Leptomeningeal disease in melanoma patients: An update to treatment, challenges, and future directions

Abstract

In February 2018, the Melanoma Research Foundation and the Moffitt Cancer Center hosted the Second Summit on Melanoma Central Nervous System Metastases in Tampa, Florida. The meeting included investigators from multiple academic centers and disciplines. A consensus summary of the progress and challenges in melanoma parenchymal brain metastases was published (Eroglu et al., Pigment Cell & Melanoma Research, 2019, 32, 458). Here, we will describe the current state of basic, translational, clinical research, and therapeutic management, for melanoma patients with leptomeningeal disease. We also outline key challenges and barriers to be overcome to make progress in this deadly disease.

Keywords: intrathecal therapy; leptomeningeal carcinomatosis; leptomeningeal disease; melanoma; neoplastic meningitis.

FIGURE 1

Schematic drawing of the blood–CSF and blood–brain barriers

FIGURE 2

Contrast enhanced axial imaging of the supratentorial brain (a,b) demonstrates curvilinear enhancement of the pial surface of the brain from leptomeningeal disease (LMD). Extensive pial enhancement involves the occipital and parietal cortex bilaterally (white arrows) as well as a focal nodular deposit involving the right frontal cortex (white curved arrow). Contrast enhanced axial imaging of the posterior fossa (c,d) demonstrates nodular enhancing LMD involving cranial nerves VII and VIII within the IAC and CPA (black block arrows), right cranial nerve V in lateral pontine cistern and Meckel’s cave (black arrows), as well as the folia of the cerebellum (white block arrows)

FIGURE 3

Contrast enhanced sagittal images of three different patients. First patient (a) does not have leptomeningeal disease (LMD) and demonstrates normal minimal enhancement involving the pial surface of the lower thoracic cord and conus (white arrows). Patient b has extensive smooth LMD involving the conus and cauda equine (white arrows). Patient c has more extensive and nodular LMD involving the lower thoracic cord and conus (black block arrows) and extensive focal leptomeningeal disease involving the sacral nerve roots (white block arrow)