2019 Research Forum

Applicant: Leila Moosavi MD R3 Faculty Sponsor Everardo Cobos MD

Leptomeningeal Carcinomatosis from Carcinoma of Unknown Primary

Leila Moosavi MD R3, Carlos D’Assumpcao MD R1, Jonathan Bowen MS IV, Arash Heidari MD, Everardo Cobos MD

INTRODUCTION Leptomeningeal metastases are a rare but frequently devastating complication of advanced cancer. The most common solid tumors giving rise to leptomeningeal metastases are breast, lung, melanoma and cancers of unknown primary. We are presenting a rare case of leptomeningeal metastases from carcinoma of unknown primary with increased intracranial pressure. A 32-year-old Hispanic woman who initially presented with shortness of breath and was found to have mediastinal and retroperitoneal lymphadenopathy. Biopsy of the mediastinal node revealed poorly differentiated carcinoma positive for cytokeratin and placental alkaline phosphatase (PLAP) suggestive of germ cell tumor vs carcinoma of unknown primary. She received 3 cycles of Carboplatin and Docetaxel with significant improvement. However, she started to have headaches. MRI brain revealed leptomeningeal enhancements suggestive of leptomeningeal carcinomatosis. She was started on intrathecal methotrexate. After the injection, she developed worsening of headaches with photophobia and meningismus. Lumbar puncture (LP) was repeated and showed significant elevation of cell count to above 400 which turned out to be malignant cell with opening pressures of 600 mmH2O. Serial LPs performed to reduce pressure. She developed fever but her infectious workup came back negative. Given worsening of symptoms, patient was switched to Cytarabine IT twice a week. Serial brain imaging did not show hydrocephalus but due to need for frequent LPs lumbar drain was suggested. Repeated cytology of CSF showed persistent presence of malignant cells plus placental alkaline phosphatase. In the attempt to find the primary source a repeat biopsy of cervical lymph node performed which showed the cytokeratin profile and expression of cdx2 are most consistent with intestinal differentiation. She developed a hematoma at the serial LP site and in light of severe leptomeningeal disease which confers a poor prognosis, the patient and her family proceeded with comfort care measures at hospice prior to any diagnostic investigation.

CONCLUSION Leptomeningeal carcinomatosis has a poor prognosis and clinicians should have high level of suspicious in the right clinical settings for prompt diagnosis.

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