy of diagnosis and treatment of LM. To better solve this problem, it is helpful to clarify the potential mechanisms of LM. Clinical manifestations, magnetic resonance imaging, and CSF biopsy are the key components in the diagnosis of NSCLC with LM. CSF cytology is insufficient and should be combined with liquid biology. The application of radiotherapy, intrathecal treatment, targeted therapy and immunotherapy provides more options for LM patients. Each treatment has a particular level of efficacy and can be used alone or in combination for individual patients. New technologies in radiotherapy, drug repositioning in intrathecal treatment, and the higher CSF permeability in TKIs have brought new breakthroughs in the treatment of LM. This review focused on clarifying the potential mechanisms, discussing the major clinical challenges, and summarizing recent advances in the diagnosis and treatment of LM from NSCLC. Future research is essential to improve the efficiency of diagnosis, to optimize therapy and to enhance patient prognosis.
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Intrathecal therapy for the management of leptomeningeal metastatic disease: a scoping review of the current literature and ongoing clinical trials. J Neurooncol 2022; 160:79-100. [PMID: 35999434 DOI: 10.1007/s11060-022-04118-0] [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: 07/29/2022] [Accepted: 08/16/2022] [Indexed: 02/01/2023]
Abstract
PURPOSE Leptomeningeal metastatic disease (LMD) from advanced malignancies has poor prognoses and limited treatments. Intrathecal therapy (ITT) protocols are available, showing variable outcomes. We reviewed the therapeutic and toxicity profiles of ITT in LMD. METHODS PubMed, EMBASE, Web-of-Science, and Scopus were searched following the PRISMA-ScR guidelines to include studies reporting ITT for LMD. CLINICALTRIAL gov and Cochrane were searched to identify ongoing clinical trials. RESULTS We included 27 published studies encompassing 2161 patients and 4 ongoing trials. LMD originated from brain metastases (85.5%), lymphomas (5.4%), high-grade gliomas (4.6%), medulloblastomas (2.3%), and leukemias (2.1%). LMD was mostly diagnosed with the co-presence of neurological-related symptoms and positive imaging and/or cerebrospinal fluid cytology (60.8%). The most common ITT agents were methotrexate (35.9%), cytarabine (21.9%), and thiotepa (8.2%), standalone or combined. Patients received a median of 6.5 ITT cycles (range, 1.0-71.0) via intraventricular (58.8%) or lumbar intrathecal (41.2%) routes. The Ommaya reservoir was implanted in 38.5% cases. Concurrent systemic chemotherapy (45.2%) and/or radiotherapy (30.6%) were used. After 1-3 cycles, 44.7% patients had improved clinical status and 29.9% converted into negative cerebrospinal fluid cytology. The most common ITT-related severe adverse events were neutropenia (6.5%), meningitis (5.2%) and encephalopathy (4.5%). Median freedom from progression was 2.4 months (range, 0.1-59.5) and median overall survival 5.5 months (range, 0.1-148.0). CONCLUSION Current ITT protocols are variable but effective and well-tolerated in LMD. Ongoing trials are investigating dose-limiting toxicity profiles and long-term overall survival. Future studies should analyze the therapeutic and safety profiles of ITT compared to newer systemic therapies.
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Advances in the Diagnosis and Treatment of Leptomeningeal Disease. Curr Neurol Neurosci Rep 2022; 22:413-425. [PMID: 35588045 DOI: 10.1007/s11910-022-01198-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2022] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Leptomeningeal disease (LMD) is a rare, late complication of systemic cancer and is associated with significant neurological morbidity and high mortality. Here we provide an overview of this condition, summarizing key recent research findings and clinical practice trends in its diagnosis and treatment. We also review current clinical trials for LMD. RECENT FINDINGS Improved molecular diagnostic tools are in development to enable more sensitive detection of LMD, including circulating tumor cells and circulating tumor DNA. The use of targeted and CNS-penetrant therapeutics has shown survival improvements with tyrosine kinase inhibitors, antibody-drug conjugates, and select chemotherapy. However, these studies have primarily been phase I/II and retrospective analyses. There remains a dearth of clinical trials that include LMD patients. The combination of patient-specific molecular information and novel therapeutic approaches holds significant promise for improving outcomes in patients with LMD.
