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BRIEF COMMUNICATIONS: Antonio M.P. Omuro, Enrico C. Lallana, Mark H. Bilsky, and Lisa M. DeAngelis Ventriculoperitoneal shunt in patients with leptomeningeal metastasis Neurology 2005; 64: 1625-1627 [Abstract] [Full text] [PDF]

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Ventriculoperitoneal shunt in patients with leptomeningeal metastasis

Marc C. Chamberlain, MD, FAAN, Michael Glantz, MD, FAAN, U Mass, Worcester, MA   (29 September 2005)

Reply to Chamberlain et al

Lisa M. DeAngelis, MD, Antonio M.P. Omuro, MD, Enrico C. Lallana, MD, Mark H. Bilsky, MD, Sloan-Kettering, New York   (29 September 2005)

Ventriculoperitoneal shunt in patients with leptomeningeal metastasis 29 September 2005
Marc C. Chamberlain, MD, FAAN, H. Lee Moffitt Cancer Center & Research Institute - Dept of Interdisciplinary Oncology 12902 Magnolia Drive, Tampa, FL 33612, Michael Glantz, MD, FAAN, U Mass, Worcester, MA Send Correspondence to journal: Re: Ventriculoperitoneal shunt in patients with leptomeningeal metastasis chambemc{at}moffitt.usf.edu Marc C. Chamberlain, MD, FAAN, et al.	Omuro et al reviewed the database from the Memorial Sloan Kettering Cancer Center and report that 6% of all patients seen with leptomeningeal metastases (LM) required ventriculoperitoneal (VP) shunting for relief of symptoms secondary to hydrocephalus. [1] In such patients, median survival following diagnosis and treatment was 2 months. Several aspects of this report merit commentary. First, LM is a metastatic disease that is recognized to result in compartmentalization of CSF flow. Hydrocephalus is one manifestation of CSF compartmentalization that is easily demonstrated by anatomic brain imaging. Utilizing radioisotope CSF flow studies, some investigators have concluded that CSF compartmentalization is common in LM. Compartmentalization is recognized to occur in a third of patients with LM of which two thirds of all CSF obstruction occurs in the spinal subarachnoid space. The remaining third of CSF obstruction is seen in the intracranial compartment and may occur at several locations in addition to intraventricular as reported by Omuro. CSF compartmentalization has been demonstrated pathologically to result from small volume tumor adhesions obstructing CSF passage and as a result, the majority of cases have no MR correlate, rendering MR ineffective in defining the site of obstruction. Dynamic radioisotope CSF flow studies are superior in this regard. Second, the demonstration of CSF compartmentalization has several treatment implications. [2-4] If intra-CSF chemotherapy is contemplated, administration of drug into a compartmentalized CSF volume results in inhomogeneous drug distribution and failure to treat LM distal to the site of CSF obstruction. Studies have shown that CSF obstruction is not responsive to intra-CSF chemotherapy and consequently, involved- field radiotherapy is required. In patients with intracranial obstruction, 50% will re-establish normal CSF flow following whole brain radiotherapy. In patients with spinal subarachnoid obstruction, 35% of patients re-establish CSF flow following site directed radiotherapy. Consequently, a significant group of patients have persistent obstruction and may require CSF diversion (as Omuro et al report) for symptomatic relief. Lastly, in patients with persistent CSF flow obstruction, outcome compared to patients with normal or re-established CSF flow is significantly worse. [5] It is our view that patients with uncorrectable CSF obstruction be offered symptom directed treatment and no chemotherapy due to the expected impoverished survival. Omuro et al emphasize the complexity of treating patients with LM and remind neurologists that there is a clinically identifiable subset of patients with LM who likely will not benefit from LM-directed therapy. References 1. Omuro AMP, Lallana EC, Bilsky MH, DeAngelis LM. Ventriculoperitoneal shunt in patients with leptomeningeal metastases. Neurology 2005;64:1625-1627. 2. Glantz MJ, Hall WA, Cole BF et al. Diagnosis, management, and survival of patients with leptomeningeal cancer based on cerebrospinal fluid-flow status. Cancer 1995;75:2919-2931. 3.Chamberlain MC. Radioisotope CSF flow studies in leptomeningeal metastases. J Neuro Oncol 1998;38:135-140. 4.Chamberlain MC, Kormanik P, Jaeckle KA et al. 111Indium-diethylenetriamine pentaacetic acid CSF flow studies predict distribution of intrathecally administered chemotherapy and outcome in patients with leptomeningeal metastases. Neurology 1999;52:216-217. The authors report no conflicts of interest.
Reply to Chamberlain et al 29 September 2005
Lisa M. DeAngelis, MD, Memorial Sloan-Kettering Cancer Center 1275 York Avenue, New York, NY 10021, Antonio M.P. Omuro, MD, Enrico C. Lallana, MD, Mark H. Bilsky, MD, Sloan-Kettering, New York Send Correspondence to journal: Re: Reply to Chamberlain et al deangell{at}mskcc.org Lisa M. DeAngelis, MD, et al.	We appreciate Drs. Chamberlain and Glantz’s interest in our article, but want to emphasize that the focus of our paper was on intracranial hypertension (ICH) in patients with leptomeningeal metastases (LM) and not CSF compartmentalization.[1] We agree that CSF compartmentalization is a common consequence of tumor in the subarachnoid space and can lead to elevated intracranial pressure.[5] However, the symptoms of ICH are often attributed to the disease itself and not to the secondary rise in intracranial pressure. Consequently, the symptomatic management is often misdirected and ineffective. The purpose of our manuscript was to describe the role of ventriculoperitoneal (VP) shunting in providing rapid symptom relief in these patients. Furthermore, this was true for three of our patients who had no evidence of hydrocephalus, highlighting the importance of recognizing ICH clinically. Drs. Chamberlain and Glantz suggest that whole brain radiotherapy may relieve CSF obstruction, but 38% of our patients had already received whole brain radiotherapy without improvement. Many of the remaining patients went on to receive whole brain radiotherapy, but treatment with cranial irradiation in the setting of uncontrolled ICH is dangerous and the intracranial pressure must be addressed first; hence, the need for VP shunt in these patients. We did not address the issue of definitive treatment for LM and did not intend to suggest that patients with ICH automatically fall into a category of patients who would not benefit from therapy. A number of our patients survived years after placement of a VP shunt. Therefore, some patients who appear initially to have a poor prognosis can do well for an extended period if vigorously treated. Reference 5. Mason WP, Yeh SD, DeAngelis LM. 111Indium-diethylenetriamine pentaacetic acid cerebrospinal fluid flow studies predict distribution of intrathecally administered chemotherapy and outcome in patients with leptomeningeal metastases. Neurology 1999;50:438-44. The authors report no conflicts of interest.