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Marenco-Hillembrand L, Bamimore MA, Rosado-Philippi J, Perdikis B, Abarbanel DN, Quinones-Hinojosa A, Chaichana KL, Sherman WJ. The Evolving Landscape of Leptomeningeal Cancer from Solid Tumors: A Systematic Review of Clinical Trials. Cancers (Basel) 2023; 15. [PMID: 36765643 DOI: 10.3390/cancers15030685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [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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Smets L, Claerhout H, Van Laer C, Boeckx N. Malignant invasion of the cerebrospinal fluid in adult and paediatric patients with haematological and solid malignancies: a monocentric retrospective study. Acta Clin Belg 2022; 77:524-532. [PMID: 33729099 DOI: 10.1080/17843286.2021.1900493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES In this study, we describe the clinical presentation, the cerebrospinal fluid (CSF) characteristics and outcome of children and adults with leptomeningeal invasion due to haematological and solid malignancies. METHODS Routine CSF samples analyzed from 2008 to 2018 at our institution were retrospectively reviewed for the presence of malignant cells based on cytomorphological analysis. RESULTS Leptomeningeal invasion was identified in 212 patients: 45 children versus 167 adults, and 92 haematological versus 120 solid malignancies. Leukaemic invasion in childhood was mainly due to ALL, and lymphoma invasion was often due to a high-grade B-cell lymphoma in adults. Metastatic invasion by solid tumours was almost exclusively seen in adults. Patients suffered most frequently from cranial neuropathy and headache (both 32%), while asymptomatic presentations were seen mainly in children (33%) and haematological malignancies (17%). Laboratory CSF parameters often showed an elevated WBC count (87%), total protein (74%) and lactate (76%) and a decreased glucose (77%). These deviations were especially found in solid malignancies (>84%) and adults (>82%). Brain and/or spinal cord imaging was more often suggestive for the leptomeningeal invasion in solid than in haematological malignancies (86% vs. 46%). The 5-year overall survival (OS) rates for patients with haematological and solid malignancies were 21.5% and 5.9%, respectively. The 5-year OS rate for children (55.6%) was significantly better than for adults (3.5%). CONCLUSION Leptomeningeal invasion is more often asymptomatic, and CSF parameters and imaging are more often normal in children and haematological malignancies than in adults and solid malignancies, possibly leading to underdiagnosis.
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Affiliation(s)
- Leonie Smets
- Clinical Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Helena Claerhout
- Clinical Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Christine Van Laer
- Clinical Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium. Department of Cardiovascular Sciences, Centre for Molecular and Vascular Biology, Leuven, Belgium
| | - Nancy Boeckx
- Clinical Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium. Departement of Oncology, Leuven, Belgium
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Abstract
Background Neoplastic meningitis (NM) is considered as a terminal event with poor prognosis. Its impact in clinical oncology is growing. Objective To analyze the clinical outcome of patients with carcinoma breast diagnosed with NM. Materials and Methods This study was an observational study in breast cancer patients diagnosed with NM. Patients with typical clinical symptoms and signs with either presence of cerebrospinal fluid (CSF) cytology positive for neoplastic cells or typical radiological features of leptomeningeal involvement in the presence of neurological symptoms or signs were taken as leptomeningeal metastasis (LM) or NM. The estimation of survival was done by Kaplan-Meier method. Results Out of 1,200 patients diagnosed with carcinoma breast during the study period, 15 developed NM. The median age of study population was 51 (range: 44-55) years. Most common presentations were headache (47%), vomiting (47%), diplopia (20%), seizure (20%), and cerebellar signs (7%). Seven (46%) patients were hormone receptor positive, four (30%) were HER2 (Human epidermal growth factor receptor 2) positive and seven (46%) were triple-negative breast cancer. Median time to develop LM from the time of diagnosis of breast cancer was 6 (range: 3-8) months. Nine patients (90%) had features of NM in CSF cytology. Thirteen patients received palliative whole brain radiotherapy (20 Gy in five fractions). Nine out of 12 patients received single-agent Capecitabine as first-line chemotherapy after palliative radiation therapy (RT). Intrathecal methotrexate was given for seven patients. The median overall survival was 3 (range: 0.5-4) months. Conclusion LM is a very aggressive metastatic disease with poor outcome. There is an unmet need for proper guidelines and an overwhelming necessity for a better focus on research for new modalities of disease in this scenario.
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Affiliation(s)
- Anju Anna Abraham
- Department of Medical Oncology, Regional Cancer Center, Thiruvananthapuram, Kerala, India
| | - Anoop T.M
- Department of Medical Oncology, Regional Cancer Center, Thiruvananthapuram, Kerala, India
| | - Rona Joseph P.
- Department of Medical Oncology, Regional Cancer Center, Thiruvananthapuram, Kerala, India
| | - Arun Vasudevan
- Department of Medical Oncology, Regional Cancer Center, Thiruvananthapuram, Kerala, India
| | - Bhavya S. Kumar
- Department of Medical Oncology, Regional Cancer Center, Thiruvananthapuram, Kerala, India
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Sytsma TT, Theel ES, Temesgan Z, Toledano M. Assessing Utilization of the Cerebrospinal Fluid Venereal Disease Research Laboratory Test for Diagnosis of Neurosyphilis: a Cohort Study. J Gen Intern Med 2021; 36:77-83. [PMID: 32869202 DOI: 10.1007/s11606-020-06127-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 08/10/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Inappropriate use of diagnostic tests contributes to rising healthcare expenditures, and improving appropriate utilization rates is important for high-value patient care. The Venereal Disease Research Laboratory (VDRL) test performed in cerebrospinal fluid (CSF) has historically been improperly utilized, although there is no recent evaluation of its use in clinical practice. OBJECTIVES Quantify the rates of appropriate CSF-VDRL testing, determine the CSF-VDRL false-positivity rate, and describe the causes of false-positive CSF-VDRL reactivity. DESIGN Retrospective cohort study PATIENTS: A total of 32,626 patients with CSF-VDRL testing at one of three Mayo Clinic sites (Rochester, MN; Jacksonville, FL; and Scottsdale, AZ) from January 1, 1994, to February 28, 2018. MAIN MEASURES Rate of appropriate CSF-VDRL test utilization from January 1, 2011, to December 31, 2017, and CSF-VDRL true- and false-positivity rates from January 1, 1994, to February 28, 2018. KEY RESULTS Among 8553 persons with negative CSF-VDRL results, testing was inappropriately ordered for 8399 (98.2%) of these patients. The word "syphilis" or "neurosyphilis" appeared in the notes of 1184 (13.8%) individuals with a negative CSF-VDRL result. From January 1994 through February 2018, 33,933 CSF-VDRL tests were performed on 32,626 individual patients. Among the 60 positive CSF-VDRL results, 43 (71.7%) were true-positives and 17 (28.3%) were false-positives. All patients with false-positive CSF-VDRL results were tested unnecessarily. Neoplastic meningitis was a common cause of false-positive CSF-VDRL results. CONCLUSIONS Inappropriate use of CSF-VDRL testing for the diagnosis of neurosyphilis remains problematic in clinical practice. Following recommended testing algorithms would prevent unnecessary testing and minimize false-positive results.
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Davidson C, Achilleos K, Crawley F, Petchey W. A case of mistaken identity: An unusual presentation of neoplastic meningitis and a reminder of the hallmark features. Clin Case Rep 2020; 8:2969-2972. [PMID: 33363861 PMCID: PMC7752328 DOI: 10.1002/ccr3.3289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 08/05/2020] [Indexed: 11/24/2022] Open
Abstract
This case offers an opportunity for education on the manifestations of neoplastic meningitis, a revision of the hallmark investigative features, and a reminder of the utilization of lumbar puncture in investigating unexplained neurological symptoms. Additionally, it emphasises the need for clinicians to avoid "diagnostic anchoring" when faced with recurrent attenders.
