Meningeal carcinomatosis from an ovarian primary with complete response to adjuvant chemotherapy after cranial irradiation

Prolonged Survival and Restored Useful Life by Early Induction of Intrathecal Chemotherapy in a Patient with Leptomeningeal Carcinomatosis from Ovarian Cancer

Leptomeningeal carcinomatosis (LMC) is a rare but devastating complication of advanced cancer. Breast cancer, lung cancer, and melanoma are the three most common causes of LMC, whereas it is rare in ovarian cancer. Here, we report the case of a 59-year-old woman who was diagnosed with LMC from ovarian cancer and was successfully treated with intrathecal chemotherapy via Ommaya reservoir and radiation therapy. The patient had an amelioration of symptoms and prolonged survival. Though LMC from ovarian cancer is thought to be rare, it is not going to remain a rare entity because the incidence of LMC in general is thought to be increasing, which is also the case with ovarian cancer. According to 31 cases whose treatment course is reported in literature, despite the absence of an established treatment for LMC, intrathecal (IT) chemotherapy whose survival benefit has been suggested in past studies might also prolong survival in patients with LMC from ovarian cancer. IT chemotherapy via Ommaya reservoir may be preferred to the lumbar puncture route. The presentation of non-specific symptoms of LMC in patients may hinder its diagnosis; however, early diagnosis and treatment induction is the key for patients' prolonged survival and restored useful life.

Iatrogenic Leptomeningeal Carcinomatosis Following Craniotomy for Resection of Metastatic Serous Ovarian Carcinoma: A Systematic Literature Review and Case Report

Metastasis of ovarian carcinoma to the central nervous system occurs in <2% of cases and classically localizes within the brain parenchyma. Moreover, leptomeningeal spread of these tumors is an exceedingly rare phenomenon. Here, we conduct a systematic review of the current literature on the natural history, treatment options, and proposed pathogenic mechanisms of leptomeningeal carcinomatosis in ovarian carcinoma. We also report a case of a 67-year-old female with stage IV metastatic ovarian serous carcinoma initially confined to the peritoneal cavity with a stable disease burden over the course of three years. Follow-up imaging demonstrated an intracranial lesion, which was resected via craniotomy, and pathology was consistent with the original diagnosis. Three months after surgery, she developed rapidly progressive dizziness, generalized weakness, fatigue, and ataxia. Repeat MRI demonstrated interval development of extensive and diffusely enhancing dural nodularity, numerous avidly enhancing supratentorial and infratentorial lesions, enhancement of the bilateral trigeminal nerves, internal auditory canals, and exit wound from the surgical site into the posterior aspect of the right-sided neck musculature consistent with diffuse leptomeningeal dissemination. The present case highlights that leptomeningeal dissemination of ovarian carcinoma is a potential yet rare consequence following surgical resection of an ovarian parenchymal metastasis. Progressive clinical symptomatology that develops postoperatively in this patient population should prompt urgent workup to rule out leptomeningeal disease and an expedited radiation oncology consultation if identified.

Cauda equina syndrome in an ovarian malignant-mixed müllerian tumor with leptomeningeal spread

Leptomeningeal metastasis is extremely rare in patients with ovarian cancer, but should be considered in patients presenting with neurologic deficits such as cauda equine syndrome. Given its poor prognosis and lack of data currently on management, additional studies are needed to optimize treatment regimens and improve outcomes.

Epithelial Ovarian Carcinoma Associated with Metastases to Central Nervous System: Two Case Reports

We experienced two rare cases of metastases to the central nervous system (cerebral and leptomeningeal metastases) from primary epithelial ovarian carcinoma. The first case was a 55-year-old woman who developed carcinomatous meningitis while on chemotherapy for ovarian cancer stage IIIC. Cytological analysis confirmed carcinomatous cells of ovarian origin in the cerebrospinal fluid. Magnetic resonance imaging demonstrated abnormal hyperintensity in the cerebral sulci on fluid attenuated inversion recovery (FLAIR) sequence with enhanced gadolinium indicating leptomeningeal metastases. Her consciousness rapidly declined and she died 42 days after diagnosis. The second case was a 63-year-old woman who underwent surgery for ovarian cancer and who was diagnosed as stage IA. Thirty-eight months after surgery, she developed weakness of the left hand and headaches. A CT scan revealed metastases to the right cerebrum and she was treated with surgical resection followed by radiotherapy. Five months after resection, she developed ileus caused by multiple relapses in the pelvis. Despite chemotherapy, her performance status declined and she died nine months after the resection. Both cases were rare because the first case was isolated leptomeningeal metastases, and the second case was confirmed relapse site in the cerebrum due to neurological symptoms despite her early clinical stage.

