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Chu et al. Meningeal carcinomatosis: a retrospective analysis

DISCUSSION above can cause increase in the intracranial pressure.
This is confirmed by lumbar puncture measurement.
MC is a special type of metastatic carcinoma of the Regular and biochemical tests were used in 62 cases.
central nervous system with a incidence of 5-10% in The protein level and white blood cell count in CSF
all solid tumors. [5,6] As a gradual increase of incidence were found elevated in 47 (47/62, 73.4%) cases and
and a high mortality have been observed over time, 36 (36/62, 57.1%) cases, respectively. The obstruction
early diagnosis is crucial. Due to its diverse clinical of CSF circulation path, the disruption of the blood-
manifestations, it is difficult to make a diagnosis brain barrier and the increase of vascular endothelial
only with imaging examinations and CSF cytology is permeability may cause the protein extravasation and
necessary to find abnormal cells. diapedesis. Interestingly, 30 (30/62, 48.4%) cases
showed a lower CSF glucose content than normal,
At onset, the age is similar between MC and other which could be the result of glucose consumption
tumors. In fact, MC can be found at any age, but it caused by the proliferation and strong metabolism
is more common in the elderly. Most patients present of tumor cells. In addition, as it is difficult for blood
with acute or subacute onset, while a small number of glucose to pass through the blood brain barrier, the
patients with primary tumors may be in chronic onset. CSF glucose lacks the timely supply from blood, which
Since cancer cells can move into the CSF and infiltrate is another reason for the drop in glucose content.
[10]
the dura and the brain parenchyma, clinical evidence In 26 (41.9%) cases lower CSF chloride value was
of the disease could appear as symptoms of meninges observed. A lot of glycolysis produced a great amount
and brain parenchyma damage, cranial nerve palsy of acid metabolites, facilitating the CSF chloride decline
[7]
and spinal nerve root symptoms. The most frequent (as the chloride reduces easily in acid conditions). At
[8]
initial symptom is intracranial hypertension such as the same time, loss of large amount of gastric acid
headache, nausea and vomit. The main reason for after frequent vomiting is another reason for chloride
headache is the increasing intracranial pressure reduction. So the overall abnormal rate of protein,
caused by cancerous obstruction of CSF circulation glucose, chloride and white cells in CSF was high.
pathway. Besides, the meninges irritation is partly
responsible for headache. Seventy-three cases underwent CSF cytology
examination. Tumor cells in the CSF were found by
In this study, we found 11 (14.3%) cases of convulsions, one lumbar puncture and two lumbar punctures in 60
5 (6.5%) of mental disorders such as illusion and cases (82.2%) and 6 cases (8.2%), respectively. Only
personality change, 3 (3.9%) of conscious disorder and in one case tumor cells were not found until the third
other CNS damaged symptoms. The common signs time lumbar puncture. Enough samples combined with
include 41 (53.2%) cases of meningeal stimulation accurate assessment from clinical physicians would
and 20 (26%) cases of positive pyramidal tract, etc. improve the diagnostic rate. Only in 3 cases, CSF
[11]
The most common damaged nerves include abducens tumor markers were abnormal. It is difficult to diagnose
nerve, oculomotor nerve and facial nerve, and each the source of tumor cells on the basis of cytology
type of damaged nerve accounts for 10 cases (13%) in morphology. We can combine cytology examination
our study. The other cranial nerves such as optic nerve, with CSF tumor markers to diagnose the properties
auditory nerve, hypoglossal nerve, glossopharyngeal and origin of tumor cells. [12]
nerve also can be involved, which was similar with
what already described in the literature. In this study, It is difficult to diagnose MC through standard MRI
[9]
there were 12 (15.6%) patients with bilateral limbs scan. But we can find some indirect signs such as
weakness or paresthesia, 11 (14.3%) patients with ventricular expansion, hydrocephalus, etc. There are
tendon reflexes diminished or disappeared, 5 (6.5%) a lot of dural blood capillaries in normal humans, but
patients with the neck shoulder pain which is the effect there is no blood brain barrier because lack of close
of the infiltration of tumor cells and the irritation of the connection between endothelial cells. Although the
spinal nerve root. In addition, there was one case with capillaries of leptomeninges are fewer than dura,
rectal bladder dysfunction and saddle area sensory the blood brain barrier exists because there are lots
deficiency. The Kernig sign and the Lasegue sign may of close connection between endothelial cells. The
[13]
be positive in the physical examination. normal dura may be strengthened during head MRI
enhanced scanning, but it does not show nodular or
The cerebral vascular endothelial permeability increases hybrid reinforcement. MC also destroys blood brain
when the meninges are stimulated by tumor cells and barrier, in fact the majority of patients shows dural
produce various chemicals, at the same time the CSF abnormal reinforcement such as nodositas, line type
circulation path may be blocked by tumor cells. All of and mixed type. A small number of patients have no
4 Neuroimmunology and Neuroinflammation ¦ Volume 4 ¦ January 20, 2017