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Jaeckle KA, Dixon JG, Anderson SK, Moreno-Aspitia A, Colon-Otero G, Hebenstreit K, Patel TA, Reddy SL, Perez EA. Intra-CSF topotecan in treatment of breast cancer patients with leptomeningeal metastases. Cancer Med 2020; 9:7935-7942. [PMID: 32885617 PMCID: PMC7643683 DOI: 10.1002/cam4.3422] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 07/24/2020] [Accepted: 08/07/2020] [Indexed: 12/13/2022] Open
Abstract
Background There are few treatment options for patients with leptomeningeal metastases (LM). Methods We report a case series of patients with breast cancer and LM treated with intra‐CSF topotecan (TOPO). Outcome was assessed by clinical exam and MRI at baseline, at end of induction (4‐5 weeks), then every 3 months; CSF cytology was determined at baseline and with each treatment. Results Thirty‐one women [median age, 58 (37‐81); median KPS 60 (40‐100)] received treatment. At baseline, 68% had positive CSF cytology, and 90%, leptomeningeal enhancement on MRI. 84% of patients also received focal RT (not during TOPO) and 77% received concomitant systemic hormonal or chemotherapy. Median number of TOPO treatments was 14.5 (range, 3‐71); median duration of treatment, 11 weeks (1‐176); and median OS, 6.9 months (range, 0.9‐48.8). Patients remaining progression‐free during 4‐6 weeks of induction (81%) had a median OS of 11.5 months (range, 1.8‐48.8). Overall neurologic PFS at 6, 12, and 24 months was 39%, 26%, and 6%, respectively. Clearing of CSF malignant cells for >3 consecutive samples occurred in 10/21 (48%) patients with positive CSF cytology at baseline, remaining clear for a median duration of 15.9 months (range, 1.4‐34.5). Grade 3 adverse events included headache or vomiting (3pts), T2 hyperintensity surrounding the ventricular catheter (2 pts), and meningitis (2 pts). Conclusions Intra‐CSF TOPO, with focal RT as needed for symptomatic areas of enhancement produced durable clearing of CSF malignant cells in 48% of patients positive at baseline, with promising median PFS and OS.
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Affiliation(s)
| | | | | | | | | | | | - Tejal A Patel
- Houston Methodist Hospital Cancer Center, Houston, TX, USA
| | - Samarth L Reddy
- Hematology Oncology Associates of Boca Raton, Boca Raton, FL, USA
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7
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Jagtap SV, Khoja S, Jagtap SS, Gudur R, Janugade H. Leptomeningeal Carcinomatosis Secondary to Esophageal Cancer Diagnosed on Cytology. J Neurosci Rural Pract 2020; 11:495-497. [PMID: 32753822 PMCID: PMC7394655 DOI: 10.1055/s-0040-1713576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Esophageal carcinoma is considered a common malignancy across the globe. These patients usually present with an advanced stage of the disease at the time of diagnosis. Herein, we report a 55-year male patient who presented with leptomeningeal carcinomatosis, detected on cerebrospinal fluid (CSF) cytology in a case of adenocarcinoma lower third esophagus. On radiological imaging, he also had extensive metastatic deposits in the liver, pleura, and regional and paravertebral lymph nodes.
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Affiliation(s)
- Sunil Vitthalrao Jagtap
- Department of Pathology, Krishna Institute of Medical Sciences University, Karad, Maharashtra, India
| | - Shoaib Khoja
- Department of Pathology, Krishna Institute of Medical Sciences University, Karad, Maharashtra, India
| | | | - Rashmi Gudur
- Department of Oncology and Radiotherapy, Krishna Hospital and Medical Research Centre, Karad, Maharashtra, India
| | - Hemant Janugade
- Department of Surgery, Krishna Hospital and Medical Research Centre, Karad, Maharashtra, India
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8
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Glitza IC, Smalley KSM, Brastianos PK, Davies MA, McCutcheon I, Liu JKC, Ahmed KA, Arrington JA, Evernden BR, Smalley I, Eroglu Z, Khushalani N, Margolin K, Kluger H, Atkins MB, Tawbi H, Boire A, Forsyth P. Leptomeningeal disease in melanoma patients: An update to treatment, challenges, and future directions. Pigment Cell Melanoma Res 2020; 33:527-541. [PMID: 31916400 PMCID: PMC10126834 DOI: 10.1111/pcmr.12861] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 11/26/2019] [Accepted: 01/03/2020] [Indexed: 01/31/2023]
Abstract
In February 2018, the Melanoma Research Foundation and the Moffitt Cancer Center hosted the Second Summit on Melanoma Central Nervous System Metastases in Tampa, Florida. The meeting included investigators from multiple academic centers and disciplines. A consensus summary of the progress and challenges in melanoma parenchymal brain metastases was published (Eroglu et al., Pigment Cell & Melanoma Research, 2019, 32, 458). Here, we will describe the current state of basic, translational, clinical research, and therapeutic management, for melanoma patients with leptomeningeal disease. We also outline key challenges and barriers to be overcome to make progress in this deadly disease.
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Affiliation(s)
- Isabella C. Glitza
- Department of Melanoma Medical Oncology, UT MD Anderson Cancer Center, Houston, TX, USA
| | - Keiran S. M. Smalley
- Melanoma Research Center of Excellence, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | | | - Michael A. Davies
- Department of Melanoma Medical Oncology, UT MD Anderson Cancer Center, Houston, TX, USA
| | - Ian McCutcheon
- Department of Neurosurgery, UT MD Anderson Cancer Center, Houston, TX, USA
| | - James K. C. Liu
- Department of Neuro-Oncology & Tumor Biology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Kamran A. Ahmed
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - John A. Arrington
- Head of Neuroradiology Section, Department of Radiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Brittany R. Evernden
- Department of Neuro-Oncology & Tumor Biology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Inna Smalley
- Department of Tumor Biology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Zeynep Eroglu
- Department of Cutaneous Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Nikhil Khushalani
- Department of Cutaneous Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Kim Margolin
- Department of Medical Oncology and Therapeutics Research, City of Hope National Medical Center, Duarte, CA, USA
| | - Harriet Kluger
- Department of Medical Oncology, Yale Cancer Center, New Haven, CT, USA
| | - Michael B. Atkins
- Department of Medical Oncology, Georgetown University Medical Center, Washington, DC, USA
| | - Hussein Tawbi
- Department of Melanoma Medical Oncology, UT MD Anderson Cancer Center, Houston, TX, USA
| | - Adrienne Boire
- Department of Neuro-Oncology, Memorial Sloan Kettering, New York, NY, USA
| | - Peter Forsyth
- Department of Neuro-Oncology & Tumor Biology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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9
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Diamanti L, Berzero G, Franciotta D, Bini P, Furione M, Farina LM, Bastianello S, Colombo AA, Marchioni E. Cranial nerve palsies in patients with hematological malignancies: a case series. Int J Neurosci 2020; 130:777-780. [PMID: 31906752 DOI: 10.1080/00207454.2019.1705810] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Objectives: Cranial neuropathies (CNs) can be due to a wide spectrum of causes, and the differential diagnosis is particularly challenging in patients with positive history of hematological malignancies, when neoplastic meningitis (NM) must be excluded.Patients and Methods: We retrospectively selected a series of twelve haematological patients with isolated cranial neuropathies (ICNs) or multiple cranial neuropathies (MCNs). among 71 patients that developed neurologic symptoms during different stages of the cancer, between 1 January, 2010 and 31 December, 2017. Brain and cauda equina magnetic resonance imaging (MRI) with gadolinium, cerebrospinal fluid (CSF) analysis, including flow cytometry for cell immunophenotyping and microbiological exams were performed in all patients.Results: Patients developed signs and symptoms of involvement of isolated (n = 11) or multiple (n = 1) cranial nerves, at different stages of the primary disease, and, in 5 of these cases in complete remission after hematopoietic stem cell transplantation. Among the 5 cases that eventually were diagnosed as having NM, cerebrospinal fluid was positive for neoplastic cells in 3, and MRI gadolinium-enhancement was present in 3. The other episodes were attributed to heterogeneous pathologies that were unrelated to meningeal infiltration by neoplastic cells.Conclusions: Our observations confirm that NM in haematological malignancies can yield insidious isolated signs of cranial nerves. Only a multidisciplinary approach allows prompt recognition of these conditions through a challenging process of differential diagnosis, and proper therapies.
