Whole brain radiotherapy combined with intrathecal liposomal cytarabine for leptomeningeal metastasis-a safety analysis and validation of the EANO-ESMO classification

Sarah Iglseder; Martha Nowosielski; Gabriel Bsteh; Armin Muigg; Johanna Heugenhauser; Elke Mayer; Astrid Grams; Günther Stockhammer; Meinhard Nevinny-Stickel

doi:10.1007/s00066-022-01910-9

Whole brain radiotherapy combined with intrathecal liposomal cytarabine for leptomeningeal metastasis-a safety analysis and validation of the EANO-ESMO classification

Strahlenther Onkol. 2022 May;198(5):475-483. doi: 10.1007/s00066-022-01910-9. Epub 2022 Mar 10.

Authors

Sarah Iglseder¹, Martha Nowosielski², Gabriel Bsteh³, Armin Muigg¹, Johanna Heugenhauser¹, Elke Mayer⁴, Astrid Grams⁵, Günther Stockhammer¹, Meinhard Nevinny-Stickel⁴

Affiliations

¹ Department of Neurology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria.
² Department of Neurology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria. martha.nowosielski@i-med.ac.at.
³ Department of Neurology, Medical University of Vienna, Vienna, Austria.
⁴ Department of Therapeutic Radiology and Oncology, Medical University of Innsbruck, Innsbruck, Austria.
⁵ Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria.

Abstract

Background: Although there is no proven standard therapy for leptomeningeal metastases (LM), treatment often includes intrathecal chemotherapy combined with whole brain radiation therapy (WBRT). Little is known about the toxicity of such combination therapies. We performed a retrospective safety analysis for the combination of intrathecal liposomal cytarabine with WBRT in patients with LM and validated the EANO-ESMO (European Association of Neuro-oncology-European Society for Medical Oncology) classification in this unique cohort.

Methods: Treatment toxicities in patients diagnosed with LM between 2004 and 2014 were retrospectively analyzed according to RTOG (Radiation Therapy Oncology Group) toxicity criteria and NCI CTCAE V5.0 (National Cancer Institute Common Terminology Criteria for Adverse Events, Version 5.0). Diagnostic criteria and treatment response as assessed by EANO-ESMO classification were correlated with survival by Kaplan-Meier analysis and Breslow test.

Results: In all, 40 patients with LM who were treated with combined WBRT and intrathecal cytarabine, were identified. Ten patients (25%) experienced adverse events ≥grade 3 according to RTOG toxicity criteria; in 22 patients (55%) NCI CTCAE ≥grade 3 were detected. Median overall survival was 124 days. Median time to neurological progression was 52 days. Patients with positive cerebrospinal fluid (CSF) cytology (n = 26) showed worse prognosis compared to patients with negative CSF cytology (n = 14; mOS (median overall survival) 84 days versus 198 days, p = 0.006, respectively). The EANO-ESMO response assessment was significantly associated with survival: "stable" (n = 7) mOS 233 days, "response" (n = 10) mOS 206 days, "progression" (n = 17) mOS 45 days, "suspicion of progression" (n = 6) mOS 133 days; overall, p < 0.001.

Conclusions: In this retrospective analysis, combined treatment of WBRT and intrathecal liposomal cytarabine shows an acceptable safety profile and may indicate a trend towards improved efficacy. The EANO-ESMO classification for diagnosis and treatment response predicts survival.

Keywords: Intrathecal therapy (DepoCyte®); Leptomeningeal metastases; Outcome; Survival analysis.

MeSH terms

Brain
Cytarabine / adverse effects
Humans
Immunotherapy
Meningeal Carcinomatosis* / drug therapy
Retrospective Studies

Substances

Cytarabine