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Focusing on Intrathecal Pemetrexed for Treating Leptomeningeal Metastases From NSCLC. J Thorac Oncol 2022; 17:e31-e32. [PMID: 35216736 DOI: 10.1016/j.jtho.2021.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 09/27/2021] [Accepted: 09/29/2021] [Indexed: 11/22/2022]
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Li N, Bian Z, Cong M, Liu Y. Survival Outcomes of Patients With Epidermal Growth Factor Receptor Mutations in Non-Small Cell Lung Cancer With Leptomeningeal Metastasis. Front Oncol 2022; 11:723562. [PMID: 35127465 PMCID: PMC8811957 DOI: 10.3389/fonc.2021.723562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 11/01/2021] [Indexed: 12/13/2022] Open
Abstract
BackgroundLeptomeningeal metastasis (LM) is a commonly observed complication in patients with epidermal growth factor receptor (EGFR)-mutated non-small cell lung cancer (NSCLC). This study aimed to investigate the gene mutations, treatment strategies, and clinical outcomes in patients with LM.MethodsWe retrospectively analyzed the clinical and survival outcomes of 53 patients with EGFR-mutated NSCLC with LM.ResultsThe median overall survival after LM diagnosis was 13.0 months, ranging from 0.5 to 42.0 months (95% CI = 9.067–16.933), with 64.2% maturity. Patients who received osimertinib after developing LM (n = 35) had a significantly higher rate of LM disease control (p = 0.008) and significantly longer overall survival (15.0 versus 6.0 months; hazard ratio (HR), 2.4292; 95% CI, 1.234–4.779; p = 0.045) than those who received previous generations of EGFR tyrosine kinase inhibitors (TKIs) or other localized therapies (n = 6). Logistic regression analysis showed that LM disease control status was a positive predictive factor for overall survival after developing LM (p < 0.001, odds ratio = 10.797, 95% CI = 4.102–28.419).ConclusionsOur study provides real-world clinical evidence that patients with EGFR-mutated NSCLC diagnosed with LM who developed LM had better clinical outcomes with osimertinib therapy. Our findings also suggest that LM disease control is the most effective strategy to prolong the overall survival outcomes of these patients.
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Affiliation(s)
- Ning Li
- Department of Comprehensive Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Zhimin Bian
- Department of Comprehensive Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Minghua Cong
- Department of Comprehensive Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- *Correspondence: Yutao Liu, ; Minghua Cong,
| | - Yutao Liu
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- *Correspondence: Yutao Liu, ; Minghua Cong,
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20
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Geng D, Guo Q, Huang S, Zhang H, Guo S, Li X. A Retrospective Study of Intrathecal Pemetrexed Combined With Systemic Therapy for Leptomeningeal Metastasis of Lung Cancer. Technol Cancer Res Treat 2022; 21:15330338221078429. [PMID: 35289201 PMCID: PMC8928347 DOI: 10.1177/15330338221078429] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Objective This retrospective study aimed to investigate the clinical features of lung cancer patients with leptomeningeal metastasis (LM) and explore the clinical efficacy and tolerance of intrathecal pemetrexed (IP) combined with systemic antitumor therapy. Methods Thirty-four lung cancer patients (11 men, 23 women) with LM receiving IP at our hospital were retrospectively reviewed between August 2018 and December 2019. Identified cases showed either positive cerebrospinal fluid cytology or typical findings (leptomeningeal enhancement or ventricle broadening) upon imaging examination. Results Before the diagnosis of LM, 24 (70.6%) patients received EGFR-TKI therapy with or without other agents (antivascular therapy, or chemotherapy), 5 (14.7%) patients received chemotherapy, 1 (2.9%) patient received antivascular therapy, and 3 (8.8%) patients received ALK inhibitors. Fourteen (41.2%) patients did not change the systematic regimen at the beginning of IP, while 20 (58.8%) patients changed to antitumor agents. IP was administered for a median of 3 times (range, 1-12 times). The IP dose was 15, 20, 25, 30, and 40 mg in 8 (23.5%), 21 (58.8%), 2 (5.9%), 2 (5.9%), and 1 (5.9%) patient, respectively. In all IP dose levels, the major adverse events were myelosuppression and elevation of hepatic aminotransferases (EHA). Grade 1/2 myelosuppression occurred in 4 (11.8%) patients. Grade 1/2 EHA also occurred in 4 (11.8%) patients. Grades 3/4 adverse events were not observed. After IP and systematic therapy, the clinical manifestations related to LM in 26 (76.5%) patients improved. In the whole cohort, the median overall survival was 20 months. The median time from the initial IP administration until death or the last follow-up was 3.5 months. Conclusions IP showed controllable toxicity and good efficacy, prolonged the survival time, and improved the quality of life when combined with tailored systemic antitumor therapy in lung cancer patients.