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Affiliation(s)
- Luca Diamanti
- IRCCS C. Mondino Foundation, Pavia, Italy.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Giulia Berzero
- IRCCS C. Mondino Foundation, Pavia, Italy.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | | | - Paola Bini
- IRCCS C. Mondino Foundation, Pavia, Italy
| | - Milena Furione
- Department of Microbiology and Virology, Molecular Virology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Stefano Bastianello
- IRCCS C. Mondino Foundation, Pavia, Italy.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Anna Amelia Colombo
- Transplantation Unit, Department of Hematology and Oncology, Foundation IRCCS, Policlinico San Matteo, Pavia, Italy
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10
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Buszek SM, Chung C. Radiotherapy in Leptomeningeal Disease: A Systematic Review of Randomized and Non-randomized Trials. Front Oncol 2019; 9:1224. [PMID: 31803614 PMCID: PMC6872542 DOI: 10.3389/fonc.2019.01224] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 10/25/2019] [Indexed: 01/12/2023] Open
Abstract
Background: Leptomeningeal disease (LMD), also known as neoplastic meningitis, leptomeningeal carcinomatosis, or carcinomatous meningitis, is a rare cancer complication occurring in ~5% of cases and ultimately leads to significant morbidity and mortality. In the modern era, incidence of this condition continues to rise with longer survival of patients with advanced and even metastatic disease due to continued improvements in systemic therapies that are providing prolonged control of distant disease, but with limited effect in the central nervous system (CNS). Typical treatment strategies include optimal systemic therapy for the primary disease, as well as neuroaxis directed therapies, which may include intrathecal chemotherapy (ITC) or radiotherapy (RT). Methods: A systematic review of radiotherapy for LMD was performed. Medline, EMBASE, and Cochrane databases were searched from 1946 to 2018 for clinical trials, retrospective/prospective reviews, and case series with ≥2 human subjects that used radiation therapy techniques in the treatment of LMD. The outcome measures of interest included: characteristics of trial participants, inclusion/exclusion criteria, study type, number of participants, primary cancer histology, type of intervention for LMD, survival results if reported, length of follow up, and study conclusion. Results: Of 547 unique citations, 62 studies met the pre-specified eligibility criteria. These studies included 36 retrospective cohorts, 11 prospective series, 12 case series, and a single citation of guidelines, NCDB analysis, and a randomized control trial. Owing to study heterogeneity, meta-analyses of the endpoint data could not be performed. Conclusions: LMD is a devastating complication of cancer with reported survivals ranging from 2 to 4 months. Based on this systematic review, the recommendation for the treatment of LMD is for multimodality discussion of cases and treatment, including the use of radiotherapy, for LMD. However, with continued advances in systemic therapy as well as imaging advances, the landscape of LMD is evolving rapidly and the role of RT will likely also continue to evolve and advance. There is limited high-quality evidence to guide the optimal use of RT for the treatment of LMD, and there is a great need for prospective, histology specific investigation of the role of radiotherapy for LMD in the era of modern systemic therapies.
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Affiliation(s)
- Samantha M Buszek
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Caroline Chung
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
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11
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Marchiò C, Mariani S, Bertero L, Di Bello C, Francia Di Celle P, Papotti M, Rudà R, Soffietti R, Cassoni P. Liquoral liquid biopsy in neoplastic meningitis enables molecular diagnosis and mutation tracking: a proof of concept. Neuro Oncol 2019; 19:451-453. [PMID: 27838647 PMCID: PMC5464358 DOI: 10.1093/neuonc/now244] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 09/29/2016] [Indexed: 11/12/2022] Open
Affiliation(s)
- Caterina Marchiò
- Department of Medical Sciences, University of Turin, Turin, Italy.,Pathology Division, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Sara Mariani
- Department of Medical Sciences, University of Turin, Turin, Italy.,Pathology Division, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Luca Bertero
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Cristiana Di Bello
- Pathology Division, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Paola Francia Di Celle
- Pathology Division, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Mauro Papotti
- Pathology Division, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy.,Department of Oncology, University of Turin, Turin, Italy
| | - Roberta Rudà
- Department of Neuro-Oncology, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Riccardo Soffietti
- Department of Neuro-Oncology, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy.,Department of Neurosciences, University of Turin, Turin, Italy
| | - Paola Cassoni
- Department of Medical Sciences, University of Turin, Turin, Italy.,Pathology Division, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
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12
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Abstract
Purpose Leptomeningeal metastasis (LM) is an increasingly common complication of late-stage systemic cancer, for which there is no standard treatment. We analyzed outcome and toxicity in patients with LM undergoing craniospinal irradiation via helical tomotherapy (HT-CSI) at our institution. Patients and methods The charts of 15 patients diagnosed with LM and undergoing HT-CSI between 2006 and 2014 were retrospectively assessed. Main neoplasms included breast cancer, lung cancer, and lymphoma. All patients presented with cranial neuropathy due to LM. Follow-up was performed regularly. Survival analysis was performed by the Kaplan–Meier method, and prognostic factors were tested using the COX-regression model. Results Median survival by cancer type was 6 (breast cancer), 1 (lung cancer), and 2 months (lymphoma), respectively. Median overall survival and relapse-free survival were calculated to be between 2 and 3 months. Six- and 12-month survival was 30% (95% CI 0.08–0.5) and 20% (95% CI 0.05–0.4), respectively. Symptom palliation occurred in 53% of patients in general, but in 67% of breast cancer patients, in particular. Patients with lung cancer experienced no improvement. Most common acute treatment-related toxicity at different levels were hematological toxicity, multiple cranial neuropathy, fatigue, infections, nausea, and headache. Conclusion HT-CSI can help meet the challenge of treating patients with LM, especially because it can palliate symptoms and improve neurological functions. One-year survival remains as disappointing as before.
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Affiliation(s)
- Sanziana Ri Schiopu
- Department of Internal Medicine V, Ludwig-Maximilian University, Munich, Germany, .,Department of Radiation Oncology, Heidelberg University, Heidelberg, Germany,
| | - Gregor Habl
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University, Munich, Germany
| | - Matthias Haefner
- Department of Radiation Oncology, Heidelberg University, Heidelberg, Germany,
| | - Sonja Katayama
- Department of Radiation Oncology, Heidelberg University, Heidelberg, Germany,
| | - Klaus Herfarth
- Department of Radiation Oncology, Heidelberg University, Heidelberg, Germany, .,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Juergen Debus
- Department of Radiation Oncology, Heidelberg University, Heidelberg, Germany, .,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Florian Sterzing
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Radiation Oncology, Kempten Clinic, Kempten, Germany
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13
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Suresh PK, Kini JR, Basavaiah SH, Kini H, Khadilkar UN, Chakraborti S. Neoplastic Meningitis: A Study from a Tertiary Care Hospital from Coastal India. J Cytol 2018; 35:255-259. [PMID: 30498301 PMCID: PMC6210820 DOI: 10.4103/joc.joc_167_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introduction: Neoplastic involvement of cerebrospinal fluid (CSF) secondary to known or unknown primaries elsewhere is a poor prognostic factor and is equivalent to stage IV disease. Aim: The aim of the study is to analyse the cytological features of neoplastic meningitis in a tertiary care center. Materials and Methods: A retrospective study of 400 consecutive CSF samples was done in the cytology laboratory of our hospital. The fluid obtained by spinal tap was sent for microbiological, biochemical and cytological evaluation. Smears that showed the presence of malignant cells were included in this study. Results: Out of 400 cases, 36 (9%) showed neoplastic meningitis. Of which, 13 cases (36%) revealed leukemic infiltration, 2 (6%) lymphomatous infiltration and 21 (58%) carcinomatous meningitis. The leukemia cases included seven cases of acute lymphoblastic leukemia and six cases of acute myeloid leukemia. Among the carcinomatous meningitis cases, eight were metastasis from carcinoma breast, six from lung carcinoma and one each from malignancies of gallbladder, stomach and retinoblastoma. Four cases were metastatic adenocarcinoma from unknown primary. Pleocytosis was a significant finding seen in 58% cases (n = 21). Elevated protein and hypoglychorrhachia was noted in 68% cases (n = 18). Conclusion: A combined diagnostic approach including biochemical, microbiological and pathological evaluation was useful in eliminating infectious meningitis and confirming neoplastic meningitis in these cases. Cytology should be performed on cerebrospinal specimens from all patients with known or suspected malignancy with meningismus. Detection of malignant cells on cytological examination of CSF is the diagnostic gold standard for neoplastic meningitis.
