Approach to the patient with leptomeningeal metastases

Leptomeningeal spread occurs in both solid tumors and hematologic malignancies. Common solid tumors that metastasize to the leptomeninges include melanoma, breast cancer, small-cell lung cancer, and non-small-cell lung cancer. Leptomeningeal disease (LMD) for all primary cancer types portends a very poor prognosis with average survival of 4-6 weeks post diagnosis if left untreated and an average of 3.5 months if treated. LMD can be diagnosed with positive CSF cytology for malignancy, positive radiologic findings with supportive clinical findings, or signs and symptoms suggestive of cerebrospinal fluid (CSF) involvement in a patient with known malignancy. Treatment is individualized based on various factors including performance status, type and state of systemic cancer, burden of leptomeningeal disease, and clinical symptoms. Management includes a multidisciplinary approach with involvement of palliative care for symptom management, radiation oncology, and hemato-oncology in conjunction with neuro-oncology for systemic and intra-CSF therapies as well as neurosurgery for placement of Ommaya and ventriculoperitoneal (VP) shunt when appropriate. Continued work in this area holds promise for future advances in prognosis.