Utility of Cerebrospinal Fluid Cell-Free DNA in Patients with EGFR-Mutant Non-Small-Cell Lung Cancer with Leptomeningeal Metastasis



Leptomeningeal metastasis (LM) is a fatal complication of advanced non-small-cell lung cancer (NSCLC).


The aim of this study was to evaluate the utility of cerebrospinal fluid (CSF) as a medium for epidermal growth factor receptor (EGFR) mutation testing in clinical practice.

Patients and methods

We prospectively enrolled patients with EGFR-mutant NSCLC who underwent CSF sampling for suspected LM. The supernatant of CSF after routine cytology examination was collected. The diagnosis of LM was established according to EANO-ESMO criteria. CSF and plasma cell-free DNA (cfDNA) were retrieved for EGFR mutation testing.


Fifty-one patients with a median age of 62.7 years were enrolled. The median duration from initial diagnosis to CSF sampling was 23.0 months and most patients (94.1%) had received at least one EGFR-tyrosine kinase inhibitor. Adenocarcinoma cells were found in 37 CSF samples (72.5%), and 48 (94.1%) patients had confirmed or probable LM. Thirty-five of these 48 patients (72.9%) had valid EGFR mutation-testing results using CSF cfDNA and tended to have higher white blood cell counts and positive cytology in their CSF compared to those with invalid mutation testing results. The overall detection rate of EGFR mutation in CSF cfDNA was 68.8%, and the T790M detection rate was 14.6%. In 37 patients with paired CSF and plasma samples, the concordance rate of the EGFR mutation results was 29.7%.


For patients with EGFR-mutant NSCLC with LM, CSF supernatant is a valuable source for EGFR mutation testing and may provide important information.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2


  1. 1.

    Remon J, Le Rhun E, Besse B. Leptomeningeal carcinomatosis in non-small cell lung cancer patients: a continuing challenge in the personalized treatment era. Cancer Treat Rev. 2017;53:128–37. https://doi.org/10.1016/j.ctrv.2016.12.006.

    CAS  Article  PubMed  Google Scholar 

  2. 2.

    Li YS, Jiang BY, Yang JJ, Tu HY, Zhou Q, Guo WB, et al. Leptomeningeal metastases in patients with NSCLC with EGFR mutations. J Thorac Oncol. 2016;11(11):1962–9. https://doi.org/10.1016/j.jtho.2016.06.029.

    Article  PubMed  Google Scholar 

  3. 3.

    Liao BC, Lee JH, Lin CC, Chen YF, Chang CH, Ho CC, et al. Epidermal growth factor receptor tyrosine kinase inhibitors for non-small-cell lung cancer patients with leptomeningeal carcinomatosis. J Thorac Oncol. 2015;10(12):1754–61. https://doi.org/10.1097/JTO.0000000000000669.

    CAS  Article  PubMed  Google Scholar 

  4. 4.

    Cheng H, Perez-Soler R. Leptomeningeal metastases in non-small-cell lung cancer. Lancet Oncol. 2018;19(1):e43–55. https://doi.org/10.1016/s1470-2045(17)30689-7.

    Article  PubMed  Google Scholar 

  5. 5.

    Chamberlain MC. Leptomeningeal metastasis. Curr Opin Oncol. 2010;22(6):627–35. https://doi.org/10.1097/CCO.0b013e32833de986.

    Article  PubMed  Google Scholar 

  6. 6.

    Mandel P, Metais P. Nuclear acids in human blood plasma. C R Seances Soc Biol Fil. 1948;142(3–4):241–3.

    CAS  PubMed  Google Scholar 

  7. 7.

    Sidransky D. Nucleic acid-based methods for the detection of cancer. Science. 1997;278(5340):1054–9.

    CAS  Article  Google Scholar 

  8. 8.

    Bettegowda C, Sausen M, Leary RJ, Kinde I, Wang Y, Agrawal N, et al. Detection of circulating tumor DNA in early- and late-stage human malignancies. Sci Transl Med. 2014;6(224):224ra24. https://doi.org/10.1126/scitranslmed.3007094.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  9. 9.

    Mok T, Wu YL, Lee JS, Yu CJ, Sriuranpong V, Sandoval-Tan J, et al. Detection and dynamic changes of EGFR mutations from circulating tumor DNA as a predictor of survival outcomes in NSCLC patients treated with first-line intercalated erlotinib and chemotherapy. Clin Cancer Res. 2015;21(14):3196–203. https://doi.org/10.1158/1078-0432.ccr-14-2594.

    CAS  Article  PubMed  Google Scholar 

  10. 10.

