The role of the neurologist in the diagnosis and treatment of brain metastases and carcinomatous meningitis.

Traditionally, in the past, most of central nervous system metastases from solid tumors were associated with an advanced phase of the disease needing palliation only, while to date they increasingly develop as an early and/or solitary relapse in patients with the systemic disease under control. This review will cover all the aspects of a modern management of brain and leptomeningeal metastases from diagnosis to the different therapeutic options, either local (surgery, stereotactic radiosurgery, whole-brain radiotherapy with hippocampal avoidance) or systemic. Particular emphasis is reserved to the new-targeted drugs, that allow to target specifically driver molecular alterations. These new compounds pose new problems in terms of monitoring efficacy and adverse events, but increasingly they allow improvement of outcome in comparison to historical controls.

Cerebrospinal fluid diversion and outcomes for lung cancer patients with leptomeningeal carcinomatosis.

OBJECTIVE: To investigate the outcomes of cerebrospinal fluid (CSF) diversion in lung cancer patients with leptomeningeal carcinomatosis (LMC). METHODS: A retrospective review of consecutive lung cancer patients with LMC suffering from increased intracranial pressure (IICP) and hydrocephalus between February 2017 and February 2020. We evaluated the survival benefit of CSF diversion surgery and assessed the outcomes of treatments administered post-LMC in terms of overall survival and shunt-related complications. RESULTS: The study cohort included 50 patients (median age: 59 years). Ventricular peritoneal (VP) shunts were placed in 33 patients, and lumbar peritoneal (LP) shunts were placed in 7 patients. Programmable shunts were placed in 36 patients. Shunt adjustment was performed in 19 patients. Kaplan-Meier analysis revealed that shunt placement increased overall survival from 1.95 months to 6.21 months (p = 0.0012) and increased Karnofsky Performance Scores (KPS) from 60 to 70. Univariate analysis revealed no difference between VP or LP shunts in terms of survival. No differences in post-shunt systemic treatments (tyrosine kinase inhibitors (TKIs) or systemic treatments) were observed in overall survival. Shunt-related complications were noted in 7 patients, including shunt obstruction (n = 4), infection (n = 1), and over-drainage (n = 2). CONCLUSION: CSF diversion (VP or LP shunt) appears to be an effective and safe treatment for lung cancer patients with LMC and hydrocephalus. Programmable shunts should be considered for complex cases, which commonly require pressure adjustments as the disease progresses.

Meningeal carcinomatosis following a curative endoscopic submucosal dissection of early gastric cancer: a case report.

Meningeal carcinomatosis (MC) is reported to occur in 4%-15% of patients with solid tumors. MC is not commonly associated with gastric carcinoma and is extremely rare in patients with early gastric cancer (EGC). MC derived from EGC after curative endoscopic submucosal dissection (ESD) has not been reported before. We present a rare case of a 49-year-old patient who developed MC after curative ESD of EGC. The cancer was an ulcerated lesion approximately 1.0 cm in diameter in endoscopic appearance in the minor curvature of the gastric antrum. The pathological examination after ESD indicated high-grade intraepithelial neoplasia (1.3 × 2.1 cm in size) with localized moderately differentiated adenocarcinoma (0-IIc in tumor stage, intestinal type in Lauren classification), which was confined to the mucosal layer with an intact submucosal layer and muscularis propria. The lesion was removed entirely by curative dissection without vertical and horizontal resection margins involvement in pathology. Two months after ESD, the patient was readmitted for severe headache and vomiting. Cytological examination of the cerebrospinal fluid found malignant tumor cells, which were considered by pathologists to have metastasized from the stomach, further confirming MC derived from EGC. The patient's condition deteriorated dramatically, which prevented him from receiving further therapies, such as chemotherapy, and he died 3 days after the diagnosis of MC. In conclusion, EGC can cause MC, even after curative ESD. New neurological manifestations in patients with EGC can alert physicians to a diagnosis of MC, and more attention needs to be paid to evaluating the nervous system and establishing diagnostic and therapeutic strategies as soon as possible.

Successful salvage of recurrent leptomeningeal disease in large cell neuroendocrine lung cancer with stereotactic radiotherapy.

