A Case of Leptomeningeal Carcinomatosis from Aggressive Metastatic Prostate Cancer

Abstract

Leptomeningeal carcinomatosis (LC) is a rare leptomeningeal spread of diffusely metastatic tumors. It occurs more commonly with hematologic tumors, less commonly with solid tumors, and is exceedingly rare in prostate cancer. Due to its scarcity, it has traditionally been difficult to diagnose LC but advancement of MRI has helped considerably. However, even with technological improvements, pre-mortem diagnosis of LC remains difficult and controversial. Our case is a 71-year-old male with prostate cancer with bone metastases who presented to our facility with altered mental status (AMS), lower extremity weakness, and worsening diarrhea. The diarrhea was responsive to antibiotic therapy, but his AMS did not resolve. A head CT without contrast was negative but follow-up brain MRI revealed leptomeningeal enhancement highly suggestive of LC. Cerebrospinal fluid (CSF) cytology results were negative and other CSF studies were inconclusive. Although further studies were planned, the patient continued to deteriorate, and the family elected to withdraw care. He passed away without beginning treatment for the LC. Despite advances in cancer therapies, LC remains difficult to diagnose and treat. Imaging may be suggestive of the condition but the confirmatory tests such as repeated CSF cytology or meningeal biopsy are not only invasive but also usually occur postmortem. Additional methods of CSF testing have been studied to evaluate their role in accurately diagnosing LC but low specificity for LC has somewhat limited their use. Although treatment options are mainly palliative in nature, prompt recognition and early treatment could grant valuable time for patients and families.

Leptomeningeal involvement by prostate carcinoma an ominous head of a well-known Hydra

“…Specific MRI findings are considered highly suggestive but the confirmatory tests such as repeated CSF cytology or meningeal biopsy are invasive and are needed for pathologic confirmation. Often times due to late diagnosis, patients are symptomatic with decline in functional status which might limit the willingness to undergo invasive diagnostic procedures 13. In our case, the negative LP with the absence of intracerebral disease, and the patient preference to seek active treatment dictated the confirmation of LPMC through a meningeal biopsy.…”

Solitary Leptomeningeal Recurrence From Prostate Adenocarcinoma After Treatment With Cytotoxic Gene Therapy, Radiation Therapy, and Androgen Deprivation Therapy

“…Leptomeningeal disease is a rare manifestation of prostate cancer with only 46 previously reported cases in the literature. 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 In a large review of 41,830 prostate cancer patients at a MD Anderson Cancer Center, only 7 patients (<0.02%) had leptomeningeal disease. 18 An Italian study evaluating 943 patients with castrate resistant prostate cancer who received docetaxel found 9 patients (0.95%) with leptomeningeal disease.…”

“…A total of 46 previous cases of leptomeningeal metastatic prostate adenocarcinoma have been reported in the literature. 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 Only one reported a patient with solitary leptomeningeal recurrence (ie, no other systemic metastasis) of prostate adenocarcinoma- a very inexplicable situation. 16 We report the second such case, and the first autopsy-proven solitary leptomeningeal recurrence of prostate adenocarcinoma in a patient who received gene-RT with androgen deprivation therapy.…”

Unexpected infiltration of meninges by generalised diffuse large B-cell lymphoma manifesting as multiple cranial neuropathies in a patient with history of breast carcinoma

“…Leptomeningeal spread of malignant tumorous cells occurs more commonly in haematological malignancies (incidence of 10-15%) and less often with solid tumours such as breast cancer, lung cancer, and melanoma (incidence of 1-5%) [1]. Diagnostic methods mainly include clinical assessment, ce rebrospinal fluid cytological examinations [2], and magnetic resonance imaging (MRI) to distinguish brain metastases from other brain tumours [3].…”