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Affiliation(s)
- Di Geng
- 191599Department of Medical Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Qianqian Guo
- 191599Department of Medical Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Siyuan Huang
- 191599Department of Medical Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Huixian Zhang
- 191599Department of Medical Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Sanxing Guo
- 191599Department of Medical Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Xingya Li
- 191599Department of Medical Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
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21
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Zheng MM, Li YS, Sun H, Chen HJ, Wu YL. Intrathecal Pemetrexed: Another Potential Treatment Modality for Tyrosine Kinase Inhibitor-Failed Leptomeningeal Metastases? J Thorac Oncol 2021; 16:e82-e84. [PMID: 34561041 DOI: 10.1016/j.jtho.2021.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 06/10/2021] [Accepted: 06/13/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Mei-Mei Zheng
- School of Medicine, South China University of Technology, Guangzhou, People's Republic of China; Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Yang-Si Li
- School of Medicine, South China University of Technology, Guangzhou, People's Republic of China; Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Hao Sun
- Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Hua-Jun Chen
- Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Yi-Long Wu
- School of Medicine, South China University of Technology, Guangzhou, People's Republic of China; Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China.
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22
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Fan C, Zhao Q, Jiang Z, Xin T. Response to Letter to the Editor Titled "Intrathecal Pemetrexed: Another Potential Treatment Modality for TKI-Failed Leptomeningeal Metastases?". J Thorac Oncol 2021; 16:e85. [PMID: 34561042 DOI: 10.1016/j.jtho.2021.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 08/19/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Chengjuan Fan
- Department of Oncology, The Second Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China
| | - Qiuyu Zhao
- Department of Oncology, The Second Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China
| | - Zhengjun Jiang
- Department of Oncology, The Second Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China
| | - Tao Xin
- Department of Oncology, The Second Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China.
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Development and Validation of an HPLC Method for Analysis of Topotecan in Human Cerebrospinal Fluid and Its Application in Elimination Evaluation of Topotecan after Intraventricular Injection. Cancers (Basel) 2021; 13:cancers13184643. [PMID: 34572867 PMCID: PMC8471976 DOI: 10.3390/cancers13184643] [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: 08/06/2021] [Revised: 09/13/2021] [Accepted: 09/14/2021] [Indexed: 11/17/2022] Open
Abstract
Intrathecal administration of anticancer drugs is an effective dosage strategy, but the elimination of intraventricular drugs is not uniform in all patients. For safety, a system to evaluate local pharmacokinetics in the ventricles after administration is desired. In this study, we developed a simple and reproducible method to measure topotecan concentration in the cerebrospinal fluid (CSF) and confirmed its clinical applicability. High-performance liquid chromatography (HPLC) analysis was performed using a C18 column to measure the total topotecan concentration in the CSF. Clinical CSF samples were obtained from a 1-year old child with poor CSF absorption and stagnation. The patient received topotecan via an intraventricular subcutaneous reservoir. The HPLC method complied with the validation criteria. The lower limit of quantitation of this method was 0.04 µM. Using the developed method, we could determine the difference in topotecan CSF concentrations at 24 and 48 h after administration. The patient's topotecan elimination rate was extremely low, and signs of adverse effects were observed at high CSF concentration of topotecan. The developed method could detect the delay in topotecan elimination after intrathecal injection. The findings of this study are valuable for the development of personalized treatments for the intrathecal administration of anticancer drugs.