    Yung TK, Chan KC, Mok TS, Tong J, To KF, Lo YM. Single-molecule detection of epidermal growth factor receptor mutations in plasma by microfluidics digital PCR in non-small cell lung cancer patients. Clin Cancer Res. 2009;15(6):2076–84. https://doi.org/10.1158/1078-0432.ccr-08-2622.

    CAS  Article  PubMed  Google Scholar 

  11. 11.

    De Mattos-Arruda L, Mayor R, Ng CK, Weigelt B, Martinez-Ricarte F, Torrejon D, et al. Cerebrospinal fluid-derived circulating tumour DNA better represents the genomic alterations of brain tumours than plasma. Nat Commun. 2015;6:8839. https://doi.org/10.1038/ncomms9839.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  12. 12.

    Pentsova EI, Shah RH, Tang J, Boire A, You D, Briggs S, et al. Evaluating cancer of the central nervous system through next-generation sequencing of cerebrospinal fluid. J Clin Oncol. 2016;34(20):2404–15. https://doi.org/10.1200/jco.2016.66.6487.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  13. 13.

    Le Rhun E, Weller M, Brandsma D, Van den Bent M, de Azambuja E, Henriksson R, et al. EANO-ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up of patients with leptomeningeal metastasis from solid tumours. Ann Oncol. 2017;28(suppl_4):vi84–99. https://doi.org/10.1093/annonc/mdx221.

    Article  Google Scholar 

  14. 14.

    Nayar G, Ejikeme T, Chongsathidkiet P, Elsamadicy AA, Blackwell KL, Clarke JM, et al. Leptomeningeal disease: current diagnostic and therapeutic strategies. Oncotarget. 2017;8(42):73312–28. https://doi.org/10.18632/oncotarget.20272.

    Article  PubMed  PubMed Central  Google Scholar 

  15. 15.

    Li YS, Jiang BY, Yang JJ, Zhang XC, Zhang Z, Ye JY, et al. Unique genetic profiles from cerebrospinal fluid cell-free DNA in leptomeningeal metastases of EGFR-mutant non-small-cell lung cancer: a new medium of liquid biopsy. Ann Oncol. 2018;29(4):945–52. https://doi.org/10.1093/annonc/mdy009.

    CAS  Article  PubMed  Google Scholar 

  16. 16.

    Huang R, Xu X, Li D, Chen K, Zhan Q, Ge M, et al. Digital PCR-based detection of EGFR mutations in paired plasma and CSF samples of lung adenocarcinoma patients with central nervous system metastases. Target Oncol. 2019;14(3):343–50. https://doi.org/10.1007/s11523-019-00645-5.

    Article  PubMed  Google Scholar 

  17. 17.

    Suryavanshi M, Jaipuria J, Panigrahi MK, Goyal N, Singal R, Mehta A, et al. CSF cell-free DNA EGFR testing using DdPCR holds promise over conventional modalities for diagnosing leptomeningeal involvement in patients with non-small cell lung cancer. Lung Cancer. 2020;148:33–9. https://doi.org/10.1016/j.lungcan.2020.07.034.

    Article  PubMed  Google Scholar 

  18. 18.

    Kawahara A, Abe H, Murata K, Ishii H, Azuma K, Takase Y, et al. Screening system for epidermal growth factor receptor mutation detection in cytology cell-free DNA of cerebrospinal fluid based on assured sample quality. Cytopathology. 2019;30(2):144–9. https://doi.org/10.1111/cyt.12660.

    Article  PubMed  Google Scholar 

  19. 19.

    Moss J, Magenheim J, Neiman D, Zemmour H, Loyfer N, Korach A, et al. Comprehensive human cell-type methylation atlas reveals origins of circulating cell-free DNA in health and disease. Nat Commun. 2018;9(1):5068. https://doi.org/10.1038/s41467-018-07466-6.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  20. 20.

    Socinski MA, Villaruz LC, Ross J. Understanding mechanisms of resistance in the epithelial growth factor receptor in non-small cell lung cancer and the role of biopsy at progression. Oncologist. 2017;22(1):3–11. https://doi.org/10.1634/theoncologist.2016-0285.

    CAS  Article  PubMed  Google Scholar 

  21. 21.

    Nanjo S, Arai S, Wang W, Takeuchi S, Yamada T, Hata A, et al. MET copy number gain is associated with gefitinib resistance in leptomeningeal carcinomatosis of EGFR-mutant lung cancer. Mol Cancer Ther. 2017;16(3):506–15. https://doi.org/10.1158/1535-7163.MCT-16-0522.

