[Cytology of cerebrospinal fluid : Standards, importance and modern methods]. / Liquorzytologie : Standards, Stellenwert und moderne Methoden.

Cytology is an integral part of cerebrospinal fluid (CSF) analysis. It is relevant for the diagnostics and differential diagnosis of inflammatory, hemorrhagic and neoplastic central nervous system (CNS) processes. This article summarizes the recommended procedures and typical clinical patterns. In addition, modern immunocytochemical and flow cytometry methods for CSF cytology are presented. In particular, the diagnostic contribution and clinical relevance in several CNS conditions are discussed.

Glioma infiltration of the corpus callosum: early signs detected by DTI.

The most frequent primary brain tumors, anaplastic astrocytomas (AA) and glioblastomas (GBM): tend to invasion of the surrounding brain. Histopathological studies found malignant cells in macroscopically unsuspicious brain parenchyma remote from the primary tumor, even affecting the contralateral hemisphere. In early stages, diffuse interneural infiltration with changes of the apparent diffusion coefficient (ADC) and fractional anisotropy (FA) is suspected. The purpose of this study was to investigate the value of DTI as a possible instrument of depicting evidence of tumor invasion into the corpus callosum (CC). Preoperatively, 31 patients with high-grade brain tumors (8 AA and 23 GBM) were examined by MRI at 3 T, applying a high-resolution diffusion tensor imaging (DTI) sequence. ADC- and FA-values were analyzed in the tumor-associated area of the CC as identified by fiber tracking, and were compared to matched healthy controls. In (MR-)morphologically normal appearing CC the ADC values were elevated in the tumor patients (n = 22; 0.978 × 10(-3) mm²/s) compared to matched controls (0.917 × 10(-3) mm²/s, p < 0.05), and the corresponding relative FA was reduced (rFA: 88 %, p < 0.01). The effect was pronounced in case of affection of the CC visible on MRI (n = 9; 0.978 × 10(-3) mm²/s, p < 0.05; rFA: 72 %, p < 0.01). Changes in diffusivity and anisotropy in the CC can be interpreted as an indicator of tumor spread into the contralateral hemisphere not visible on conventional MRI.

Neoplastic meningitis: How MRI and CSF cytology are influenced by CSF cell count and tumor type.

BACKGROUND: Although CSF cytology and MRI are standard methods to diagnose neoplastic meningitis (NM), this complication of neoplastic disease remains difficult to detect. We therefore reevaluated the sensitivity of gadolinium (GD)-enhanced MRI and cerebrospinal-fluid (CSF)-cytology and the relevance of tumor type and CSF cell count. METHODS: We retrospectively identified 111 cases of NM diagnosed in our CSF laboratory since 1990 with complete documentation of both MRI and CSF cytology. 37 had haematological and 74 solid neoplasms. CSF cell counts were increased in 74 and normal in 37 patients. RESULTS: In hematological neoplasms, MRI was positive in 49% and CSF cytology in 97%. In solid tumors, the sensitivity of MRI was 80% and of cytology 78%. With normal CSF cell counts, MRI was positive in 59% (50% hematological, 72% solid malignancies) and CSF cytology in 76% (92% in hematological, 68% in solid neoplasms). In cases of elevated cell counts, the sensitivity of MRI was 72% (50% for hematological, 83% for solid malignancies) and of CSF cytology 91% (100% for haematological and 85% for solid neoplasms). 91% of cytologically positive cases were diagnosed at first and another 7% at second lumbar puncture. Routine protein analyses had a low sensitivity in detecting NM. CONCLUSIONS: The high overall sensitivity of MRI was only confirmed for NM from solid tumors and for elevated CSF cell counts. With normal cell counts and haematological neoplasms, CSF-cytology was superior to MRI. None of the analysed routine CSF proteins had an acceptable sensitivity and specificity in detecting leptomeningeal disease.

Carcinoembryonic antigen in the CSF of cancer patients--the value of intrathecal synthesis and correlation with IgA-diffusion dynamics.

