Neoplastic Meningitis Due to Lung, Breast, and Melanoma Metastases

Emilie Le Rhun, MD; Sophie Taillibert, MD; Marc C. Chamberlain, MD

Disclosures

Cancer Control. 2017;24(1):22-32. 

In This Article

Abstract and Introduction

Abstract

Background. Neoplastic meningitis, a central nervous system (CNS) complication of cancer metastatic to the meninges and cerebrospinal fluid (CSF), is relevant to oncologists due to the impact of the disease on patient quality of life and survival rates.

Methods. A review of the literature of articles published in English was conducted with regard to neoplastic meningitis.

Results. The incidence of neoplastic meningitis is increasing because patients with cancer are surviving longer in part because of the use of novel therapies with poor CNS penetration. Up to 5% of patients with solid tumors develop neoplastic meningitis during the disease course (breast cancer, lung cancer, and melanoma being the predominantly causative cancers). The rate of median survival in patients with untreated neoplastic meningitis is 1 to 2 months, although it can be as long as 5 months in some cases. Therapeutic options for the treatment of neoplastic meningitis include systemic therapy (cancer-specific, CNS-penetrating chemotherapy or targeted therapies), intra-CSF administration of chemotherapy (methotrexate, cytarabine, thiotepa) and CNS site-specific radiotherapy.

Determining whom to treat with neoplastic meningitis remains challenging and, in part, relates to the extent of systemic disease, the neurological burden of disease, the available systemic therapies, and estimated rates of survival.

Conclusions. The prognosis of neoplastic meningitis remains poor. The increasing use of novel, targeted therapies and immunotherapy in solid tumors and its impact on neoplastic meningitis remains to be determined and is an area of active research. Thus, well conducted trials are needed.

Introduction

Neoplastic meningitis, also known as leptomeningeal metastasis or carcinomatous meningitis, reflects the metastatic infiltration of the cerebrospinal fluid (CSF) and leptomeninges (pia and arachnoid) by cancer. Neoplastic meningitis is the third most common cause of central nervous system (CNS) metastases after brain metastases and epidural spinal cord compression.[1] The diagnosis and treatment of neoplastic meningitis are of clinical relevance due to their impact on patient quality of life and rate of survival.

The incidence of neoplastic meningitis is increasing due in part to improved rates of survival, because more effective systemic agents with poor CNS penetration are being used.[2,3] Up to 5% of patients with solid tumors will develop neoplastic meningitis during the course of their disease.[4] The incidence of undiagnosed neoplastic meningitis may be 40% or more in solid tumors.[5]

Among solid tumors, breast cancer (12%–35% of all cases of neoplastic meningitis), lung cancer (10%–26%), and melanoma (5%–25%) represent the most common causative cancers that result in neoplastic meningitis.[4,6–9] Due to its high incidence, breast cancer is the most common cause of solid tumor– related neoplastic meningitis, with an estimated occurrence of 3% to 5%.[4] The incidence of neoplastic meningitis in non–small-cell lung cancer (NSCLC) is approximately 1% to 3%.[4,7] Neoplastic meningitis may be observed in up to 20% of patients with metastatic melanoma.[4,7] Neoplastic meningitis is diagnosed in most patients (70% overall) with active systemic disease; however, neoplastic meningitis can present as the first site of metastatic disease after a disease-free interval (20%) or may be the first manifestation of cancer (5%).[4,8]

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