Neoplastic meningitis overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Sujit Routray, M.D. [2]
Overview
Neoplastic meningitis is the development of meningitis due to infiltration of the subarachnoid space by tumor cells. Neoplastic meningitis was first reported in the 1870's.[1] Neoplastic meningitis refers to the spread of malignant cells through the cerebrospinal fluid space. These cells can be originated both in primary CNS tumors (e.g. drop-metastases), as well as from distant tumors that have metastasized (hematogenous spread).[2] The microscopic pathology of neoplastic meningitis may vary according to the primary cancer involved. Generally, on microscopic histopathological analysis, neoplastic meningitis is characterized by large, hyperchromatic cells.[3] Common causes of neoplastic meningitis include primary intracerebral malignancies (glioblastoma multiforme, anaplastic astrocytoma, medulloblastoma) and metastatic disease (breast cancer, lung cancer, melanoma, lymphoma, leukemia).[4] Neoplastic meningitis must be differentiated from infections (meningitis, Lyme disease, neurocysticercosis), neoplastic (intracerebral metastasis, dural metastasis), inflammatory (rheumatoid arthritis, multiple sclerosis, polychondritis), and granulomatous disorders (sarcoidosis, histiocytosis, Wegener's granulomatosis, vasculitis).[5] Neoplastic meningitis occurs in approximately 3-5% of patients with solid tumor, 5-15% of patients with leukemia, and 1-2% of patients with primary brain tumors.[6][7] Neoplastic meningitis has a widely disseminated and progressive presentation. If left untreated, neoplastic meningitis may progress to develop seizures, hydrocephalus, encephalopathy, and ultimately death.[8] Complications of neoplastic meningitis include hydrocephalus, encephalopathy, empyema, cerebritis, cerebral abscess, and stroke.[8] The median survival time of patients without treatment of neoplastic meningitis is 4-6 weeks.[9] Neoplastic meningitis should be suspected if there are simultaneous occurrence of symptoms or signs in more than one area of the neuraxis.[10] Symptoms of neoplastic meningitis include headaches, confusion, memory loss, seizures, double vision, hearing loss, paresthesia and pain in the neck and back, and limb weakness.[11] Common physical examination findings of neoplastic meningitis include altered mental status, dementia, hemiparesis, ptosis, nuchal rigidity, bowel and bladder dysfunction, and papilledema.[11] Laboratory findings consistent with the diagnosis of neoplastic meningitis include abnormal CSF analysis (increased opening pressure, increased leukocytes, elevated protein, decreased glucose, and positive tumor markers). Only 50% of those suspected with neoplastic meningitis are actually diagnosed and only the presence of malignant cells in the CSF is diagnostic.[12] Brain MRI is helpful in the diagnosis of neoplastic meningitis. On MRI, neoplastic meningitis is characterized by normal T1- and T2-weighted images. On contrast administration, there may be leptomeningeal enhancement scattered over the brain in a 'sugar coated' manner, which is fairly diagnostic for neoplastic meningitis.[13] Other diagnostic studies for neoplastic meningitis include meningeal biopsy, which may be diagnostic if there are no systemic manifestations and the CSF analysis remain inconclusive.[14] The mainstay of therapy for neoplastic meningitis is intrathecal chemotherapy.[11] Radiotherapy may be used in patients with neoplastic meningitis for palliation of symptoms, reduce the bulky tumors, and correction of cerebrospinal fluid flow abnormalities.[11] Supportive care should be directed towards all patients with neoplastic meningitis, regardless of the treatment regimen (anticonvulsants, corticosteroids, and opiates).[11] Surgery is not the first-line treatment option for patients with neoplastic meningitis. Surgery is usually reserved for patients who need an intraventricular catheter placement for administration of cytotoxic drugs or placement of a ventriculoperitoneal shunt in patients with symptomatic hydrocephalus.[11]
Historical Perspective
Neoplastic meningitis was first reported in the 1870's.[1]
Classification
There is no classification system established for neoplastic meningitis.