OBJECTIVE: The diagnostic impact of carcinoembryonic antigen (CEA) was evaluated in serum and CSF of cancer and control patients. METHODS: 97 analyses of CEA in CSF and serum from 83 cancer patients were compared with 41 cases without malignancy. CEA diffusion dynamics were evaluated with IgA CSF/serum quotients (Q IgA). Intrathecal synthesis of CEA was analysed both by calculating an index Q CEA/Q IgA and within the IgA-diagram. RESULTS: In 73 samples without synthesis of IgA or CEA, both quotients correlated well with a mean Q CEA/Q IgA of 1.1 (95% CI 0.97-1.2). The Q CEA/Q IgA was significantly higher in metastasizing adenocarcinomas than in controls or other malignancies. In leptomeningeal disease from adenocarcinoma, Q CEA/Q IgA was significantly higher than in controls, while patients with CNS and/or bone metastases had intermediate values. The sensitivity to detect leptomeningeal disease was 91% and 69% for brain metastases. Q CEA/Q IgA and CEA synthesis assessed with the IgA diagram were equally sensitive. CONCLUSIONS: Evaluation of CEA in the IgA diagram is feasible and of clinical value. The consideration of intrathecal CEA synthesis correlates better with the clinical status than absolute CSF-CEA or the correlation with albumin.

[Neoplastic meningitis. Diagnosis and individualised therapy]. / Meningeosis neoplastica. Diagnostik und individualisierte Therapie.

Neoplastic meningitis is a diffuse dissemination of tumour cells in the cerebrospinal fluid (CSF), leptomeninges, or both. It occurs in approximately 5-10% of malignant diseases, most often in breast cancer, lung cancer, melanoma, and B-cell lymphoma. Symptoms of neoplastic meningitis include head or back pain, cranial nerve palsies, diffuse radicular symptoms, and psychiatric disturbances. Magnetic resonance imaging shows nodular contrast enhancement lining the CSF spaces. Positive CSF cytology requires optimal sampling and processing, and the treatment of neoplastic meningitis must be individualized. The CSF dissemination can be treated with intrathecal chemotherapy with methotrexate or Ara-C. Radiotherapy should be applied only to symptomatic solid spinal manifestations or fast progressing cranial nerve palsies. Systemic chemotherapy is needed to control solid manifestations or, in the case of substances entering the CSF, to support intrathecal chemotherapy.

[Primary brain tumors and brain metastases. Symptomatic epilepsy and driving ability - systematic review and expert opinion]. / Primäre Hirntumoren und Hirnmetastasen. Symptomatische Epilepsie und Fahreignung - Expertenumfrage und systematisches Review.

PURPOSE: Primary brain tumors and metastases are common causes of symptomatic epilepsy. Seizures, neurological and neuropsychological deficits can interfere with driving ability. The present paper aims to systematically review the incidence of epileptic seizures in brain tumor patients and to discuss driving ability in the context of the current German guidelines and expert opinions. METHODS: To evaluate the incidence of epileptic seizures which occur at the beginning and in the course of the disease, we performed a systematic literature research in PubMed from 1960 to 2007. Additionally on the basis of this data we performed a survey collecting expert opinions regarding the driving ability of brain tumor patients from members of the German working groups "Arbeitsgemeinschaft für prächirurgische Epilepsiediagnostik und operative Epilepsietherapie" (Working Group for Presurgical Epilepsy Diagnostics and Operative Epileptic Therapy) and "Neuroonkologische Arbeitsgemeinschaft" (Neuro-oncological Working Group). RESULTS: The incidence of epileptic seizures depends on the entity, dignity and localization of the tumor. The driving ability of brain tumor patients is not explicitly regulated in Germany. Of the interviewed experts 72% judged the guidelines to be precise enough and 44% did not want to deprive the patients of their driving ability without a first seizure, independent of the individual risk. DISCUSSION: The available studies are methodologically insufficient and show that a further evaluation is necessary to assess the driving ability. Possible restrictions of the driving ability in patients with a high risk of seizures in the course of the disease have to take into account the balance between individual rights and the interests of the general public.

S1 guidelines "lumbar puncture and cerebrospinal fluid analysis" (abridged and translated version).

