From the Department of Neurology, Brigham and Women's/Dana Farber Cancer Center, Harvard Medical School, Boston, MA, and the Division of Hematology and Oncology, Departments of Neurology and Radiation Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
Authors’ disclosures of potential conflicts of interest are found at the end of this article.
Address reprint requests to Tracy T. Batchelor, MD, MPH, Associate Professor in Neurology, Division of Hematology and Oncology, Departments of Neurology and Radiation Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Yawkey Center 9E, 55 Fruit St, Boston, MA, 02114; e-mail: tbatchelor{at}partners.org
Overview: Leptomeningeal metastasis (LM) occurs in approximately 8% of all patients with cancer and is increasingly recognized as a late complication, as survival from systemic disease increases and newer chemotherapies fail to penetrate the blood-brain barrier. LM occurs when cancer cells enter cerebrospinal fluid (CSF) pathways, causing either multifocal or diffuse infiltration of the subarachnoid space of the brain and spinal cord. The hallmark of clinical presentation is a patient with cancer with multifocal neurological dysfunction. LM is a disease affecting the entire neuraxis, and therefore staging and treatment must encompass all CSF compartments. Staging of LM includes contrast-enhanced cranial computed tomography or gadolinium-enhanced magnetic resonance imaging (MRI), contrast-enhanced spine MRI, and radionuclide CSF flow study. Treatment of LM incorporates involved-field radiotherapy of bulky or symptomatic disease sites and intrathecal chemotherapy. Systemic chemotherapy can be considered in selected patients with good performance status and chemotherapy-sensitive tumors and may obviate the need for itrathecal drug administration. Intrathecally administered agents include methotrexate, cytarabine, and thio-TEPA administered by a variety of schedules by either intralumbar or intraventricular injection. The treatment of LM is palliative, and the goal is to stabilize and protect patients from further neurological deterioration. Although most individuals survive for only a few months, treatment occasionally results in prolonged survival and improvement of neurological function.
