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carcinomatous meningitis (leptomeningeal metastases)
Etiology:
- metastatic solid tumor
a) clinical evidence is present in ~8%
b) prevalence as high as 19% in autopsies
c) adenocarcinoma of breast & melanoma most common
d) lymphoma/leukemia
Pathology:
1) three patterns
a) diffuse coating of leptomeninges by tumor cells
b) nodular growth on meninges or nerve root
c) plaquelike metastases with cells in subarachnoid space extending into Virchow-Robin spaces
2) hydrocephalus, communicating hydrocephalus
3) encephalopathy
Clinical manifestations:
1) headache or spine pain
2) cranial nerve pain or spinal radicular pain
3) mental status changes
4) focal neurological deficit from associated intracranial metastases
Laboratory:
- cerebrospinal fluid (CSF)
a) findings of inflammatory meningitis are negative
b) lymphocytic pleocytosis
c) elevated CSF protein
d) normal to low CSF glucose
e) oligoclonal increase of IgG sometimes
Radiology:
- magnetic resonance imaging (MRI) with gadolinium enhancement
a) diffuse meningeal enhancement (brain, spinal cord, nerve roots)
b) nodular tumor deposits on meninges
c) ventricular enlargement, communicating hydrocephalus
Management:
1) chemotherapy followed by radiation therapy [2]
a) methotrexate & cytarabine
b) intrathecal chemotherapy [1]
c) focal beam radiotherapy
2) ventriculoperitoneal shunt for hydrocephalus
Interactions
disease interactions
General
meningeal neoplasm
meningitis
metastasis
References
- Harrison's Principles of Internal Medicine, 14th ed.
Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 2406-7
- Medical Knowledge Self Assessment Program (MKSAP) 14,
American College of Physicians, Philadelphia 2006
- - Medical Knowledge Self Assessment Program (MKSAP) 19
Board Basics. An Enhancement to MKSAP19.
American College of Physicians, Philadelphia 2022