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24
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Fan C, Zhao Q, Li L, Shen W, Du Y, Teng C, Gao F, Song X, Jiang Q, Huang D, Jin Y, Lv Y, Wei L, Shi T, Zhao X, Gao N, Jiang Z, Xin T. Efficacy and Safety of Intrathecal Pemetrexed Combined With Dexamethasone for Treating Tyrosine Kinase Inhibitor-Failed Leptomeningeal Metastases From EGFR-Mutant NSCLC-a Prospective, Open-Label, Single-Arm Phase 1/2 Clinical Trial (Unique Identifier: ChiCTR1800016615). J Thorac Oncol 2021; 16:1359-1368. [PMID: 33989780 DOI: 10.1016/j.jtho.2021.04.018] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 04/29/2021] [Accepted: 04/30/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION We aimed to evaluate the efficacy and safety of intrathecal pemetrexed (IP) for treating EGFR-mutant leptomeningeal metastases (LMs) from EGFR-mutant NSCLC. METHODS Patients with EGFR-mutant NSCLC with LM who had failed tyrosine kinase inhibitors were recruited. The dose of IP was escalated from 15 mg to 80 mg using an accelerated titration design in a phase 1 study. The recommended dose (RD) determined in phase 1 was used in the phase 2 study. The primary end point was treatment efficacy measured as the clinical response rate. Overall survival and adverse events (AEs) were evaluated as secondary end points. RESULTS The RD observed in the phase 1 study was 50 mg pemetrexed. A total of 30 cases of LM-NSCLC were enrolled in the phase 2 study, including 14 males and 16 females. Four patients did not survive for 4 weeks and could not be evaluated for efficacy. The clinical response rate was 84.6% (22 of 26). The median overall survival of all patients was 9.0 months (n = 30, 95% confidence interval: 6.6-11.4 mo). Most AEs were mild, and the most frequent AE of any grade was myelosuppression (n = 9, 30%), which returned to normal after symptomatic treatment. CONCLUSIONS This study revealed that 50 mg pemetrexed is the RD which results in few AEs and a good response rate. IP is an effective treatment for patients with EGFR-mutant NSCLC-LM who had failed on tyrosine kinase inhibitor.
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Affiliation(s)
- Chengjuan Fan
- Department of Oncology, The Second Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China
| | - Qiuyu Zhao
- Department of Oncology, The Second Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China
| | - Li Li
- Department of Oncology, The Second Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China
| | - Weixi Shen
- Department of Oncology, The Second Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China
| | - Yang Du
- Department of Oncology, The Second Tumor Hospital of Heilongjiang Province, Harbin, People's Republic of China
| | - Chong Teng
- Department of Oncology, The Second Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China
| | - Feng Gao
- Department of Oncology, The Second Tumor Hospital of Heilongjiang Province, Harbin, People's Republic of China
| | - Xiaowei Song
- Department of Oncology, The Second Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China
| | - Qiuying Jiang
- Department of Oncology, The Second Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China
| | - Dayong Huang
- Department of Oncology, The Second Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China
| | - Yinghua Jin
- Department of Oncology, The Third Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China
| | - Yanju Lv
- Department of Oncology, The Second Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China
| | - Lingxiao Wei
- Department of Oncology, Yunnan Cancer Hospital, Kunming, People's Republic of China
| | - Tengfei Shi
- Department of Oncology, The Third Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China
| | - Xue Zhao
- Department of Oncology, The Second Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China
| | - Naisheng Gao
- Department of Oncology, The Second Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China
| | - Zhengjun Jiang
- Department of Oncology, The Second Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China
| | - Tao Xin
- Department of Oncology, The Second Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China.
