Leptomeningeal Metastases of the Spine: A Systematic Review

Abstract

Background/Aim: Leptomeningeal metastases (LMs) of the spine have complex management. We reviewed the literature on spine LMs. Materials and Methods: PubMed, EMBASE, Scopus, Web-of-Science, and Cochrane were searched following the PRISMA guidelines to include studies of spine LMs. Results: We included 46 studies comprising 72 patients. The most frequent primary tumors were lung (19.4%) and breast cancers (19.4%). Median time from primary tumors was 12 months (range=0-252 months). Cauda equina syndrome occurred in 34 patients (48.6%). Nodular spine LMs (63.6%) were more frequent. Concurrent intracranial LMs were present in 27 cases (50.9%). Cerebrospinal fluid cytology was positive in 31 cases (63.6%). Cases were managed using palliative steroids (73.6%) with locoregional radiotherapy (55.6%) chemotherapy (47.2%), or decompressive laminectomy (8.3%). Post-treatment symptom improvement (32%) and favorable radiological response (28.3%) were not different based on treatment (p=0.966; p=0.727). Median overallsurvival was 3 months (range=0.3-60 months), not significantly different between radiotherapy and chemotherapy (p=0.217). Conclusion: Spine LMs have poor prognoses. Radiotherapy, chemotherapy, and surgery are only palliative, as described for intracranial LMs.Leptomeningeal metastases (LMs) are late-stage complications of systemic malignancies, occurring approximately in 5-10% of patients with solid and hematologic neoplasms (1, 2). Frequently manifesting with new neurological deficits, LMs may be detected at T1-contrast MRI follow-ups as nodular or diffuse meningeal enhancement, and may be confirmed with high-volume cerebrospinal fluid (CSF) taps for cytology (3,4). Several systemic therapeutic options are available, but the treatment goal remains palliation, as mean survival ranges 3-6 months (3,5,6).LMs involving the spine represent unique entities that may severely impact patients' functional status (7, 8). While diffuse spinal LMs may remain clinically silent and go undetected, nodular spinal LMs frequently compress spinal nerve roots causing radicular pain or neurological impairments (2, 9). Nodular spinal LMs may also lead to acute or progressive cauda equina syndrome, which require urgent diagnosis and management (10,11). While surgical decompression may provide prompt symptomatic relief, patients may not be good candidates due to their significant tumor burden (2, 3). In these cases, locoregional radiation, chemotherapy, and other systemic treatments may be pursued to achieve similar clinical outcomes (12, 13).Although spinal LMs pose significant challenges in the oncological care of patients with systemic metastases, only 619 This article is freely accessible online.

Intradural Extramedullary Spinal Metastases from Non-neurogenic Primary Tumors: A Systematic Review

“…Accurate evaluation of sensorimotor deficits and regional axial pain may assist in localizing affected spine levels, but may be underestimated at early stages in case of lesions with moderate growth and non-severe spinal cord compression (7,44). As found in this pooled cohort, acute CES has been frequently reported in lesions involving the lumbar-sacral spine, which may facilitate a differential diagnosis with other intramedullary tumors (17,72). Although CES-related symptoms, such as lumbar or radicular leg pain, and mild motor deficits with preservation of sphincter functions, may simulate lumbar disc diseases, their quick progression may serve as an important red flag mandating further, prompt diagnostic assessments (73).…”

“…Targeted adjuvant SRS (with a 10 Gy dose) was used in the recent report of Pagano et al (64) with no radiation-induced adverse events, suggesting the feasibility and safety of this protocol for the management of IESMs. Newer immunotherapy and targeted molecular therapies have been studied and are currently used in the multidisciplinary management of systemic cancers, but their benefits in patients with IESMs have yet to be evaluated (72,76).…”

“…These elements, added to the lack of available systemic therapies selectively directed against IESMs, may account for the differences in survival noted in comparison to patients with vertebral metastases, with OS up to 2 years when receiving immunotherapy or targeted molecular therapies (71). Tumor resection and locoregional radiation were mostly intended for palliation, achieving desirable short-term rates of clinical (70.8%) and radiological (64.2%) improvement, superior than those described in patients with spine LMs (72). Optimal outcomes were obtained by performing decompressive laminectomy and tumor resection in patients with paraparesis and ambulatory difficulty, which led to walking improvement and quality of life amelioration in most cases (27,65,67).…”

Leptomeningeal carcinomatosis from a recurrent cutaneous squamous cell carcinoma with perineural invasion in a lung transplant patient

“…Patients with leptomeningeal carcinomatosis have a median survival time of 3 to 4 months. 2 Treatment is mainly palliative, but 1 case reported successful disease stabilization using intrathecal methotrexate and systemic epidermal growth factor receptor (EGFR) inhibitors. 3 In patients with leptomeningeal melanoma metastases, intrathecal interferon alfa and interleukin 2, and systemic ipilimumab and nivolumab have been reported to prolong survival.…”

Giant Myxopapillary Ependymoma with Multi-Site Neural Axis Metastases: A Rare Case with Suboptimal Outcome

“…The primary locations where myxopapillary ependymoma (MPE) is predominantly found are the conus medullaris and the filum terminale. However, there have been occasional reports of rare cases where tumors have occurred in the brain, upper spinal cord, or even outside the central nervous system (CNS) [ 5 – 7 ].…”