Leptomeningeal Metastasis: Primary Mucinous Carcinoma of the Ovary;

CASE PRESENTATION

Leptomeningeal carcinomatosis (LMC) is an extremely rare site for metastasis from a primary ovarian cancer. We present a case of a 60 years old female patient, who was a known case of Malignant Pleural Mesothelioma diagnosed in January 2022, heavily treated with chemotherapy showing partial response after two years and developed chemotherapy induced Myelodysplatic Syndrome (Bone marrow biopsy suggestive of Megaloblastic Anemia leading to pancytopenia).

Then she developed ascites which was found to be positive for metastatic Serous papillary adenocarcinoma of Mullerian origin, received Carboplatin & Paclitaxel. Respose PET CT revealed progression of B/L adnexal disease.

Later she complained of giddiness, nausea, vomiting. MRI brain suggestive of edema like changes in Right occipital lobe with minimal leptomeningeal enhancement possibility of ? posterior reversible leukoencephalopathy/ toxic encephal-opathy more likely than metastasis, adv clinical correlation & sos CSF. CSF cytology was positive for malignant cells adenocarcinoma.

TREATMENT

She was treated with Radiation Treatment 30 Gy/10 fractions to whole brain with palliative intent for leptomeningeal metastasis, steroids and received weekly Triple drug Intrathecal chemotherapy and Bevacizumab two weekly.

DISCUSSION

• Leptomeningeal metastasis is an extremely rare site for metastasis from Primary ovarian cancer.
• Serous ovarian cancer makes up most cases leading to brain metastasis from a primary ovarian neoplasm, which accounts for the most common subtype of ovarian cancer leading to leptomeningeal disease
• The patient in this case presented with headaches, vomiting, and gait disturbances, which are the most common presenting symptoms of Leptomeningeal metastasis.
• The new onset of her neurologic symptoms on the background of her mucinous ovarian carcinoma prompted further investigations.
• In patients with cancer and leptomeningeal enhancement on MRI, leptomeningeal carcinomatosis must be considered as the diagnosis until proven otherwise.
• Management of patients with LMC focuses on improving the neurologic symptoms, quality of life, and prolonging survival while at the same time minimizing toxicity of definitive treatment options.
• The use of systemic chemotherapy, whole-brain radio-therapy, intrathecal chemotherapy, and surgical resection alone or in combination has been the mainstay of treatment in the reported literature.
• Concerning treatments, a multimodal strategy (including surgery, radiotherapy and chemotherapy), if feasible, seems to be the best way to improve survival rates.

CONCLUSION

Leptomeningeal carcinomatosis secondary to ovarian cancer, as illustrated by the case in this study, is linked to a poor prognosis. Despite utilizing multiple therapeutic approaches such as radiation, intravenous, and intrathecal chemotherapy, effective management remains a significant challenge. Our findings highlight the critical need for heightened clinical awareness in patients with primary ovarian cancer and prompt investigation in suspected cases to improve the prognosis and care for these patients.

Authors: Dr. Inderpreet Kaur, Dr. Vibha Naik, Dr. Rushi Panchal, Dr. C. Srinivasan, Dr. Swati Gupta

Ref. Dye A, Stein R, Lewis G, et al. (January 02, 2024) Leptomeningeal Carcinomatosis From Primary Mucinous Carcinoma of the Ovary. Cureus 16(1): e51556. doi:10.7759/cureus.51556