Leptomeningeal carcinomatosis from oesophageal cancer, presenting as meningitis

Abstract

SUMMARYA 47-year-old woman presented with headache, neck pain, dizziness, nausea and vomiting for 4-5 days. She also had a history of weight loss and difficulty in swallowing. On physical examination, she had nuchal rigidity with a positive Kernig's sign. Cerebrospinal fluid analysis revealed mild pleocytosis but some atypical cells were also noted. Cytopathological analysis of the atypical cells showed high nuclear/cytoplasmic ratios and eccentric nuclei with prominent nucleoli, consistent with malignancy. A CT scan of the head and neck showed multiple lytic lesions involving the left calvarium, and diffuse thickening and enhancement of meninges over the left cerebral area. Extensive osteolytic lesions were also noted on the vertebral bodies, pedicles and lamina, at multiple levels of the cervical spine. An endoscopy revealed a mass at the gastro-oesophageal junction, and biopsy confirmed moderately differentiated adenocarcinoma of the oesophagus. The patient was started on chemotherapy along with radiation therapy. BACKGROUND

Isolated leptomeningeal carcinomatosis and possible fungal meningitis as late sequelae of oesophageal adenocarcinoma

“…Carcinomatous meningitis is a rare cause of delirium, and recurrence of a solid malignancy as isolated leptomeningeal metastases not visible on imaging is rarer still. Neurological complications resulting from leptomeningeal carcinomatosis secondary to a primary oesophageal cancer have previously been described,4 5 7 but this is the first report of a recurrence presenting in this fashion. A possible mechanism for the development of leptomeningeal metastases without nodal disease could be dural injury and seeding at the time of resection; however, the description of previous similar cases, particularly that described by Lobo et al , which presented with leptomeningeal seeding without any surgical intervention,7 raises the possibility that this could be a natural, rather than iatrogenic, phenomenon.…”

“…Neurological sequelae of oesophageal carcinoma are rare and may be due to cerebral or leptomeningeal metastases and paraneoplastic phenomena. Previous case reports illustrate the primary presentation of oesophageal carcinoma as classic meningitis,4 malignant meningitis causing sensorineural hearing loss,5 limbic encephalitis6 and confusion 7. Recurrence following treatment has also been described presenting with haemorrhagic brain metastasis 8.…”

Intrathecal topotecan with systemic checkpoint inhibitor therapy for gastroesophageal cancer with leptomeningeal involvement: two case reports and review of the literature

“…Specifically, the diagnosis can be made by one of the following: (I) positive CSF cytology for tumor cells (gold standard); (II) positive radiologic findings with supportive clinical findings; or (III) symptoms with suggestive CSF in a patient with cancer (CSF may have high white blood cell count, low glucose, and high protein) ( 7 ). Table 3 outlines published cases of GE cancers with LM ( 1 , 3 , 8 - 12 ).…”

“…The most commonly associated solid tumors with LM include breast cancer, lung cancer, and melanoma ( 3 ). LM in gastroesophageal (GE) malignancies is exceedingly rare, with an estimated incidence of 0.17–0.19% ( 4 , 5 ).…”