New hope for leptomeningeal disease care

When cancer spreads to the central nervous system, it usually goes to
the brain tissue. In a small but growing number of cases, though, it
shows up in the cerebrospinal fluid surrounding the brain and
spinal cord and/or in the leptomeninges, the lining of the brain and
spinal cord. This type of metastasis is known as leptomeningeal disease (LMD), or leptomeningeal carcinomatosis.

Since leptomeningeal disease cancer cells float in the cerebrospinal
fluid, they can quickly spread throughout the central nervous system.
As a result, leptomeningeal disease has a poor prognosis, with
survival typically measured in months.

The Neuro-Oncology department at MD
is expanding its LMD program dedicated to better
understanding and treating the disease. Barbara O’Brien, M.D., assistant professor of
neuro-oncology, recently spoke with us about leptomeningeal disease
and our effort to help patients with this condition.

What cancer types are most prone to leptomeningeal disease?

Leptomeningeal disease tends to occur most commonly with cancers
that spread to the central nervous system. This includes breast cancer, lung cancer and melanoma.

What are the most common symptoms of leptomeningeal disease?

The most common symptoms include an altered mental state, which
means confusion, and a pressure headache that is worst in the morning
and that gets progressively more intense over several days and weeks.
Other symptoms can include seizures, double vision or even a numb chin.

What led to the creation of MD
leptomeningeal disease program?

We desperately need better treatments for our patients. We also need
to understand why some patients may be at higher risk of developing
leptomeningeal disease. Classically, leptomeningeal disease was
considered a very late-stage complication of cancer, and there wasn’t
much we could for those patients. Now, more patients are surviving
longer with cancer and otherwise are doing well at the time they’re
diagnosed with leptomeningeal disease. So we’re actively working to
find better treatments for them.

What are we doing to improve care at MD Anderson?

Our doctors and nurses keep a close eye out for leptomeningeal
disease symptoms, which can lead to earlier detection. If they see
someone they suspect may have leptomeningeal disease, they send the
patient for a neurologic evaluation pretty quickly. Our team consists
of a neuro-oncologist, neurosurgeon and/or radiation-oncologist. We
work closely with the patient’s primary oncologist to provide expert
care that includes diagnosis and treatment options, as well as
education and support for patients and caregivers.

We’re also conducting a pilot study for small cell lung cancer
patients, who have a high risk of developing brain metastases and
leptomeningeal disease early. When a patient comes in newly diagnosed
with small cell lung cancer, they meet with a neuro-oncologist soon
after meeting their lung doctor. They undergo a full neurologic
evaluation, including a neurologic exam, an MRI scan of the brain and
a lumbar puncture, also known as a spinal tap. This study paves the
way for earlier diagnosis and earlier treatment of leptomeningeal disease.

What treatments can we offer to leptomeningeal disease patients?

Goals for treatment include prolonging survival and stabilizing
neurological symptoms. While there’s no cure for leptomeningeal
disease yet, radiation and chemotherapy are the two most common
treatments. Since it’s very hard for drugs to make it into the central
nervous system, the chemotherapy is delivered intrathecally. That
means we drill a small hole in the skull and insert a port, which is
used to deliver the drug. Intrathecal chemotherapy can only penetrate
a few millimeters. If the tumor is any thicker, we may give radiation
first to try to shrink it down.

We’re also exploring new treatments. We’re working on a clinical
trial for breast cancer patients with leptomeningeal disease, and we
have an open clinical trial for non-small cell lung cancer patients.

What is leptomeningeal disease research focusing on?

Our goal is to develop effective strategies to prevent and treat
leptomeningeal disease and improve the overall quality of life for our
patients. We want to learn more about the biology of leptomeningeal
disease. If we understand more about the cerebrospinal fluid and the
tumor cells that get to the leptomeninges, we can better understand
how to treat these patients and prolong survival. For example, with
the small cell lung cancer patients we monitor, we’re doing some tests
on the spinal fluid to see if there are any molecular changes that
signal the patient is going to develop leptomeningeal disease. We know
patients with small cell lung cancer are at high risk of developing
central nervous system metastases. We’re trying to figure out why
they’re at high risk and how to predict when and if a patient will
develop leptomeningeal disease. If we can figure that out, we can
learn how to better treat leptomeningeal disease and maybe eventually
prevent it.

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