Clinical Trial of Proton Craniospinal Irradiation for Leptomeningeal Metastases.

BACKGROUND Leptomeningeal metastases (LM) are associated with limited survival and treatment options. While involved-field radiotherapy is effective for local palliation, it lacks durability. We evaluated the toxicities of proton craniospinal irradiation (CSI), a treatment encompassing the entire central nervous system (CNS) compartment, for patients with LM from solid tumors. METHODS We enrolled patients with LM to receive hypofractionated proton CSI in this phase I prospective trial. The primary end point was to describe treatment-related toxicity, with dose-limiting toxicity (DLT) defined as any radiation-related grade ≥ 3 non-hematologic toxicity or grade ≥ 4 hematologic toxicity according to CTCAE that occurred during or within 4 weeks of completion of proton CSI. Secondary end points included CNS progression-free survival (PFS) and overall survival (OS). RESULTS We enrolled 24 patients between June 2018 and April 2019. Their median follow-up was 11 months. Twenty patients were evaluable for protocol treatment-related toxicities and 21 for CNS PFS and OS. Two patients in the dose expansion cohort experienced DLTs consisted of Grade 4 lymphopenia, Grade 4 thrombocytopenia, and/or Grade 3 fatigue. All DLTs resolved without medical intervention. The median CNS PFS was 7 months (95% CI 5-13) and the median OS was 8 months (95% CI 6 to not reached). Four patients (19%) were progression free in the CNS for more than 12 months. CONCLUSIONS Hypofractionated proton CSI using proton therapy is a safe treatment for patients with LM from solid tumors. We saw durable disease control in some patients.