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Affiliation(s)
- Pooja K Suresh
- Department of Pathology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Karnataka, India
| | - Jyoti Ramanath Kini
- Department of Pathology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Karnataka, India
| | - Sridevi H Basavaiah
- Department of Pathology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Karnataka, India
| | - Hema Kini
- Department of Pathology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Karnataka, India
| | - Urmila N Khadilkar
- Department of Pathology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Karnataka, India
| | - Shrijeet Chakraborti
- Department of Cellular Pathology, Leighton Hospital, Crewe, Cheshire, United Kingdom
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14
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Abstract
Leptomeningeal metastasis (LM) results from dissemination of cancer cells to both the leptomeninges (pia and arachnoid) and cerebrospinal fluid (CSF) compartment. Breast cancer, lung cancer, and melanoma are the most common solid tumors that cause LM. Recent approval of more active anticancer therapies has resulted in improvement in survival that is partly responsible for an increased incidence of LM. Neurologic deficits, once manifest, are mostly irreversible, and often have a significant impact on patient quality of life. LM-directed therapy is based on symptom palliation, circumscribed use of neurosurgery, limited field radiotherapy, intra-CSF and systemic therapies. Novel methods of detecting LM include detection of CSF circulating tumor cells and tumor cell-free DNA. A recent international guideline for a standardization of response assessment in LM may improve cross-trial comparisons as well as within-trial evaluation of treatment. An increasing number of retrospective studies suggest that molecular-targeted therapy, such as EGFR and ALK inhibitors in lung cancer, trastuzumab in HER2+ breast cancer, and BRAF inhibitors in melanoma, may be effective as part of the multidisciplinary management of LM. Prospective randomized trials with standardized response assessment are needed to further validate these preliminary findings.
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15
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Marrodan M, Bensi C, Alessandro L, Muggeri AD, Farez MF. Chronic and Subacute Meningitis: Differentiating Neoplastic From Non-Neoplastic Etiologies. Neurohospitalist 2018; 8:177-182. [PMID: 30245767 DOI: 10.1177/1941874418773924] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background and Purpose Although incidence rates vary, infectious, autoimmune, and neoplastic diseases can all cause chronic and subacute meningitis (CSM). We report a Latin-American, single center, CSM case series, analyzing the main clinical characteristics as well as ancillary diagnostic methods differentiating neoplastic from non-neoplastic etiologies. Methods Retrospective review of CSM cases from a single center in Buenos Aires, Argentina. Results Seventy patients with CSM diagnosis were identified, 49 with neoplastic and 21 with non-neoplastic meningitis. A history of previous cancer was significantly higher in neoplastic cases, whereas prevalence of autoimmune disease and fever was more common in non-neoplastic meningitis. C-reactive protein values were higher in non-neoplastic CSM, as was pleocytosis in cerebrospinal fluid analysis. The most frequent etiologies were breast and lung cancer for neoplastic meningitis cases; and idiopathic, tuberculous, and fungal infection for non-neoplastic cases. Conclusions Chronic and subacute meningitis diagnosis is challenging in daily neurological practice. The results we report contribute information from Latin America regarding etiologies of CSM, which can be identified after a comprehensive evaluation in a majority of cases.
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Affiliation(s)
- Mariano Marrodan
- Department of Neurology, Epidemiology and Publich Health (CEBES), Institute for Neurological Research Dr. Raúl Carrea (FLENI), Buenos Aires, Argentina
| | - Catalina Bensi
- Department of Neurology, Epidemiology and Publich Health (CEBES), Institute for Neurological Research Dr. Raúl Carrea (FLENI), Buenos Aires, Argentina
| | - Lucas Alessandro
- Department of Neurology, Epidemiology and Publich Health (CEBES), Institute for Neurological Research Dr. Raúl Carrea (FLENI), Buenos Aires, Argentina
| | - Alejandro D Muggeri
- Department of Neuro-Oncology, Epidemiology and Publich Health (CEBES), Neurological Research Dr. Raúl Carrea (FLENI), Buenos Aires, Argentina
| | - Mauricio F Farez
- Center for Research on Neuroimmunological Diseases (CIEN), Epidemiology and Publich Health (CEBES), Neurological Research Dr. Raúl Carrea (FLENI), Buenos Aires, Argentina.,Center for Biostatistics, Epidemiology and Publich Health (CEBES), Neurological Research Dr. Raúl Carrea (FLENI), Buenos Aires, Argentina
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16
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Abstract
Cerebrospinal fluid (CSF) cytology, i.e., the cytologic evaluation of its cellular composition, forms an integral part of the neurologist's armamentarium. Total and differential cell counts provide important first information across a spectrum of pathologic conditions involving the central nervous system and its coverings. CSF samples require immediate processing, ideally within 1 hour from collection. Upon centrifugation cytology is commonly assessed on May-Grunwald-Giemsa stains. Several additional stains are available for the identification of infectious agents such as bacteria or fungi, or the further specification of neoplastic cells by immunocytochemistry. The evaluation warrants familiarity with cytologic characteristics of cells across normal and diseased states. In normal CSF, lymphocytes and monocytes are encountered. A predominance of neutrophil granulocytes suggests bacterial meningitis and prompts search for intracellular bacteria. In contrast, in viral and chronic infections lymphocytes and monocytes prevail. Upon activation lymphocytes typically enlarge and eventually differentiate into plasma cells. Similarly, monocytes differentiate into macrophages that clear cellular debris. Macrophages that contain fragments of erythrocytes or hemoglobin degradation products are referred to as erythro- or siderophages, both of which indicate prior subarachnoid hemorrhage. Likewise, the detection of tumor cells is specific for neoplastic meningitis, although false-negative CSF cytologies are frequent. In summary, detailed morphologic workup of CSF samples provides valuable diagnostic information and is mandated in all cases with elevated cell count, computed tomography-negative suspected subarachnoid hemorrhage, and neoplastic meningitis. In all cases it needs to be interpreted in the clinical context and complements other clinical and laboratory findings.
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Affiliation(s)
- Jasmin Rahimi
- Institute of Neurology, Medical University of Vienna, Vienna, Austria; Department of Neurology and Karl Landsteiner Institute for Neuroimmunological and Neurodegenerative Conditions, Donauspital, Vienna, Austria
| | - Adelheid Woehrer
- Institute of Neurology, Medical University of Vienna, Vienna, Austria.
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17
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Durand B, Zairi F, Boulanger T, Bonneterre J, Mortier L, Le Rhun E. Chemical meningitis related to intra-CSF liposomal cytarabine. CNS Oncol 2017; 6:261-267. [PMID: 29057672 PMCID: PMC6004879 DOI: 10.2217/cns-2016-0046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 05/03/2017] [Indexed: 12/29/2022] Open
Abstract
Therapeutic options of leptomeningeal metastases include intra-cerebrospinal fluid (CSF) chemotherapy. Among intra-CSF agents, liposomal cytarabine has advantages but can induce specific toxicities. A BRAF-V600E-mutated melanoma leptomeningeal metastases patient, treated by dabrafenib and liposomal cytarabine, presented after the first injection of liposomal cytarabine with hyperthermia and headaches. Despite sterile CSF/blood analyses, extended intravenous antibiotics were given and the second injection was delayed. The diagnosis of chemical meningitis was finally made. Dose reduction and appropriate symptomatic treatment permitted the administration of 15 injections of liposomal cytarabine combined with dabrafenib. A confirmation of the diagnosis of chemical meningitis is essential in order (1) not to delay intra-CSF or systemic chemotherapy or (2) to limit the administration of unnecessary but potentially toxic antibiotics.
