From the Guidelines
The management of leptomeningeal enhancement should prioritize early diagnosis and treatment, with a focus on the underlying cause, and may involve a combination of intrathecal chemotherapy, systemic therapy, radiation, and supportive care, as recommended by the most recent guidelines from the Society for Neuro-Oncology and American Society of Clinical Oncology 1.
The approach to managing leptomeningeal enhancement depends on the underlying cause, which can be infectious, neoplastic, or inflammatory.
- For infectious causes like bacterial meningitis, empiric antibiotics such as ceftriaxone (2g IV every 12 hours) plus vancomycin (15-20 mg/kg IV every 8-12 hours) should be started immediately, with adjustments based on culture results and continued for 10-14 days.
- Viral meningitis may require acyclovir (10 mg/kg IV every 8 hours) if herpes is suspected.
- For neoplastic causes (leptomeningeal carcinomatosis), intrathecal chemotherapy (methotrexate 12 mg twice weekly or cytarabine 50 mg twice weekly) combined with systemic therapy and/or radiation is often used, with a focus on systemic therapies with CNS bioactivity and blood-CSF barrier permeability 1.
- Inflammatory conditions like sarcoidosis or autoimmune disorders require immunosuppression, typically with corticosteroids (prednisone 0.5-1 mg/kg/day) followed by steroid-sparing agents.
Supportive care is essential across all etiologies, including:
- Pain management
- Anticonvulsants for seizures
- CSF diversion procedures if hydrocephalus develops Early diagnosis through CSF analysis, neuroimaging, and sometimes meningeal biopsy is crucial for directing appropriate therapy, as treatment delay can significantly impact neurological outcomes and survival 1.
The integration of systemic therapies with appreciable activity in the CNS should be considered in all patients with leptomeningeal metastases, either in addition to or in lieu of treatment with radiotherapy and intrathecal therapies 1. The use of proton CSI has demonstrated reasonable toxicity and superior survival compared to IFRT in adults with leptomeningeal metastases in phase I/II studies, and may be a therapeutic option with careful consideration of a patient’s performance status, extracranial disease, and goals of care 1.
Intrathecal chemotherapies are most effective in patients with thin linear leptomeningeal deposits and unobstructed CSF flow, and ventricular access devices are preferred over lumbar drug delivery in patients receiving intrathecal chemotherapy 1.
Overall, the management of leptomeningeal enhancement requires a multidisciplinary approach, with a focus on early diagnosis, individualized treatment, and supportive care, as recommended by the most recent guidelines from the Society for Neuro-Oncology and American Society of Clinical Oncology 1.
From the Research
Management Approach for Leptomeningeal Enhancement
The management approach for leptomeningeal enhancement typically involves a combination of treatments, including:
- Intrathecal chemotherapy: This involves administering chemotherapy drugs directly into the cerebrospinal fluid (CSF) to target cancer cells in the leptomeninges 2, 3, 4.
- Systemic chemotherapy: This involves administering chemotherapy drugs orally or intravenously to target cancer cells throughout the body 5, 3, 4.
- Radiation therapy: This involves using high-energy rays to kill cancer cells in the leptomeninges 5, 3, 4.
- Molecular targeted therapies: These are newer treatments that target specific molecules involved in cancer cell growth and survival, such as epidermal growth factor receptor (EGFR) inhibitors or anaplastic lymphoma kinase (ALK) inhibitors 3.
Diagnosis and Prognosis
Leptomeningeal enhancement is often diagnosed using a combination of clinical presentation, imaging studies (such as MRI or CT scans), and CSF analysis 4, 6. The prognosis for patients with leptomeningeal enhancement is generally poor, with a median survival of less than 6 months 2, 5, 3, 4. However, early diagnosis and treatment can help improve symptoms and prolong survival.
Treatment Outcomes
The outcomes of treatment for leptomeningeal enhancement can vary depending on the specific treatment approach and the individual patient's condition. Some studies have reported improved survival and symptom control with intrathecal chemotherapy and molecular targeted therapies 2, 3. However, more research is needed to fully understand the effectiveness of these treatments and to develop new and more effective therapies for leptomeningeal enhancement.
Patterns of Meningeal Enhancement
The patterns of meningeal enhancement can help differentiate between infectious and carcinomatous meningitis. Leptomeningeal enhancement is more commonly seen in infectious meningitis, while pachymeningeal enhancement is more commonly seen in carcinomatous meningitis 6.