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Cerebrospinal fluid diversion for leptomeningeal metastasis: palliative, procedural and oncologic outcomes

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Abstract

Background

Leptomeningeal metastasis (LM) occurs in 3–5% of patients with solid metastatic tumors and often portends a severe prognosis including symptomatic hydrocephalus and intracranial hypertension. Cerebrospinal fluid (CSF) shunting can provide symptomatic relief in this patient subset; however, few studies have examined the role of shunting in the palliation, prognosis and overall oncologic care of these patients.

Objective

To identify and evaluate risk factors associated with prognosis after CSF diversion and assess surgical, symptomatic and oncologic outcomes in this population.

Methods

A retrospective study was conducted on patients with solid-malignancy LM treated with a shunt at a NCI-designated Comprehensive Cancer Center between 2010 and 2019.

Results

One hundred and ninety patients with metastatic LM underwent CSF diversion. Overall survival was 4.14 months from LM diagnosis (95% CI: 3.29–4.70) and 2.43 months (95% CI: 2.01–3.09) from shunting. Karnofsky performance status (KPS) at time of shunting and brain metastases (BrM) number at LM diagnosis demonstrated significant associations with survival (HR = 0.66; 95% CI [0.51–0.86], p = 0.002; HR = 1.40; 95% CI [1.01–1.93] per 10 BrM, p = 0.04, respectively). Eighty-three percent of patients experienced symptomatic relief, and 79% were discharged home or to rehabilitation facilities post-shunting. Post-shunt, 56% of patients received additional systemic therapy or started or completed WBRT. Complications included infection (5%), symptomatic subdural hygroma/hematoma (6.3%), and shunt externalization/removal/repair (8%). Abdominal seeding was not identified.

Conclusions

CSF diversion for LM with hydrocephalus and intracranial hypertension secondary to metastasis can achieve symptomatic relief, hospital discharge, and return to further oncologic therapy, with a complication profile unique to this pathophysiology. However, decision-making in this population must incorporate end-of-life goals of care given limited prognosis.

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Funding

This research was funded in part through the NIH/NCI Cancer Center Support Grant P30 CA008748. Evan Bander is supported by the Leon Levy Foundation Fellowship in Neuroscience.

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Authors and Affiliations

  1. Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA

    Evan D. Bander, Melissa Yuan, Andrew L. A. Garton, Cameron W. Brennan, Viviane Tabar & Nelson S. Moss

  2. Department of Neurosurgery, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA

    Evan D. Bander & Andrew L. A. Garton

  3. Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA

    Anne S. Reiner & Katherine S. Panageas

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  1. Evan D. Bander
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  2. Melissa Yuan
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Contributions

Conception and design: EDB, NSM; Acquisition of data: MY, EDB, ALAG; Analysis and interpretation: EB, ASR KSP, NSM; Drafting or revising of article: EDB, NSM, ASR, KSP; All authors approved the final manuscript.

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Conflict of interest

At the time of research execution and publication, all authors are affiliated with Memorial Sloan Kettering Cancer Center. The authors of this research deny any conflict of interest regarding this study and make the following disclosures: NSM: consulting fees for advisory board participation from AstraZeneca and trial support from GT Medical Technologies (to institution) unrelated to the current work.

Ethical approval

This study was approved by the IRB at Memorial Sloan Kettering Cancer Center.

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Informed consent was obtained from all individual participants included in the study.

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Bander, E.D., Yuan, M., Reiner, A.S. et al. Cerebrospinal fluid diversion for leptomeningeal metastasis: palliative, procedural and oncologic outcomes. J Neurooncol 154, 301–313 (2021). https://doi.org/10.1007/s11060-021-03827-2

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  • DOI: https://doi.org/10.1007/s11060-021-03827-2

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