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Affiliation(s)
- Bénédicte Durand
- Lille University, F-59000 Lille, France
- Oscar Lambret Center, Medical Oncology Department, F-59000 Lille, France
| | - Fahed Zairi
- Lille University, F-59000 Lille, France
- Inserm, U-1192, F-59000 Lille, France
- CHU Lille, Neurosurgery Department, F-59000Lille, France
| | - Thomas Boulanger
- Oscar Lambret Center, Department of Radiology, F-59000 Lille, France
| | - Jacques Bonneterre
- Lille University, F-59000 Lille, France
- Oscar Lambret Center, Medical Oncology Department, F-59000 Lille, France
| | - Laurent Mortier
- Lille University, F-59000 Lille, France
- CHU Lille, Dermatology Department, F-59000Lille, France
| | - Emilie Le Rhun
- Lille University, F-59000 Lille, France
- Oscar Lambret Center, Medical Oncology Department, F-59000 Lille, France
- Inserm, U-1192, F-59000 Lille, France
- CHU Lille, Neurosurgery Department, F-59000Lille, France
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18
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Nayar G, Ejikeme T, Chongsathidkiet P, Elsamadicy AA, Blackwell KL, Clarke JM, Lad SP, Fecci PE. Leptomeningeal disease: current diagnostic and therapeutic strategies. Oncotarget 2017; 8:73312-73328. [PMID: 29069871 PMCID: PMC5641214 DOI: 10.18632/oncotarget.20272] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 07/20/2017] [Indexed: 12/28/2022] Open
Abstract
Leptomeningeal disease has become increasingly prevalent as novel therapeutic interventions extend the survival of cancer patients. Although a majority of leptomeningeal spread occurs secondary to breast cancer, lung cancer, and melanoma, a wide variety of malignancies have been reported as primary sources. Symptoms on presentation are equally diverse, often involving a combination of neurological deficits with the possibility of obstructive hydrocephalus. Diagnosis is definitively made via cerebrospinal fluid cytology for malignant cells, but neuro-imaging with high quality T1-weighted magnetic resonance imaging can aid diagnosis and localization. While leptomeningeal disease is still a terminal, late-stage complication, a variety of treatment modalities, such as intrathecal chemotherapeutics and radiation therapy, have improved median survival from 4–6 weeks to 3–6 months. Positive prognosticative factors for survival include younger age, high performance scores, and controlled systemic disease. In looking to the future, diagnostics that improve early detection and chemotherapeutics tailored to the primary malignancy will likely be the most significant advances in improving survival.
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Affiliation(s)
- Gautam Nayar
- Duke Brain Tumor Immunotherapy Program, Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.,The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA.,Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Tiffany Ejikeme
- Duke Brain Tumor Immunotherapy Program, Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.,The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA.,Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Pakawat Chongsathidkiet
- Duke Brain Tumor Immunotherapy Program, Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.,The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA.,Department of Pathology, Duke University Medical Center, Durham, NC, USA
| | - Aladine A Elsamadicy
- Duke Brain Tumor Immunotherapy Program, Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.,The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA.,Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Kimberly L Blackwell
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey M Clarke
- Division of Medical Oncology, Duke University Medical Center, Durham, NC, USA
| | - Shivanand P Lad
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Peter E Fecci
- Duke Brain Tumor Immunotherapy Program, Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.,The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA.,Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.,Department of Pathology, Duke University Medical Center, Durham, NC, USA
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19
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Abstract
Leptomeningeal carcinomatosis (LC) is a rare and mainly secondary site of metastasis in solid tumors. In gastric cancer (GC), it is associated with a devastating prognosis, lacking an efficient and standardized treatment approach. We report a case of primary manifestation of LC due to metastatic GC with rapid deterioration and refractory course to conventional and intrathecal chemotherapy. We review the literature and discuss the therapeutic challenges.
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Affiliation(s)
- Maria Vergoulidou
- Division of Hematology and Oncology, First Internal Medicine Department, Dietrich-Bonhoeffer-Klinikum, Neubrandenburg, Germany
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20
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Ursu R, Taillibert S, Banissi C, Vicaut E, Bailon O, Le Rhun E, Guillamo JS, Psimaras D, Tibi A, Sacko A, Marantidou A, Belin C, Carpentier AF. Immunotherapy with CpG-ODN in neoplastic meningitis: A phase I trial. Cancer Sci 2015; 106:1212-8. [PMID: 26094710 PMCID: PMC4582991 DOI: 10.1111/cas.12724] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 05/05/2015] [Accepted: 06/15/2015] [Indexed: 11/30/2022] Open
Abstract
TLR-9 agonists are immunostimulating agents that have antitumor effects in animal models. A phase I trial was conducted to define the safety profile of subcutaneous injections, combined with intrathecally administration of CpG-28, a TRL 9 agonist, in patients with neoplastic meningitis (NM). Cohorts of 3–6 patients with NM were treated for 5 weeks with escalating doses of CpG-28. The primary endpoint was tolerance. Secondary endpoints were progression free survival (PFS) and overall survival (OS). Twenty-nine patients were treated with CpG-28. The primary cancers were malignant glioma, lung carcinoma, breast cancer, melanoma or melanocytoma, ependymoma, and colorectal cancer. The median age was 56 years and median Karnovsky Performance status (KPS) was 70%. The treatment was well tolerated. Adverse effects that were possibly or probably related to the studied drug were grade 2 lymphopenia, anemia and neutropenia, local erythema at injection sites, fever and seizure. There were five serious adverse events: two confusions, two infections of ventricular devices and one grade 4 thrombopenia and neutropenia. The median PFS was 7 weeks and median OS was 15 weeks. Interestingly, the median survival was slightly (but not significantly) higher in the eight patients who were concomitantly treated with bevacizumab (19 weeks vs 15 weeks; P = 0.11). CpG-28 was well tolerated at doses up to 0.3 mg/kg subcutaneously and 18 mg intrathecally. Additional trials are warranted.
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Affiliation(s)
- Renata Ursu
- Department of Neurology, Hôpital Avicenne, Bobigny, France
| | - Sophie Taillibert
- Department of Neurology Mazarin, Hôpital Pitié-Salpêtrière, University Pierre et Marie Curie, Paris, France
| | - Claire Banissi
- Department of Neurology, Hôpital Avicenne, Bobigny, France
| | - Eric Vicaut
- Methodology and Statistical Unit, Centre Hospitalier Universitaire Lariboisière, Paris, France
| | - Olivier Bailon
- Department of Neurology, Hôpital Avicenne, Bobigny, France
| | - Emilie Le Rhun
- Breast Unit, Department of Medical Oncology, Oscar Lambert Center, Lille, France
| | | | - Dimitri Psimaras
- Department of Neurology Mazarin, Hôpital Pitié-Salpêtrière, University Pierre et Marie Curie, Paris, France
| | - Annick Tibi
- Agence Générale des Equipements et Produits de Santé (AGEPS), Paris, France
| | - Adama Sacko
- Department of Neurology, Hôpital Avicenne, Bobigny, France.,UFR de Santé, Médecine et Biologie Humaine de Bobigny - Université Paris 13, Paris, France
| | - Athina Marantidou
- Department of Neurology, Hôpital Avicenne, Bobigny, France.,UFR de Santé, Médecine et Biologie Humaine de Bobigny - Université Paris 13, Paris, France
| | | | - Antoine F Carpentier
- Department of Neurology, Hôpital Avicenne, Bobigny, France.,UFR de Santé, Médecine et Biologie Humaine de Bobigny - Université Paris 13, Paris, France
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21
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Chilkulwar A, Pottimutyapu R, Wu F, Padooru KR, Pingali SR, Kassem M. Leptomeningeal carcinomatosis associated with papillary renal cell carcinoma. Ecancermedicalscience 2014; 8:468. [PMID: 25374616 PMCID: PMC4203475 DOI: 10.3332/ecancer.2014.468] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Indexed: 12/30/2022] Open
Abstract
Leptomeningeal carcinomatosis (LMC), or neoplastic meningitis, occurs in about 5–20% of patients with metastatic cancer, depending on the type of the primary malignancy and kind of treatment received. The association of LMC with renal cell carcinoma (RCC) is a rare entity, and only two cases of papillary renal cell cancer with leptomeningeal metastasis have been reported. Leptomeningeal spread usually confers a poor prognosis despite the use of modern treatment strategies as compared to patients with extracranial metastases. We report a case of papillary RCC, a less common type of RCC presenting with LMC.
