MRI Findings in Cranial Meningeal Carcinomatosis: Case Series and Literature Review

1
MRI Findings in Cranial Meningeal Carcinomatosis
Case Series and Literature Review
2
Eun Joo Park, Khashayar Rafatzand, Carlos I
Torres, Raquel del Carpio-O'Donovan

• McGill University Health CentreDepartment of
  Diagnostic Radiology

3
Introduction

• Meningeal carcinomatosis is a life-threatening
  complication occurring in approximately 5 of all
  patients with cancer1,2 .
• Early diagnosis and treatment are important as
  therapy is rarely of benefit once deficits
  develop3.

4
Introduction

• CSF cytology, although the current gold standart,
  is often inconclusive with sensitivity of
  70-804.
• In this setting, brain MRI plays an important
  role in the work-up of suspected meningeal
  carcinomatosis.

5
Introduction

• We present the most common MRI signs and
  patterns associated with cranial meningeal
  metastatic disease in a series of 63 patients.

6
Cases and methods

• Design retrospective MRI review
• Cases patients with known primary tumour in whom
  metastatic disease to the brain was suspected.

7
Cases and methods

• The study group included 63 cancer patients who
  presented to the MGH between 1999 and 2004 with
  clinical and MRI findings compatible with
  meningeal carcinomatosis .
• The major imaging findings were classified and
  ranked according to frequency.

8
Cases and methods

• Our protocol
• -Sagittal and axial T1 weighted (TR 600ms/TE
  25ms, 2 Nex),
• -Axial T2 weighted ( TR 3000ms/TE 30ms 1 Nex),
• -Axial proton-density weighted ( TR 3000 ms/TE
  30ms 1 Nex)
• -Sagittal, axial and coronal T1W sequences after
  administration of intravenous paramagnetic
  contrast medium (Gadolinium-DTPA, Berlex
  Laboratories 0.1 mmol/kg),
• -The slice thickness was 5mm, the post contrast
  images were all obtained within 10 minutes of the
  injection.

9
Primary tumours

• The most common primary tumour was
• 1-breast cancer in 26 of 63 patients ( 41.3),
• 2-lung in 23/63 patients ( 36.5),
• 3- lymphoma in 3/63 cases ( 4.8),
• 4- gastric carcinoma in 2/63 cases ( 3.2).
• Frequencies are compatible with those
  previously described in the literature 5,6.

10
Meningeal Carcinomatosis

• Most common patterns of meningeal carcinomatosis
  was
• 1-leptomeningeal in 42 of 63 cases (66.7)
• 2-dural metastasis in 11/63 (17.5)
• 3-combination of leptomeningeal and dural
  metastasis in 4 /63 (6.3 ).

11
Leptomeningeal Carcinomatosis

• Among the patients with leptomeningeal
  carcinomatosis (42 patients), two morphological
  patterns were identified
• 1-nodular 35/42 ( 83.3),
• -linear 6/42 (14.3),
• - the combination of both 5/42 (11.9).

12
Post contrast T1W axial images show multiple
superficial nodular enhancing lesions
representing metastatic deposits in the
leptomeninges
13
Contrast-enhanced T1W axial images show linear
leptomeningeal enhancement over the surface of
both cerebellar hemispheres.
14
Meningeal carcinomatosis

• Association between meningeal and
  intraparenchymal metastasis found in 24 cases (
  38.1).
• Thought to result from hematogenous dissemination
  or invasion of tumour from the pial membrane
  into the adjacent brain tissue.7

15
Post contrast T1W axial image show multiple
superficial nodular enhancing lesions
representing metastatic deposits in the
leptomeninges (left). On FLAIR (right), some of
the lesions are associated with edema suggestive
of intraparenchymal invasion.
16
Leptomeningeal Carcinomatosis

• 22 of 42 (52.4) patients showed exclusively
  leptomeningeal involvement, without dural or
  intraparenchymal involvement.
• 13/42 ( 31) patients had leptomeningeal
  carcinomatosis associated with perivascular
  involvement (Virchow-Robin spaces).

