DIAGNOSIS, MANAGEMENT, AND SURVIVAL OF PATIENTS WITH LEPTOMENINGEAL CANCER BASED ON CEREBROSPINAL FLUID-FLOW STATUS

Background. The authors assessed cerebrospinal fluid (CSF) flow in pat ients with carcinomatous meningitis using technetium-99m-DTPA (Tc-99) ventriculography to determine the frequency of flow abnormalities, the ir reversibility with treatment, and the implications for successful t herapy and survival. Methods. Technetium-99m-DTPA flow studies were pe rformed in 31 patients after placement of Ommaya reservoirs (Baxter, M cGaw Park, IL). Two millicuries of Tc-99 were injected into the reserv oir. Planar images of the head and entire spine were obtained after 10 and 30 minutes and after 1, 4, 6, and 24 hours. Follow-up studies wer e performed for 12 patients whose initial studies were abnormal or who developed complications of therapy. Results. In 19 of the 31 patients (61%), ventricular-outlet, spinal, or convexity blocks were identifie d. In 11 of these 19 patients, focal radiotherapy to the site of the b lock restored normal flow. Survival among patients with initially norm al, abnormal but correctable, and abnormal but uncorrectable CSF flow differed significantly (6.9, 13.0, and 0.7 months respectively; P < 0. 001). Some patients who were treated intrathecally despite abnormal CS F flow experienced drug-related toxicity. Conclusions. Cerebrospinal f luid-now blocks are common in patients with carcinomatous meningitis a nd may occur at the skull base, in the spinal canal, and over the conv exities. These flow abnormalities often can be corrected with appropri ately directed radiotherapy. If untreated, CSF tumor progression (prot ected site effect), neurotoxicity (high concentration effect), and sys temic toxicity (reservoir effect) can occur, resulting in shortened su rvival and treatment-related morbidity. Therefore, intrathecal chemoth erapy should be preceded by a radionuclide flow study and should be de layed if abnormal flow is documented until appropriate radiotherapy re establishes normal flow.