title: Benefit of ventriculoperitoneal cerebrospinal fluid shunting and intrathecal chemotherapy in neoplastic meningitis: a retrospective, case-controlled study.
abstract: OBJECTIVE
  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.
authors: Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.
authors: Ning
authors: N
authors: Lin
authors: Ian F
authors: IF
authors: Dunn
authors: Michael
authors: M
authors: Glantz
authors: Dana L
authors: DL
authors: Allison
authors: Randy
authors: R
authors: Jensen
authors: Mark D
authors: MD
authors: Johnson
authors: Robert M
authors: RM
authors: Friedlander
authors: Santosh
authors: S
authors: Kesari
mesh_terms: D000328:Adult; D000368:Aged; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000008:administration & dosage* / Q000627:therapeutic use; D016022:Case-Control Studies; D003131:Combined Modality Therapy; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D007278:Injections, Spinal; D008297:Male; D055756:Meningeal Carcinomatosis / Q000188:drug therapy / Q000601:surgery / Q000628:therapy*; D008875:Middle Aged; D012189:Retrospective Studies; D016896:Treatment Outcome; D017287:Ventriculoperitoneal Shunt