Detection of Neoplasms by Metagenomic Sequencing of Cerebrospinal Fluid

Importance: Malignant neoplasms of the central nervous system (CNS) are frequently not detected by cerebrospinal fluid (CSF) flow cytometry or cytology, and clinical phenotypes can overlap with inflammatory meningoencephalitis. Objective: To determine whether an existing CSF metagenomic next-generation sequencing (mNGS) assay can identify a hallmark of malignant neoplasms -aneuploidy - in difficult-to-diagnose cases of CNS malignancy. Design: Two retrospective, case-control studies included a total of 155 samples from patients with an eventual diagnosis of a CNS malignancy (n=59 patients) and controls with other CNS diseases (n=73 patients). The first study was used to evaluate test performance in positive and negative controls. The second study was used to assess the potential utility of aneuploidy detection in patients whose CSF was sent for mNGS because of suspected neuroinflammatory disease who were ultimately found to have a CNS malignancy. Setting: This is a single site study at a large tertiary care center, University of California San Francisco, that enrolled from 2014 to 2019. Participants: The test performance case-control study enrolled positive control patients with a CNS malignancy (n=47 patients) and negative controls with other neurologic diseases (n=56 patients) who had had CSF flow cytometry and/or cytology performed. The second case-control study enrolled patients with suspected neuroinflammatory disease who were ultimately diagnosed with a CNS malignancy (n=12) and other neurologic disease controls (n=17). Main Outcome(s) and Measure(s): The primary outcome measures were the performance characteristics of detecting aneuploidy in CSF by a cell-free DNA mNGS assay compared to cytology and/or flow cytometry and the tumor fraction in CSF from patients with CNS malignancies. Results: Across the two case-control studies, the overall sensitivity of the CSF mNGS assay for detecting aneuploidy in patients ultimately diagnosed with a CNS malignancy was 75% (63-96%, 95% CI), and specificity was 100% (96-100%, 95% CI). Notably, CSF mNGS detected aneuploidy in 64% of the non-diagnostic cytology and flow cytometry cases in the test performance study and in 55% of the cases with suspected neuroinflammatory disease who were ultimately diagnosed with a CNS malignancy. Of the cases in whom aneuploidy was detected, 90% had multiple chromosomal copy number variants with tumor fractions ranging from 31% to 49%. Conclusions and Relevance: Metagenomic NGS of CSF, originally designed to diagnose neurologic infections, detects evidence of CNS malignancies (i.e., aneuploidy) in cases where CSF flow cytometry and/or cytology were negative with a low risk of false positive results.

A Child with Glioblastoma Multiforme — Case Report

Introduction. Glioblastoma multiforme (GBM) is the most common central nervous system (CNS) malignancy. It is characterized by an aggressive course with the presence of rapidly growing cells, infiltrating the adjacent brain tissues. Case Report. The case report concerns a 16-year-old child with glioblastoma multiforme. The paper presents selected care problems observed in the child. Discussion. In caring for a child diagnosed with high-grade glioma, the most important care problems are severe, recurrent headaches, nausea and vomiting due to chemotherapy, chronic stress and anxiety, as well as a significant decrease in mood, resulting in e.g. social isolation. A nurse caring for a child with glioblastoma should not only focus on activities directly related to medical care, but also provide psychological support, which certainly improves the quality of life of the child and his family. Conclusions. A patient with high-grade glioma has many different types of care problems. Some are problems related to the physical sphere, others concern the psychological and social sphere. (JNNN 2020;9(4):152–159) Key Words: care, child, glioblastoma multiforme

P14.86 Bevacizumab-associated intracerebral hemorrhage in patients with CNS malignancy: A single-center retrospective cohort study

BACKGROUND Gliomas are a known risk factor for the development of spontaneous intracranial hemorrhage (ICH) independent of therapies directed against them, with studies reporting an incidence of 1.9–3.8%. Bevacizumab (BEV) is a humanized monoclonal antibody targeting vascular endothelial growth factor (VEGF) FDA approved for recurrent glioblastoma. ICH is commonly considered to be a potential adverse effect of BEV use in patients with glioma, with previous retrospective studies describing incidence of intracerebral hemorrhage ranging from 1.9–3.3%. Material and METHODS We performed a single center (Mayo Clinic, Rochester, MN) retrospective chart review of all patients who received BEV therapy at our institution for a diagnosis of primary CNS malignancy. We used ICD-9 and ICD-10 codes to identify adult patients with primary CNS neoplasms that subsequently developed ICH. RESULTS We screened 10,507 adult patients with a diagnosis of primary CNS neoplasm treated at our center from 01/31/2008 to 12/31/2018 and found 644 patients treated with bevacizumab. Of these, 23 (3.6%) suffered an ICH within 12 weeks of a BEV infusion (median 9 days post infusion, 1–24 IQR). The dose of BEV in all hemorrhages was either 10 mg/kg every two weeks (n = 21) or 15 mg/kg every three weeks (n = 2). No patients treated with infusions at 7.5 mg/kg every three weeks (n = 79) or 5 mg/kg every two weeks (n = 17) suffered ICH events, however this did not meet significance (P = 0.06) when compared to patients on 10 mg/kg or above. The median ICH score was 1 (0–2 IQR). There was an increase in ECOG scores documented at clinical follow up following the hemorrhage compared to the pre-hemorrhage functional status (ECOG 3.28 versus 1.2, p = < 0.0001), with 13 patients (56%) having developed severe debility or death (ECOG 4 n = 3, ECOG 5 n = 10). CONCLUSION In our single-center cohort of patients with a primary diagnosis of CNS neoplasms treated with BEV, ICH occurred in 3.6% of patients. Those who experienced an ICH in proximity to BEV infusion had significant morbidity and mortality with a clear decline in functional status. There was a signal of dose response as far as ICH incidence in our cohort with dosages 10 mg/kg per infusion or above.