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Affiliation(s)
- Abhishek Chilkulwar
- Department of Haematology and Oncology, Allegheny General Hospital, Pittsburgh, PA 15212, USA
| | - Ramya Pottimutyapu
- Department of Internal Medicine, Mount Sinai Hospital Medical Centre, Chicago, Illinois 60608, USA
| | - Fawng Wu
- Department of Internal Medicine, Mount Sinai Hospital Medical Centre, Chicago, Illinois 60608, USA
| | - Keerthi R Padooru
- Department of Medicine, S.V.S Medical College, Mahbub Nagar, Telangana 509001, India
| | - Sai Ravi Pingali
- Houston Methodist Cancer Centre, 6445 Main St, Houston, TX 77030, USA
| | - Mohammed Kassem
- Department of Internal Medicine, Mount Sinai Hospital Medical Centre, Chicago, Illinois 60608, USA
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22
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Jabeen SA, Chowdary AH, Kandadai RM, Uppin MS, Meena AK, Borgohain R, Sundaram C. Primary diffuse leptomeningeal gliomatosis: An autopsy case report. Ann Indian Acad Neurol 2014; 17:227-30. [PMID: 25024582 PMCID: PMC4090857 DOI: 10.4103/0972-2327.132647] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Revised: 01/02/2013] [Accepted: 02/09/2013] [Indexed: 11/21/2022] Open
Abstract
Primary diffuse leptomeningeal gliomatosis (PDLG) is a rare condition, characterized by infiltration of the meninges by glial cells without evidence of the primary tumor in the brain or spinal cord parenchyma. Glioma arising primarily from the leptomeninges is extremely rare and often diagnosed only in post mortem examination and the diagnosis may be missed in meningeal biopsy. We describe a young female who presented with symptoms of raised intracranial pressure with imaging evidence of diffuse leptomeningeal enhancement in whom autopsy confirmed the diagnosis of PDLG. Our case illustrates the diagnostic difficulties in making the pre-mortem diagnosis even with multiple cerebrospinal fluid cytologies and leptomeningeal biopsy.
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Affiliation(s)
- Shaik Afshan Jabeen
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | | | | | - Megha S Uppin
- Department of Pathology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | | | - Rupam Borgohain
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Challa Sundaram
- Department of Pathology, Nizam's Institute of Medical Sciences, Hyderabad, India
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23
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Kon T, Funamizu Y, Miki Y, Tomiyama M, Baba M, Kurotaki H, Wakabayashi K. An autopsy case of meningeal carcinomatosis with parenchymal invasion through the cranial and spinal nerve roots. Neuropathology 2014; 34:499-503. [PMID: 24779918 DOI: 10.1111/neup.12127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Revised: 04/01/2014] [Accepted: 04/02/2014] [Indexed: 11/28/2022]
Abstract
Meningeal carcinomatosis is a well-known complication of malignant neoplasms. We report a case of meningeal carcinomatosis of 2 months' duration in a 22-year-old man, in whom the initial symptom was gradually worsening headache. Postmortem examination revealed infiltrating adenocarcinoma of the stomach. Carcinoma cells showed diffuse spread to the subarachnoid space of the brain and spinal cord. In many places, subarachnoid tumor cells had infiltrated to the cranial and spinal nerves. Moreover, carcinoma cells in the nerve roots extended to the parenchyma of the brain and spinal cord beyond the CNS-peripheral nervous system junction. These findings suggest that cranial and spinal nerve roots can be a possible route of parenchymal invasion in meningeal carcinomatosis.
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Affiliation(s)
- Tomoya Kon
- Department of Neuropathology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan; Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan
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24
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Abstract
Objective: To report a case of drug-induced aseptic meningitis (DIAM) in a patient receiving intrathecal trastuzumab (ITT) for leptomeningeal carcinomatosis (LC) secondary to HER-2/neu positive breast cancer. Case Summary: A 43-year-old female with stage IV breast cancer presented with headache, parasthesias, and aphasia. Brain imaging suggested leptomeningeal enhancement. Adenocarcinoma cells were found on cerebrospinal fluid analysis, and infectious etiologies were excluded. The patient received 30 mg of ITT via Ommaya reservoir and suffered sudden neurologic deterioration within 2 hours. Given the sudden onset of clinical deterioration after ITT administration, it was determined that the patient had suffered from DIAM. The patient suffered progressive neurologic decline and was unable to care for herself any further. Discussion: Treatment for LC remains challenging due to limited clinical experience and the challenging location of the disease. ITT has been used in multiple reports without adverse events. A temporal relationship existed between ITT administration and significant neurologic deterioration, possibly related to DIAM. Our patient was not exposed to any more common causative agents of DIAM. Reasons for her lack of recovery are likely multifactorial. Symptoms of DIAM may have in part been exacerbated by progressive LC; however, prior to ITT, symptoms had shown slow but persistent progression rather than significant, acute changes in severity. Retrial of the offending agent was not attempted due to patient risk; thus, a cause-and-effect relationship cannot be established. This event is a "possible" drug-induced adverse event scoring 2 on the Naranjo algorithm. Conclusions: Use of ITT for LC has been frequently reported in recent literature with substantial efficacy and lack of adverse events. This is the first published report of any significant adverse event associated with ITT. Clinicians need to be aware of the possibility of DIAM with ITT and explore options to prevent or manage this severe complication.
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25
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Singh G, Mathur SR, Iyer VK, Jain D. Cytopathology of neoplastic meningitis: A series of 66 cases from a tertiary care center. Cytojournal 2013; 10:13. [PMID: 23858323 PMCID: PMC3709425 DOI: 10.4103/1742-6413.114212] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Accepted: 05/22/2013] [Indexed: 11/25/2022] Open
Abstract
Background: Neoplastic meningitis (NM) is a condition characterized by leptomeningeal involvement by metastatic carcinoma. Detection of exfoliated malignant cells in cerebrospinal fluid (CSF) due to meningeal metastasis is frequently associated with diverse neurologic presentations. Materials and Methods: In this retrospective study of all cases of NM diagnosed in CSF samples over a 20-year period at a tertiary care referral center, the cytomorphologic features were reviewed. Results: Sixty six cases of NM were identified of which 36 already had an established diagnosis of malignancy while in 30 patients, there was no previously known tumor. The most common known primary in the former group was breast followed by ovary. Single cell pattern, cellular cannibalism, moderate cytoplasm and rounded nuclei were seen in breast and lung tumors. Papillary architecture and cytoplasmic vacuolation were seen in the ovarian primaries. Melanin pigment was seen in malignant melanoma. Conclusion: CSF cytology is an important tool for diagnosis of NM. Cytomorphologic features helped in diagnosis and for prediction of the primary site. Correct identification of this condition is important as it has therapeutic and prognostic implications.
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Affiliation(s)
- Gurdeep Singh
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
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26
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Abstract
The incidence of metastases of the central nervous system (CNS) is increasing, due to the improvement of the overall survival of cancer patients. Leptomeningeal metastases (LM) are now more often identified, although the criteria used for the diagnosis and monitoring remains inadequate. LM should be diagnosed at an early stage of the disease before the setting of neurological deficits, in order to improve the quality of life of patients. Therapeutic indications remain difficult, though some criteria have been proposed. Prolonged survivals have been reported even in the presence of identified poor prognostic factors at the time of the diagnosis of LM. The median survival of untreated patients is 4 to 6 weeks. Specific treatment may prolong survival by several months. Only six randomized studies are available. All theses studies have limitations due to the difficulty of including these patients in homogeneous trials, with a good methodology and for a time acceptable to the patient enrolment. The treatment requires a combination of chemotherapy and targeted therapies administrated systemically or via intra-cerebrospinal fluid (CSF) route, surgery and radiotherapy. Patient management is specific but requires a multidisciplinary approach, which may vary according to the characteristics of meningeal disease, the characteristics of primary tumors, the general condition of patients and previous lines of treatments. Our objective was to describe the current management of LM of solid tumors.
