Neoplastic meningitis: diagnosis and treatment considerations

Neoplastic meningitis is an increasingly recognized complication of advance d metastatic cancer and, if left undiagnosed or untreated, is characterized by rapid neurologic deterioration and death. Thus, the diagnosis and treat ment of neoplastic meningitis present challenges for the clinical oncologis t. The diagnosis of neoplastic meningitis is based on clinical signs and sy mptoms, laboratory analysis of cerebrospinal fluid to determine cell count and cytology, and analysis of neuroimaging studies for evidence of leptomen ingeal or cranial nerve enhancement. Once diagnosed, conventional treatment regimens may include radiotherapy combined with systemic or intrathecal ch emotherapy, often with the antimetabolites cytarabine and/or methotrexate. However, the prognosis for neoplastic meningitis secondary to an underlying solid tumor or recurrent leukemia is poor with conventional treatment regi mens. Therefore, novel agents for intrathecal administration, including Dep oCyt(TM), mafosfamide, and topotecan, or novel therapeutic approaches, incl uding conjugated monoclonal antibodies and immunotoxins or gene therapy, ar e currently under investigation. Such new agents and therapeutic approaches will facilitate the development of effective treatment strategies and will ultimately improve the outcome for patients with this devastating disease. This article provides an overview of the approaches to the diagnosis, eval uation, and treatment of neoplastic meningitis.