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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: 14] [Impact Index Per Article: 4.7] [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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26
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Lu ZQ, Cai J, Wang X, Wei JP, Zeng ZM, Huang L, Liu AW. Osimertinib combined with bevacizumab for leptomeningeal metastasis from EGFR-mutation non-small cell lung cancer: A phase II single-arm prospective clinical trial. Thorac Cancer 2020; 12:172-180. [PMID: 33205587 PMCID: PMC7812067 DOI: 10.1111/1759-7714.13738] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/25/2020] [Accepted: 10/28/2020] [Indexed: 12/13/2022] Open
Abstract
Background Leptomeningeal metastasis (LM) is associated with poor prognosis in non‐small cell lung cancer (NSCLC). The aim of this study was to investigate the efficacy and safety of osimertinib combined with bevacizumab for LM from epidermal growth factor receptor mutation (EGFRm) NSCLC. Methods We conducted a phase II single‐arm prospective clinical trial of EGFRm NSCLC with LM treated with osimertinib combined with bevacizumab. LM response assessment was based on the modified RANO LM radiological criteria; CNS and extra‐CNS response was evaluated according to the Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1. The primary end points included LM progression‐free survival (PFS) and objective response rate (ORR); the secondary end points included safety and LM overall survival (OS). Results A total of 14 patients were included in the study, with a median age of 61 years, and they were predominantly female (64%). EGFR mutations were reported in exons 19 del (n = 7) and 21 L858R (n = 7). When LM was diagnosed, 12 (85.7%) patients had clinical symptoms, 71.4% (10/14) of patients were diagnosed with LM by cytology, and five (35.7%) patients had a performance status (PS) score > 2. The median LM PFS was 9.3 months (95% CI: 8.2–10.4), and the LM ORR was 50%. The safety findings in the present study were consistent with the known profile of osimertinib with bevacizumab; the median LM OS was 12.6 months, and the one‐year survival rate was 35.7%. Conclusions Osimertinib combined with bevacizumab is an appropriate treatment option for patients with LM from EGFRm NSCLC. Key points Significant findings of the study To date, there is no prospective clinical study on the treatment of osimertinib combined with bevacizumab in EGFRm NSCLC with LM. What this study adds The median LM PFS was 9.3 months (95% CI: 8.2–10.4), and the LM ORR was 50%, the median LM OS was 12.6 months, and the one‐year survival rate was 35.7%. Osimertinib combined with bevacizumab is an appropriate treatment option for patients with LM from EGFRm NSCLC.
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Affiliation(s)
- Zhi-Qin Lu
- Department of Oncology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jing Cai
- Department of Oncology, The Second Affiliated Hospital of Nanchang University, Nanchang, China.,Department of Oncology, Jiangxi Key Laboratory of Clinical Translational Cancer Research, Nanchang, China
| | - Xia Wang
- Department of Oncology, The Second Affiliated Hospital of Nanchang University, Nanchang, China.,Department of Oncology, Jiangxi Key Laboratory of Clinical Translational Cancer Research, Nanchang, China
| | - Jian-Ping Wei
- Department of Oncology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Zhi-Min Zeng
- Department of Oncology, The Second Affiliated Hospital of Nanchang University, Nanchang, China.,Department of Oncology, Jiangxi Key Laboratory of Clinical Translational Cancer Research, Nanchang, China
| | - Long Huang
- Department of Oncology, The Second Affiliated Hospital of Nanchang University, Nanchang, China.,Department of Oncology, Jiangxi Key Laboratory of Clinical Translational Cancer Research, Nanchang, China
| | - An-Wen Liu
- Department of Oncology, The Second Affiliated Hospital of Nanchang University, Nanchang, China.,Department of Oncology, Jiangxi Key Laboratory of Clinical Translational Cancer Research, Nanchang, China
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Lu Z, Cai J, Zeng Z, Liu A. [Management of Drug Therapy for Leptomeningeal Metastasis of Sensitive Driver Gene Positive Non-small Cell Lung Cancer]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2020; 23:710-718. [PMID: 32758347 PMCID: PMC7467993 DOI: 10.3779/j.issn.1009-3419.2020.102.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Leptomeningeal metastasis (LM) is one of the serious complications of advanced non-small cell lung cancer (NSCLC), although the incidence is not high, the clinical symptoms are severe and the prognosis is poor. LM is prone to occur in patients with positive driver gene than negative. At present, the treatment of LM mainly includes molecular targeted therapy, systemic chemotherapy, whole brain radiotherapy, intrathecal chemotherapy and immunotherapy. Although there are many treatments, the efficacy of LM is still unsatisfactory. This article reviews the drug therapy of sensitive driver gene positive NSCLC LM.