17
Leptomeningeal Carcinomatosis

• 13/42 ( 31) patients had leptomeningeal
  carcinomatosis associated with extension into
  perivascular spaces (Virchow-Robin spaces).
• 2/42 ( 4.8) of patients had combination of the
  leptomeningeal involvement with subependymal
  metastasis.

18
Leptomeningeal carcinomatosis

• Association of leptomeningeal carcinomatosis with
  perineural metastasis was found in 1 /42 (
  2.4).
• Combination of leptomeningeal involvement,
  perivascular and perineural metastasis was found
  in 1/42 ( 2.4).

19
Post contrast T1W axial image shows nodular
enhancing lesions involving the basal ganglia
(left) without edema on FLAIR (right),
compatible with metastatic dissemination into the
perivascular spaces
20
Post contrast T1W axial image shows multiple
nodular enhancing lesions in the left basal
ganglia ( perivascular spaces), subependymal
lesion in the wall of the left lateral ventricle
and several lesions in the depths of the sulci
(left) . On FLAIR sequence (right), there is
minimal edema around some of the superficial
lesions indicative of intraparenchymal invasion (
arrow).
21
Post contrast T1W axial, coronal images show
multiple nodular enhancing lesions in the left
basal ganglia ( perivascular
spaces), several superficial lesions over the
cerebral and the cerebellar hemispheres. The Left
Meckels cave is enlarged associated with
enhancement suggestive of metastatic involvement
of the Gasserian ganglion (arrow)
22
Post contrast T1W axial, coronal images show
several enhancing lesions in the cerebellar
hemispheres, right temporal and left frontal
lobes. There is enhancement inside the left
internal auditory canal suggestive of metastatic
dissemination along the VIII nerve (arrow)
23
Dural metastasis

• Seen in 4 out of 15 patients (26.7) in
  association with skull involvement.

24
Post contrast T1W axial images show dural
thickening in the left temporo-frontal region
associated with bone erosion and enhancement of
the extracranial soft tissues
25
Hydrocephalus

• Found in 4 of 63 (6.3) cases.
• Although an infrequent finding, hydrocephalus is
  considered an important indirect sign of
  leptomeningeal carcinomatosis 8.

26
Conclusions

• Although the prognosis of meningeal
  carcinomatosis is dismal, early diagnosis and
  treatment can stabilize symptoms and avoid the
  development of permanent disabilities .
• Familiarity with the radiological signs of this
  entity is important, as early diagnosis can
  significantly improve quality of life during
  palliative care.

27
References

• 1. Aparicio A, Chamberlain MC. Neoplastic
  meningitis. Curr Neurol Neurosci Rep. 2002
  2(3)225-35.
• 2. Groves MD. The pathogenesis of neoplastic
  meningitis. Curr Oncol Rep. 2003 5(1)15-23.

28
References

• 3. Krauseneck P. Clinical relevance and current
  problems in neoplastic meningiosis. J Neurooncol
  1998 3893-95.
• 4.Glass JP, Melamed M, Chernik NL, Posner JB.
  Malignant cells in the cerebrospinal fluid(CSF)
  the meaning of a positive CSF cytology. Neurology
  1979 29 1369-1375.

29
References

• 5. Iaconetta G, Lamaida E, Rossi A, Signorelli F,
  Manto A, Giamundo A. Leptomeningeal
  carcinomatosis review of the literature. Acta
  neurol. 1994 16(4)214-220.
• 6.Baiges-Octavio JJ, Huerta-Villanueva M.
  Meningeal carcinomatosis. Rev Neurol. 2000
  31(12)1237-1241.

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References

• 7. Schumacher M, Orszagh M. Imaging techniques in
  neoplastic meningiosis. J Neurooncol 1998
  38111-120.
• 8. Watanabe M, Tanaka R, Takeda N. Correlation of
  MRI and clinical features in meningeal
  carcinomatosis. Neuroradiology. 1993 35(7)
  512-515.