A 70-year old male with stage I large cell neuroendocrine carcinoma (LCNEC) of the lung underwent resection of a metachronous 5 cm brain metastasis and received postoperative hypofractionated stereotactic radiotherapy (hfSRT). Five sequential nodular leptomeningeal metastases up to 5.3 cm in diameter were diagnosed on MRI within 10 months and were treated with SRT. Currently the patient has no evidence of intracranial disease 24 months after last irradiation without chemotherapy or whole brain radiotherapy. This is the first report of sustained complete remission of multiple large leptomeningeal metastases achieved with hfSRT, highlighting this brain-sparing approach in selected patients with LCNEC lung cancer.

Effectiveness of Palliative Cerebrospinal Fluid Shunting for Patients With Leptomeningeal Carcinomatosis-related Hydrocephalus.

BACKGROUND/AIM: Leptomeningeal carcinomatosis (LMC) with hydrocephalus is particularly difficult to treat, and its prognosis is extremely poor. The therapeutic outcomes of 14 patients with LMC-associated hydrocephalus who were treated with cerebrospinal fluid shunting are reported. PATIENTS AND METHODS: The study subjects were 14 LMC patients with solid primary cancer who had developed hydrocephalus. RESULTS: Postoperatively, both symptoms and Karnofsky performance status improved in 100% of patients. Postoperative therapy consisted of whole-brain radiotherapy in 4 cases and molecular targeted therapy in 4, with 6 patients not receiving any postoperative treatment. Median overall survival was 3.7 months, with no significant difference between those who underwent postoperative therapy and those who did not. However, two of those who received molecular targeted therapy survived for more than one year. CONCLUSION: Cerebrospinal fluid shunting for LMC-associated hydrocephalus is an effective therapeutic procedure from the palliative viewpoint. Patients for whom molecular targeted therapy is indicated may have better long-term survival.

Nodular Leptomeningeal Disease-A Distinct Pattern of Recurrence After Postresection Stereotactic Radiosurgery for Brain Metastases: A Multi-institutional Study of Interobserver Reliability.

PURPOSE: For brain metastases, surgical resection with postoperative stereotactic radiosurgery is an emerging standard of care. Postoperative cavity stereotactic radiosurgery is associated with a specific, underrecognized pattern of intracranial recurrence, herein termed nodular leptomeningeal disease (nLMD), which is distinct from classical leptomeningeal disease. We hypothesized that there is poor consensus regarding the definition of LMD, and that a formal, self-guided training module will improve interrater reliability (IRR) and validity in diagnosing LMD. METHODS AND MATERIALS: Twenty-two physicians at 16 institutions, including 15 physicians with central nervous system expertise, completed a 2-phase survey that included magnetic resonance imaging and treatment information for 30 patients. In the "pretraining" phase, physicians labeled cases using 3 patterns of recurrence commonly reported in prospective studies: local recurrence (LR), distant parenchymal recurrence (DR), and LMD. After a self-directed training module, participating physicians completed the "posttraining" phase and relabeled the 30 cases using the 4 following labels: LR, DR, classical leptomeningeal disease, and nLMD. RESULTS: IRR increased 34% after training (Fleiss' Kappa K = 0.41 to K = 0.55, P < .001). IRR increased most among non-central nervous system specialists (+58%, P < .001). Before training, IRR was lowest for LMD (K = 0.33). After training, IRR increased across all recurrence subgroups and increased most for LMD (+67%). After training, ≥27% of cases initially labeled LR or DR were later recognized as nLMD. CONCLUSIONS: This study highlights the large degree of inconsistency among clinicians in recognizing nLMD. Our findings demonstrate that a brief self-guided training module distinguishing nLMD can significantly improve IRR across all patterns of recurrence, and particularly in nLMD. To optimize outcomes reporting, prospective trials in brain metastases should incorporate central imaging review and investigator training.

Metastatic meningeal carcinomatosis from lung cancer: Report of a rare case.

Meningeal carcinomatosis (MC) refers to the diffuse or multifocal spread or infiltration of malignant tumors in the pia mater. It is a special distribution type of metastatic tumors in the central nervous system and one of the important reasons of death caused by metastatic malignant tumors. Here, we report a rare case of metastatic meningeal carcinomatosis from the lung cancer.

