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Pediatric leptomeningeal metastasis: 111In-DTPA cerebrospinal fluid flow studies
1Department of Neurosciences, University of California San Diego 92103.
Insights
Cerebrospinal fluid compartmentalization is common in pediatric leptomeningeal metastasis. Radionuclide flow studies show blockages, but involved-field radiotherapy can help resolve them.
Area of Science:
- Pediatric Oncology
- Neuroradiology
- Nuclear Medicine
Background:
- Leptomeningeal metastasis (LM) in children presents diagnostic challenges.
- Understanding cerebrospinal fluid (CSF) dynamics is crucial for treatment planning in pediatric LM.
Purpose of the Study:
- To evaluate CSF compartmentalization in pediatric patients with LM using radionuclide flow studies.
- To assess the efficacy of involved-field radiotherapy in resolving CSF flow blockages.
Main Methods:
- Nine children (1-18 years) with LM underwent cerebrospinal fluid flow studies using indium 111-diethylenetriaminepentaacetic acid (111In-DTPA).
- Histologic diagnoses included medulloblastoma, PNET, ALL, pineoblastoma, ependymoma, and astrocytoma.
- CSF flow patterns and times to radionuclide appearance in various compartments were analyzed.
Main Results:
- CSF compartmentalization was observed in 44% (4/9) of pediatric LM patients.
- Blockages in CSF flow were identified in the cervical subarachnoid space, lumbar subarachnoid space, and cisterna magna/basal cisterns.
- Involved-field radiotherapy led to resolution of CSF flow blocks in 3 out of 5 treated patients.
Conclusions:
- Cerebrospinal fluid compartmentalization is a frequent finding in pediatric leptomeningeal metastasis.
- Radionuclide ventriculography effectively demonstrates CSF flow abnormalities.
- Involved-field radiotherapy shows potential for palliating CSF flow obstructions in pediatric LM.
Abstract:
Nine children (five girls and four boys) ranging in age from 1 to 18 years (median age, 12 years) with leptomeningeal metastasis were evaluated for cerebrospinal fluid compartmentalization with cerebrospinal fluid flow studies using ventricular diethylenetriaminepentaacetic acid labeled with indium 111 (111In-DTPA). Histologic diagnosis included medulloblastoma (two), primitive neuroectodermal tumor (two), acute lymphoblastic leukemia (two), pineoblastoma (one), ependymoma (one), and anaplastic astrocytoma (one). Sixteen 111In-DTPA cerebrospinal fluid flow studies were performed, of which nine demonstrated normal anterograde cerebrospinal fluid flow of radionuclide, with the following cerebrospinal fluid compartment median times to appearance, with ranges in parentheses: ventricles, 1 minute (0 to 3 minutes); cisterna magna/basal cisterns, 5 minutes (3 to 5 minutes); cervical subarachnoid space, 8 minutes (5 to 10 minutes); thoracic subarachnoid space, 15 minutes (10 to 30 minutes); lumbar subarachnoid space, 35 minutes (20 to 45 minutes); and sylvian cistern, 80 minutes (60 to 90 minutes). Blockage of normal anterograde cerebrospinal fluid flow was seen in seven 111In-DTPA cerebrospinal fluid flow studies in the following cerebrospinal fluid compartments: cervical subarachnoid space (four), lumbar subarachnoid space (two), and cisterna magna/basal cisterns (one). Five 111In-DTPA cerebrospinal fluid flow studies were performed after demonstration of cerebrospinal fluid compartmentalization and treatment with limited-field radiation therapy to involved regions; cerebrospinal fluid flow blocks resolved in three. In conclusion, cerebrospinal fluid compartmentalization, as shown by radionuclide ventriculography, is a common occurrence in pediatric leptomeningeal metastasis (four of nine patients, or 44%) and may be palliated by involved-field radiotherapy.