INTRODUCTION: Cerebrospinal fluid (CSF) analysis is important for detecting inflammation of the nervous system and the meninges, bleeding in the area of the subarachnoid space that may not be visualized by imaging, and the spread of malignant diseases to the CSF space. In the diagnosis and differential diagnosis of neurodegenerative diseases, the importance of CSF analysis is increasing. Measuring the opening pressure of CSF in idiopathic intracranial hypertension and at spinal tap in normal pressure hydrocephalus constitute diagnostic examination procedures with therapeutic benefits.Recommendations (most important 3-5 recommendations on a glimpse): The indications and contraindications must be checked before lumbar puncture (LP) is performed, and sampling CSF requires the consent of the patient.Puncture with an atraumatic needle is associated with a lower incidence of postpuncture discomfort. The frequency of postpuncture syndrome correlates inversely with age and body mass index, and it is more common in women and patients with a history of headache. The sharp needle is preferably used in older or obese patients, also in punctures expected to be difficult.In order to avoid repeating LP, a sufficient quantity of CSF (at least 10 ml) should be collected. The CSF sample and the serum sample taken at the same time should be sent to a specialized laboratory immediately so that the emergency and basic CSF analysis program can be carried out within 2 h.The indication for LP in anticoagulant therapy should always be decided on an individual basis. The risk of interrupting anticoagulant therapy must be weighed against the increased bleeding risk of LP with anticoagulant therapy.As a quality assurance measure in CSF analysis, it is recommended that all cytological, clinical-chemical, and microbiological findings are combined in an integrated summary report and evaluated by an expert in CSF analysis. CONCLUSIONS: In view of the importance and developments in CSF analysis, the S1 guideline "Lumbar puncture and cerebrospinal fluid analysis" was recently prepared by the German Society for CSF analysis and clinical neurochemistry (DGLN) and published in German in accordance with the guidelines of the AWMF (https://www.awmf.org). /uploads/tx_szleitlinien/030-141l_S1_Lumbalpunktion_und_Liquordiagnostik_2019-08.pdf). The present article is an abridged translation of the above cited guideline. The guideline has been jointly edited by the DGLN and DGN.

Erythropoietin receptor is expressed in meningiomas and lower levels are associated with tumour recurrence.

AIMS: The Epo-EpoR pathway plays a role in tumour growth, metastasis and treatment resistance and is a potential target in oncological treatment. As the EpoR status in human meningiomas is unknown, our aim was to characterize EpoR expression in these tumours. METHODS: We examined 131 meningioma samples of all WHO grades from 116 patients by immunohistochemistry for EpoR. Among these, 25 meningiomas showed brain invasion and 29 patients had a further tumour recurrence. A group of 20 patients without tumour recurrence served as controls. In 12 cases we were able to compare both the primary and the following recurrent tumours. The presence of EpoR in meningiomas was confirmed by RT-PCR and Western blot. RESULTS: EpoR was expressed in all meningiomas. Statistical analysis revealed that the mean expression levels of EpoR were significantly lower in primary tumours with known recurrence compared with a recurrence-free control group. Additional matched pair analysis in individual cases showed no significant differences between primary and recurrent tumours. No significant correlation between EpoR expression and WHO grade, age, sex or brain invasion was detected. Using specific primer pairs for RT-PCR, we were able to detect all three known isoforms of EpoR: the full-length isoform EpoR-F, the truncated isoform EpoR-T and the soluble isoform EpoR-S. CONCLUSIONS: Our results demonstrate the expression of EpoR in meningiomas. Lower EpoR mean levels might be a useful marker for a higher recurrence risk, but further studies are needed to clarify the influence of EpoR on recurrences and the role of the different isoforms.

Roscovitine has anti-proliferative and pro-apoptotic effects on glioblastoma cell lines: A pilot study.

Purine analogue roscovitine, a cyclin-dependent kinase (CDK) inhibitor, has shown strong anti-proliferative and pro-apoptotic effects in solid and hematologic cancers such as non small-cell lung cancer and lymphomas. It targets CDK2, 7 and 9 preferentially, which are also overexpressed in glioblastoma. Τherefore, the biological effects of roscovitine in glioblastoma cell lines were investigated. Glioblastoma A172 and G28 cell lines were incubated with serial concentrations of roscovitine for 24-120 h. Proliferation was measured using the xCELLigence Real-Time Cell Analyzer, an impedance­based cell viability system. Cell cycle distribution was assessed by flow cytometry and gene expression was quantified by quantitative RT-PCR and western blot analysis. Roscovitine exhibited a clear dose-dependent anti­proliferative and pro­apoptotic effect in the A172 cell line, while G28 cells showed a anti-proliferative effect only at 100 µM. The results of the flow cytometric (FACS) analysis revealed a dose-dependent increase of the G2/M and sub-G1 fractions in A172 cells, while G28 cells responded with an elevated sub-G1 fraction only at the highest concentration. Roscovitine led to a dose­dependent decrease of transcripts of p53, CDK 7 and cyclins A and E and an increase of >4-fold of p21 in A172 cells. In G28 cells, a dose­dependent induction of CDK2, p21 and cyclin D was observed between 10 and 50 µM roscovitine after 72 h, however, at the highest concentration of 100 µM, all investigated genes were downregulated. Roscovitine exerted clear dose-dependent anti-proliferative and pro-apoptotic effects in A172 cells and less distinct effects on G28 cells. In A172 cells, roscovitine led to G2/M arrest and induced apoptosis, an effect accompanied by induced p21 and a reduced expression of CDK2, 7 and 9 and cyclins A and E. These effects requre further studies on a larger scale to confirm whether roscovitine can be used as a therapeutic agent against glioblastoma.

