From the Guidelines
For patients with leptomeningeal metastasis, systemic pharmacotherapy, such as the combination of tucatinib, trastuzumab, and capecitabine, or trastuzumab deruxtecan (T-DXd), should be considered as the primary treatment approach, given their potential to improve overall survival and quality of life, as seen in recent studies 1.
Treatment Overview
Leptomeningeal metastasis is a serious complication of cancer where tumor cells spread to the membranes (meninges) surrounding the brain and spinal cord. The management of leptomeningeal metastases is complex and typically involves a multidisciplinary approach.
Current Recommendations
- Systemic Therapy: The use of systemic pharmacotherapy, such as the combination of tucatinib, trastuzumab, and capecitabine, or T-DXd, is recommended for patients with HER2-positive breast cancer and leptomeningeal metastasis, based on recent data showing improved median overall survival 1.
- Intrathecal Therapy: Intrathecal chemotherapy, including agents like methotrexate, cytarabine, or liposomal cytarabine, may be considered in specific cases, although its use is controversial and should be decided on a case-by-case basis, considering the presence of tumor cells in the cerebrospinal fluid and the patient's overall condition 1.
- Radiation Therapy: Whole-brain radiation therapy (WBRT) or stereotactic radiosurgery (SRS) may be used for symptomatic areas or for patients with limited brain metastases, but its role in leptomeningeal metastasis is more limited and should be considered based on the extent of disease and symptoms 1.
Supportive Care
Supportive care, including dexamethasone for increased intracranial pressure and pain management, is essential for improving the quality of life of patients with leptomeningeal metastasis.
Diagnosis and Prognosis
Early diagnosis through MRI with contrast and cerebrospinal fluid analysis is crucial. The prognosis remains poor, with a median survival that can vary based on the treatment approach and the patient's overall condition, but targeted therapies offer hope for improved outcomes in certain cases 1.
Key Considerations
Treatment decisions should consider the patient's performance status, primary cancer type, and previous treatments. A multidisciplinary discussion is essential for determining the best treatment plan for each patient.
From the Research
Definition and Diagnosis of Leptomeningeal Metastasis
- Leptomeningeal metastasis (LM) is a devastating and mostly late-stage complication of various solid tumors, where tumor cells seed to the cerebrospinal fluid (CSF) and the leptomeninges 2.
- Clinical signs and symptoms may include cranial nerve palsies, radicular symptoms, signs of increased intracranial pressure, and cognitive dysfunction 2.
- The highest diagnostic sensitivity is provided by the combination of CSF cytology and contrast-enhanced MRI (cranial as well as complete spine) 2.
Treatment Options for Leptomeningeal Metastasis
- The therapeutic spectrum includes radiotherapy of the clinically involved region, as well as systemic and intrathecal chemotherapy 2.
- The choice of treatment modalities depends on the type of LM, additional systemic involvement, and additional involvement of the CNS parenchyma 2.
- Intrathecal chemotherapy is most important in cases of LM of the non-adherent type, with methotrexate, cytarabine, and thiotepa being the three substances for routine use 2.
- Liposomal cytarabine shows advantages in terms of longer injection intervals and improved quality-of-life 2.
- Systemic high-dose methotrexate and intrathecal liposomal cytarabine have shown promising efficacy and tolerability in the treatment of leptomeningeal carcinomatosis from breast cancer 3.
Role of New Agents in Intrathecal Therapy
- The role of new agents, such as rituximab and trastuzumab, for intrathecal therapy is still unclear 2.
- However, a study has shown that intrathecal trastuzumab with cytarabine and methotrexate is associated with promising benefit in the treatment of leptomeningeal carcinomatosis in breast cancer patients 4.
Nursing Care and Management of Patients with Leptomeningeal Metastasis
- Nursing care of patients with LM requires an understanding of neurologic anatomy and physiology, along with associated treatments and complications 5.
- Treatment of LM may involve intrathecal or intraventricular chemotherapy, and nursing care should include monitoring for signs and symptoms of LM, as well as management of treatment-related complications 5.