CC BY-NC-ND 4.0 · Arq Neuropsiquiatr 2021; 79(09): 816-823
DOI: 10.1590/0004-282X-ANP-2020-0554
Article

A new approach for leptomeningeal metastases: chemotherapy administered through lumbar intrathecal port

Un nuevo abordaje para el tratamiento de las metástasis leptomeníngeas: uso de catéter implantado para el suministro de quimioterapia vía intratecal lumbar
1   Gayrettepe Florence Nightingale Hastanesi, Department of Anesthesiology and Reanimation, Istanbul, Turkey.
,
2   Demiroglu Bilim Üniversitesi, Department of Medical Oncology, Istanbul, Turkey.
› Author Affiliations

ABSTRACT

Background: Intrathecal chemotherapy is a local therapeutic modality used for treatment of leptomeningeal metastases. However, the techniques currently used, i.e. repeated lumbar puncture and Ommaya reservoir, have certain disadvantages. Lumbar intrathecal port (LIP) placement is a relatively novel technique, which has been used for pain management in cancer patients. Objective: To investigate the use of LIP for intrathecal administration of chemotherapeutic agents in patients with leptomeningeal metastases. Methods: Retrospective study of 13 patients treated with intrathecal chemotherapy for secondary leptomeningeal involvement of a primary solid tumor were included in this retrospective study. The patients received intrathecal chemotherapy through a LIP. Results: The patients received a total of 123 intrathecal chemotherapy doses. No grade 3-4 toxicity, technical problem or severe complication developed. During a median of 136 days of follow-up (range, 67-376 days), 12 patients died (92.3%). The treatment resulted in symptom improvement in all patients and self-rated overall health and quality of life improved, compared with baseline. Conclusions: The LIP system, which has been used for intrathecal pain management for decades, appears to offer a safe alternative for intrathecal chemotherapy in patients with leptomeningeal metastases. Further studies are warranted to clarify its potential use in this setting.

RESUMEN

Antecedentes: La quimioterapia intratecal es una modalidad terapéutica local utilizada para el tratamiento de metástasis leptomeníngeas. Sin embargo, las técnicas empleadas actualmente, es decir, las punciones lumbares repetidas y el depósito de Ommaya, tienen algunos inconvenientes. La colocación de un puerto intratecal lumbar (LIP) es una técnica relativamente nueva que se ha utilizado para el tratamiento del dolor en pacientes con cáncer. Objetivo: Investigar el uso de LIP para la administración intratecal de agentes quimioterapéuticos en pacientes con metástasis leptomeníngeas. Métodos: Este estudio retrospectivo incluyó un total de 13 pacientes tratados con quimioterapia intratecal por afectación leptomeníngea secundaria de un tumor sólido primario. Los pacientes recibieron quimioterapia intratecal a través de un LIP. Resultados: Los pacientes recibieron un total de 123 dosis de quimioterapia intratecal. No se desarrolló toxicidad de grado 3-4, ni se presentaron problemas técnicos o complicaciones graves. Durante un promedio de 136 días de seguimiento (rango, 67-376 días), murieron 12 pacientes (92,3 %). El tratamiento dio como resultado una mejoría de los síntomas en todos los pacientes. La salud general autoevaluada y la calidad de vida mejoraron en comparación con los valores iniciales. Conclusiones: El sistema LIP que se ha utilizado para el manejo del dolor intratecal durante décadas, parece ofrecer una alternativa segura para la quimioterapia intratecal en pacientes con metástasis leptomeníngeas. Serán necesarios más estudios para determinar su uso potencial en este ámbito.

Authors’ contributions:

SC: drafted and developed the manuscript; SS: critically reviewed and revised it. Both authors read and approved the final manuscript and contributed to the study conception and design, material preparation, data collection and analysis.




