Palliative shunt surgery for patients with leptomeningeal metastasis

Comparative analysis of the lumboperitoneal shunt versus ventriculoperitoneal shunt for leptomeningeal metastasis-associated hydrocephalus in non-small cell lung cancer

PURPOSE

Leptomeningeal metastasis (LM)-associated hydrocephalus is a rare but severe complication of non-small cell lung cancer (NSCLC). The spread of malignant cells to the leptomeninges obstructs cerebrospinal fluid flow and increases intracranial pressure (ICP). This study compared the outcomes of lumboperitoneal (LP) and ventriculoperitoneal (VP) shunt surgeries in managing LM-associated hydrocephalus, focusing on symptom-free periods (SFPs) and overall survival (OS).

METHODS

A retrospective analysis was conducted on 43 NSCLC patients with LM-associated hydrocephalus who underwent shunt surgery between 2017 and 2024. Patients were classified into LP (n = 23) and VP (n = 20) groups. Clinical characteristics, surgical outcomes, and survival rates were analyzed using Kaplan-Meier survival and Cox regression analyses. Karnofsky performance status (KPS), increased intracranial pressure (IICP) symptoms, and postoperative epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKI) treatment were evaluated for prognostic significance.

RESULTS

No significant difference was observed between VP and LP shunt surgeries regarding SFP (VP: 5.02 ± 1.29 months, LP: 7.50 ± 2.86 months, p = 0.906) or OS (VP: 8.43 ± 1.89 months, LP: 9.62 ± 3.20 months, p = 0.820). High preoperative KPS, absence of ICP symptoms, and postoperative EGFR-TKI treatment were significantly associated with improved SFP and OS (p < 0.05). LP shunt surgery had shorter anesthesia and fewer complications compared to VP shunt surgery, representing a viable option for patients unsuitable for general anesthesia.

CONCLUSION

LP and VP shunt surgeries are equally effective for patients with LM-associated hydrocephalus in NSCLC. LP shunt surgery under local anesthesia could be recommended for its safety and patient acceptability. Favorable prognostic factors, including high KPS, absence of ICP, and postoperative EGFR-TKI treatment, should guide individualized treatment strategies to enhance patient outcomes and quality of life.

Improved Survival and Symptom Relief Following Palliative Cerebrospinal Fluid Diversion for Leptomeningeal Disease from Brain Cancers: A Case Series and Systematic Review

BACKGROUND

Leptomeningeal disease (LMD) from cancer indicates advanced cancer and can lead to obstructive hydrocephalus, for which palliative cerebrospinal fluid (CSF) diversion may be indicated to alleviate symptoms. We investigated surgical outcomes for hydrocephalus for adult patients with LMD and conducted a systematic review on pediatric and adult cases.

METHODS

We analyzed outcomes from a 10-year period of patients with neoplastic LMD, obstructive hydrocephalus, and documented date of death. We also searched databases from inception until 20 August 2022, using search terms including 'cancer', 'hydrocephalus', and 'shunt'. Preferred reporting items for systematic reviews and meta-analyses guidelines were followed.

RESULTS

Among 50 patients, 30 (60%) underwent CSF diversion after LMD diagnosis with comparable median age in both the surgery (58.4 ± 14.4 years) and non-surgery (57.8 ± 14.5 years) groups. Twenty-three patients (76.7%) achieved symptom relief. The surgery group lived longer after LMD diagnosis than the non-surgery group (6.6 ± 6.0 vs. 1.3 ± 4.3 months, p < 0.001) and had a higher likelihood of survival (hazard ratio 2.49, 95% confidence interval 1.37-4.52, p = 0.002). Median survival after surgery was 2.8 ± 3.8 months. From 23 articles, 995 patients (34.3%) presented with LMD. Complication rates were 0-37.7% with no extraneural metastases. Symptom relief rates were 50-100%. Three studies reported median survival after surgery (2-3.3 months).

CONCLUSIONS

A rare entity with dismal prognosis, LMD can present as symptomatic hydrocephalus in patients with cancer. Symptom relief and improved survival can be achieved with palliative CSF diversion with low complication rates. Prospective studies are needed to assess the outcomes and needs of these patients.

