A variety of medical therapies are utilized in the care of patients with leptomeningeal metastasis irrespective of whether the patient is offered aggressive neoplastic meningitis-directed therapy. A minority of patients will manifest seizures as a consequence of neoplastic meningitis and the use of non-sedating anticonvulsant drugs is appropriate for this group of patients. Patients with difficult to control pain may be managed with narcotics or, in the instance of neuropathic pain, either anticonvulsant drug or tricyclic antidepressant drug therapy. Depression is a very common symptom in patients with cancer and is often neglected or not recognized. Early recognition and initiation of antidepressants in symptomatic patients is recognized to improve quality of life and benefit both patients and families. In addition, antidepressants, especially tricyclic agents, are also useful for chronic insomnia. Corticosteroids are most useful to control vasogenic edema secondary to parenchymal brain or epidural metastases but have very limited use in the management of neoplastic meningitis-related neurologic symptoms. Steroids may be useful in patients with raised intracranial pressure or in patients with chronic nausea or vomiting. Similarly, nausea or vomiting may be managed by anti-emetics. Concurrent steroids, megestrol acetate or cannabinols may mitigate weight loss and cancer-related anorexia. Finally, decreased attention and somnolence, common side effects of whole brain irradiation and chemotherapy, may be improved modestly by the use of psychostimulants such as dextroamphetamine or modafinil.
Neoplastic meningitis is a complicated disease for a variety of reasons. Not all patients necessarily warrant aggressive CNS-directed therapy, yet few guidelines exist permitting appropriate choice of therapy. In general, only pain-related neurologic symptoms improve with treatment. Neurologic signs such as confusion, cranial nerve deficit(s), ataxia and segmental weakness minimally improve or stabilize with successful treatment. The majority of patients die due to progressive systemic disease occurring either in isolation or in combination with progressive neoplastic meningitis. Notwithstanding aggressive treatment, survival ranges only from 2-10 months depending upon tumor histology, and in adult neoplastic meningitis, therapy is considered palliative rather than curative. However, specific tumor histologies may have different responses to therapy. For example, the consensus is that breast cancer is inherently more chemosensitive than non-small cell lung cancer or melanoma, and therefore, survival following chemotherapy is likely to be
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