Publication History

Received: 27 November 2020

Accepted: 28 February 2021

Article published online:
01 June 2023

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  • REFERENCES

  • 1 Suh JH, Kotecha R, Chao ST, Ahluwalia MS, Sahgal A, Chang EL. Current approaches to the management of brain metastases. Nat Rev Clin Oncol. 2020 May;17(5):279-99. https://doi.org/10.1038/s41571-019-0320-3
  • 2 Scoccianti S, Ricardi U. Treatment of brain metastases: review of phase III randomized controlled trials. Radiother Oncol. 2012 Feb;102(2):168-79. https://doi.org/10.1016/j.radonc.2011.08.041
  • 3 Chamberlain MC. Leptomeningeal metastasis. Curr Opin Oncol. 2010 Nov;22(6):627-35. https://doi.org/10.1097/CCO.0b013e32833de986
  • 4 Le Rhun E, Taillibert S, Chamberlain MC. Carcinomatous meningitis: Leptomeningeal metastases in solid tumors. Surg Neurol Int. 2013 May 2;4(Suppl 4):S265-88. https://doi.org/10.4103/2152-7806.111304
  • 5 Thakkar JP, Kumthekar P, Dixit KS, Stupp R, Lukas RV. Leptomeningeal metastasis from solid tumors. J Neurol Sci. 2020 Apr 15;411:116706. https://doi.org/10.1016/j.jns.2020.116706
  • 6 Le Rhun E, Weller M, Brandsma D, Van den Bent M, de Azambuja E, Henriksson R, et al. EANO-ESMO clinical practice guidelines for diagnosis, treatment and follow-up of patients with leptomeningeal metastasis from solid tumours. Ann Oncol. 2017 Jul 1;28 Suppl 4:iv84-99. https://doi.org/10.1093/annonc/mdx221
  • 7 Zagouri F, Zoumpourlis P, Le Rhun E, Bartsch R, Zografos E, Apostolidou K, et al. Intrathecal administration of anti-HER2 treatment for the treatment of meningeal carcinomatosis in breast cancer: a metanalysis with meta-regression. Cancer Treat Rev. 2020 Aug;88:102046. https://doi.org/10.1016/j.ctrv.2020.102046
  • 8 Glantz MJ, Van Horn A, Fisher R, Chamberlain MC. Route of intracerebrospinal fluid chemotherapy administration and efficacy of therapy in neoplastic meningitis. Cancer. 2010 Apr 15;116(8):1947-52. https://doi.org/10.1002/cncr.24921
  • 9 Shapiro WR, Schmid M, Glantz M, Miller JJ. A randomized phase III/IV study to determine benefit and safety of cytarabine liposome injection for treatment of neoplastic meningitis. J Clin Oncol. 2006 Jun 20;24(18):1528-28. https://doi.org/10.1200/jco.2006.24.18_suppl.1528
  • 10 Zairi F, Le Rhun E, Bertrand N, Boulanger T, Taillibert S, Aboukais R, et al. Complications related to the use of an intraventricular access device for the treatment of leptomeningeal metastases from solid tumor: a single centre experience in 112 patients. J Neurooncol. 2015 Sep;124(2):317-23. https://doi.org/10.1007/s11060-015-1842-x
  • 11 Kennedy BC, Brown LT, Komotar RJ, McKhann GM 2nd. Stereotactic catheter placement for Ommaya reservoirs. J Clin Neurosci. 2016 May 1;27:44-7. https://doi.org/10.1016/j.jocn.2015.11.005
  • 12 Morgenstern PF, Connors S, Reiner AS, Greenfield JP. Image guidance for placement of Ommaya reservoirs: comparison of fluoroscopy and frameless stereotactic navigation in 145 patients. World Neurosurg. 2016 Sep;93:154-8. https://doi.org/10.1016/j.wneu.2016.04.090
  • 13 Major K, Schlauderaff A, Brawley A, Hale DE, Rizk E. Safe placement of Ommaya reservoirs in Thrombocytopenic patients: one institutions experience. Cureus. 2019 Jul 31;11(7):e5291. https://doi.org/10.7759/cureus.5291
  • 14 Chamberlain MC, Kormanik PA, Barba D. Complications associated with intraventricular chemotherapy in patients with leptomeningeal metastases. J Neurosurg. 1997 Nov;87(5):694-9. https://doi.org/10.3171/jns.1997.87.5.0694
  • 15 Lau JC, Kosteniuk SE, Macdonald DR, Megyesi JF. Image-guided Ommaya reservoir insertion for intraventricular chemotherapy: a retrospective series. Acta Neurochir (Wien). 2018 Mar;160(3):539-44. https://doi.org/10.1007/s00701-017-3454-z
  • 16 Shapiro WR, Young DF, Mehta BM. Methotrexate: distribution in cerebrospinal fluid after intravenous, ventricular and lumbar injections. N Engl J Med. 1975 Jul 24;293(4):161-6. https://doi.org/10.1056/NEJM197507242930402
  • 17 Krames ES, Gershow J, Glassberg A, Kenefick T, Lyons A, Taylor P, et al. Continuous infusion of spinally administered narcotics for the relief of pain due to malignant disorders. Cancer. 1985 Aug 1;56(3):696-702. https://doi.org/10.1002/1097-0142(19850801)56:3<696::aid-cncr2820560343>3.0.co;2-8
  • 18 Oken MM, Creech RH, Tormey DC, Horton J, Davis TE, McFadden ET, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol. 1982 Dec;5(6):649-55.