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Affiliation(s)
- Zhiqin Lu
- Department of Oncology, The Second Affiliated of Nanchang University, Nanchang 330006, China
| | - Jing Cai
- Department of Oncology, The Second Affiliated of Nanchang University, Nanchang 330006, China.,Jiangxi Key Laboratory of Clinical Translational Cancer Research, Nanchang 330006, China
| | - Zhimin Zeng
- Department of Oncology, The Second Affiliated of Nanchang University, Nanchang 330006, China.,Jiangxi Key Laboratory of Clinical Translational Cancer Research, Nanchang 330006, China
| | - Anwen Liu
- Department of Oncology, The Second Affiliated of Nanchang University, Nanchang 330006, China.,Jiangxi Key Laboratory of Clinical Translational Cancer Research, Nanchang 330006, China
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Leptomeningeal Metastases in Non-small Cell Lung Cancer: Optimal Systemic Management in NSCLC With and Without Driver Mutations. Curr Treat Options Oncol 2020; 21:72. [PMID: 32725549 DOI: 10.1007/s11864-020-00759-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OPINION STATEMENT As a devastating complication of non-small cell lung cancer (NSCLC), the incidence of leptomeningeal metastasis (LM) is rising, largely due to overall longer survival of NSCLC, especially in patients with targetable molecular driver mutations. There is no clear consensus on the optimal management of LM. This review will cover recent advances in diagnosis, monitoring, and treatment of LM in NSCLC. In LM without oncogene drivers, systemic chemotherapy, intrathecal therapy, and radiation have modestly improved the clinical outcomes. Emerging data have also suggested encouraging activity of immunotherapy. At the same time, in LM with sensitizing EGFR mutations, osimertinib should be considered regardless of T790M status. Pulse erlotinib, afatinib, and newer agents with improved CNS penetration have also shown benefits. Moreover, accumulating evidences support potential benefits of molecularly targeted therapy in ALK-rearranged and other oncogene-driven NSCLC with LM. Future studies are warranted to better define the underlying mechanism, to optimize the clinical management, and to improve patient outcomes.
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Pan Z, Yang G, He H, Cui J, Li W, Yuan T, Chen K, Jiang T, Gao P, Sun Y, Cong X, Li Z, Wang Y, Pang X, Song Y, Zhao G. Intrathecal pemetrexed combined with involved-field radiotherapy as a first-line intra-CSF therapy for leptomeningeal metastases from solid tumors: a phase I/II study. Ther Adv Med Oncol 2020; 12:1758835920937953. [PMID: 32733606 PMCID: PMC7370561 DOI: 10.1177/1758835920937953] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 05/21/2020] [Indexed: 12/22/2022] Open
Abstract
Purpose: A phase I/II study of intrathecal pemetrexed (IP) combined with involved-field radiotherapy (IFRT) was performed to determine feasibility, safety, and antitumor activity for leptomeningeal metastases (LM) from solid tumors. Methods: Participants first received induction IP administration, followed by concomitant radiotherapy within 3 days. The concomitant regimen consisted of IP (pemetrexed 10 mg, dexamethasone 5 mg, once per week, 4 times in 4 weeks) and IFRT (40 Gy in 20 fractions). Six participants were recruited to assess feasibility in phase I, and then 28 patients were recruited further. All patients were assessed to investigate safety, efficacy, and outcomes. Results: Between April 2018 and December 2018, 34 patients (male: 15; female: 19; median age: 56 years) were enrolled, including non-small-cell lung cancer (21), small-cell lung cancer (5), breast cancer (4), and others (4). Thirty-two patients received concurrent therapy and 25 (74%) patients completed the treatment. Major adverse events (AEs) consisted of myelosuppression, the elevation of hepatic aminotransferases, and radiculitis. Total AEs rate was 53% (18/34), including 6 (18%) patients with grade 3 and 1 (3%) with grade 4 AEs. The response rate was 68% (23/34). The median overall survival was 5.5 (0.3–16.6) months. Median neurological progression-free survival (NPFS) was 3.5 (0.3–15.2) months. Six-month NPFS rate was 47%. One-year survival rate was 21.6%. Conclusion: IP at a 10 mg dose on a schedule of 1–2 times per week presented good efficacy and safety in CSF. The concomitant regimen is an efficacious therapeutic option for LM patients with solid tumors. Trial Registration: This study (IPLM) was registered at https://register.clinicaltrials.gov [ClinicalTrials.gov identifier: NCT03507244].