Pathophysiology
Neoplastic meningitis refers to the spread of malignant cells through the cerebrospinal fluid space. These cells can be originated both in primary CNS tumors (e.g. drop-metastases), as well as from distant tumors that have metastasized (hematogenous spread).[2] The microscopic pathology of neoplastic meningitis may vary according to the primary cancer involved. Generally, on microscopic histopathological analysis, neoplastic meningitis is characterized by large, hyperchromatic cells.[3]
Causes
Common causes of neoplastic meningitis include primary intracerebral malignancies (glioblastoma multiforme, anaplastic astrocytoma, medulloblastoma) and metastatic disease (breast cancer, lung cancer, melanoma, lymphoma, leukemia).[4]
Differentiating Neoplastic Meningitis from other Diseases
Neoplastic meningitis must be differentiated from infections (meningitis, Lyme disease, neurocysticercosis), neoplastic (intracerebral metastasis, dural metastasis), inflammatory (rheumatoid arthritis, multiple sclerosis, polychondritis), and granulomatous disorders (sarcoidosis, histiocytosis, Wegener's granulomatosis, vasculitis).[5]
Epidemiology and Demographics
Neoplastic meningitis occurs in approximately 3-5% of patients with solid tumor, 5-15% of patients with leukemia, and 1-2% of patients with primary brain tumors.[6][7]
Risk Factors
There are no established risk factors for neoplastic meningitis.
Screening
There is insufficient evidence to recommend routine screening for neoplastic meningitis.[15]
Natural History, Complications and Prognosis
Neoplastic meningitis has a widely disseminated and progressive presentation. If left untreated, neoplastic meningitis may progress to develop seizures, hydrocephalus, encephalopathy, and ultimately death.[8] Complications of neoplastic meningitis include hydrocephalus, encephalopathy, empyema, cerebritis, cerebral abscess, and stroke.[8] The median survival time of patients without treatment of neoplastic meningitis is 4-6 weeks.[9]
Diagnosis
Staging
There is no established system for the staging of choroid plexus papilloma.[16]
History and Symptoms
When evaluating a patient for neoplastic meningitis, you should take a detailed history of the presenting symptom (onset, duration, and progression), other associated symptoms, and a thorough family and past medical history review. Other specific areas of focus when obtaining the history include review of common associated conditions such as intracerebral metastases and the distant primary tumors. Neoplastic meningitis should be suspected if there are simultaneous occurrence of symptoms or signs in more than one area of the neuraxis.[17] Symptoms of neoplastic meningitis include headaches, confusion, memory loss, seizures, double vision, hearing loss, paresthesia and pain in the neck and back, and limb weakness.[11]
Physical Examination
Common physical examination findings of neoplastic meningitis include altered mental status, dementia, hemiparesis, ptosis, nuchal rigidity, bowel and bladder dysfunction, and papilledema.[11]
Laboratory Findings
Laboratory findings consistent with the diagnosis of neoplastic meningitis include abnormal CSF analysis (increased opening pressure, increased leukocytes, elevated protein, decreased glucose, and positive tumor markers). Only 50% of those suspected with neoplastic meningitis are actually diagnosed and only the presence of malignant cells in the CSF is diagnostic.[12]
CT
There are no CT scan findings associated with neoplastic meningitis.[11]
MRI
Brain MRI is helpful in the diagnosis of neoplastic meningitis. On MRI, neoplastic meningitis is characterized by normal T1- and T2-weighted images. On contrast administration, there may be leptomeningeal enhancement scattered over the brain in a 'sugar coated' manner, which is fairly diagnostic for neoplastic meningitis.[13]
Other Imaging Findings
There are no other imaging findings associated with neoplastic meningitis.[11]
Other Diagnostic Studies
Other diagnostic studies for neoplastic meningitis include meningeal biopsy, which may be diagnostic if there are no systemic manifestations and the CSF analysis remain inconclusive.[14]
Treatment
Medical Therapy
The mainstay of therapy for neoplastic meningitis is intrathecal chemotherapy.[11] Radiotherapy may be used in patients with neoplastic meningitis for palliation of symptoms, reduce the bulky tumors, and correction of cerebrospinal fluid flow abnormalities.[11] Supportive care should be directed towards all patients with neoplastic meningitis, regardless of the treatment regimen (anticonvulsants, corticosteroids, and opiates).[11]
Surgery
Surgery is not the first-line treatment option for patients with neoplastic meningitis. Surgery is usually reserved for patients who need an intraventricular catheter placement for administration of cytotoxic drugs or placement of a ventriculoperitoneal shunt in patients with symptomatic hydrocephalus.[11]
Prevention
There are no primary or secondary preventive measures available for neoplastic meningitis.