Ventriculoperitoneal Shunt and Endoscopic Third Ventriculostomy for Hydrocephalus in Adult Patients With Brain Metastases

BACKGROUND

Patients with brain metastases and concurrent hydrocephalus warrant expedited treatment. This study evaluated survival outcomes of patients with brain metastases and hydrocephalus treated with endoscopic third ventriculostomy (ETV) or ventriculoperitoneal shunt (VPS) placement.  Materials and methods: Twenty patients with brain metastases and hydrocephalus were treated with ETV or VPS over 10 years (July 18, 2013-November 20, 2023). Our findings were juxtaposed against data from 77 published controls to assess whether ETV and VPS management correlated with enhanced survival.  Results: The most common primary cancer diagnoses were breast (9 [45%]) and non-small cell lung cancer (5 [25%]). Seven (35%) patients had leptomeningeal carcinomatosis. The initial procedure to treat hydrocephalus was a VPS in 13 (65%) patients; seven (35%) had an ETV first. Patients with a single brain metastatic lesion had a longer median overall survival (OS) than those with more than one metastatic site (154.5 versus 67.0 days). Our cohort had a similar median OS following the ETV/VPS procedure compared to published data (92.5 versus 91 days). In both ETV and VPS subsets, our cohort had a longer median OS than published data: 106 versus 56 days for ETV and 79 versus 56 days for VPS.  Conclusions: Patients with brain metastases and hydrocephalus who underwent an ETV or VPS placement had improved survival compared to historical controls and if they had only one metastatic lesion. Interdisciplinary evaluation of patients with brain metastases by neurosurgeons as well as medical and radiation oncologists is warranted to facilitate systemic therapy after hydrocephalus relief.

Ventriculoperitoneal shunting with an on-off valve for patients with leptomeningeal metastases and intracranial hypertension

Background

We report our experience with using a ventriculoperitoneal shunt (VPS) with an on-off valve and in-line Ommaya reservoir for the treatment of hydrocephalus or intracranial hypertension in patients with leptomeningeal disease (LMD). Our goal was to determine whether control of intracranial pressure elevation combined with intrathecal (IT) chemotherapy would extend patient survival.

Methods

In this IRB-approved retrospective study, we reviewed 58 cases of adult patients with LMD from solid cancers who received a VPS with a reservoir and an on-off valve at M D Anderson Cancer Center from November 1996 through December 2021. Primary tumors were most often melanoma (n = 19) or breast carcinoma (n = 20). Hydrocephalus was diagnosed by clinical symptoms and findings on magnetic resonance imaging (MRI), and LMD by MRI or cerebrospinal fluid analysis. Differences in overall survival (OS) were assessed with standard statistical techniques.

Results

Patients who received a VPS and more than 3 IT chemotherapy sessions survived longer (n = 26; OS time from implantation 11.7 ± 3.6 months) than those who received an occludable shunt but no IT chemotherapy (n = 24; OS time from implantation 2.8 ± 0.7 months, P < .018). Peritoneal seeding appeared after shunt insertion in only two patients (3%).

Conclusions

This is the largest series reported to date of patients with LMD who had had shunts with on-off valves placed to relieve symptoms of intracranial hypertension. Use of IT chemotherapy and control of hydrocephalus via such shunts was associated with improved survival.

Building Team Medicine in the Management of CNS Metastases

CNS metastases are often terminal for cancer patients and occur at an approximately 10-fold higher rate than primary CNS tumors. The incidence of these tumors is approximately 70,000-400,000 cases annually in the US. Advances that have occurred over the past two decades have led to more personalized treatment approaches. Newer surgical and radiation techniques, as well as targeted and immune therapies, have enanled patient to live longer, thus increasing the risk for the development of CNS, brain, and leptomeningeal metastases (BM and LM). Patients who develop CNS metastases have often been heavily treated, and options for future treatment could best be addressed by multidisciplinary teams. Studies have indicated that patients with brain metastases have improved survival outcomes when cared for in high-volume academic institutions using multidisciplinary teams. This manuscript discusses a multidisciplinary approach for both parenchymal brain metastases as well as leptomeningeal metastases implemented in three academic institutions. Additionally, with the increasing development of healthcare systems, we discuss optimizing the management of CNS metastases across healthcare systems and integrating basic and translational science into our clinical care to further improve outcomes. This paper summarizes the existing therapeutic approaches to the treatment of BM and LM and discusses novel and emerging approaches to optimizing access to neuro-oncologic care while simultaneously integrating multidisciplinary teams in the care of patients with BM and LM.

