Citation, DOI & article data
Citation:
Gaillard F, Knipe H, Worsley C, et al. Leptomeningeal metastases. Reference article, Radiopaedia.org (Accessed on 06 Feb 2023) https://doi.org/10.53347/rID-1579
Leptomeningeal metastases, also known as carcinomatous meningitis and meningeal carcinomatosis, refers to the spread of malignant cells through the CSF space. These cells can originate from primary CNS tumors (e.g. in the form of drop metastases), as well as from distant tumors that have metastasized via hematogenous spread.
This article has a focus on subarachnoid space involvement. Refer to intradural extramedullary metastases for a discussion of leptomeningeal metastases in the spine. For other intracranial metastatic locations, please refer to the main article on intracranial metastases.
The demographics follow those of the underlying malignancy. Meningeal metastases were found in 8% of patients with systemic cancer in cadaveric studies 22.
Clinical presentation is varied, but most commonly includes a headache, spine or radicular limb pain or sensory abnormalities, nausea and vomiting, and focal neurological deficits 3. Meningism is only present in a minority of patients (13% 3).
The primary intracranial malignancies that may cause metastases to the subarachnoid space are:
The vast majority of leptomeningeal metastases occur in the context of widespread metastatic disease, likely by hematogenous spread. Over 50% of cases have concurrent brain (parenchymal) metastases 13. The most common primary sites are:
Less common reported primary sites include:
MRI
-
T1: usually normal
-
T1 C+ (Gd): leptomeningeal enhancement is the primary mode of diagnosis, often scattered over the brain in a 'sugar coated' manner
-
T2: usually normal; may show hyperintensity
-
FLAIR
- abnormally elevated signal within sulci 2
- can be performed both non-contrast and post-contrast but is slightly less specific if performed post-contrast 1
Treatment and prognosis
Leptomeningeal metastases have a poor prognosis with patients usually succumbing within a few months (median overall survival 2.4 months 13). Treatment may extend survival to 6-10 months 2,3. Treatment can consist of 3:
- intrathecal chemotherapy
- radiotherapy
Resection is usually inappropriate due to the presence of widespread metastases at the time of diagnosis.
- leptomeningeal inflammation: leptomeningitis
- slow flow in vessels
- propofol, high oxygen tension, and subarachnoid blood (hemorrhage) can all elevate sulcal FLAIR signal
- 1. Singh S, Leeds N, Ginsberg L. MR Imaging of Leptomeningeal Metastases: Comparison of Three Sequences. AJNR Am J Neuroradiol. 2002;23(5):817-21. PMC7974747 - Pubmed
- 2. Singh S, Agris J, Leeds N, Ginsberg L. Intracranial Leptomeningeal Metastases: Comparison of Depiction at FLAIR and Contrast-Enhanced MR Imaging. Radiology. 2000;217(1):50-3. doi:10.1148/radiology.217.1.r00oc3550 - Pubmed
- 3. Balm M & Hammack J. Leptomeningeal Carcinomatosis. Presenting Features and Prognostic Factors. Arch Neurol. 1996;53(7):626-32. doi:10.1001/archneur.1996.00550070064013 - Pubmed
- 4. Bulut G, Erden A, Karaca B, Göker E. Leptomeningeal Carcinomatosis of Gastric Adenocarcinoma. Turk J Gastroenterol. 2011;22(2):195-8. doi:10.4318/tjg.2011.0191 - Pubmed
- 5. Wolfgang Dähnert. Radiology Review Manual. (2011) ISBN: 9781609139438 - Google Books