References
- ↑ 1.0 1.1 Neoplastic meningitis. Wikipedia 2016. https://en.wikipedia.org/wiki/Neoplastic_meningitis. Accessed on January 19, 2016
- ↑ 2.0 2.1 Leptomeningeal metastases. Dr Bruno Di Muzio and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/leptomeningeal-metastases. Accessed on January 20, 2016
- ↑ 3.0 3.1 Berzero, Giulia; Diamanti, Luca; Di Stefano, Anna Luisa; Bini, Paola; Franciotta, Diego; Imarisio, Ilaria; Pedrazzoli, Paolo; Magrassi, Lorenzo; Morbini, Patrizia; Farina, Lisa Maria; Bastianello, Stefano; Ceroni, Mauro; Marchioni, Enrico (2015). "Meningeal Melanomatosis: A Challenge for Timely Diagnosis". BioMed Research International. 2015: 1–6. doi:10.1155/2015/948497. ISSN 2314-6133.
- ↑ 4.0 4.1 Pathology of leptomeningeal metastases. Dr Bruno Di Muzio and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/leptomeningeal-metastases. Accessed on January 19, 2016
- ↑ 5.0 5.1 Leptomeningitis. Dr Amir Rezaee and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/leptomeningitis. Accessed on January 21, 2016
- ↑ 6.0 6.1 Gleissner, Beate; Chamberlain, Marc Charles (2006). "Neoplastic meningitis". The Lancet Neurology. 5 (5): 443–452. doi:10.1016/S1474-4422(06)70443-4. ISSN 1474-4422.
- ↑ 7.0 7.1 Hayat, M. A. Brain metastases from primary tumors : epidemiology, biology, and therapy. London: Elsevier/Academic Press, 2014. Print.| url=https://books.google.com/books?id=IloXAwAAQBAJ&pg=PA43&lpg=PA43&dq=leptomeningeal+carcinomatosis+is+present+in+1-5%25+of+patients+with+solid+tumors,+5-15%25+of+patients+with+leukemia,+and+1-2%25+of+patients+with+primary+brain+tumors.&source=bl&ots=ehEaDBCT5f&sig=vvSxdxDjNMBe0CdCP6fEcMaYJqU&hl=en&sa=X&ved=0ahUKEwi2ueuw37bKAhUG8j4KHWUUCoIQ6AEILTAC#v=onepage&q=leptomeningeal%20carcinomatosis%20is%20present%20in%201-5%25%20of%20patients%20with%20solid%20tumors%2C%205-15%25%20of%20patients%20with%20leukemia%2C%20and%201-2%25%20of%20patients%20with%20primary%20brain%20tumors.&f=false. Accessed on January 19, 2016
- ↑ 8.0 8.1 8.2 8.3 Complications of leptomeningitis. Dr Amir Rezaee and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/leptomeningitis. Accessed on January 21, 2016
- ↑ 9.0 9.1 Prognosis of neoplastic meningitis. Wikipedia 2016. https://en.wikipedia.org/wiki/Neoplastic_meningitis. Accessed on January 20, 2016
- ↑ "Infiltration of the Leptomeninges by Systemic Cancer-A Clinical and Pathologic Study". doi:10.1001/archneur.1974.00490320010002. Check
|doi=value (help). - ↑ 11.00 11.01 11.02 11.03 11.04 11.05 11.06 11.07 11.08 11.09 11.10 11.11 11.12 11.13 Chamberlain, M. C. (2008). "Neoplastic Meningitis". The Oncologist. 13 (9): 967–977. doi:10.1634/theoncologist.2008-0138. ISSN 1083-7159.
- ↑ 12.0 12.1 Diagnosis of neoplastic meningitis. Wikipedia 2016. https://en.wikipedia.org/wiki/Neoplastic_meningitis. Accessed on January 20, 2016
- ↑ 13.0 13.1 Radiographic features of leptomeningeal metastases. Dr Bruno Di Muzio and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/leptomeningeal-metastases. Accessed on January 19, 2016
- ↑ 14.0 14.1 Ahn, Shin; Lim, Kyung Soo (2013). "Three Cases of Neoplastic Meningitis Initially Diagnosed with Infectious Meningitis in Emergency Department". Case Reports in Emergency Medicine. 2013: 1–4. doi:10.1155/2013/561475. ISSN 2090-648X.
- ↑ Early detection, diagnosis, and staging of brain tumors. American cancer society. http://www.cancer.org/cancer/braincnstumorsinadults/detailedguide/brain-and-spinal-cord-tumors-in-adults-detection
- ↑ Chandana SR, Movva S, Arora M, Singh T (2008). "Primary brain tumors in adults". Am Fam Physician. 77 (10): 1423–30. PMID 18533376.
- ↑ "Infiltration of the Leptomeninges by Systemic Cancer-A Clinical and Pathologic Study". doi:10.1001/archneur.1974.00490320010002. Check
|doi=value (help).