The prognosis of LM from solid tumor remains poor. The median survival is four to six weeks without treatment. Treatment can stabilize the neurological symptoms and prolong survival for a few months but less than
10% of patients are alive after one year. Breast cancer has the best prognosis; about 15% of patients survive more than a year.120'75 Prognosis remains poor in patients with lung cancer and melanoma.26 In these patients, some clinicians question the usefulness of vigorous treatment and favor palliative care once the diagnosis is made. There are some conflicting data in regards to prognostic factors, but in general, patients with breast cancer (especially if progesterone positive), a better performance status (Karnofsky performance scale > 60), controlled systemic cancer, absence of bulky disease, normal CSF protein, absence of cerebral involvement and a chemosensitive primary, benefit the most from aggressive treatment.9'18'23'24,
8. CLINICAL GUIDELINES
When a patient with solid tumor presents with multiple neurological symptoms or signs, LM needs to be ruled out. In addition, LM should be considered in a patient with incidental finding of hydrocephalus. MRI with and without gadolinium of the involved area is the test of choice; if positive, the whole neuro-axis should be evaluated. If MRI is negative, the CSF needs to be examined. Repeat examination of CSF, including cisternal puncture may be necessary to make the diagnosis of LM. Occasionally, treatment decisions are based on clinical findings despite a negative work up.
After the diagnosis of LM is established, a VP shunt should be placed if hydrocephalus is present. Radiation therapy is then given to symptomatic sites, nodular lesions, or areas of CSF blockage. If the patient has breast cancer, and good prognostic factors, an Ommaya device can be placed and IT MTX can be considered. Alternatively, it is reasonable to treat the LM and concomitant systemic disease with systemic chemotherapy; agents used should have activity against the primary tumor with CSF penetration. If the patient has a poor prognosis, symptomatic therapy and palliative care should be the focus.
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