Tumor cell phenotype and heterogeneity differences in IDH1 mutant vs wild-type gliomas

Glioma is recognized to be a highly heterogeneous CNS malignancy, whose diverse cellular composition and cellular interactions have not been well characterized. To gain new clinical- and biological-insights into the genetically-bifurcated IDH1 mutant (mt) vs wildtype (wt) forms of glioma, we integrated multiplexed immunofluorescence single cell data for 43 protein markers across cancer hallmarks, in addition to cell spatial metrics, genomic sequencing and magnetic resonance imaging (MRI) quantitative features. Molecular and spatial heterogeneity scores for angiogenesis and cell invasion differ between IDHmt and wt gliomas irrespective of prior treatment and tumor grade; these differences also persisted in the MR imaging features of peritumoral edema and contrast enhancement volumes. Longer overall survival for IDH1mt glioma patients may reflect generalized altered cellular, molecular, spatial heterogeneity which manifest in discernable radiological manifestations.

Bevacizumab-associated intracerebral hemorrhage in patients with CNS malignancy: A single-center retrospective cohort study.

e13509 Background: Gliomas are a known risk factor for the development of spontaneous intracranial hemorrhage (ICH) independent of therapies directed against them, with studies reporting an incidence of 1.9-3.8%. Bevacizumab (BEV) is a humanized monoclonal antibody targeting vascular endothelial growth factor (VEGF) FDA approved for recurrent glioblastoma. ICH is commonly considered to be a potential adverse effect of BEV use in patients with glioma, with previous retrospective studies describing incidence of intracerebral hemorrhage ranging from 1.9-3.3%. Methods: We performed a single center (Mayo Clinic, Rochester, MN) retrospective chart review of all patients who received BEV therapy at our institution for a diagnosis of primary CNS malignancy. We used ICD-9 and ICD-10 codes to identify adult patients with primary CNS neoplasms that subsequently developed ICH. Results: We screened 10,507 adult patients with a diagnosis of primary CNS neoplasm treated at our center from 01/31/2008 to 12/31/2018 and found 644 patients treated with bevacizumab. Of these, 23 (3.6%) suffered an ICH within 12 weeks of a BEV infusion (median 9 days post infusion, 1-24 IQR). The dose of BEV in all hemorrhages was either 10 mg/kg every two weeks (n = 21) or 15 mg/kg every three weeks (n = 2). No patients treated with infusions at 7.5 mg/kg every three weeks (n = 79) or 5 mg/kg every two weeks (n = 17) suffered ICH events, however this did not meet significance (P = 0.06) when compared to patients on 10 mg/kg or above. The median ICH score was 1 (0-2 IQR). There was an increase in ECOG scores documented at clinical follow up following the hemorrhage compared to the pre-hemorrhage functional status (ECOG 3.28 versus 1.2, p = < 0.0001), with 13 patients (56%) having developed severe debility or death (ECOG 4 n = 3, ECOG 5 n = 10). Conclusions: In our single-center cohort of patients with a primary diagnosis of CNS neoplasms treated with BEV, ICH occurred in 3.6% of patients. Those who experienced an ICH in proximity to BEV infusion had significant morbidity and mortality with a clear decline in functional status. There was a signal of dose response as far as ICH incidence in our cohort with dosages 10 mg/kg per infusion or above.

WED 244 CSF cytology alone is unable to predict CNS neoplastic process

Incidence of both primary and secondary central nervous system (CNS) malignancies are increasing, yet detection and diagnosis of which remains challenging. Neurological examination, CSF cytology and neuroimaging each offer diagnostic value, however, individually, each method has relatively low sensitivity. CSF cytology is often routinely requested as part of the diagnostic work-up. Therefore, we reviewed the value of CSF cytology in predicting CNS neoplastic process.We systematically analysed 296 patients who had had CSF cytology. All consecutive patients over the last 2 years were included. The 12 patients positive for CSF cytology were also found to have concurrent; clinical findings (92%), radiological findings (92%), or both (83%). In no patient CNS malignancy was identified by CSF cytology alone. Additionally, only 7 of the 12 CSF positive cases were collected by means of lumbar puncture, the rest were carried out during neurosurgical procedures.We conclude that if there is neither clinical findings nor abnormal neuroimaging, assessing CSF cytology does not contribute towards diagnosis of CNS malignancy. Yield of CSF cytology is high when both clinical and radiological evidence are present. Where neuroimaging is normal but suspicion remains, the low sensitivity of the CSF-cytology would make it a weak corroborator to exclude malignancy.