Neoplastic meningitis — a puzzling case with important lessons
Maciej M. Mrugala
Department of Neurology, Mayo Clinic, Phoenix, Arizona, United States
LETTER TO THE EDITORS
Neurologia i Neurochirurgia Polska
Polish Journal of Neurology and Neurosurgery
2022, Volume 56, no. 1, pages: –105
DOI: 10.5603/PJNNS.a2022.0001
Copyright © 2022 Polish Neurological Society
ISSN: 0028-3843, e-ISSN: 1897-4260
Address for correspondence: Maciej M. Mrugala, Department of Neurology, Mayo Clinic, Phoenix, Arizona, United States, e-mail: Mrugala.Maciej@mayo.edu
Received: 5.11.2021 Accepted: 8.11.2021 Early publication date: 4.01.2022
This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0) license, allowing to download articles and share them with others as long as they credit the authors and the publisher, but without permission to change them in any way or use them commercially.
Key words: lymphoma, neoplastic meningitis, subdural hematoma, cerebrospinal fluid
(Neurol Neurochir Pol 2022; 56 (1): )
I read with great interest the case report published in the last issue of the Polish Journal of Neurology and Neurosurgery entitled ‘Unexpected infiltration of meninges by generalised diffuse large B-cell lymphoma manifesting as multiple cranial neuropathies in a patient with history of breast carcinoma’ by Malá et al. [1].
The authors described the case of a patient with a dual cancer diagnosis posing a clinical challenge and causing potential delay in treatment initiation. The patient’s presentation with multiple cranial nerve palsies was certainly suspicious for leptomeningeal involvement. In the setting of prior breast carcinoma, the relationship was plausible. Breast cancer is the second most common malignancy (after lung) leading to brain metastases and carcinomatous meningitis. A complicating factor was a subdural haematoma of uncertain aetiology (prior fall?,anti-coagulation?). What is puzzling is that MRI of the brain showed haematoma regression, thus making the diagnosis of lymphoma less likely, especially in the absence of steroid treatment. CSF analysis was abnormal and suggested malignancy. The authors did not specify whether flow cytometry was performed during the first or second spinal tap, although immunocytochemical typing was carried out with the third CSF analysis, and suggested lymphoma.
This case teaches us several important lessons:
Cranial nerve involvement in a patient with a known diagnosis of cancer should always alert the clinician to the possibility of leptomeningeal carcinomatosis (LM);
Work up for LM should be guided by primary malignancy and appropriate testing should be requested i.e. cytology for solid tumours and flow cytometry for haematological malignancies;
Liquid biopsy assays to look for circulating tumour cells and tumour DNA are entering the clinical arena, and can facilitate the diagnostic process [2]; Subdural haematomas of uncertain aetiology or unusual clinical course should raise a clinical suspicion for an underlying malignancy [3]; When CNS lymphoma is suspected, prompt diagnostic evaluation is critical, as this disease is highly chemo- and radiosensitive and many patients, even those who are very ill, can be saved with prompt intervention.
I would like to thank the authors of this report for sharing their experience with the readers of the Polish Journal of Neurology and Neurosurgery.