Ovarian small cell carcinoma complicated by carcinomatous meningitis

Meningeal metastasis is rare in the clinical course of ovarian carcinoma and its prognosis is extremely poor. We experienced a case of carcinomatous meningitis from metastatic ovarian small cell carcinoma. A 33-year-old woman with atypical genital bleeding, was diagnosed with a right ovarian tumor and referred to our department. She underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and lymphadenectomy. It was an optimal debulking surgery. She was diagnosed with ovarian carcinoma classified as Stage IIIc according to the Féderation Internationale de Gynécologie et d'Obstétrique classification system. Histological findings showed small cell carcinoma of the pulmonary type. The tumor was bilateral with paraaortic lymph node involvement. The patient was treated with irinotecan and cisplatin (CPT-P therapy). After 4 courses of CPT-P therapy, multiple liver metastases and Virchow's lymph node metastases were found. She was treated with amrubicin as a second-line chemotherapy, but the treatment was ineffective. Five months after surgery, the patient complained of severe headache and nausea. Lumbar puncture was performed and cytology was positive. Magnetic resonance brain imaging indicated meningeal thickening. The patient was diagnosed with meningeal metastasis and received 19-Gy whole cranial irradiation. In spite of these treatments, her disease progressed rapidly and she was often drowsy. She died of aspiration pneumonia 6 months after surgery.

Leptomeningeal carcinomatosis from ovarian cancer

Ovarian cancer is the most common cause of mortality among women with gynecologic malignancies and the fifth leading cause of death in all women. It usually spreads locally; hematogenous dissemination is rare, most often involving the liver and lungs. Cerebral metastases are reported in less than 2% of cases and tend to localize to the parenchyma, usually in the cerebrum. Leptomeningeal involvement is exceptionally rare. We report a case of a woman with metastatic ovarian cancer who developed leptomeningeal carcinomatosis while receiving systemic chemotherapy. We also provide an extensive review of the existing literature on neoplastic meningitis from ovarian cancer.

Meningeal dissemination from an ovarian carcinoma with effective response to intrathecal chemotherapy

Meningeal dissemination is rare in the clinical course of ovarian carcinoma, and its prognosis is poor. Although it is treated by the intrathecal administration of methotrexate (MTX) and/or total brain irradiation, these treatments are usually ineffective. We report a 58-year-old woman with stage IIIc ovarian cancer who had received nine courses of adjuvant chemotherapy after surgery. But her carbohydrate antigen (CA) 125 serum level had increased further (38.9 U/ml) after five courses of biweekly paclitaxel (Taxol; Bristol-Myers Squibb, Tokyo, Japan; BT) maintenance therapy. Fainting occurred, with a few seconds of unconsciousness, as did severe headaches. However, results of head computed tomography (CT), head magnetic resonance imaging, and electroencephalogram were normal. Lumbar puncture (LP) was performed. The opening pressure was 30 cmH2O or greater. Meningeal dissemination of the ovarian cancer was diagnosed, as adenocarcinoma cells were found by cerebrospinal fluid (CSF) cytology. We started chemotherapy with intrathecal injections of MTX and hydrocortisone acetate. Establishing a diagnosis of carcinomatous meningitis may be difficult. Clinical signs and biological data are not conclusive. In this patient, CSF cytology was very effective in establishing the diagnosis, and the intrathecal administration of MTX and hydrocortisone was very effective.

Meningeal carcinomatosis and uterine carcinoma: three different clinical settings and review of the literature

INTRODUCTION

Leptomeningeal carcinomatosis is a rare metastatic event in gynecological neoplasias, and most cases occur in ovarian cancer. It is extremely infrequent in cervical cancer, and so far, there are not any reports of this complication in association with endometrial cancer.

PATIENTS AND METHODS

We report a case of leptomeningeal carcinomatosis secondary to endometrial carcinoma and 2 complex cervix cancer cases. A MEDLINE search was done to review all published cases of this complication in gynecological cancer to identify predictive factors for this diagnosis.

RESULTS AND DISCUSSION

Leptomeningeal carcinomatosis is usually diagnosed late in the course of the disease, and most reports concern ovarian cancer patients. The number of cases describing this neurologic complication in cervix cancer is increasing. Gadolinium-enhanced magnetic resonance imaging may be necessary for this diagnosis, because cerebrospinal fluid analysis results may be negative. Most cervix cases had squamous cell (8/14) or neuroendocrine histologic subtype (3/14), and when reported, differentiation was usually poor. The case we report of endometrial carcinoma, unique in the literature, is a serous adenocarcinoma.

