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Cui et al. Diagnosis and treatment of meningeal carcinomatosis

Any stimulation of the pia mater, such as subarachnoid Moreover, lumboperitoneal shunting may also be a
blood, infection and cancer can produce enhancement therapeutic option in relieving clinical symptoms of
of MRI. Lumbar puncture itself can induce a meningeal intracranial hypertension in MC. [47,48] There are two
reaction resulting in leptomeningeal enhancement, so types of reservoirs that be generally inserted in a
it would be better to conduct MRI examination prior the region in the right frontal lobe: the Rickham reservoir,
procedure. Nevertheless, negative findings cannot which be placed over a burr hole, and the Ommaya
[38]
be excluded the diagnosis of MC absolutely. reservoir, a domed shape device that could be easily
palpated. The objective is to ensure a more uniform
[49]
Researches on radionuclide using either distribution of the drug within the subarachnoid space
99
111 Indiumdiethylenetriamine penta-acetic acid or Tc and to improve the curative effect of drug.
macroaggregated albumin are regarded as effective
technique of choice to monitor and evaluate CSF Radiotherapy
flow dynamics. [39,40] CSF flow blocks have been Radiotherapy is an integral part of MC therapy
demonstrated in 30-70% of patients with MC, with for patients with a syndrome of cauda equina,
blocks usually arises in the skull base, within the spine coexisting parenchymal brain metastases and CSF
and over the cerebral convexities. [40,41] Patients with flow disturbance, which will alleviate symptoms,
CSF flow obstruction confirmed by radionuclide show reduce bulky tumors volume and rectify CSF flow
shorter survival time when compared with those with obstructions. Irradiation range of the whole brain
normal CSF flow. [42,43] Managements of affected areas irradiation (WBRT) include the cerebral meninges,
radiotherapy to the location of CSF flow obstruction basis cranii, basilar cistern, and the spinal canal
resume flow in 30% of patients with spinal affected and to the plane of cervical vertebrae 1 and 2. WBRT
in 50% of patients with intracranial involved. [44] is usually recommended at a dose of 30-36 Gy in
fractions of 3 Gy, 40 Gy in 2 Gy fractions administered
TREATMENT to patients with favorable prognosis, [45] for cases
with a poor prognosis 5 × 4 Gy is an alternative
Treatment of MC focuses on two aspects: therapy to shortens the course of treatment. [50] It relieved
toward meningeal involvement and toward the primary pain and alleviated nervous system symptom but
cancer. In other words, patients with MC were given demonstrated no benefit to improve survival. [34]
meningeal involvement therapy based on the primary Craniospinal irradiation is rarely administered in
cancer. As almost all patients with MC have been in MC because of its significant bone marrow toxicity.
advanced stage at presentation, palliative treatment Focal radiotherapy can be administered safely in
such as radiotherapy, chemotherapy, biotherapy and patients with bulky disease and obstructive lesions
molecular targeted therapy, etc. are usually the main in short periods using a single dose via stereotactic
treatment for primary tumor. Current treatments for radiosurgery, which is beneficial for patients with
meningeal involvement include surgery, radiation obvious syndrome of radicular pain and can result
therapy (RT), systemic therapy, and intrathecal therapy, in reduced use of pain medicine. [45] In general,
molecular targeted therapy and immunotherapy. symptoms usually can be controlled after RT. [51,52]
Treatment should be targeted at alleviating the
neurological symptoms, improving the quality of life Chemotherapy
and prolonging the survival time for the patients with Intrathecal therapy
MC. Therapy toward meningeal involvement mainly Intrathecal chemotherapy is generally regarded as a
from the following aspects introduced. modality to evade the blood-brain barrier (BBB) and
blood-CSF barriers in MC. Four chemotherapy agents
Surgery are received FDA approval for intrathecal injection:
The main operative treatment in MC is ventriculo- methotrexate (MTX), cytosine arabinoside (Ara-C),
peritoneal shunting for hydrocephalus due to CSF liposomal Ara-C, and thiotepa, with methotrexate as
circulatory disorders and implantation of intraventricular the broadest used drug in the treatment of MC. As
reservoir for administration of cytotoxic chemotherapy antimetabolites, MTX and Ara-C are the firm rock in
drugs. Communicating hydrocephalus often occurs in medical practice for MC caused by any primary cancer
patients with MC leading to symptoms of intracranial in decades. Liposomal Ara-C has similar curative
hypertension. Increased intracranial pressure can be effect, but its advantage lies in decreased frequency
relieved by surgery with a ventriculoperitoneal shunt to of intrathecal injection. Additionally, trastuzumab
[53]
improve clinical symptoms if hydrocephalus continues. and topotecan has recently been used in intrathecal
If possible, an on-off valve may be placed to permit chemotherapy in MC from breast cancer. [54-56]
the administration of intra-CSF chemotherapy. [45,46] Topotecan, an alkylating agent, showed variable
170 Neuroimmunology and Neuroinflammation ¦ Volume 4 ¦ September 18, 2017