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

Abstract

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.

Leptomeningeal Disease (LMD) in Patients with Melanoma Metastases

“…Lumbar puncture is another procedure to relieve symptoms from hydrocephalus as well as allowing CSF collection for further analysis [ 52 , 55 , 73 ]. In cases of obstructive hydrocephalus, due to bulky tumor mass, palliative radiotherapy is an initial treatment option; however, sometimes RT cannot manage the patient’s symptoms, and CSF diversion using ventriculoperitoneal shunting is an alternative treatment [ 145 , 146 , 147 , 148 ].…”

Stereotactic Radiosurgery for Intraventricular Metastases: A Multicenter Study

“…Patient management should be aimed toward palliative symptomatic relief in accordance with patients' goal of care, especially in the case of LMD-associated hydrocephalus and in patients with limited expected survival. 31,32 AREs represent a major complication of SRS, with the risk increasing exponentially with lesion size and prescription doses used. 17 Although lower single-fraction prescription doses can mitigate this risk, hypofractionated SRS has been increasingly favored for large tumors to reduce the incidence of AREs and…”

“…Patient management should be aimed toward palliative symptomatic relief in accordance with patients' goal of care, especially in the case of LMD-associated hydrocephalus and in patients with limited expected survival. 31,32…”

The Spectrum of Headache in Leptomeningeal Metastases: A Comprehensive Review with Clinical Management Guidelines

“…Large volume CSF removal of 20–30 cm 3 often provides rapid but transient improvement in headache and neurologic symptoms, as CSF re-accumulation generally occurs over the subsequent 12–24 h. A more permanent solution involves neurosurgical consultation for placement of a ventriculoperitoneal or ventriculoatrial shunt, which will drain excess CSF into the peritoneal cavity or systemic circulation, respectively. Extracranial shunting in patients with leptomeningeal metastases is a palliative procedure and may allow patients to continue with tumor-directed therapy [ 44 ]. However, as the presence of increased ICP is usually indicative of more advanced leptomeningeal metastases and high neurologic symptom burden, survival after extracranial shunt placement is generally only 3–5 months.…”