CONCLUSIONS

A high index of suspicion is necessary, and leptomeningeal carcinomatosis should be considered in patients with unexplained neurologic symptoms whose gynecologic tumors are poorly undifferentiated or have a serous component.

Multiple cerebral and leptomeningeal metastases from ovarian carcinoma: unusual early presentation

Although virtually any systemic malignancy is capable of metastasizing to the brain, ovarian carcinoma, one of the more common female genital malignancies, is one of the rarer forms of brain metastases. In general, the outcome for ovarian carcinoma with brain metastases is extremely poor as most of these patients have widespread lesions elsewhere. This report describes the first known case of multiple cerebral and leptomeningeal metastases as the initial manifestation of ovarian carcinoma in a 41-year old woman who presented with a one-week history of headache, vomiting and confusion. CT scan of the brain was unremarkable, but lumbar puncture revealed atypical cells in the CSF. MRI scan of the brain showed multiple small enhancing lesions. Craniotomy for excision of one of these lesions demonstrated metastatic adenocarcinoma. A large ovarian tumour identified on pelvic CT scan was resected and the patient subsequently received chemotherapy and radiotherapy. Unfortunately she continued to decline and died within six months. Unlike primary tumours such as malignant melanoma, ovarian carcinoma does not have a predilection for the central nervous system (CNS), but the rare instances with CNS involvement occur at an advanced stage of the disease. Once the CNS is involved, the outcome is abysmal, even with multimodality therapy. It is extremely unusual for ovarian carcinoma to present with multiple CNS involvement.

Cancer antigen 125 associated with multiple benign and malignant pathologies

BACKGROUND

Cancer antigen (CA) 125 tumor-associated antigen is a high molecular glycoprotein used for follow-up of epithelial ovarian cancer. The test is often requested as a differential diagnosis in patients with pleural or peritoneal fluid. This study analyzes the prevalence of CA-125 increases in a population of patients attending a general hospital and discusses the possible clinical implications of increased levels.

METHODS

On 4 different days, 380 CA-125 assays were performed in randomly selected patients attending our hospital. Serum CA-125 was measured with a commercial enzyme immunoassay, and clinical records were reviewed for assessment of clinical parameters.

RESULTS

Sixty-one patients (16%) had increased CA-125. The pathologies of these patients were heart failure in 9 (14.7%), lung disease 11 (18%), hepatic cirrhosis in 7 (11.4%), malignant tumors in 9 (14.7%), intra-abdominal nonhepatic disease in 6 (10%), previous surgery in 17 (27.8%), and miscellaneous in 2 (3%). Effusions were seen in 34 patients (55.7%).

CONCLUSIONS

Our data confirm the variety of benign and malignant pathologies coursing with increased CA-125. Cardiovascular and chronic liver disease were the most frequent diagnoses in patients with increased CA-125; this supports the opinion that CA-125 lacks utility as a marker for malignancy. CA-125 could have a role in the follow-up of cardiovascular, hepatic, and tumoral diseases with serosal involvement.

Leptomeningeal metastases

LM is an increasingly common neurologic complication of cancer with variable clinical manifestations. Although there are no curative treatments, currently available therapies can preserve neurologic function and potentially improve quality of life. Further research into the mechanisms of leptomeningeal metastasis will elucidate molecular and cellular pathways that may allow identification of potential targets to interrupt this process early or to prevent this complication. Animal models are needed to further define the pathophysiology of LM and to provide an experimental system to test novel treatments [242-245]. There is an urgent need to develop new drug-based or radiation-based treatments for patients with LM. Randomized clinical trials are the appropriate study design to determine the efficacy of new treatments for LM. However, surrogate markers for response must be developed to facilitate the identification of effective regimens. Survival is not the optimal end point for such studies as most patients who develop this complication already have advanced, incurable cancer. Prevention of or delay in neurologic progression is one objective that has been utilized in recent randomized trials in patients with LM, and this end point deserves further attention. Although the development of LM represents a poor prognostic marker in patients with cancer it is important for physicians to recognize the symptoms and signs of the disease and establish the diagnosis as early in the disease course as possible. This may provide an opportunity for effective intervention that can improve quality of life, prevent further neurologic deterioration and, for a subset of patients, improve survival.