MRI based neuroanatomical segmentation in breast cancer patients: leptomeningeal carcinomatosis vs. oligometastatic brain disease vs. multimetastastic brain disease.

PURPOSE: Pathogenesis of brain metastases/meningeal cancer and the emotional and neurological outcomes are not yet well understood. The hypothesis of our study is that patients with leptomeningeal cancer show volumetric differences in brain substructures compared to patients with cerebral metastases. METHODS: Three groups consisting of female breast cancer patients prior to brain radiotherapy were compared. Leptomeningeal cancer patients (LMC Group), oligometastatic patients (1-3 brain metastases) prior to radiosurgery (OMRS Group) and patients prior to whole brain radiation (WB Group) were included. All patients had MRI imaging before treatment. T1 MRI sequences were segmented using automatic segmentation. For each patient, 14 bilateral and 11 central/median subcortical structures were tested. Overall 1127 structures were analyzed and compared between groups using age matched two-sided t-tests. RESULTS: The average age of patients in the OMRS group was 60.8 years (± 14.7), 65.3 (± 10.3) in the LMC group and 62.6 (± 10.2) in the WB group. LMC patients showed a significantly larger fourth ventricle compared to OMRS (p = 0.001) and WB (p = 0.003). The central corpus callosum appeared smaller in the LMC group (LMC vs OMRS p = 0.01; LMC vs WB p = 0.026). The right amygdala in the WB group appeared larger compared with the OMRS (p = 0.035). CONCLUSIONS: Differences in the size of brain substructures of the three groups were found. The results appear promising and should be taken into account for further prospective studies also involving healthy controls. The volumetrically determined size of the fourth ventricle might be a helpful diagnostic marker in the future.

Unexpected diagnosis of spinal leptomeningeal metastatic disease on MRI myelography.

We present a case of leptomeningeal metastatic disease to the cauda equina detected on Magnetic Resonance myelography. The heavy T2-weighting and small field-of-view of this MRI technique are designed to detect CSF leaks, but also provide exquisite detail of the cauda equina and any associated nodularity. Magnetic Resonance myelography thus shows promise as an adjunct to the MRI evaluation of patients with suspected leptomeningeal metastatic disease and other tumours affecting the cauda equina.

Leptomeningeal Carcinomatosis After Neoplastic Cerebral Aneurysm Rupture.

BACKGROUND: Several possible mechanisms exist for the spread of a primary tumor to the leptomeninges in leptomeningeal carcinomatosis. This report describes a case caused by direct bleeding in the subarachnoid space from a neoplastic cerebral aneurysm rupture. CASE DESCRIPTION: A 48-year-old Japanese woman, who was diagnosed with breast carcinoma (pT3 pN2 M0) at the age of 45 years and underwent mastectomy and chemotherapy, was admitted in a coma following a sudden-onset severe headache. Computed tomography revealed diffuse hemorrhage in the subarachnoid space, and angiography revealed an aneurysm at the distal middle cerebral artery. Superficial temporal artery-middle cerebral artery bypass, aneurysmal trapping, and aneurysm resection were performed within 24 hours of admission. Staining for AE1/AE3 revealed accumulation of atypical cells with a high nuclear-cytoplasmic ratio in the aneurysmal wall. After showing initial improvement, she developed disturbed consciousness due to complicated ventricular enlargement on day 45. Although the cerebrospinal fluid in the acute phase had no atypical cells, subsequent testing revealed atypical cells, which supported a diagnosis of leptomeningeal carcinomatosis due to breast cancer dissemination. The patient died on day 78 after receiving standard endocrine therapy and radiation therapy. CONCLUSIONS: Tumor cells reach the leptomeninges via hematogenous spread or direct extension from preexisting lesions and can undergo neuraxis dissemination via the cerebrospinal fluid. Subarachnoid hemorrhage and leptomeningeal carcinomatosis are both devastating conditions with extremely poor prognoses. This patient experienced delayed disturbed consciousness leptomeningeal carcinomatosis with decreased performance status, which made it difficult to justify aggressive treatment on the basis of her poor prognosis.

Treatment outcomes of radiotherapy for primary spinal cord glioma.