  • 19 National Cancer Institute. Common Terminology Criteria for Adverse Events (CTCAE) Version 5.0. Washington (DC): U.S. Department of Health and Human Services; 2017. Available from: https://ctep.cancer.gov/protocoldevelopment/electronic_applications/docs/CTCAE_v5_Quick_Reference_8.5x11.pdf
  • 20 Ali A, Bosse RC, Doonan BP, Narayan P, Jester GA, Delaune JD, et al. Ommaya reservoir related complications: a single center experience and review of current literature. Int J Clin Oncol Cancer Res. 2019 Apr;4(2):10-24. https://doi.org/10.11648/j.ijcocr.20190402.12
  • 21 Szvalb AD, Raad II, Weinberg JS, Suki D, Mayer R, Viola GM. Ommaya reservoir-related infections: clinical manifestations and treatment outcomes. J Infect. 2014 Mar;68(3):216-24. https://doi.org/10.1016/j.jinf.2013.12.002
  • 22 Onofrio BM, Yaksh TL. Long-term pain relief produced by intrathecal morphine infusion in 53 patients. J Neurosurg. 1990 Feb;72(2):200-9. https://doi.org/10.3171/jns.1990.72.2.0200
  • 23 Smyth C, Ahmadzai N, Wentzell J, Pardoe A, Tse A, Nguyen T, et al. Intrathecal analgesia for chronic refractory pain: current and future prospects. Drugs. 2015 Nov;75(17):1957-80. https://doi.org/10.1007/s40265-015-0471-1
  • 24 Aprili D, Bandschapp O, Rochlitz C, Urwyler A, Ruppen W. Serious complications associated with external intrathecal catheters used in cancer pain patients: a systematic review and meta-analysis. Anesthesiology. 2009 Dec;111(6):1346-55. https://doi.org/10.1097/ALN.0b013e3181bfab9a
  • 25 Holmfred A, Vikerfors T, Berggren L, Gupta A. Intrathecal catheters with subcutaneous port systems in patients with severe cancer-related pain managed out of hospital: the risk of infection. J Pain Symptom Manage. 2006 Jun 1;31(6):P568-72. https://doi.org/10.1016/j.jpainsymman.2005.11.010
  • 26 Park JH, Kim YJ, Lee J-O, Lee K-W, Kim JH, Bang S-M, et al. Clinical outcomes of leptomeningeal metastasis in patients with non-small cell lung cancer in the modern chemotherapy era. Lung Cancer. 2012 Jun 1;76(3):P387-92. https://doi.org/10.1016/j.lungcan.2011.11.022
  • 27 Franzoi MA, Hortobagyi GN. Leptomeningeal carcinomatosis in patients with breast cancer. Crit Rev Oncol Hematol. 2019 Mar;135:85-94. https://doi.org/10.1016/j.critrevonc.2019.01.020
  • 28 Lara-Medina F, Crismatt A, Villarreal-Garza C, Alvarado-Miranda A, Flores-Hernandez L, Gonzalez-Pinedo M, et al. Clinical features and prognostic factors in patients with carcinomatous meningitis secondary to breast cancer. Breast J. 2012 May-Jun;18(3):233-41. https://doi.org/10.1111/j.1524-4741.2012.01228.x
  • 29 Rudnicka H, Niwińska A, Murawska M. Breast cancer leptomeningeal metastasis--the role of multimodality treatment. J Neurooncol. 2007 Aug;84(1):57-62. https://doi.org/10.1007/s11060-007-9340-4
  • 30 Le Rhun E, Taillibert S, Zairi F, Kotecki N, Devos P, Mailliez A, et al. A retrospective case series of 103 consecutive patients with leptomeningeal metastasis and breast cancer. J Neurooncol. 2013 May;113(1):83-92. https://doi.org/10.1007/s11060-013-1092-8
  • 31 Niwińska A, Rudnicka H, Murawska M. Breast cancer leptomeningeal metastasis: the results of combined treatment and the comparison of methotrexate and liposomal cytarabine as intra-cerebrospinal fluid chemotherapy. Clin Breast Cancer. 2015 Feb 1;15(1):P66-72. https://doi.org/10.1016/j.clbc.2014.07.004
  • 32 Lee SJ, Lee J-I, Nam D-H, Ahn YC, Han JH, Sun J-M, et al. Leptomeningeal carcinomatosis in non-small-cell lung cancer patients: impact on survival and correlated prognostic factors. J Thorac Oncol. 2013 Feb 1;8(2):P185-91. https://doi.org/10.1097/JTO.0b013e3182773f21
  • 33 Kuiper JL, Hendriks LE, van der Wekken AJ, de Langen AJ, Bahce I, Thunnissen E, et al. Treatment and survival of patients with EGFR-mutated non-small cell lung cancer and leptomeningeal metastasis: a retrospective cohort analysis. Lung Cancer. 2015 Sep 1;89(3):P255-61. https://doi.org/10.1016/j.lungcan.2015.05.023
  • 34 Riess JW, Nagpal S, Iv M, Zeineh M, Gubens MA, Ramchandran K, et al. Prolonged survival of patients with non-small-cell lung cancer with leptomeningeal carcinomatosis in the modern treatment era. Clin Lung Cancer. 2014 May 1;15(3):P202-6. https://doi.org/10.1016/j.cllc.2013.12.009
  • 35 Ferguson SD, Bindal S, Bassett Jr RL, Haydu LE, McCutcheon IE, Heimberger AB, et al. Predictors of survival in metastatic melanoma patients with leptomeningeal disease (LMD). J Neurooncol. 2019 May 1;142(3):499-509. https://doi.org/10.1007/s11060-019-03121-2
  • 36 Foppen MHG, Brandsma D, Blank CU, van Thienen JV, Haanen JB, Boogerd W. Targeted treatment and immunotherapy in leptomeningeal metastases from melanoma. Ann Oncol. 2016 Jun 1;27(6):1138-42. https://doi.org/10.1093/annonc/mdw134