Benefit of ventriculoperitoneal cerebrospinal fluid shunting and intrathecal chemotherapy in neoplastic meningitis: a retrospective, case-controlled study

Clinical article

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Object

Neoplastic meningitis (NM) is a debilitating and increasingly frequent neurological complication of cancer characterized by infiltration of tumor cells into the leptomeninges and the subarachnoid space. Although NM is rarely curable, combined intrathecal chemotherapy and focal radiation can improve disease-related symptoms and survival. Hydrocephalus occurs in a significant proportion of patients, is associated with poor prognosis and reduced quality of life, and usually precludes the use of intrathecal therapy.

Methods

Since January of 2005, the authors have used a combined treatment approach for patients with both NM and hydrocephalus that employs a subcutaneously placed reservoir connected in series to an on/off valve and a ventriculoperitoneal shunt for both diversion of CSF and injection of intrathecal chemotherapy. They conducted a retrospective, case-controlled study from 2 independent institutions to review their experience.

Results

Twenty-four patients with NM and hydrocephalus underwent placement of a CSF reservoir-on/off valve-ventriculoperitoneal shunt (RO-VPS) construct. There was no perioperative mortality, and there were only 2 minor complications. One shunt failure and no shunt-associated infections were observed over a median of 28 weeks of follow-up. Symptomatic improvement and improved performance status were seen in 20 patients (83.3%) and were sustained over 6 months. Eighteen patients received intraventricular chemotherapy without unexpected toxicity, and cytological responses were found in 11 patients (61.1%). Median progression-free and overall survival was 14 and 31 weeks, respectively. Compared with a contemporaneous comparison group of 24 demographically matched patients with NM who underwent CSF reservoir placement only, those who received RO-VPS constructs (p = 0.02) and had primary diagnosis of breast cancer (p = 0.04) had significant advantage in overall survival.

Conclusions

A combined RO-VPS system is safe and practical to install, results in symptomatic improvement in most patients, and allows uncomplicated and effective administration of intrathecal chemotherapy in patients with NM. Cerebrospinal fluid diversion surgery should be considered in NM patients in conjunction with intrathecal and systemic treatments.

Abbreviations used in this paper: KPS = Karnofsky Performance Scale; NM = neoplastic meningitis; RO-VPS = reservoir–on/off valve–ventriculoperitoneal shunt.

Article Information

Current affiliation for Dr. Friedlander: Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.

Address correspondence to: Santosh Kesari, M.D., Ph.D., University of California, San Diego, Moores Cancer Center, 3855 Health Sciences Drive, MC 0819, La Jolla, California 92093-0819. email: skesari@ucsd.edu.

Please include this information when citing this paper: published online July 1, 2011; DOI: 10.3171/2011.5.JNS101768.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Postoperative CT scan (A) and skull radiograph (B), and photograph (C) showing the RO-VPS construct. The intraventricular catheter is placed through a bur hole at the Kocher point and connected to the Ommaya reservoir (A). The RO-VPS construct is located in an extended subgaleal pocket above the pericranium (B). The 3-part apparatus (C) includes an Ommaya reservoir (1), an on-off valve (2), and a programmable shunt valve (3). All connections are tied with 2-0 silk sutures.

  • View in gallery

    Karnofsky Performance Scale scores before and after shunt placement. The KPS score drops precipitously from the initial diagnosis of primary cancer to just prior to the RO-VPS placement procedure. This trend is reversed after the operation and the effect is sustained for up to 6 months. The time stamps indicate diagnosis of primary cancer (Initial Dx), diagnosis of NM (NM Dx), prior to surgical placement of RO-VPS construct (Pre-op), 2 weeks after the operation (Post-op), 3 months after the operation, and 6 months after the operation.

  • View in gallery

    Kaplan-Meier curves for patients in the Ommaya reservoir group and the RO-VPS group. Patients in the RO-VPS group have significantly better overall survival (p = 0.008).

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