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Meningitis Carcinomotosa
05 November 2004
Carcinomatous
meningitis, neoplastic meningitis, leptomeningeal seeding, leptomeningeal
metastasis
Diagnostic
difficulty
On post mortem,
may not even be macroscopically visible
Multifocal nature
Frequency
Increasingly
recognized
10%
ALL as initial
model
|
Primary Tumor |
Autopsy number |
% with
meningitis carcinomotosa |
|
ALL |
87 |
21 |
|
AML |
104 |
5 |
|
Hodgkin
lymphoma |
119 |
2 |
|
Non Hodgkin
lymphoma |
190 |
13 |
|
Breast |
324 |
11 |
|
Melanoma |
125 |
6 |
|
Lung |
297 |
4 |
|
Gastrointestinal |
311 |
3 |
|
Sarcoma |
126 |
1 |
UTILITY OF
CEREBRAL SYMPTOMS & SIGNS
|
SYMPTOM
|
% |
|
Headache |
40 |
|
Mental change |
30 |
|
Nausea &
vomiting |
20 |
|
Vertigo |
4 |
|
Gait
difficulty |
68 |
|
Dysarthria /
dysphasia |
12 |
|
Loss of
consciousness |
13 |
|
SIGN |
|
|
Papilledema |
12 |
|
Seizures |
15 |
|
Extensor
plantars |
66 |
|
Hemiparesis |
1 |
|
Diabetes
insipidus |
2 |
UTILITY OF
CRANIAL NERVE SYMPTOM & SIGNS
|
SYMTOM |
% |
|
Visual loss |
12 |
|
Diplopia |
20 |
|
Facial
numbness |
4 |
|
Hearing loss |
9 |
|
Tinnitus |
4 |
|
Dysphagia |
4 |
|
Decreased
taste |
2 |
|
Hoarseness |
1 |
|
SIGN |
|
|
Optic
neuropathy |
22 |
|
Ocular muscle
paresis |
38 |
|
Trigeminal
neuropathy |
14 |
|
Facial
weakness |
26 |
|
Hearing loss |
20 |
|
Decreased gag
reflex |
9 |
|
Hypoglossal
neuropathy |
10 |
UTILITY OF
SPINAL NERVE SYMPTOM & SIGNS
|
SYMPTOM |
% |
|
Pain |
40 |
|
Paresthesia |
42 |
|
Weakness |
50 |
|
Bladder /
bowel dysfunction |
17 |
|
SIGN |
|
|
Neck stiffness |
17 |
|
Neck pain with
movement |
6 |
|
Straight leg
raising |
16 |
|
Absent reflex |
76 |
|
Dermatomal
sensory loss |
50 |
|
LMN weakness |
78 |
UTIITY OF
LUMBAR PUNCTURE (3 LP)
|
CSF |
% |
|
Pressure > 16
cm |
71 |
|
Cells >5/mm3 |
72 |
|
Protein >50
mg/dl |
90 |
|
Glucose <40
mg/dl |
41 |
|
Cytology |
91 |
|
Normal |
1 |
Immunocytochemistry: 9% increase in sensitivity (esp lymphoma)
Biochem:
Specific: CEA, B-HCG (choriocarcinoma, embryonal carcinoma, germ
cell tumor), AFP (teratocarcinoma, yolk sac tumor,
embryonal carcinoma),
CA-125 (ovarian cancer), CA 15-3 (breast cancer),
melanin (melanoma)
Nonspecific: B2 microglobulin, glucuronidase,
LDH.
Flow cytometry
CT/MRI with
contrast
Myelography
DSA
Meningeal biopsy
WHEN DIAGNOSIS
UNCERTAIN
Repeat LP in 2
weeks
Repeat MRI with
more contrast
Diagnosis will
make itself known in several weeks
PROGNOSIS
6-8 weeks from
time of diagnosis
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