Postoperative course of cerebrospinal fluid diversion in the setting of leptomeningeal disease: a systematic review, meta-analysis, and meta-regression with an illustrative case

BACKGROUND

Management of hydrocephalus symptoms in the setting of leptomeningeal disease (LMD) includes cerebrospinal fluid (CSF) diversion, which can in the form of ventriculoperitoneal shunting (VPS) and lumboperitoneal shunting (LPS). However, the quantifiable postoperative course following this intervention is poorly defined. Correspondingly the aim of our study was to quantitatively define and analyze the pooled metadata regarding this topic.

METHODS

Multiple electronic databases from inception to March 2023 were searched following PRISMA guidelines. Respective cohort-level outcomes were then abstracted and pooled by means of meta-analyses and analyzed by means meta-regression, both utilizing random-effects modeling. Post-hoc bias evaluation was then performed for all outcomes.

RESULTS

A total of 12 studies were identified for inclusion, describing 503 LMD patients managed by CSF diversion - 442 (88%) by VPS and 61 (12%) by LPS. Median male percentage and age at diversion were 32% and 58 years respectively, with lung and breast cancer the most common primary diagnoses. Meta-analysis demonstrated pooled incidence of symptom resolution in 79% (95% CI 68-88%) of patients after index shunt surgery, and shunt revision required in 10% (95% CI 6-15%) of cases. Pooled overall survival from index shunt surgery was 3.8 mo (95% CI 2.9-4.6 mo) across all studies. Meta-regression demonstrated that studies published later trended towards significantly shorter overall survival from index shunt surgery (co-efficient=-0.38, P = 0.023), whereas the proportion of VPS to LPS in each study did not impact survival (P = 0.89). When accounting for these biases, overall survival from index shunt surgery was re-estimated to be shorter 3.1 mo (95% CI 1.7-4.4 mo). We present an illustrative case demonstrating the course of symptom improvement, shunt revision and an overall survival of 2 weeks from index CSF diversion.

CONCLUSION

Although CSF diversion in the setting of LMD can improve hydrocephalus symptoms in the majority of patients, there is a non-negligible proportion that will require shunt revision. Postoperatively, the prognosis of LMD remains poor irrespective of shunt type, and despite possible biases within the current literature, the expected median overall survival after index surgery is a matter of months. These findings support CSF diversion as an effective palliative procedure when considering symptoms and quality of life. Further research is required to understand how postoperative expectations can be managed to respect the best wishes of patients, their family, and the treating clinical team.

Cerebrospinal fluid diversion and outcomes for lung cancer patients with leptomeningeal carcinomatosis

OBJECTIVE

To investigate the outcomes of cerebrospinal fluid (CSF) diversion in lung cancer patients with leptomeningeal carcinomatosis (LMC).

METHODS

A retrospective review of consecutive lung cancer patients with LMC suffering from increased intracranial pressure (IICP) and hydrocephalus between February 2017 and February 2020. We evaluated the survival benefit of CSF diversion surgery and assessed the outcomes of treatments administered post-LMC in terms of overall survival and shunt-related complications.

RESULTS

The study cohort included 50 patients (median age: 59 years). Ventricular peritoneal (VP) shunts were placed in 33 patients, and lumbar peritoneal (LP) shunts were placed in 7 patients. Programmable shunts were placed in 36 patients. Shunt adjustment was performed in 19 patients. Kaplan-Meier analysis revealed that shunt placement increased overall survival from 1.95 months to 6.21 months (p = 0.0012) and increased Karnofsky Performance Scores (KPS) from 60 to 70. Univariate analysis revealed no difference between VP or LP shunts in terms of survival. No differences in post-shunt systemic treatments (tyrosine kinase inhibitors (TKIs) or systemic treatments) were observed in overall survival. Shunt-related complications were noted in 7 patients, including shunt obstruction (n = 4), infection (n = 1), and over-drainage (n = 2).

CONCLUSION

CSF diversion (VP or LP shunt) appears to be an effective and safe treatment for lung cancer patients with LMC and hydrocephalus. Programmable shunts should be considered for complex cases, which commonly require pressure adjustments as the disease progresses.