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Affiliation(s)
- Zhenyu Pan
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, China
| | - Guozi Yang
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, China
| | - Hua He
- Cancer Center, The First Hospital of Jilin University, Changchun, China
| | - Jiuwei Cui
- Cancer Center, The First Hospital of Jilin University, Changchun, China
| | - Wei Li
- Cancer Center, The First Hospital of Jilin University, Changchun, China
| | - Tingting Yuan
- Department of Radiology, The First Hospital of Jilin University, Changchun, China
| | - Kunzhi Chen
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, China
| | - Tongchao Jiang
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, China
| | - Pengxiang Gao
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, China
| | - Yanan Sun
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, China
| | - Xiaofeng Cong
- Cancer Center, The First Hospital of Jilin University, Changchun, China
| | - Zhi Li
- Cancer Center, The First Hospital of Jilin University, Changchun, China
| | - Yongxiang Wang
- Department of Clinical Laboratory, The First Hospital of Jilin University, Changchun, China
| | - Xiaochuan Pang
- Department of Clinical Laboratory, The First Hospital of Jilin University, Changchun, China
| | - Yuanyuan Song
- Department of Clinical Laboratory, The First Hospital of Jilin University, 71 Xinmin Street, Changchun, 130021, China
| | - Gang Zhao
- Department of Neuro-Oncological Surgery, The First Hospital of Jilin University, 71 Xinmin Street, Changchun, 130021, China
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Pan Z, Yang G, He H, Gao P, Jiang T, Chen Y, Zhao G. Identification of Cerebrospinal Fluid MicroRNAs Associated With Leptomeningeal Metastasis From Lung Adenocarcinoma. Front Oncol 2020; 10:387. [PMID: 32328453 PMCID: PMC7152668 DOI: 10.3389/fonc.2020.00387] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 03/04/2020] [Indexed: 01/04/2023] Open
Abstract
Background: Leptomeningeal metastasis (LM) has frequently been observed in patients with lung adenocarcinoma. So far, its diagnosis and disease course monitoring are still extremely difficult. Moreover, there is no effective treatment regimen for LM due to a lack knowledge on the molecular mechanism of LM. This study aimed to identify LM-related cerebrospinal fluid (CSF) miRNAs, which have potential value for diagnosing and monitoring LM and exploring the molecular mechanism. Methods: CSF miRNAs were screened and verified by microarray analysis and quantitative real-time PCR (qRT-PCR) in LM patients with lung adenocarcinoma and non-LM controls, and the diagnostic performance of candidate miRNAs was evaluated. Then, candidate miRNAs in matched CSF samples from LM patients at diagnosis, after initial therapy, at relapse, and after salvage therapy, were analyzed to assess the relationship between CSF miRNAs and LM disease course. The effect of candidate miRNAs on proliferation, invasion, and migration of lung adenocarcinoma cell lines was assessed. The targeted genes of the candidate miRNA were predicted by TargetScan, miRDB, and miRTarbase online analysis tools. Gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) were used to analyze the functional categories of predicted target genes. Results: CSF miR-7975, miR-7977, and miR-7641 were screened and verified to be statistically significantly up-regulated in LM patients compared to non-LM controls. The three miRNAs, when combined, exhibited optimal diagnostic performance. Longitudinal data of CSF miR-7975 and miR-7977 correlated well with clinical courses of LM. Overexpression of miR-7977 promoted proliferation, migration, and invasion of lung adenocarcinoma cells. Moreover, 385 targeted genes of miR-7977 were predicted and were involved in various pathways related to cancer metastasis. Conclusions: This study offers insights for future research of CSF miRNAs as robust tools for diagnosing and monitoring LM. It also reveals a novel pathway for exploration of underlying mechanisms of LM.
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Affiliation(s)
- Zhenyu Pan
- Department of Neuro-Oncological Surgery, The First Hospital of Jilin University, Changchun, China.,Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, China.,VA Palo Alto Health Care System, Stanford University Medical School, Palo Alto, CA, United States
| | - Guozi Yang
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, China.,VA Palo Alto Health Care System, Stanford University Medical School, Palo Alto, CA, United States
| | - Hua He
- Cancer Center, The First Hospital of Jilin University, Changchun, China
| | - Pengxiang Gao
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, China
| | - Tongchao Jiang
- Department of Radiation-Oncology, The First Hospital of Jilin University, Changchun, China
| | - Yong Chen
- Department of Neuro-Oncological Surgery, The First Hospital of Jilin University, Changchun, China
| | - Gang Zhao
- Department of Neuro-Oncological Surgery, The First Hospital of Jilin University, Changchun, China
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