Diagnosis, management, and survival of patients with leptomeningeal cancer based on cerebrospinal fluid-flow status

Abstract

Background. The authors assessed cerebrospinal fluid (CSF) flow in patients with carcinomatous meningitis using technetium‐99m‐DTPA (Tc‐99) ventriculography to determine the frequency of flow abnormalities, their reversibility with treatment, and the implications for successful therapy and survival. Methods. Technetium‐99m‐DTPA flow studies were performed in 31 patients after placement of Ommaya reservoirs (Baxter, McGaw Park, IL). Two millicuries of Tc‐99 were injected into the reservoir. Planar images of the head and entire spine were obtained after 10 and 30 minutes and after 1, 4, 6, and 24 hours. Follow‐up studies were performed for 12 patients whose initial studies were abnormal or who developed complications of therapy. Results. In 19 of the 31 patients (61%), ventricularoutlet, spinal, or convexity blocks were identified. In 11 of these 19 patients, focal radiotherapy to the site of the block restored normal flow. Survival among patients with initially normal, abnormal but correctable, and abnormal but uncorrectable CSF flow differed significantly (6.9, 13.0, and 0.7 months respectively; P < 0.001). Some patients who were treated intrathecally despite abnormal CSF flow experienced drug‐related toxicity. Conclusions. Cerebrospinal fluid‐flow blocks are common in patients with carcinomatous meningitis and may occur at the skull base, in the spinal canal, and over the convexities. These flow abnormalities often can be corrected with appropriately directed radiotherapy. If untreated, CSF tumor progression (protected site effect), neurotoxicity (high concentration effect), and systemic toxicity (reservoir effect) can occur, resulting in shortened survival and treatment‐related morbidity. Therefore, intrathecal chemotherapy should be preceded by a radionuclide flow study and should be delayed if abnormal flow is documented until appropriate radiotherapy reestablishes normal flow. Cancer 1995;75:2919–31.

Neoplastic Meningitis

“…Radionuclide studies, using either 111 indium-diethylenetriamine pentaacetic acid or 99 Tc macroaggregated albumin, constitute the technique of choice to evaluate CSF flow dynamics [17,49]. Abnormal CSF circulation has been demonstrated in 30%-70% of patients with NM, with blocks commonly occurring at the skull base, in the spinal canal, and over the cerebral convexities [46,49,50].…”

“…Abnormal CSF circulation has been demonstrated in 30%-70% of patients with NM, with blocks commonly occurring at the skull base, in the spinal canal, and over the cerebral convexities [46,49,50]. Patients with interruption of CSF flow demonstrated by radionuclide ventriculography were shown, in three clinical series, to have a shorter survival time than those with normal CSF flow [49,51,52]. Involved-field radiotherapy to the site of CSF flow obstruction restores flow in 30% of patients with spinal disease and 50% of patients with intracranial disease [53,54].…”

“…Involved-field radiotherapy to the site of CSF flow obstruction restores flow in 30% of patients with spinal disease and 50% of patients with intracranial disease [53,54]. Re-establishment of CSF flow with involved-field radiotherapy followed by intrathecal chemotherapy led to longer survival, lower rates of treatmentrelated morbidity, and a lower rate of death from progressive NM, compared with the group that had persistent CSF blocks [49,51].…”

Leptomeningeal carcinomatosis

“…There are weaknesses in the studies: Some have included in their series hematologic or primary brain tumors, they show important differences in sample size and analyzed variables, they have evaluated selected subsets of patients, and only univariate analyses were considered. 5,9,11,[13][14][15][16][17][18][19][20]22 Accordingly, currently, there are no useful prognostic markers, except for cerebrospinal fluid (CSF) blocks, 23,24 that could help clinicians to decide the best therapeutic approach for patients with LC. The objective of this study was to identify prognostic factors related to LC survival and enable clinicians to select patients who are more likely to benefit from chemotherapy treatment.…”

A Silent and Debilitating Case of Obstructing Hydrocephalus

“…Poor prognosis is defined by NCCN consisting of low Karnofsky index (<60% to 70%), severe neurological deficits, parenchymal brain metastases and blockage of the CSF flow, extensive tumor involvement with little opportunity to response to systemic therapy [6,7].…”