A Case of Isolated Leptomeningeal Carcinomatosis from Advanced Gastric Cancer

Jung Geun Ji; Joo Won Chung; Seung Woo Nam; Seung Kyu Choi; Dong Won Lee; Dae In Kim; Byung Gwan Jeon; Yun Jae Shin

doi:10.4166/kjg.2016.68.2.93

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Ji, Chung, Nam, Choi, Lee, Kim, Jeon, and Shin: A Case of Isolated Leptomeningeal Carcinomatosis from Advanced Gastric Cancer

Case Report

Korean J Gastroenterol 2016;68(2):93-98.

Published online: 4 October 2016

DOI: https://doi.org/10.4166/kjg.2016.68.2.93

A Case of Isolated Leptomeningeal Carcinomatosis from Advanced Gastric Cancer

Jung Geun Ji, Joo Won Chung, Seung Woo Nam, Seung Kyu Choi, Dong Won Lee, Dae In Kim, Byung Gwan Jeon, Yun Jae Shin

Gastrointestinal Center, Department of Internal Medicine, National Medical Center, Seoul, Korea

Correspondence to: Joo Won Chung, Gastrointestinal Center, Department of Internal Medicine, National Medical Center, 245 Eulji-ro, Jung-gu, Seoul 04564, Korea. Tel: +82-2-2276-2267, Fax: +82-2-2267-8685, E-mail: drbeatrix@daum.net

Received 12 April 2016 Revised 13 May 2016 Accepted 14 May 2016

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Leptomeningeal carcinomatosis (LMC) is rare metastatic form of gastric cancer. Most cases are diagnosed in the final stage after multiple distant metastasis. An 84-year-old woman was admitted with melena, headache and vomiting. Esophagogastroduodenoscopy showed an ulceroinfiltrating lesion at the stomach (Borrmann class III), and biopsy revealed a signet ring cell carcinoma. The abdominal-pelvic CT showed no evidence of metastasis. A sudden decrease of consciousness was noted, but the brain CT showed no active lesion while the brain MRI revealed enhancement of leptomeninges. A lumbar puncture was performed and the cerebrospinal fluid study revealed malignant neoplastic cells. With family consent, no further evaluation and treatment were administered and she died six weeks after the diagnosis of gastric cancer. We report an extremely rare case of a patient who initially presented with neurologic symptoms, and was diagnosed LMC from advanced gastric cancer without any evidence of metastasis in abdomen and pelvis.

Keywords: Gastric cancer, Leptomeningeal carcinomatosis, Neurologic manifestations

References

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Fig. 1.

Endoscopic finding. Endoscopy shows a 3 cm ulceroinfiltrative lesion with irregular base, nodular elevated margin, and abnormalities of surrounding folds (Borrmann class III) at the posterior wall of the upper body.

Fig. 2.

Pathologic findings (H&E). (A) The biopsy of stomach shows cellular infiltration with poorly differentiated adenocarcinoma, bizarre/ pleomorphic cells and few eosinophilic cells (×100). (B) Signet ring cells, characterized by a central optical clearing and globoid droplet of cytoplasmic mucin with an eccentrically placed nucleus, are observed (×400).

Fig. 3.

MRI findings. (A) Brain MRI with gadolinium-enhanced, T1-weighted axial image shows multifocal diffuse leptomeningeal enhancement at cerebrum and cerebellum. (B) Focal enhancing nodule of 1 cm is noted on right infratentorium.

Fig. 4.

Cytological findings (Wright's stain). (A) The cerebrospinal fluid shows a few large malignant cells with high nuclear/cytoplasmic ratio, 2–3 nucleoli, and basophilic cytoplasms (×400). (B) Adenocarcinoma includes small vacuoles and protoplasmic projection (×400).

Table 1.

Summary of Six Retrospective Studies of Leptomeningeal Carcinomatosis in Gastric Cancer

Referencce	Patient	Bormann classification III or IV	Poorly differentiated adenocarcinoma	Signet ring cell	Cancer stage III or IV	Median duration from diagnosis of gastric cancer to diagnosis of LMC (mo)	Median surviva time from diagnosis of LMC (wk)
Lisenko et al., 2003²	8	5/8 (62.5)	8/8 (100)	6/8 (75)	7/8 (87.5)	12.0	6.0
Lee et al., 2004¹	19	18/19 (94.7)	15/19 (79.0)	8/19 (42.1)	19/19 (100)	6.6	4.0
Oh et al., 2009^4,a	54	38/45 (84.4)	44/47 (93.6)	19/47 (40.4)	49/51 (96.1)	6.3	6.7
Emoto et al., 2011⁵	7	7/7 (100)	6/7 (85.7)	5/7 (71.4)	7/7 (100)	13.0	4.7
Tomita et al., 2012⁹	12	NA	NA	NA	9/12 (75.0)	15.6	8.6
Kim et al., 2014³	9	8/9 (88.9)	5/9 (55.6)	2/9 (22.2)	7/8 (87.5)	10.0	4.0

Values are presented as n only or n (%).

LMC, leptomeningeal carcinomatosis; NA, not available.

^a Multi-center study at four institutions from 1994 to 2007.

Table 2.

Cases of Leptomeningeal Carcinomatosis from Gastric Cancer without Involvement of Any Other Sites

Reference	Age (yr)/ sex	Initial presenting symptom	Endoscopic & histologic finding (site/Bormann type/differentiation)	MRI finding	Treatment	Survival time from diagnosis of LMC
Deeb et al., 1997¹³	53/M	Nausea, vomiting, dizziness	EG junction/ – / PDAC–	Normal	Intrathecal CTx (MTX)	＞6 mo
Yamada et al., 2008¹²	53/M	Anorexia, headache, diplopia	Antrum/Bormann II/ PDAC	Slight enhancement of cerebellar sulcus	Whole brain RTx	4.2 mo
Guo et al., 2014⁸	40/F	Headache, cervical pain	Antrum/Bormann I/ PDAC	Hydrocephalus, enhancement along ventral surface of brain stem, cerebellum and spinal cord (C1-T4)	No	4 mo
Present case	81/F	Melena, headache, vomiting	Upper body/Bormann III/PDAC with signet ring cell	Multifocal enhancement along ventral surface of cerebrum and cerebellum	No	6 wk

M, male; F, female; EG, esophago-gastric; PDAC, poorly differentiated adenocarcinoma; CTx, chemotherapy; MTX, methotrexate; RTx, radiotherapy; LMC, leptomeningeal carcinomatosis.

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