Neoplastic meningitis (patient information)
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Overview
- Neoplastic meningitis is a secondary cancer of the subarachnoid space, meninges and pia matter from a primary tumor source. It is one of the dreaded complications of terminal malignancy. It could be from a distant metastasis or from a primary brain tumor. Most commonly documented primary distant source is beast cancer.
What are the symptoms of Neoplastic meningitis?
- The 3 affected neurologic domains of neoplastic meningitis in order of involvement is spinal cord and roots (60%) cranial nerve (35%) and cerebral hemisphere (15%)[1]
- Documented spinal cord manifestations of NM include: weakness (upper limb greater than the lower limb), sensory deficits in dermatomal origin and pain in the neck, back and upper extremity that is most frequently radicular.
- Cranial nerve manifestation includes diplopia which is the most common sign in this category; trigeminal sensory and motor loss, cochlear dysfunction and optic neuropathy have also been observed.
- Cerebral hemisphere manifestations are mostly vague and non-specific includes headache and mental status changes.
What causes Neoplastic meningitis?
- Neoplastic meningitis is caused by another tumor seeding into the CNS
- Cancer from a distant source enter the CSF by means of the following:[2]
- Hematogenous Spreadfrom a distant primary tumor site - cancer cells produce enzymes that allows them to microscopically invade blood vessels to reach the subarachnoid space through the systemic arterial circulation or by the Batsons venous plexus.
- Invasion from a primary brain tumor to the meninges - when cancer cells lodge into small arteries causing local ischemia and blood vessel damage leading to spillage of neoplastic cells to the Virchow-Robin spacesthereby providing access to the subarachnoid space.
- Infiltration to the spinal cord - Cancer cells gain access to the subarachnoid space through this route via the perivascular tissues the surround the blood vessels at the brain entrance. Direct infiltration of the spinal nerve roots (dorsal and ventral) has also been documented.
- Cancer spread a neural pathways to reach the meninges - The CSF carries cancer cells through the brain tracts. This occurs mostly in tumors of the head and neck.[3]
- Iatrogenic - from surgical procedures involving removal of a primary brain tumor
- Primary neoplastic meningitis has also been documented particularly with melanoma.[4]
- Cancer from a distant source enter the CSF by means of the following:[2]
Who is at highest risk?
- Patients with advanced breast cancer have increased propensity for NM. ER-, PR-positivity in beast cancer increases incidence of neoplastic meningitis. Triple negative breast cancer and the HER2/neu gene positivity displays tropism for CNS metastasis. Among the histologic subtypes of breast cancer, loblular carcinoma demonstrated the highest prevalence for neoplastic meningitis.
- Brain surgery increases the chance of developing NM. It has been observed after resection of brain tumor (particularly piecemeal resection vs en-block resection) particularly tumors located in the cerebellum. Other cranial surgeries done with involvement of ventricular system manipulation in a patient with known brain metastasis increases the risk. Furthermore, the incidence of neoplastic meningitis seem higher in patient treated with surgery followed by stereotactic radiosurgery compared with radiosurgery alone.
- Primary brain cancer always poses a risk for the development of neoplastic meningitis. It is diagnosed in 1-2% of cases of ependymoma, medulloblastoma, germinoma and glioblastoma combined.
- Brain metastasis is one of the more obvious risk factors for neoplastic meningitis. Coexisting brain metastasis are associated with neoplastic meningitis in breast cancer (33-54%), lung cancer (56-82%) and melanoma (87-96%).
Diagnosis
When to seek urgent medical care?
Treatment options
Where to find medical care for Neoplastic meningitis?
Directions to Hospitals Treating Neoplastic meningitis