Bag-1 and Bcl-2 gene transfer in malignant glioma: modulation of cell cycle regulation and apoptosis.

Bag-1 is a heat shock 70 kDa (Hsp70)-binding protein that can collaborate with Bcl-2 in suppressing apoptosis under some conditions. Here, we report that 11 of 12 human glioma cell lines express Bag-1 protein in vitro. Moreover, 15 of 19 human glioblastomas expressed Bag-1 as assessed by immunohistochemistry in primary tumor specimens. To examine the biological effects of Bag-1 in glioma cells, we expressed Bag-1 or Bcl-2 transgenes in 2 human malignant glioma cell lines, LN-18 and LN-229. Bag-1 significantly slowed glioma cell growth and reduced clonogenicity of both cell lines in vitro. Coexpressed Bcl-2 abrogated these effects of Bag-1. Intracranial LN-229 glioma xenografts implanted into nude mice revealed a substantial growth advantage afforded by Bcl-2. Bag-1 had no such effect, either in the absence or presence of Bcl-2. Upon serum starvation in vitro, Bcl-2 prevented cell death whereas Bag-1 did not. Both Bcl-2 and Bag-1 slowed proliferation of serum-starved cells when expressed alone. Importantly, coexpression of Bcl-2 and Bag-1 provided a distinct growth advantage under conditions of serum starvation that is probably the result of (i) the death-preventing activity of Bcl-2 and (ii) the property of Bag-1 to overcome a Bcl-2-mediated enhancement of exit from the cell cycle. In contrast to these Bcl-2/Bag-1 interactions observed under serum starvation conditions, Bag-1 did not further enhance the strong protection from staurosporine-, CD95 (Fas/Apo1) ligand-, Apo2 ligand (TRAIL)- or chemotherapeutic drug-induced apoptosis afforded by Bcl-2. Taken together, these results indicate a role for Bag-1/Bcl-2 interactions in providing a survival advantage to cancer cells in a deprived microenvironment that may be characteristic of ischemic/hypoxic tumors such as human glioblastoma multiforme, and suggest that Bcl-2/Bag-1 interactions also modulate cell proliferation.

Expression and functional activity of heat shock proteins in human glioblastoma multiforme.

OBJECTIVE: To assess the expression of heat shock proteins (HSP) in glioma cells in vitro and in vivo and to examine their role in resistance to apoptosis. BACKGROUND: HSP are expressed in response to various forms of stress. Constitutive HSP expression may confer resistance to cytotoxic stimuli in human cancers. METHODS: HSP expression was assessed by immunoblot analysis in glioma cells in vitro and by immunocytochemistry in human glioblastomas in vivo. Modulation of apoptosis by hyperthermia-mediated HSP induction was examined in glioma cell lines in vitro. RESULTS: Immunoblot analysis revealed constitutive expression of HSP27, HSP72, HSP73, and HSP90 in all 12 human glioma cell lines. B-crystallin (alphaBC) was expressed in 3 of 12 cell lines. High levels of alphaBC and HSP72 correlated with drug resistance and high p53 levels in vitro. Transient hyperthermia (43 degrees C/2 hours) induced HSP27 and HSP72 expression but had no effect on the levels of alphaBC, HSP73, or HSP90. HSP induction provided no survival advantage against subsequent cytotoxic challenges, including cytotoxic cytokines and radiochemotherapy. Immunohistochemistry showed strong expression of all HSP in vivo. The comparative analysis of HSP27, alphaBC, HSP72, HSP73, and HSP90 expression in 24 paired samples of first resections and recurrences of human glioblastoma multiforme revealed no impact of HSP expression on response to adjuvant radiochemotherapy and no modulation of HSP expression by radiochemotherapy. CONCLUSIONS: High constitutive, as opposed to inducible, expression of HSP may play a role in the primary resistance of human malignant gliomas to cytotoxic radiochemotherapy. Superinduction of HSP levels by hyperthermia in vitro provided no further survival advantage.