    CAS  Article  PubMed  Google Scholar 

  22. 22.

    Mok TS, Wu YL, Ahn MJ, Garassino MC, Kim HR, Ramalingam SS, et al. Osimertinib or platinum-pemetrexed in EGFR T790M-positive lung cancer. N Engl J Med. 2017;376(7):629–40. https://doi.org/10.1056/NEJMoa1612674.

    CAS  Article  PubMed  Google Scholar 

  23. 23.

    Aldea M, Hendriks L, Mezquita L, Jovelet C, Planchard D, Auclin E, et al. Circulating tumor DNA analysis for patients with oncogene-addicted NSCLC with isolated central nervous system progression. J Thorac Oncol. 2020;15(3):383–91. https://doi.org/10.1016/j.jtho.2019.11.024.

    CAS  Article  PubMed  Google Scholar 

  24. 24.

    Nanjo S, Hata A, Okuda C, Kaji R, Okada H, Tamura D, et al. Standard-dose osimertinib for refractory leptomeningeal metastases in T790M-positive EGFR-mutant non-small cell lung cancer. Br J Cancer. 2018;118(1):32–7. https://doi.org/10.1038/bjc.2017.394.

    CAS  Article  PubMed  Google Scholar 

  25. 25.

    Ahn MJ, Chiu CH, Cheng Y, Han JY, Goldberg SB, Greystoke A, et al. Osimertinib for patients with leptomeningeal metastases associated with EGFR T790M-positive advanced NSCLC: the AURA leptomeningeal metastases analysis. J Thorac Oncol. 2020;15(4):637–48. https://doi.org/10.1016/j.jtho.2019.12.113.

    CAS  Article  PubMed  Google Scholar 

  26. 26.

    Yang JCH, Kim SW, Kim DW, Lee JS, Cho BC, Ahn JS, et al. Osimertinib in patients with epidermal growth factor receptor mutation-positive non-small-cell lung cancer and leptomeningeal metastases: the BLOOM study. J Clin Oncol. 2020;38(6):538–47. https://doi.org/10.1200/jco.19.00457.

    CAS  Article  PubMed  Google Scholar 

  27. 27.

    Goldman JW, Noor ZS, Remon J, Besse B, Rosenfeld N. Are liquid biopsies a surrogate for tissue EGFR testing? Ann Oncol. 2018;29(suppl_1):i38–46. https://doi.org/10.1093/annonc/mdx706.

    CAS  Article  PubMed  Google Scholar 

Download references

Author information



Corresponding author

Correspondence to Chao-Hua Chiu.

Ethics declarations


This work was supported by the Ministry of Science and Technology, Taiwan (Grant number MOST106-2314-B-075-031-MY), Ministry of Health and Welfare, Taiwan (Grant number MOHW109-TDU-B-211-134019), and Taipei Veterans General Hospital (Grant number V110B-008).

Conflict of interest

CLC has received honoraria from AstraZeneca, Boehringer Ingelheim, and Roche. YHL has received honoraria from AstraZeneca, Boehringer Ingelheim, and Pfizer. THS has received honoraria from Boehringer Ingelheim and Novartis. YMC has received honoraria from Boehringer Ingelheim, Eli Lilly, Roche/Genentech/Chugai, MSD, Pfizer, Novartis, BMS, Ono Pharmaceutical, AstraZeneca, and Takeda Oncology; and served as advisor for Boehringer Ingelheim, Eli Lilly, Roche/Chugai, MSD, AstraZeneca, and Takeda Oncology. CHC has received honoraria from AstraZeneca, Boehringer Ingelheim, Pfizer, and Roche. The other authors declare no conflicts of interest that might be relevant to the contents of this article.

Ethics approval

The Institutional Review Board of Taipei Veterans General Hospital approved this study.

Consent to participate

Not applicable.

Consent for publication

Not applicable.

Data availability

Not applicable.

Code availability

Not applicable.

Author contributions

Conceptualization: CLC, CHC, YMC, TYC. Data collection, experiment, and analysis: CCL, CHW, HCH, YCY, CIS, YHL, THS. Statistics: CLC, HJC, YTH. First draft preparation: CLC, CHC. Review and final approval: all authors.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (PDF 776 KB)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Chiang, CL., Lee, CC., Huang, HC. et al. Utility of Cerebrospinal Fluid Cell-Free DNA in Patients with EGFR-Mutant Non-Small-Cell Lung Cancer with Leptomeningeal Metastasis. Targ Oncol 16, 207–214 (2021). https://doi.org/10.1007/s11523-021-00791-9

Download citation