How to treat leptomeningeal carcinomatosis

[hoop]

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I'm a radiation oncology resident Thailand.
There were cases with leptomeningeal metastases, some from solid tumors and some from lymphoma with CNS involvement.
In my center most of cases were treated with intrathecal chemotherapy and sent to do whole brain irradiation. But in many literatures, they recommend just local field irradiation to the bulky disease area or area that causes the symptoms only.
So I'm little confused about the treatment.

 

[medgator]

In the US, most of these patients are treated with supportive care, and possibly steroids and radiation therapy, either to the brain or spine depending on location. The overall prognosis is very poor, and it's rare to see intrathecal chemotherapy used.

 

[Palex80]

Best supportive care is my choice of treatment for patients with KI <80.

Intrathecal chemotherapy is a pain in the ass, if you can't use the (expensive) Depocyte, cause you have to do all these intrathecal applications over and over again to a dying patient and "torture" him in his final weeks, with rather vague chance of success.

Whole brain radiation therapy is a good option in motivated patients, who want treatment, you can offer it. I would not go for focal treatment only. The worst thing that could happen is a local relapse on some cranial nerve, leading to function loss while/closely after you are done with your focal treatment.

I've only done a craniospinal axis once in a female patient with leptomeningeal spread by metastatic breast cancer. The metastatic disease was solely to the CSF, no lesions on MRI-brain and whole body CT. I think I gave her 36 in 1.8 Gy/d to the CS-axis, followed by a WB-boost up to 45 Gy (she had symptoms coming solely from the brain, no peripheral nerve function impairment). She tolerated it fine, but died a couple of months later from progressive disease in the CNS.

 

[hoop]

Thank you.