Large cell anaplastic (KI-1) brain lymphoma of T-cell genotype.

Three cerebral lesions were neuroradiologically detected in a 63-year-old man without evidence of an extracranial neoplasm. The biopsy specimen from one lesion showed a large cell anaplastic lymphoma (LCAL). Immunohistochemically, tumor cells were positive for CD3, CD30, CD45RO, and HLA-DR. The polymerase chain reaction (PCR) of the rearranged T-cell receptor beta chain genome (TcR beta) derived from paraffin sections showed monoclonality. This case shows that primary cerebral T-cell lymphomas genotypically correspond to nodal T-cell lymphomas, a correspondence that has previously been demonstrated for the more common brain lymphomas of B-cell lineage.

Glutathione S-transferase and drug sensitivity in malignant glioma.

Malignant gliomas are largely resistant to current approaches of adjuvant chemotherapy. Gluthatione S-transferases (GST) have been attributed a role in the resistance of cancer cells, e.g., to nitrosoureas. Here, we assessed the expression levels of GST-pi and GST-mu RNA and protein as well as total GST activity in a panel of 12 human glioma cell lines and correlated these data with p53 status, BCL-2 family protein expression and drug sensitivity in these cells. Neither GST protein levels nor GST activity correlated with genetic or functional p53 status or with the expression of various BCL-2 family proteins. No evidence for GST-mediated protection from chemotherapeutic drugs became apparent. In contrast, high levels of GST-pi protein, probably the major source of GST activity in glioma cells, and of total GST activity correlated with enhanced sensitivity to vincristine-induced clonogenic cell death. Expression of GST-pi in human glioblastomas in vivo was confirmed by immunohistochemistry. Neither total, nor cytoplasmic or nuclear, GST-pi immunoreactivity correlated with the response to adjuvant radiotherapy or radiochemotherapy. A comparative analysis of primary and recurrent tumors showed that GST expression was not enhanced by radiochemotherapy in vivo. We conclude that GST does not account for the differential chemosensitivity of glioma cell lines in vitro and does not accumulate in glioma subpopulations that form recurrent tumors after radiochemotherapy in vivo.

Heat shock protein expression in human gliomas.

BACKGROUND: Heat shock proteins (HSP) are cytoprotective, antiapoptotic proteins which may predict clinical prognosis in various types of cancer. Here, we asked whether the differential response to radiochemotherapy and different overall prognosis for astrocytic and oligodendroglial tumours can be accounted for by differences in HSP expression. MATERIAL AND METHODS: We examined aB-crystallin, HSP27, HSP70, HSC70 (HSP73) and HSP90 expression in 44 human gliomas (5 anaplastic and 5 low-grade astrocytomas, 5 anaplastic and 5 low-grade oligodendrogliomas and 24 glioblastomas) by immunohistochemistry. RESULTS: HSP were expressed in the tumour parenchyma of all high-grade and most low-grade gliomas, including oligodendrogliomas. Endothelial cells were more often positive for HSC70 and HSP90, but more often negative for HSP27, in glioblastomas than in the other tumours. HSP were also observed in macrophages/microglial cells, but not in a tumour-specific pattern. CONCLUSION: Different patterns of HSP expression seem not to account for the differential response of these tumours to adjuvant cytotoxic therapy.

The impact of progesterone receptor expression on relapse in the long-term clinical course of 93 benign meningiomas.

BACKGROUND: Previous clinicopathological observations have pointed towards an impact of progesterone receptor (PgR) expression on the clinical course of meningiomas. MATERIALS AND METHODS: EXpression of PgR and the proliferation marker MIB-1 was assessed by immunohistochemistry in the primary tumours of 30 cases of benign, completely resected, recurrent meningiomas and compared with 63 cases of meningioma without recurrence for 14 or more years. RESULTS: Univariate analysis showed a significantly higher risk for recurrence (odds ratio 3.533) for tumours with a low expression of PgR. A tendency for a higher risk for tumours with higher proliferation rate (odds ratio 6.889) was not significant. In 20 cases in which the primary tumour could be compared with its recurrence, no consistent changes of PgR expression were observed. CONCLUSION: Our findings support previous studies that found an association of low or absent expression of PgR with a higher risk of recurrence. This encourages attempts at a hormonal therapy for patients with PgR-positive meningioma.

Obtaining phonetic transcriptions: a comparison between expert listeners and a continuous speech recognizer.

