Diagnosis and individualized therapy of neoplastic meningitis

Abstract

Neoplastic meningitis is a diffuse dissemination of tumor cells into the cerebrospinal fluid (CSF) and/or leptomeninges. It occurs in approximately 5-10% of malignant diseases, most often in breast cancer, lung cancer, melanoma or B-cell lymphoma. Symptoms of neoplastic meningitis are head or back pain, cranial nerve palsies, diffuse radicular symptoms or psychiatric disturbances. MRI shows nodular contrast enhancement lining CSF spaces. Positive CSF cytology requires optimal sampling and processing. Treatment must be individually shaped: the CSF dissemination may be treated with intrathecal chemotherapy with methotrexate or cytarabinoside (Ara-C). Liposomal Ara-C is distributed over the entire CSF space even after lumbar application and maintains cytotoxic levels for at least 2 weeks. 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.

Safety and Efficacy of Liposomal Cytarabine in the Treatment of Neoplastic Meningitis

“…In this palliative care setting, invasive or poorly tolerated and painful interventions should be avoided. Traditionally, intrathecal chemotherapy of NM consists of 2-3 applications per week, either by lumbar puncture or via an Ommaya reservoir [14]. Against this background, the intrathecal liposomal cytarabine formulation seems to be a valuable and comfortable treatment option, as the reduced frequency of administration represents an important advantage.…”

Clinical Presentation, Diagnosis, and Radiological Findings of Neoplastic Meningitis

“…62 Novel assays are being tested that may enhance the early identification of malignant cells in CSF. [63][64][65] Until then, the diagnosis is generally made after the onset of neurological manifestations, which have a rapidly fatal course for many patients. 5 When symptoms appear, most tumors have widely disseminated throughout the meninges.…”

“…Glial fibrillary acidic protein assessed by immunohistochemistry in CSF may facilitate the identification of malignant glial cells. 1,[63][64][65]97 Several studies have demonstrated that the sensitivity of flow cytometry is several-fold higher than that of cytology for detecting CSF leukemia or lym-phoma. 98,99 Flow cytometry allows for the early detection of neoplastic meningitis before the onset of clinical symptoms and CSF pleocytosis; therefore, its use may enable more effective treatment.…”

“…100 Future consensus regarding standardized antibody panels for flow cytometry that uniformly define positivity is likely to advance the early detection of neoplastic meningitis and will help permit its broader clinical applicability. 1,[63][64][65] Another group of researchers studied patients with epithelial cell cancers to explore how flow cytometry immunophenotyping contributed to the diagnosis and prognosis of neoplastic meningitis. 101 CSF samples from patients diagnosed with neoplastic meningitis were studied using flow cytometry immunophenotyping.…”

Recovery from Carcinomatous Meningitis by Erlotinib

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Treatment options include whole-brain irradiation, systemic chemotherapy, and intrathecal chemotherapy such as methotrexate [2]. Despite these measures, the prognosis is poor with a median survival of 2-3 months, and focal neurologic dysfunctions do not improve in most cases [1].

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