Malignant Meningitis Associated with Hydrocephalus

Malignant meningitis (MM) is the diffuse involvement of the leptomeninges by infiltrating cancer cells, most frequently from lung and breast cancers. This review is aimed to discuss the current advances in the diagnosis and management of MM, along with management of MM-associated hydrocephalus. We reviewed the literature using PubMed and Google Scholar search engines, focusing on various recent randomized controlled trials and clinical trials on MM. Given the hallmark multifocal involvement, the clinical symptoms and signs are also random and asymmetric. There are three important pillars for establishing a diagnosis of MM: clinical examination, neuroimaging, and CSF cytological findings. Several factors should be considered in decision-making, including performance status, neurological findings (clinical, MRI, and CSF flow dynamic), and evaluation of the primary tumor (nature and systemic dissemination). Response Assessment in Neuro-Oncology (RANO) working group recommended the objective assessment of disease for evaluating the progression and response to therapy. Pillars of current management are mainly focal irradiation and intrathecal or systemic chemotherapy. Symptomatic hydrocephalus is managed with a ventriculoperitoneal shunt, lumboperitoneal shunt, or endoscopic third ventriculostomy as palliative procedures, providing significant improvement in performance scores in the limited survival time of patients with MM. Studies using novel therapeutic approaches, such as new biological or cytotoxic compounds, are ongoing. Despite the use of all the combinations, the overall prognosis remains grim; therefore, decision-making for treatment should predominantly be based on attaining an optimal quality of life.

Cerebrospinal fluid diversion for leptomeningeal metastasis: palliative, procedural and oncologic outcomes

BACKGROUND

Leptomeningeal metastasis (LM) occurs in 3-5% of patients with solid metastatic tumors and often portends a severe prognosis including symptomatic hydrocephalus and intracranial hypertension. Cerebrospinal fluid (CSF) shunting can provide symptomatic relief in this patient subset; however, few studies have examined the role of shunting in the palliation, prognosis and overall oncologic care of these patients.

OBJECTIVE

To identify and evaluate risk factors associated with prognosis after CSF diversion and assess surgical, symptomatic and oncologic outcomes in this population.

METHODS

A retrospective study was conducted on patients with solid-malignancy LM treated with a shunt at a NCI-designated Comprehensive Cancer Center between 2010 and 2019.

RESULTS

One hundred and ninety patients with metastatic LM underwent CSF diversion. Overall survival was 4.14 months from LM diagnosis (95% CI: 3.29-4.70) and 2.43 months (95% CI: 2.01-3.09) from shunting. Karnofsky performance status (KPS) at time of shunting and brain metastases (BrM) number at LM diagnosis demonstrated significant associations with survival (HR = 0.66; 95% CI [0.51-0.86], p = 0.002; HR = 1.40; 95% CI [1.01-1.93] per 10 BrM, p = 0.04, respectively). Eighty-three percent of patients experienced symptomatic relief, and 79% were discharged home or to rehabilitation facilities post-shunting. Post-shunt, 56% of patients received additional systemic therapy or started or completed WBRT. Complications included infection (5%), symptomatic subdural hygroma/hematoma (6.3%), and shunt externalization/removal/repair (8%). Abdominal seeding was not identified.

CONCLUSIONS

CSF diversion for LM with hydrocephalus and intracranial hypertension secondary to metastasis can achieve symptomatic relief, hospital discharge, and return to further oncologic therapy, with a complication profile unique to this pathophysiology. However, decision-making in this population must incorporate end-of-life goals of care given limited prognosis.

Whole brain radiotherapy (WBRT) for leptomeningeal metastasis from NSCLC in the era of targeted therapy: a retrospective study

Background and purpose

Leptomeningeal metastasis (LM) is a rare but detrimental complication in patients with non-small cell lung cancer (NSCLC). Although whole brain radiotherapy (WBRT) is used to eliminating cancer cells or microscopic foci, it is becoming less favorable due to the concerns over neurocognitive toxicity. This study aimed to re-evaluate the role of WBRT in the setting of modern targeted therapy.

Materials and methods

From December 2014 to March 2019, 80 NSCLC patients with cytologically and/or radiologically proven LM diagnosis were retrospectively analyzed.

