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Lung Cancer |

Rare Case of Leptomeningeal Carcinomatosis Without Evidence of Brain Metastasis Presenting as First Sign of Recurrent NSCLC

Dhruv Lowe, MBBS; Shreya Sinha, MD; Arunpreet Kahlon, MBBS
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SUNY Upstate Medical University, Syracuse, NY


Chest. 2014;146(4_MeetingAbstracts):668A. doi:10.1378/chest.1993804
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Abstract

SESSION TITLE: Cancer Student/Resident Case Report Posters III

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Leptomeningeal carcinomatosis is a rare but grave consequence of advanced cancers with median overall survival of 2-3 months. Patients can present with a broad range of symptoms, hence, diagnosis requires a high index of suspicion.

CASE PRESENTATION: We present a case of a 71 year old female with h/o ovarian cancer s/p TAH-BSO, pulmonary adenocarcinoma s/p left lung lobectomy who presented to the hospital with a one month history of intermittent lightheadedness and headaches. Recent bone and PET scan did not reveal any residual malignant disease. Her mentation progressively deteriorated and she became very drowsy. An EEG showed diffuse slow waves. A contrast enhanced MRI showed lateral, 3rd and 4th ventricular enlargement with non-specific bilateral peri-ventricular signal hyper-intensity. CSF analysis revealed glucose 7mg/dl, protein 110mg/dl and mild lymphocytic leukocytosis. Cytology was positive for malignant cells likely adenocarcinoma consistent with a diagnosis of LM. As the patient had poor performance status with encephalopathy, she was not suitable for any therapeutic intervention. She was eventually discharged on hospice care.

DISCUSSION: LM occurs in 5% of advanced cancer, and in only 1% without evidence of any brain metastasis. It can have a varied presentation depending on site of involvement, most commonly as headache (39%). Altered mental status is found in only 16% of cases and is associated with poor prognosis. Although, commonly associated with breast cancer, 10-26% cases occur in lung cancer. Diagnosis is achieved through neuroimaging (contrast enhanced MRI) and CSF analysis. CSF cytology positive for malignant cells is still the gold standard with highest specificity. Our case is unique as the patient had no evidence of residual malignant disease based on bone and PET scan findings one month prior to presentation and her only symptoms were headache with altered mental status. Our case points to the fact that we should keep a low threshold to do MRI and CSF analysis in patients presenting with neurological symptoms including altered mental status with h/o solid tumors as even though LM is associated with a poor prognosis, early intervention can help improve neurological symptoms, prolong survival or assist in palliative measures.

CONCLUSIONS: Although a diagnosis of LM represents a poor prognostic marker for cancer patients, it is important to keep a high index of suspicion for diagnosis in patients presenting with typical signs and symptoms as this provides an opportunity for effective intervention that can improve quality of life.

Reference #1: Clarke JL, Perez HR, Jacks LM, et al. Leptomeningeal metastases in the MRI era. Neurology 2010; 74:1449

Reference #2: Jayson GC, Howell A. Carcinomatous meningitis in solid tumours. Ann Oncol 1996; 7:773

Reference #3: Clarke JL. Leptomeningeal metastasis from systemic cancer. Continuum (Minneap Minn) 2012; 18:328

DISCLOSURE: The following authors have nothing to disclose: Dhruv Lowe, Shreya Sinha, Arunpreet Kahlon

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