Management of carcinomatous meningitis in a patient with advanced lung adenocarcinoma
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1 Management of carcinomatous meningitis in a patient with advanced lung adenocarcinoma Clinical Case Presentation Emilie Le Rhun Centre Hospitalier Régional et Universitaire (CHRU) de Lille Neurochirurgie - Hôpital Roger Salengro Lille, France 1
2 DISCLOSURES Honoraria: Novartis, Mundipharma Research funding: Mundipharma, Amgen 2
3 CASE VIGNETTE 46 year-old male January 2012 : lung adenocarcinoma, EGFR non evaluable, pt2b pn1 M0 February 2012 : lung + axillary resection followed by cisplatin- vinorelbine X 4 cycles August 2015 : mediastinal lymph nodes progression : local radiotherapy then carboplatin + paclitaxel November 2015 : repeated falls leading to a brain MRI EGFR, epidermal growth factor receptor; MRI, magnetic resonance imaging
4 A cerebral MRI is performed and is normal MRI, magnetic resonance imaging
5 Q1. How do you complete the evaluation? 1. Clinical follow-up only 2. Brain MRI in 2-3 months 3. Thorax/abdomen CT scan 4. PET 5. Spinal MRI 6. CSF cytology 7. CSF EGFR 8. CSF flow study (several correct answers)
6 If the MRI was this one, how do you complete the evaluation? MRI, magnetic resonance imaging
7 Q2. How do you complete the evaluation? 1. Thorax/abdomen CT scan 2. PET 3. Spinal MRI 4. CSF cytology 5. CSF EGFR status 6. CSF flow study 7. No more examination (several correct answers)
8 59 year-old male 2012 : lung adenocarcinoma, EGFR undetermined 2012 : lung + axillary resection followed by cisplatin/vinorelbine X4 cycles August 2015 : mediastinal lymph nodes progression, local radiotherapy then carboplatin + paclitaxel November 2015 : repeated falls leading to a brain MRI Brain and spinal MRI with diffuse linear contrast enhancement Detailed neurological evaluation with mild reduction of visual acuity, left tinnitus, mild gait disorder, mild left lower limb deficits, urinary incontinence No progression of the extra-cns disease Re-assessment of EGFR: exon 19 del CSF: atypical CSF, cerebrospinal fluid; CNS, central nervous system; EGFR, epidermal growth factor receptor; MRI, Magnetic resonance imaging 8
9 Q3. What now? 1. Whole brain radiotherapy? 2. Systemic pharmacotherapy? 3. Intrathecal pharmacotherapy? ? ? ? ? 8. Best supportive care? (one preferred option) 9
10 59 year-old male 2012 : lung adenocarcinoma, EGFR undetermined 2012 : lung + axillary resection followed by cisplatin- vinorelbine X 4 cycles August 2015 : mediastinal lymph nodes progression : local radiotherapy then carboplatin + paclitaxel November 2015 : repeated falls leading to a brain MRI Brain and spinal MRI with diffuse linear contrast enhancement Detailed neurological evaluation with mild reduction of visual acuity, left tinnitus, mild gait disorder, mild left lower limb deficits, urinary incontinence No progression of the extra-cns disease Re-assessment of EGFR and ALK: no mutation/no translocation CSF: atypical ALK, anaplastic lymphoma kinase; CSF, cerebrospinal fluid; CNS, central nervous system; EGFR, epidermal growth factor receptor; MRI, Magnetic resonance imaging 10
11 Q4. What now? 1. Whole brain radiotherapy? 2. Systemic pharmacotherapy? 3. Intrathecal pharmacotherapy? ? ? ? ? 8. Best supportive care? (one preferred option) 11