In this article, we address the issue of using a continuous speech recognition tool to obtain phonetic or phonological representations of speech. Two experiments were carried out in which the performance of a continuous speech recognizer (CSR) was compared to the performance of expert listeners in a task of judging whether a number of prespecified phones had been realized in an utterance. In the first experiment, nine expert listeners and the CSR carried out exactly the same task: deciding whether a segment was present or not in 467 cases. In the second experiment, we expanded on the first experiment by focusing on two phonological processes: schwa-deletion and schwa-insertion. The results of these experiments show that significant differences in performance were found between the CSR and the listeners, but also between individual listeners. Although some of these differences appeared to be statistically significant, their magnitude is such that they may very well be acceptable depending on what the transcriptions are needed for. In other words, although the CSR is not infallible, it makes it possible to explore large datasets, which might outweigh the errors introduced by the mistakes the CSR makes. For these reasons, we can conclude that the CSR can be used instead of a listener to carry out this type of task: deciding whether a phone is present or not.

Minocycline as potent anticonvulsant in a patient with astrocytoma and drug resistant epilepsy.

Minocycline, a tetracycline family antibiotic, is known to inhibit microglial activation and proinflammatory cytokine release in animal models. Experimental data show that these immune processes may play a role in epilepto- and ictogenesis. We present the case of a patient with marked reduction in seizure frequency during minocycline therapy with severe symptomatic epilepsy due to an astrocytoma.

High expression levels of erythropoietin and its receptor are not correlated with shorter survival in human glioblastoma.

Erythropoietin (EPO) is used to treat anemia in neoplastic disease. EPO also exerts neuroprotective effects on neuronal cells, making a prophylactic use against the neurocognitive effects of radiochemotherapy probable. However, EPO/EPO-receptor (EPOR) signalling has been also detected in glioblastoma cells. Data collected in vitro and in vivo show conflicting results on the effect of EPO on malignant gliomas. The association between EPO and EPOR expression and the prognosis of human glioblastomas was analyzed. Probes of human glioblastomas with complete documentation of clinical course and treatment were assessed by immunohistochemistry for the expression of EPO and EPOR (n=80). Using univariate and multivariate survival analysis, the association with age, gender, radiation, chemotherapy and extent of resection was determined. High levels of EPOR were correlated with a median survival advantage of 7 months (p<0.01). By univariate, but not multivariate, analysis, high levels of EPO and EPOR were associated with a significant prolongation of 7 months median survival when compared to low levels of both molecules. In patients treated with radiochemotherapy adjuvant to surgery, the median survival was 6.5 months longer in patients with high levels of EPOR (p<0.04). According to previous studies, longer patient survival is associated with EPOR expression. Therefore, EPO appears to be safe for the treatment of anemia in glioblastoma patients. However, a prophylactic use, i.e., for neuroprotection, is not recommended in light of the functional studies described in the literature.

Neoplastic meningitis from breast cancer: feasibility and activity of long-term intrathecal liposomal Ara-C combined with dose-dense temozolomide.

BACKGROUND: Patients with neoplastic meningitis (NM) from breast cancer have a median survival of 4-8 months with specific treatment. Here, good tolerance and long-term stabilization with combined intrathecal liposomal cytarabine (Ara-C), which is probably the most promising drug for intrathecal chemotherapy to date, near-continuous temozolomide and radiotherapy is reported in two patients with leptomeningeal and solid central nervous system (CNS) metastases from breast cancer. CASE REPORTS: A 42- and a 43-year-old female presented with NM and disseminated CNS metastases from human epidermal growth factor receptor type 2 (Her2)-positive breast cancer. After irradiation of the symptomatic sites, intrathecal liposomal Ara-C every 2-4 weeks was combined with temozolomide 100 mg/m(2) day 1-5/7. Cerebrospinal fluid (CSF) cytology and neurological symptoms improved in both patients and stabilized for several months. The patients survived 10 and 17 months after diagnosis of NM, without signs of neurological toxicity. CONCLUSION: Intensive treatment is complicated by extensive pre-treatment and the lack of active CNS-penetrating systemic drugs. The long-term results with up to 17 intrathecal injections of liposomal Ara-C show that this treatment regimen is feasible and well-tolerated. The stabilization of both patients indicates activity of this combined intrathecal and systemic regimen that is based on long-term exposure of the tumour cells to both Ara-C and temozolomide. The results need to be confirmed prospectively.