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27
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Le Rhun E, Taillibert S, Chamberlain MC. Carcinomatous meningitis: Leptomeningeal metastases in solid tumors. Surg Neurol Int 2013; 4:S265-88. [PMID: 23717798 PMCID: PMC3656567 DOI: 10.4103/2152-7806.111304] [Citation(s) in RCA: 180] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 04/11/2013] [Indexed: 11/04/2022] Open
Abstract
Leptomeningeal metastasis (LM) results from metastatic spread of cancer to the leptomeninges, giving rise to central nervous system dysfunction. Breast cancer, lung cancer, and melanoma are the most frequent causes of LM among solid tumors in adults. An early diagnosis of LM, before fixed neurologic deficits are manifest, permits earlier and potentially more effective treatment, thus leading to a better quality of life in patients so affected. Apart from a clinical suspicion of LM, diagnosis is dependent upon demonstration of cancer in cerebrospinal fluid (CSF) or radiographic manifestations as revealed by neuraxis imaging. Potentially of use, though not commonly employed, today are use of biomarkers and protein profiling in the CSF. Symptomatic treatment is directed at pain including headache, nausea, and vomiting, whereas more specific LM-directed therapies include intra-CSF chemotherapy, systemic chemotherapy, and site-specific radiotherapy. A special emphasis in the review discusses novel agents including targeted therapies, that may be promising in the future management of LM. These new therapies include anti-epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors erlotinib and gefitinib in nonsmall cell lung cancer, anti-HER2 monoclonal antibody trastuzumab in breast cancer, anti-CTLA4 ipilimumab and anti-BRAF tyrosine kinase inhibitors such as vermurafenib in melanoma, and the antivascular endothelial growth factor monoclonal antibody bevacizumab are currently under investigation in patients with LM. Challenges of managing patients with LM are manifold and include determining the appropriate patients for treatment as well as the optimal route of administration of intra-CSF drug therapy.
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Affiliation(s)
- Emilie Le Rhun
- Breast Unit, Department of Medical Oncology, Centre Oscar Lambret and Department of Neuro Oncology, Roger Salengro Hospital, University Hospital, Lille, France
| | - Sophie Taillibert
- Neurology, Mazarin and Radiation Oncology, Pitié Salpétrière Hospital, University Pierre et Marie Curie, Paris VI, Paris, France
| | - Marc C. Chamberlain
- Neurology and Neurological Surgery, University of Washington, Fred Hutchinson Research Cancer Center, Seattle, WA, USA
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Le Rhun E, Taillibert S, Zairi F, Pannier D, Boulanger T, Andre C, Cazin JL, Dubois F, Bonneterre J, Chamberlain MC. Prolonged survival of patients with breast cancer-related leptomeningeal metastases. Anticancer Res 2013; 33:2057-2063. [PMID: 23645756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND/AIM Prolonged overall survival (OS) has been reported for selected patients with leptomeningeal metastases (LM). The management and treatment of such patients is poorly-described. We report our experience on breast cancer (BC)-associated LM and patients with prolonged survival. PATIENTS AND METHODS Eleven patients with BC and LM had an OS >12 months in which treatment is described. RESULTS Combined intra-cerebro spinal fluid (CSF) and systemic treatment were administered until disease progression or toxicity in all but two patients. Involved-field radiotherapy was administered to two patients. Median OS in this selected cohort following LM diagnosis, was 21.0 (range=13-33.3) months. CONCLUSION Prolonged OS but also prolonged responses can be observed in BC with LM. An individualized and multi-disciplinary approach is advised for the management of these patients.
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Affiliation(s)
- Emilie Le Rhun
- Breast unit, Department of Medical Oncology, Oscar Lambret Center, Lille Cedex, France.
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Blaney SM, Tagen M, Onar-Thomas A, Berg SL, Gururangan S, Scorsone K, Su J, Goldman S, Kieran MW, Kun L, Boyett J, Stewart C. A phase-1 pharmacokinetic optimal dosing study of intraventricular topotecan for children with neoplastic meningitis: a Pediatric Brain Tumor Consortium study. Pediatr Blood Cancer 2013; 60:627-32. [PMID: 23002039 PMCID: PMC3573253 DOI: 10.1002/pbc.24309] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Accepted: 08/09/2012] [Indexed: 11/09/2022]
Abstract
PURPOSE We performed a phase-1 pharmacokinetic optimal dosing study of intraventricular topotecan (IT), administered daily 5×, to determine whether, the maximum tolerated dose of IT topotecan was also the pharmacokinetic optimal dose. PATIENTS AND METHODS Patients received topotecan administered through an intraventricular access device (0.1 or 0.2 mg/dose), daily × 5 every other week 2× (Induction); every 3 weeks × 2 (Consolidation); then every 4 weeks for up to 11 courses (Maintenance). Ventricular CSF pharmacokinetic studies were performed on day 1, week 1 of induction, and in a subset of patients after a single intralumbar topotecan dose on day 1, week 3. RESULTS Nineteen patients were enrolled. All were evaluable for toxicity and 18 were assessable for pharmacokinetics. Arachnoiditis requiring corticosteroid therapy occurred in or one of three patients at the 0.1 mg dose level and two of the initial three patients enrolled at the 0.2 mg dose level. All subsequent patients were therefore treated with concomitant dexamethasone. Pharmacokinetic evaluation after accrual of the first seven patients revealed that a topotecan lactone concentration >1 ng/ml for 8 hours was attained in all patients and thus, further dose escalation was not pursued. Results of simulation studies showed that at the dose levels evaluated, >99.9% of patients are expected to achieve CSF topotecan lactone concentrations >1 ng/ml for at least 8 hours. CONCLUSION Intraventricular topotecan, 0.2 mg, administered daily for 5 days with concomitant dexamethasone is well tolerated and was defined to be the pharmacokinetic optimal dose in this trial.
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Affiliation(s)
- Susan M. Blaney
- Texas Children’s Cancer Center/Baylor College of Medicine, Houston, TX 77030
| | - Michael Tagen
- St. Jude Children’s Research Hospital, Memphis, TN 38105
| | | | - Stacey L. Berg
- Texas Children’s Cancer Center/Baylor College of Medicine, Houston, TX 77030
| | - Sri Gururangan
- Duke University Medical Center, Durham North Carolina 27710
| | - Kathleen Scorsone
- Texas Children’s Cancer Center/Baylor College of Medicine, Houston, TX 77030
| | - Jack Su
- Texas Children’s Cancer Center/Baylor College of Medicine, Houston, TX 77030
| | | | - Mark W. Kieran
- Dana-Farber Children’s Hospital Cancer Center, Boston, MA 02215
| | - Larry Kun
- St. Jude Children’s Research Hospital, Memphis, TN 38105
| | - Jim Boyett
- St. Jude Children’s Research Hospital, Memphis, TN 38105
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Le Rhun E, Massin F, Tu Q, Bonneterre J, Bittencourt MDC, Faure GC. Development of a new method for identification and quantification in cerebrospinal fluid of malignant cells from breast carcinoma leptomeningeal metastasis. BMC Clin Pathol 2012; 12:21. [PMID: 23145812 PMCID: PMC3539901 DOI: 10.1186/1472-6890-12-21] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 11/02/2012] [Indexed: 12/22/2022] Open
Abstract
UNLABELLED BACKGROUND The diagnosis of leptomeningeal metastasis (LM) in patients with solid tumors remains difficult. The usual diagnostic methods of cytomorphological assessment of cerebro-spinal fluid (CSF) and gadolinium enhanced MRI of the entire neuraxis lack both specificity and sensitivity. The Veridex CellSearch® technology has been designed for the detection of circulating tumor cells (CTC) in blood from cancer patients and validated for the follow-up and prognosis of breast, prostate, colorectal, and lung cancer. Our aim was to adapt this technology for the detection and the enumeration of tumor cells in the CSF of breast cancer patients presenting with LM. METHODS On the occasion of a randomized phase III study evaluating the role of the intrathecal treatment in LM from breast cancer (DEPOSEIN, EudraCT N°: 2010-023134-23), the CellSearch® technology was adapted to direct enrichment, enumeration and visualization of tumor cells in 5 mL CSF samples, collected on CellSave® Preservative Tubes and analyzed within 3 days after CSF sampling. RESULTS Sixteen CSF of 8 patients with primary breast cancer presenting with LM were studied. EpCAM+/cytokeratin + cells with typical morphology could be observed and enumerated sequentially with reproducible results in low or elevated numbers in 8 patients. CONCLUSION This methodology, established on a limited volume of sample and allowing delayed processing, could prove of great interest in the diagnosis and follow-up of cancer patients with LM, especially to appreciate the efficacy of chemotherapy.