12 59 year-old male 2012 : lung adenocarcinoma, EGFR undetermined 2012 : lung + axillary resection followed by cisplatin- vinorelbine X 4 cycles August 2015 : mediastinal lymph nodes progression : local radiotherapy then carboplatin + paclitaxel November 2015 : repeated falls leading to a brain MRI Brain and spinal MRI with diffuse linear contrast enhancement Detailed neurological evaluation with mild reduction of visual acuity, left tinnitus, mild gait disorder, mild left lower limb deficits, urinary incontinence No progression of the extra-cns disease Re-assessment of EGFR: exon 19 del CSF: positive ALK, anaplastic lymphoma kinase; CSF, cerebrospinal fluid; CNS, central nervous system; EGFR, epidermal growth factor receptor; MRI, Magnetic resonance imaging 12
13 Q5. What now? 1. Whole brain radiotherapy? 2. Systemic pharmacotherapy? 3. Intrathecal pharmacotherapy? ? ? ? ? 8. Best supportive care? (one preferred option) 13
14 59 year-old male 2012 : lung adenocarcinoma, EGFR undetermined 2012 : lung + axillary resection followed by cisplatin- vinorelbine X 4 cycles August 2015 : mediastinal lymph nodes progression : local radiotherapy then carboplatin + paclitaxel November 2015 : repeated falls leading to a brain MRI Brain and spinal MRI with diffuse linear contrast enhancement; detailed neurological evaluation with mild reduction of visual acuity, left tinnitus, mild gait disorder, mild left lower limb deficits, urinary incontinence No progression of the extra-cns disease Re-assessment of EGFR and ALK: no mutation/no translocation CSF: positive ALK, anaplastic lymphoma kinase; CSF, cerebrospinal fluid; CNS, central nervous system; EGFR, epidermal growth factor receptor; MRI, Magnetic resonance imaging 14
15 Q6. What now? 1. Whole brain radiotherapy? 2. Systemic pharmacotherapy? 3. Intrathecal pharmacotherapy? ? ? ? ? 8. Best supportive care? (one preferred option) 15
16 59 year-old male 2012 : lung adenocarcinoma, EGFR undetermined 2012 : lung + axillary resection followed by cisplatin- vinorelbine X 4 cycles August 2015 : mediastinal lymph nodes progression : local radiotherapy then carboplatin + paclitaxel November 2015 : repeated falls leading to a brain MRI Brain and spinal MRI with diffuse linear contrast enhancement; detailed neurological evaluation with mild reduction of visual acuity, left tinnitus, mild gait disorder, mild left lower limb deficits, urinary incontinence No progression of the extra-cns disease Re-assessment of EGFR: exon 19 del CSF: negative CSF, cerebrospinal fluid; CNS, central nervous system; EGFR, epidermal growth factor receptor; MRI, Magnetic resonance imaging 16
17 Q7.What now? 1. Whole brain radiotherapy? 2. Systemic pharmacotherapy? 3. Intrathecal pharmacotherapy? ? ? ? ? 8. Best supportive care? (one preferred option) 17
18 59 year-old male 2012 : lung adenocarcinoma, EGFR undetermined 2012 : lung + axillary resection followed by cisplatin- vinorelbine X 4 cycles August 2015 : mediastinal lymph nodes progression : local radiotherapy then carboplatin + paclitaxel November 2015 : repeated falls leading to a brain MRI Brain and spinal MRI with diffuse linear contrast enhancement Detailed neurological evaluation with mild reduction of visual acuity, left tinnitus, mild gait disorder, mild left lower limb deficits, urinary incontinence No progression of the extra-cns disease Re-assessment of EGFR and ALK: no mutation/no translocation CSF: negative ALK, anaplastic lymphoma kinase; CSF, cerebrospinal fluid; CNS, central nervous system; EGFR, epidermal growth factor receptor; MRI, Magnetic resonance imaging 18
19 Q8. What now? 1. Whole brain radiotherapy? 2. Systemic pharmacotherapy? 3. Intrathecal pharmacotherapy? ? ? ? ? 8. Best supportive care? (one preferred option) 19
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