PURPOSE: Spinal cord gliomas are rare, and there is no consensus on the optimal radiotherapy (RT) regimen. Herein, we investigated therapeutic outcomes in spinal cord gliomas to obtain clues for the optimal RT regimen. METHODS: We assessed 45 patients who received RT for primary spinal cord non-ependymoma gliomas between 2005 and 2017: 37 (82%) received postoperative RT, 6 (13%) underwent definitive RT without surgery, and 2 (5%) received salvage RT for recurrent tumors. Craniospinal irradiation (CSI; median, 40 Gy) was administered in 4 patients with seeding at diagnosis; all other patients received local RT only (median, 50.4 Gy). RESULTS: In all 23 failures occurred (20 in patients without initial seeding +3 in patients with initial seeding and CSI; median follow-up, 33 months). The 2­year overall survival and progression-free survival rates were 74 and 54%, respectively. Overall, 13 (32%) new seeding events outside the local RT field developed either first or subsequently. Tumor grade was significantly associated with survival endpoints (p = 0.009, 0.028) and overall seeding rates (p = 0.042). In grade II tumors, seeding developed in 23%, with a dismal prognosis (median, 10 months after RT). In grade III tumors, seeding developed in 45% with diverse prognosis. In grade IV tumors, seeding developed in 45%. The survival of patients with newly developed seeding was significantly worse than the others (2-year 50%, p < 0.001). CONCLUSION: To encompass a considerable rate of progressive disease seeding, aggressive treatment such as pre-emptive application of CSI needs to be considered for high-grade spinal cord gliomas with adverse features. Prophylactic CSI could be an option for survival prolongation and requires prospective validation.

Meningeal carcinomatosis: three case-reports.

BACKGROUND: Meningeal carcinomatosis (MC) is characterized by diffuse infiltration of tumor cells in meninges. There is no tumor mass in the brain and parenchyma of the spinal cord. MC is divided into primary and metastatic types. MC cases were previously diagnosed postoperatively or at autopsy. Recent advances in spinal abbreviation cytology and imaging have led to increase in number of reported cases. In this study, we discuss the manifestations of MC patients based on magnetic resonance imaging (MRI) findings, as well as the correlation between the manifestations and pathology. CASE PRESENTATION: MC was confirmed in all three cases by lumbar puncture and gadopentetate dimeglumine-enhanced magnetic resonance imaging. Due to different primary diseases, the patients had specific imaging manifestations. CONCLUSION: Enhanced MRI examination is extremely sensitive for detecting abnormalities in meninges, which plays a very important role in the diagnosis of MC. Since meninges of some MC patients cannot be enhanced, the enhanced MRI examination cannot be replaced by conventional cerebrospinal abbreviation examination. Attribute to the diversity of MR contrast agents, which could provide higher lesion conspicuity and enhances lesion detection, there may be some more choices to improve the detection rate of MC patients and prolong their survival lifetime.

Palliative shunt surgery for patients with leptomeningeal metastasis.

OBJECTIVES: Leptomeningeal metastasis (LM) is associated with poor prognosis and affects the quality of life (QOL) of end-stage cancer patients. Severe headache associated with hydrocephalus causes reduced QOL. We investigated the clinical value of surgical treatment for hydrocephalus in LM patients. PATIENTS AND METHODS: The medical records of 11 consecutive patients who underwent lumboperitoneal shunt (LPS) or ventriculoperitoneal shunt (VPS) at our institution between 2007 and 2016 were investigated. Primary brain tumor patients were excluded. We assessed the neurological status and therapeutic effects at 1 month after the shunt surgery. RESULTS: The patients were three males and eight females with a median age of 58 years (interquartile range [IR] 52-68 years). The median preoperative neutrophil-to-lymphocyte ratio was 6.4 (IR 4.8-9.2). Symptom improvement was observed in nine patients, and severe headache was relieved in seven (88%) out of eight patients. The median Karnofsky performance status scale increased from 40 to 60, and the median overall survival after primary malignancy diagnosis was 27.4 months (IR 19.6-63.1 months). The median survival after the diagnosis of brain parenchymal metastasis, LM, and shunt surgery were 7.2 months (IR 5.1-14.1 months), 3.9 months (IR 3.5-6.3 months), and 3.3 months (IR 2.9-5.7 months), respectively. CONCLUSION: Shunt surgery for hydrocephalus could offer an effective palliative surgical option for symptom relief especially relief of severe headache, contributing improvement of QOL in LM patients.