- 6. Trinh V, Medina-Flores R, Chohan M. Leptomeningeal Carcinomatosis as Primary Manifestation of Pancreatic Cancer. J Clin Neurosci. 2016;30:124-7. doi:10.1016/j.jocn.2015.12.027 - Pubmed
- 7. Miller E, Dy I, Herzog T. Leptomeningeal Carcinomatosis from Ovarian Cancer. Med Oncol. 2012;29(3):2010-5. doi:10.1007/s12032-011-0076-9 - Pubmed
- 8. Taylor G, Karlin N, Halfdanarson T, Coppola K, Grothey A. Leptomeningeal Carcinomatosis in Colorectal Cancer: The Mayo Clinic Experience. Clin Colorectal Cancer. 2018;17(2):e183-7. doi:10.1016/j.clcc.2017.11.003 - Pubmed
- 9. Dalhaug A, Haukland E, Nieder C. Leptomeningeal Carcinomatosis from Renal Cell Cancer: Treatment Attempt with Radiation and Sunitinib (Case Report). World J Surg Oncol. 2010;8(1):36. doi:10.1186/1477-7819-8-36 - Pubmed
- 10. Han L, Bhan R, Johnson S, Zak I, Husain M, Al-Abbadi M. Leptomeningeal Metastasis in a Patient with Squamous Cell Carcinoma of the Uterine Cervix: Report of a Case and Review of the Literature. Diagn Cytopathol. 2007;35(10):660-2. doi:10.1002/dc.20705 - Pubmed
- 11. Capone G, Della Pepa G, Sabatino G et al. A Rare Bone-Leptomeningeal Metastasis from an Adrenal Cortical Carcinoma. J Clin Neurosci. 2009;16(7):977-80. doi:10.1016/j.jocn.2008.10.013 - Pubmed
- 12. Ahmed M, Begum T, Omer A, Khan I. Leptomeningeal Carcinomatosis from Oesophageal Cancer, Presenting as Meningitis. BMJ Case Rep. 2016;2016:bcr2015210974. doi:10.1136/bcr-2015-210974 - Pubmed
- 13. Clarke J, Perez H, Jacks L, Panageas K, Deangelis L. Leptomeningeal Metastases in the MRI Era. Neurology. 2010;74(18):1449-54. doi:10.1212/WNL.0b013e3181dc1a69 - Pubmed
- 14. Sugimori K, Kobayashi K, Hayashi M, Sakai N, Sasaki M, Koshino Y. Leptomeningeal Carcinomatosis from Urinary Bladder Adenocarcinoma: A Clinicopathological Case Study. Neuropathology. 2005;25(1):89-94. doi:10.1111/j.1440-1789.2004.00580.x - Pubmed
- 15. Cante D, Franco P, Sciacero P et al. Leptomeningeal Metastasis from Prostate Cancer. Tumori. 2013;99(1):6e-10e. doi:10.1700/1248.13803 - Pubmed
- 16. Petrovic B, Kozic D, Semnic R et al. Leptomeningeal Metastasis from Malignant Pleural Mesothelioma. AJNR Am J Neuroradiol. 2004;25(7):1223-4. PMC7976544 - Pubmed
- 17. Onesti E, Fabi A, Mingoia M, Savarese A, Anelli V, Koudriavtseva T. Leptomeningeal Carcinomatosis in Aggressive Germ Non-Seminoma Testicular Tumor: A Case Report and Review of Literature. Clin Neurol Neurosurg. 2012;114(7):1081-5. doi:10.1016/j.clineuro.2012.02.007 - Pubmed
- 18. Stark A & Mehdorn H. Leptomeningeal Metastasis of an Intradural Malignant Peripheral Nerve Sheath Tumor. J Clin Neurosci. 2013;20(8):1181-3. doi:10.1016/j.jocn.2012.09.039 - Pubmed
- 19. Solomon B, Rischin D, Lyons B, Peters L. Leptomeningeal Metastases from Anaplastic Thyroid Carcinoma. Aust N Z J Med. 2000;30(6):724-5. doi:10.1111/j.1445-5994.2000.tb04369.x - Pubmed
- 20. Eng C, Cunningham D, Quade B, Schwamm L, Kantoff P, Skarin A. Meningeal Carcinomatosis from Transitional Cell Carcinoma of the Bladder. Cancer. 1993;72(2):553-7. doi:10.1002/1097-0142(19930715)72:2<553::aid-cncr2820720236>3.0.co;2-z - Pubmed
- 21. William B & Grem J. Brain Metastasis and Leptomeningeal Carcinomatosis in a Patient with Cholangiocarcinoma. Gastrointest Cancer Res. 2011;4(4):144-5. PMC3283108 - Pubmed
- 22. Vossough A & Henson J. Intracranial Metastases. Handbook of Neuro-Oncology Neuroimaging. 2016;:643-52. doi:10.1016/b978-0-12-800945-1.00052-5
Promoted articles (advertising)