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Leptomeningeal metastasis

Key sources
The following summarized guidelines for the evaluation and management of leptomeningeal metastasis are prepared by our editorial team based on guidelines from the European Association of Neuro-Oncology (EANO/ESMO 2023) and the National Comprehensive Cancer Network (NCCN 2023).
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Guidelines

1.Classification and risk stratification

Classification
Classify leptomeningeal metastasis based on clinical, imaging, and CSF cytology assessments.
B
Use standardized diagnostic criteria to define cohorts of patients with leptomeningeal metastasis.
B
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  • Risk assessment

2.Diagnostic investigations

Indications for testing
Suspect leptomeningeal metastasis particularly in patients with breast cancer, lung cancer, or melanoma presenting with neurological symptoms or signs.
B
Suspect leptomeningeal metastasis in patients with typical clinical signs of leptomeningeal metastasis, such as headache, nausea and vomiting, mental changes, gait difficulties, cranial nerve palsies with diplopia, visual disturbances, hearing loss, sensorimotor deficits of extremities and cauda equina syndrome, radicular, neck and back pain, especially in the presence of cancer.
B

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  • Neurological examination

  • Diagnostic imaging

3.Diagnostic procedures

Lumbar puncture
As per EANO 2023 guidelines:
Obtain CSF analysis using optimized analysis conditions in the evaluation of patients with suspected leptomeningeal metastasis.
B
Perform a repeat lumbar puncture with optimized analysis conditions in patients with suspected leptomeningeal metastasis and initial negative or equivocal cytological CSF results.
B

4.Medical management

Systemic therapy: as per EANO 2023 guidelines, consider offering systemic pharmacotherapy based on the primary tumor and previous treatments in most patients with type B/C leptomeningeal metastasis.
C

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5.Therapeutic procedures

Intra-cerebrospinal fluid therapy
As per EANO 2023 guidelines:
Consider offering intra-CSF pharmacotherapy in patients with type IA/C leptomeningeal metastasis.
C
Administer intra-CSF chemotherapy via the ventricular rather than lumbar route whenever feasible.
B

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  • Radiotherapy

6.Follow-up and surveillance

Assessment of treatment response: assess treatment response and plan subsequent management based on CSF cytology.
B
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  • Follow-up