Leptomeningeal carcinomatosis in a young patient with obstructive colorectal signet-ring cell adenocarcinoma

No disponible

[Experience of shunting surgery in treatment for meningeal carcinomatosis].

OBJECTIVE: To evaluate the value of shunting surgery in the treatment for patients with meningeal carcinomatosis.
 Methods: The therapeutic process of shunting surgery was analyzed in 5 meningeal carcinomatosis patients.
 Results: The intracranial pressure could effectively be controlled, and the associated symptoms could be relieved. No complications associated with shunting surgery were found during the hospitalization and follow-up. One patient, who did not receive the surgery, died in 2 months later.
 Conclusion: Shunting surgery can effectively relieve the intracranial pressure caused by meningeal carcinomatosis, decrease the mortality and morbidity caused by intractable intracranial hypertension in these patients, and improve their live quality.

A Novel Approach Using Electromagnetic Neuronavigation and a Flexible Neuroendoscope for Placement of Ommaya Reservoirs.

OBJECTIVE: Placement of intraventricular catheters in oncology patients can be associated with morbidity given their small to slit-like ventricles and underlying hematologic disorders. We studied the accuracy of placing Ommaya reservoirs using neuronavigation and a flexible neuroendoscope to verify catheter positioning. METHODS: Ommaya reservoirs placed in 25 oncology patients between 2013 and 2015 were retrospectively reviewed. Twenty-five ventricular catheters were placed using the AxiEM stealth frameless neuronavigation system and a flexible neuroendoscope. Postoperative catheter accuracy, operative complications, and postoperative complications were assessed. We discuss surgical protocol and technical nuances. RESULTS: All ventricular catheters were successfully placed into the ipsilateral (84%) or contralateral (16%) foramen of Monro. A single ventricular catheter pass was needed to cannulate the ventricle in 96% of patients. The mean accuracy was 4.09 ± 3.47 mm from the target, the ipsilateral foramen of Monro. One patient had a catheter tract hemorrhage seen on postoperative imaging related to thrombocytopenia. No postoperative neurologic deficits were seen. CONCLUSIONS: A combined neuronavigation and neuroendoscopic approach improved catheter tip accuracy compared with accuracy rates described in the literature using other techniques. This approach can be adapted toward routine clinical practice of placing ventricular shunt catheters and Ommaya reservoirs.

Anaplastic extramedullary cervical ependymoma with leptomeningeal metastasis.

We present a rare extramedullary ependymoma with diffuse spinal metastatic disease, and review the previous reports of extramedullary spinal ependymomas. Ependymomas are the most common intramedullary spinal cord tumor in adults. These tumors rarely present as extramedullary masses. We treated a 23-year-old man with a history of progressive neck, shoulder and arm pain, with sensory and motor symptoms in the C7 dermatome. MRI of the cervical spine demonstrated a ventral contrast-enhancing lesion with evidence of enhancement along the dura and spinal cord of the upper cervical spine, thoracic spine, and cauda equina. He underwent a tumor debulking procedure without complications. Following surgery, he received craniospinal radiation to treat the remaining tumor and diffuse leptomeningeal disease. The final pathology of the tumor revealed that is was a World Health Organization Grade III anaplastic ependymoma. At the 1 year follow-up, the patient had stable imaging and had returned to his preoperative functional status. Of the 19 reported patients with primary intradural, extramedullary spinal ependymomas, two had extradural components and seven had anaplastic grades. Only one tumor with an anaplastic grade resulted in metastatic disease, but without spinal recurrence. To our knowledge, this is the first report of an intradural, extramedullary spinal ependymoma with an anaplastic grade, presenting with concomitant diffuse, nodular leptomeningeal metastasis involving the upper cervical spine, thoracic spine, conus medullaris, and cauda equina. Similar to the treatment of intramedullary ependymomas with metastasis, this patient underwent an aggressive debulking procedure followed by radiation therapy to the entire neuroaxis.