Assessment of Leptomeningeal Carcinomatosis Diagnosis, Management and Outcomes in Patients with Solid Tumors Over a Decade of Experience

Early Outcomes from Proton Craniospinal Irradiation for Leptomeningeal Metastasis From Solid Tumors

Purpose

Treatment options for leptomeningeal metastasis (LM) are limited. A recent phase 2 study found that proton craniospinal irradiation (pCSI) was well-tolerated and improved survival. We report our experience with pCSI for solid-tumor LM.

Methods and Materials

This is a retrospective review of patients treated with pCSI for solid-tumor LM from December 2020 to January 2024 at our center. Patient characteristics were summarized using descriptive statistics. Median overall survival and median central nervous system progression-free survival from the first day of pCSI were estimated using Kaplan-Meier survival curves.

Results

We identified 45 patients who completed pCSI. The median age was 54 years (range, 23-79); 73% were female, and 53% lived more than 100 miles from our center. Breast cancer (53%), lung cancer (20%), and melanoma (9%) were the most common primary cancers; 51% of patients had stable systemic disease at LM diagnosis. All had imaging evidence of LM, and 64% of cases were confirmed using cytologic examination of the cerebrospinal fluid. Eighty percent had symptomatic LM, and the median Karnofsky performance scale at LM diagnosis was 80. The median time from primary cancer diagnosis to LM detection was 23.1 months (range, 0-221.3). Fifty-three percent of patients had active brain metastasis at LM diagnosis; 33% of all patients had received prior intracranial radiation. The median time from simulation to pCSI start was 12 days. At the first visit following pCSI, the median Karnofsky performance scale score was 70. During or right after radiation, 76% of patients reported nausea, 51% headache, and 31% fatigue. Following pCSI, 4% received intrathecal chemotherapy, 67% systemic therapy, and 9% hospice care; 18% were observed and 2% lost to follow-up. Median overall survival was 13.7 months (95% confidence interval [CI], 11.2 to not reached), and median progression-free survival was 6.5 months (95% CI, 4.9-12.8).

Conclusions

The outcomes in our cohort are comparable to those recently reported in a phase 2 trial. Further study is indicated to determine the optimal candidates for pCSI and sequential therapies.

A comprehensive review of current treatment modalities for leptomeningeal carcinomatosis in breast cancer

Leptomeningeal carcinomatosis (LC) is a metastatic complication of breast cancer that imparts a very poor prognosis and distressing neurologic symptoms in affected patients. While the incidence of LC has risen with improving survival rates for cancer patients, there remains no established treatment protocol for LC and clinical trial data comparing available therapies is limited. Here, a comprehensive literature search of the pubmed and Cochrane databases was performed. Current treatment modalities and their safety/ efficacy profiles are summarized for LC in breast cancer. Roles for emerging therapies in LC are discussed, including targeted agents, CAR-T, immune checkpoint inhibitors, CDK inhibitors and novel antibody conjugates. A treatment pathway for LC is also proposed to guide clinicians through management of this severe metastatic complication of breast cancer.

Immunotherapy for leptomeningeal disease from solid tumors: current clinical outcomes and future opportunities

Leptomeningeal disease is a debilitating, late-stage form of metastatic cancer disseminated within the cerebrospinal fluid, subarachnoid space, and leptomeninges, leading to significant neurological morbidity and mortality. As systemic cancer treatments improve, rates of leptomeningeal disease have increased, yet prognosis remains exceedingly poor. A wide range of treatment modalities have been trialed; however, no standard of care has been established. Additionally, many clinical trials exclude patients with leptomeningeal disease, limiting available prospective data. In this review, we discuss the efficacy of immunotherapy for leptomeningeal disease from solid tumors including systemic and intrathecal therapies, as well as combined therapy regimens. Our review indicates a continued deficiency in the current prospective literature and highlights ongoing research regarding the leptomeningeal immune microenvironment, which will be critical in directing future study of leptomeningeal disease treatment. Currently, the efficacy of immunotherapies on leptomeningeal disease appears limited, and further prospective research is needed to draw significant conclusions. However, recent advancement in understanding the leptomeningeal microenvironment points to potential efficacy of novel immunotherapies targeting the innate immune system, and further study is warranted to evaluate the efficacy of these treatments in this subpopulation of patients.

Diagnostics and Screening in Breast Cancer with Brain and Leptomeningeal Metastasis: A Review of the Literature

Brain and leptomeningeal metastases are complications of breast cancer with high rates of morbidity and mortality and have an estimated incidence of up to 30%. While National Comprehensive Cancer Network (NCCN) guidelines recommend screening for central nervous system metastasis in other neurotropic cancers such as non-small cell lung cancer, there are no such recommendations for asymptomatic breast cancer patients at any stage of disease. This review highlights ongoing studies into screening and diagnostics for breast cancer with brain and leptomeningeal metastasis (BCBLM) as they relate to patient outcomes and prognostication. These include imaging methods such as MRI with novel contrast agents with or without PET/CT, as well as 'liquid biopsy' testing of the cerebrospinal fluid and serum to analyze circulating tumor cells, genomic material, proteins, and metabolites. Given recent advances in radiation, neurosurgery, and systemic treatments for BCBLM, screening for CNS involvement should be considered in patients with advanced breast cancer as it may impact treatment decisions and overall survival.

Building Team Medicine in the Management of CNS Metastases

CNS metastases are often terminal for cancer patients and occur at an approximately 10-fold higher rate than primary CNS tumors. The incidence of these tumors is approximately 70,000-400,000 cases annually in the US. Advances that have occurred over the past two decades have led to more personalized treatment approaches. Newer surgical and radiation techniques, as well as targeted and immune therapies, have enanled patient to live longer, thus increasing the risk for the development of CNS, brain, and leptomeningeal metastases (BM and LM). Patients who develop CNS metastases have often been heavily treated, and options for future treatment could best be addressed by multidisciplinary teams. Studies have indicated that patients with brain metastases have improved survival outcomes when cared for in high-volume academic institutions using multidisciplinary teams. This manuscript discusses a multidisciplinary approach for both parenchymal brain metastases as well as leptomeningeal metastases implemented in three academic institutions. Additionally, with the increasing development of healthcare systems, we discuss optimizing the management of CNS metastases across healthcare systems and integrating basic and translational science into our clinical care to further improve outcomes. This paper summarizes the existing therapeutic approaches to the treatment of BM and LM and discusses novel and emerging approaches to optimizing access to neuro-oncologic care while simultaneously integrating multidisciplinary teams in the care of patients with BM and LM.

Leptomeningeal Metastasis from Non-Small Cell Lung Cancer and Current Landscape of Treatments

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.

Ophthalmoplegia in a Her2+ and β-hCG+ Patient With Leptomeningeal Carcinomatosis Secondary to Gastric Adenocarcinoma

Leptomeningeal carcinomatosis (LMC) is an uncommon and devastating late complication of metastatic malignancy that carries a poor prognosis, typically faring worse when secondary to solid tumors. Diagnosis of LMC can be challenging, especially if the underlying cancer is undiagnosed, as presenting symptoms can be nonspecific or involve focal deficits such as cranial nerve palsies. Typically, LMC can be recognized due to new central neurological findings with concomitant peripheral nerve involvement, but there has not been a case of LMC with isolated peripheral nerve findings to our knowledge. In this report, we present a case of LMC secondary to metastatic gastric adenocarcinoma in a patient whose only manifestation was cranial nerve palsies, and whose cancer was also found to be Her2+ and β-hCG positive, two markers not widely recognized in gastric cancer.