A Novel Method for Administering Intrathecal Chemotherapy in Patients With Leptomeningeal Metastases and Shunted Hydrocephalus

Abstract

Leptomeningeal metastatic disease occurs in a minority of patients with systemic neoplastic disease. Before the initiation of intrathecal chemotherapy, hydrocephalus must be addressed with a cerebrospinal fluid (CSF)-diverting shunt. CSF diversion can theoretically prematurely divert chemotherapeutic drugs that are administered intrathecally, thereby potentially reducing the efficacy of such treatments. We report on a patient with leptomeningeal disease and hydrocephalus secondary to metastatic bladder carcinoma requiring insertion of a programmable ventriculoperitoneal shunt and intrathecal chemotherapy. A novel method was utilized to administer intrathecal chemotherapy, in which the valve pressure setting was transiently increased during a 4-hour treatment session for intrathecal chemotherapy. No clinical complications occurred. Nuclear imaging was obtained sequentially after the injection of indium tracer into the ventricular system with the programmable valve at its baseline setting as well as at a maximal pressure setting. In the maximal valve setting condition, reduced outflow of nuclear tracer was observed at 1.5 and 4 h after injection, and normalized by 24 hours after injection. Programmable shunt valves can be utilized in a safe, controlled fashion to treat hydrocephalus associated with leptomeningeal disease, as well as regulate the outflow of CSF and minimize diversion of intrathecal chemotherapeutic agents.