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Affiliation(s)
- Emilie Le Rhun
- Neurology, Breast Unit, Deparment of Medical Oncology, Oscar Lambret Center, Lille, France and Neuro-oncology, University Hospital, Lille, France
| | - Frédéric Massin
- CHU Nancy, Nancytomique, Laboratoire d’Immunologie, Pôle Laboratoires, Vandoeuvre lès Nancy, Nancy, France
| | - Qian Tu
- CHU Nancy, Nancytomique, Laboratoire d’Immunologie, Pôle Laboratoires, Vandoeuvre lès Nancy, Nancy, France
| | - Jacques Bonneterre
- Breast Unit, Department of Medical Oncology, Centre Oscar Lambret, Lille, France and University of Lille Nord de France, Lille, France
| | - Marcelo De Carvalho Bittencourt
- CHU Nancy, Nancytomique, Laboratoire d’Immunologie, Pôle Laboratoires, Vandoeuvre lès Nancy, France and Université Henri Poincaré, Faculté de Médecine, Vandoeuvre lès Nancy, EA4369 RHEM, Nancy, France
| | - Gilbert C Faure
- CHU Nancy, Nancytomique, Laboratoire d’Immunologie, Pôle Laboratoires, Vandoeuvre lès Nancy, France and Université Henri Poincaré, Faculté de Médecine, Vandoeuvre lès Nancy, EA4369 RHEM, Nancy, France
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Lombardi G, Zustovich F, Farina P, Della Puppa A, Manara R, Cecchin D, Brunello A, Cappetta A, Zagonel V. Neoplastic meningitis from solid tumors: new diagnostic and therapeutic approaches. Oncologist 2011; 16:1175-88. [PMID: 21795431 PMCID: PMC3228160 DOI: 10.1634/theoncologist.2011-0101] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Accepted: 05/17/2011] [Indexed: 01/19/2023] Open
Abstract
Neoplastic meningitis is a result of the spread of malignant cells to the leptomeninges and subarachnoid space and their dissemination within the cerebrospinal fluid. This event occurs in 4%-15% of all patients with solid tumors and represents an important prognostic factor for poor survival. Neoplastic meningitis should be diagnosed in the early stages of disease to prevent important neurological deficits and to provide the most appropriate treatment. Despite new diagnostic approaches developed in recent years, such as positron emission tomography-computed tomography and new biological markers, the combination of magnetic resonance imaging without and with gadolinium enhancement and cytology still has the greatest diagnostic sensitivity. Recently, no new randomized studies comparing intrathecal (i.t.) with systemic treatment have been performed, yet there have been a few small phase II studies and case reports about new molecularly targeted substances whose successful i.t. or systemic application has been reported. Trastuzumab, gefitinib, and sorafenib are examples of possible future treatments for neoplastic meningitis, in order to better individualize therapy thus allowing better outcomes. In this review, we analyze the most recent and interesting developments on diagnostic and therapeutic approaches.
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Affiliation(s)
- Giuseppe Lombardi
- Medical Oncology 1 Unit, Istituto Oncologico Veneto–IRCCS, Padova, Italy.
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Harstad L, Hess KR, Groves MD. Prognostic factors and outcomes in patients with leptomeningeal melanomatosis. Neuro Oncol 2008; 10:1010-8. [PMID: 18708343 PMCID: PMC2718998 DOI: 10.1215/15228517-2008-062] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2007] [Accepted: 07/29/2008] [Indexed: 11/19/2022] Open
Abstract
The purpose of this study was to describe a cohort of patients with leptomeningeal melanomatosis (LM) and to determine prognostic factors for outcomes in these patients. The primary hypothesis was that more extensive burden of CNS metastasis at the time of diagnosis of LM (as evidenced by imaging of the CNS parenchyma and meninges and cerebrospinal fluid [CSF] cytology status [positive versus negative]) correlates with poorer outcomes. The records of all patients with LM treated at M. D. Anderson Cancer Center between 1944 and 2002 were reviewed. Information on clinical course and outcomes was gathered. Univariate and multivariate analyses were performed on 110 patients using Cox proportional hazards regression analysis to examine the effects of possible predictive factors on survival. The overall median survival from LM diagnosis was 10 weeks, with a 95% confidence interval (CI) of 8-14 weeks. Eighty-six (78.2%) patients had cutaneous primary lesions, and 23 (20.9%) had melanoma of unknown primary site. The primary hypothesis was not proven. Neither the presence of parenchymal CNS metastases, nor greater imaging evidence of LM, nor positive CSF cytology at diagnosis correlated with survival outcomes. Univariate analyses revealed possible predictors of longer survival, including the presence of supratentorial or spinal LM on imaging at diagnosis versus its absence and any treatment of LM, whereas elevated serum lactate dehydrogenase at the time of LM diagnosis predicted shorter survival. Multivariate analysis revealed that a history of a primary melanoma lesion originating on the trunk predicted shorter survival after LM diagnosis (hazard ratio [HR] = 2.0, 95% CI = 1.0-3.8, p = 0.035), and treatment with intrathecal chemotherapy predicted longer survival (HR = 0.5, 95% CI = 0.4-0.8, p = 0.0036). The positive result with respect to treatment is unreliable due to the inability to remove treatment selection bias from the analysis. This retrospective analysis confirmed the dismal prognosis associated with LM. The amount of CNS tumor burden at the time of diagnosis of LM did not inversely correlate with survival outcomes, contrary to our hypothesis.
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Affiliation(s)
- Laura Harstad
- Departments of Neuro-Oncology (L.H., M.D.G.) and Biostatistics (K.R.H.)., The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Kenneth R. Hess
- Departments of Neuro-Oncology (L.H., M.D.G.) and Biostatistics (K.R.H.)., The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Morris D. Groves
- Departments of Neuro-Oncology (L.H., M.D.G.) and Biostatistics (K.R.H.)., The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
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Affiliation(s)
- Nick Gutowski
- Department of Neurology, Royal Devon and Exeter Hospital.
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Jaeckle KA, Phuphanich S, Bent MJ, Aiken R, Batchelor T, Campbell T, Fulton D, Gilbert M, Heros D, Rogers L, O'Day SJ, Akerley W, Allen J, Baidas S, Gertler SZ, Greenberg HS, LaFollette S, Lesser G, Mason W, Recht L, Wong E, Chamberlain MC, Cohn A, Glantz MJ, Gutheil JC, Maria B, Moots P, New P, Russell C, Shapiro W, Swinnen L, Howell SB. Intrathecal treatment of neoplastic meningitis due to breast cancer with a slow-release formulation of cytarabine. Br J Cancer 2001; 84:157-63. [PMID: 11161370 PMCID: PMC2363714 DOI: 10.1054/bjoc.2000.1574] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
DepoCyte is a slow-release formulation of cytarabine designed for intrathecal administration. The goal of this multi-centre cohort study was to determine the safety and efficacy of DepoCyte for the intrathecal treatment of neoplastic meningitis due to breast cancer. DepoCyte 50 mg was injected once every 2 weeks for one month of induction therapy; responding patients were treated with an additional 3 months of consolidation therapy. All patients had metastatic breast cancer and a positive CSF cytology or neurologic findings characteristic of neoplastic meningitis. The median number of DepoCyte doses was 3, and 85% of patients completed the planned 1 month induction. Median follow up is currently 19 months. The primary endpoint was response, defined as conversion of the CSF cytology from positive to negative at all sites known to be positive, and the absence of neurologic progression at the time the cytologic conversion was documented. The response rate among the 43 evaluable patients was 28% (CI 95%: 14-41%); the intent-to-treat response rate was 21% (CI 95%: 12-34%). Median time to neurologic progression was 49 days (range 1-515(+)); median survival was 88 days (range 1-515(+)), and 1 year survival is projected to be 19%. The major adverse events were headache and arachnoiditis. When drug-related, these were largely of low grade, transient and reversible. Headache occurred on 11% of cycles; 90% were grade 1 or 2. Arachnoiditis occurred on 19% of cycles; 88% were grade 1 or 2. DepoCyte demonstrated activity in neoplastic meningitis due to breast cancer that is comparable to results reported with conventional intrathecal agents. However, this activity was achieved with one fourth as many intrathecal injections as typically required in conventional therapy. The every 2 week dose schedule is a major advantage for both patients and physicians.
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Affiliation(s)
- K A Jaeckle
- Department of Medicine, University of California, San Diego, La Jolla, CA 92093, USA
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