Chemotherapy and radiation are the standard treatments for leptomeningeal disease. Intrathecal (IT) chemotherapy alone, or in combination with systemic chemotherapy1 including methotrexate, cytarabine2 (Ara-C), and thiotepa3, are used to treat patients with lymphoma, leukemia, and metastatic solid tumors, such as breast carcinoma. More recently, IT, targeted radioimmunotherapy, such as 131I-3F84, has been explored for leptomeningeal tumors that are GD2-positive.
Leptomeningeal disease, by definition, is disseminated along the spinal axis and is not resectable (Fig.l).
Due to the lack of discreet, bulky tumor, neurosurgeons have a limited role in treating this disseminated disease. Their involvement usually is requested when oncologists are considering the placement of a ventricular access device. These devices are designed to enhance IT drug delivery and to more efficiently and precisely monitor treatment efficacy. Access to the cerebrospinal fluid (CSF) for delivery of chemotherapy can be achieved either by performing repeated spinal taps, or by placement of a permanent catheter into the intraventricular space. These catheters are connected to low-profile, subcutaneous reservoirs which may be easily accessed transcutaneously with small bore needles (Fig. 2).
Figure 2. Ommaya reservoir: Low-profile subcutaneous reservoir connected to intraventricular catheters allow easy access to CSF for intermittent chemotherapy infusions. Figure 2 images courtesy of Integra LifeSciences Corporation
The first such reservoir was utilized in 1963 and has since borne the name of its innovator, Dr. A.K. Ommaya.5 Ommaya reservoirs have several advantages over repeated spinal taps. For the patient, an obvious advantage is the increased convenience and comfort of accessing an Ommaya reservoir when compared with repeated lumbar spinal taps. For the oncologist, whose goal is effective drug delivery, intraventricular delivery of chemotherapy has a better volume of distribution than lumbar puncture. A further advantage is the ease with which hydrocephalus, a condition that develops in approximately 10% of patients with leptomeningeal disease, can be managed once an Ommaya reservoir has been placed6.
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