Results

The median OS (mOS) after diagnosis of LM was 8.0 (95%CI: 4.4 to 11.6) months, and the one-year OS was 39.4%. The mOS for EGFR-mutated LM patients was 12.6 (3.0 to 22.2) months versus only 4.1 (2.8 to 5.4) for patients with wild-type EGFR (P < 0.001). Younger patients (< 53.5 yrs.) appeared to have a better OS than older patients (≥53.5 yrs.) (12.6 vs. 6.1, P = 0.041). No survival benefits were found in EGFR-mutated patients who received WBRT (P = 0.490). In contrast, mOS was significantly prolonged in wild-type EGFR patients with WBRT versus non-WBRT (mOS: 8.0 vs. 2.1, P = 0.002). Multivariate analysis indicated that WBRT (P = 0.025) and younger age (P = 0.048) were independent prognostic factors that predicted prolonged survival for wild-type EGFR LM patients from NSCLC.

Conclusion

Our study demonstrated that WBRT has clear survival advantages for patients with wild-type EGFR, and molecular biological stratification of LM patients for WBRT is highly recommended.

Management of leptomeningeal carcinomatosis and challenges of trial design

PURPOSE OF REVIEW

Highlight recent data in lung and breast cancer leptomeningeal disease and address clinical trials that are open for patients.

RECENT FINDINGS

Patients with lung and breast cancer leptomeningeal disease have survival outcomes of less than 1 year, despite advances in treatment strategy. Efforts to develop liquid biopsy biomarkers of disease progression from cerebrospinal fluid and plasma are underway. There are over 10 clinical trials open for patients with leptomeningeal disease, half of which use immunotherapy.

SUMMARY

Consortium-based, multicenter clinical trials for patients with leptomeningeal disease are urgently needed to expand the treatment armamentarium.

Exclusive Cerebellar and Leptomeningeal Metastases from Early Gastric Cancer 14 Months after Proximal Gastrectomy: An Autopsy Case Report

We report a rare autopsy case in which the patient received gastrectomy after an endoscopic diagnosis of early gastric cancer, and had deteriorated due to exclusive metastatic cerebellar tumors identified 14 months after surgery. A 65-year-old male was diagnosed as having a 0-IIc-type early gastric cancer on the posterior wall of the upper stomach by gastrointestinal endoscopy in search of a cause of epigastralgia, and thus received proximal gastrectomy and pyloroplasty. Although the tumor was in the early stages and limited within the mucosal layer, adjuvant chemotherapy was started by using S-1 80 mg daily due to evidence of metastasis into lymph node #3 at the lesser curvature. Evidence of both recurrence and metastases was not detected by CT scans of the chest, abdomen, and pelvis, and the chemotherapy was completed 12 months after surgery. However, the patient was admitted to hospital 14 months postoperatively due to dizziness and gait disturbance. Cranial MRI (Magnetic Resonance Imaging) revealed multiple tumors in the bilateral cerebellar hemispheres with additional leptomeningeal involvement. The patient died 2 weeks after admission. An autopsy revealed metastatic cerebellar tumors and leptomeningeal lesions from the early gastric cancer, and obstructive hydrocephalus due to metastatic cerebellar tumors. To our knowledge, this case is the first report of metastasis exclusive to the cerebellum and leptomeninges from early gastric cancer limited to the mucosal layer.

Management of hydrocephalus in patients with leptomeningeal metastases: an ethical approach to decision-making

PURPOSE

Leptomeningeal metastases (LM) are a rare, but often debilitating complication of advanced cancer that can severely impact a patient's quality-of-life. LM can result in hydrocephalus (HC) and lead to a range of neurologic sequelae, including weakness, headaches, and altered mental status. Given that patients with LM generally have quite poor prognoses, the decision of how to manage this HC remains unclear and is not only a medical, but also an ethical one.

METHODS

We first provide a brief overview of management options for hydrocephalus secondary to LM. We then apply general ethical principles to decision making in LM-associated hydrocephalus that can help guide physicians and patients.

RESULTS

Management options for LM-associated hydrocephalus include shunt placement, repeated lumbar punctures, intraventricular reservoir placement, endoscopic third ventriculostomy, or pain management alone without intervention. While these options may offer symptomatic relief in the short-term, each is also associated with risks to the patient. Moreover, data on survival and quality-of-life following intervention is sparse. We propose that the pros and cons of each option should be evaluated not only from a clinical standpoint, but also within a larger framework that incorporates ethical principles and individual patient values.

CONCLUSIONS

The decision of how to manage LM-associated hydrocephalus is complex and requires close collaboration amongst the physician, patient, and/or patient's family/friends/community leaders. Ultimately, the decision should be rooted in the patients' values and should aim to optimize a patient's quality-of-life.