Forty-four patients with documented meningeal carcinomatosis (small-cell lung carcinoma [SCLC], 29%; breast carcinoma, 25%) were treated in a prospective randomized trial with intrathecal methotrexate (MTX) 15 mg or MTX plus cytosine arabinoside (Ara-C) 50 mg/m2. Most patients received intrathecal hydrocortisone (HC) each treatment to minimize arachnoiditis. Overall response was 55%. Seven patients achieved complete response. Response to MTX was superior to combined MTX/Ara-C, but not significantly so (61% v 45%; P greater than .10). Response was more frequent if drugs were administered via Ommaya reservoir than by lumbar puncture (65% v 48%; P greater than .10). Concurrent radiotherapy to the CNS was associated with significantly better response (73% v 35%; P less than .05). Small-cell lung carcinoma patients showed the best response (69%). Overall median survival for the whole group was 8 weeks, but responders fared better than nonresponders (median survival, 18 v 7 weeks; P less than .05). Nausea and vomiting were the most common toxicities encountered (45%), but rarely proved limiting. An unusual, previously undocumented reaction to intrathecal HC was noted. MTX is moderately effective in nonleukemic meningeal carcinomatosis, but the addition of Ara-C does not appear to improve results. Pretreatment factors did not predict outcome in this trial.

Summary Of 297 patients with metastatic testicular and extragonadal germ cell tumours (GCT), bone involvement was detected clinically in 3% (7/251) of those at first presentation and in 9% (4/46) of relapsed cases. This difference was not statistically significant (95% confidence limits -2%; +14%). Concurrent systemic metastases, commonly involving lung (7/11 cases) and para-aortic lymph nodes (6/11), were present in all patients with bone disease. All affected patients had localized bone pain and lumbar spine was the most frequent site involved (9/11). Spinal cord compression occurred in two patients while a third developed progressive vertebral collapse after chemotherapy and required extensive surgical reconstruction. At median follow-up of 4 years, survival among patients presenting with bone disease (6/7) was similar to overall survival in the whole group (84%) and appeared better than in those with liver (18/26, 69%) or central nervous system (6/9) metastases at presentation.Back pain in metastatic germ cell tumours is often due to retroperitoneal lymphadenopathy but lumbar spine osseus metastases must be recognized early if severe potential complications, such as spinal cord compression, are to be avoided. In this series, bone metastases were not seen in the absence of widespread systemic disease suggesting all solitary bony lesions in GCT patients should be biopsied.Bone is an uncommon site for metastases from testicular and extragonadal germ cell tumours (GCT) (Pugh, 1982). The large study of Dixon & Moore (1953) described metastases seen in 1,000 testicular GCT affecting United States servicemen to January 1948. Autopsy-proven bony metastases were seen in 21% of GCT containing mainly embryonal carcinoma and 36% of those with predominant teratoma but not in other histologic types. Bones of the trunk were involved most commonly. Mostofi (1973) reported 6,000 testicular tumours on the American Registry of Pathology over 25 years and noted a similar distribution of osseus metastases. These pathologic series largely predated the considerable recent advances in treatment of GCT and in methods for demonstrating bone metastases radiologically during life. With optimal radiotherapeutic techniques in seminoma, very high overall cure rates have been possible for over 20 years (Ball et al., 1982;Duncan & Munro, 1987;Hay et al., 1984). Isotope bone scans, computerized tomography (CT) and, most recently, magnetic resonance imaging (MRI) have provided much more sensitive means for diagnosing bone involvement than plain radiographs.Johnson et al. (1976) reported an autopsy series of testicular GCT where 47% of bony metastases were seen among seminoma patients, significantly more than in all other histologic subtypes. Bredael et al. (1982) showed similar results in another postmortem series. This apparent change in metastatic pattern from the older series may reflect radiotherapy-induced modification of seminoma natural history with retroperitoneal disease controlled but late recurrence occurring in other sites, incl...

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