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Postoperative course of cerebrospinal fluid diversion in the setting of leptomeningeal disease: a systematic review, meta-analysis, and meta-regression with an illustrative case

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Abstract

Background

Management of hydrocephalus symptoms in the setting of leptomeningeal disease (LMD) includes cerebrospinal fluid (CSF) diversion, which can in the form of ventriculoperitoneal shunting (VPS) and lumboperitoneal shunting (LPS). However, the quantifiable postoperative course following this intervention is poorly defined. Correspondingly the aim of our study was to quantitatively define and analyze the pooled metadata regarding this topic.

Methods

Multiple electronic databases from inception to March 2023 were searched following PRISMA guidelines. Respective cohort-level outcomes were then abstracted and pooled by means of meta-analyses and analyzed by means meta-regression, both utilizing random-effects modeling. Post-hoc bias evaluation was then performed for all outcomes.

Results

A total of 12 studies were identified for inclusion, describing 503 LMD patients managed by CSF diversion – 442 (88%) by VPS and 61 (12%) by LPS. Median male percentage and age at diversion were 32% and 58 years respectively, with lung and breast cancer the most common primary diagnoses. Meta-analysis demonstrated pooled incidence of symptom resolution in 79% (95% CI 68–88%) of patients after index shunt surgery, and shunt revision required in 10% (95% CI 6–15%) of cases. Pooled overall survival from index shunt surgery was 3.8 mo (95% CI 2.9–4.6 mo) across all studies. Meta-regression demonstrated that studies published later trended towards significantly shorter overall survival from index shunt surgery (co-efficient=-0.38, P = 0.023), whereas the proportion of VPS to LPS in each study did not impact survival (P = 0.89). When accounting for these biases, overall survival from index shunt surgery was re-estimated to be shorter 3.1 mo (95% CI 1.7–4.4 mo). We present an illustrative case demonstrating the course of symptom improvement, shunt revision and an overall survival of 2 weeks from index CSF diversion.

Conclusion

Although CSF diversion in the setting of LMD can improve hydrocephalus symptoms in the majority of patients, there is a non-negligible proportion that will require shunt revision. Postoperatively, the prognosis of LMD remains poor irrespective of shunt type, and despite possible biases within the current literature, the expected median overall survival after index surgery is a matter of months. These findings support CSF diversion as an effective palliative procedure when considering symptoms and quality of life. Further research is required to understand how postoperative expectations can be managed to respect the best wishes of patients, their family, and the treating clinical team.

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References

  1. Hitchins RN, Bell DR, Woods RL, Levi JA (1987) A prospective randomized trial of single-agent versus combination chemotherapy in meningeal carcinomatosis. J Clin Oncol 5(10):1655–1662

    Article  CAS  PubMed  Google Scholar 

  2. Glantz MJ, Jaeckle KA, Chamberlain MC et al (1999) A randomized controlled trial comparing intrathecal sustained-release cytarabine (DepoCyt) to intrathecal methotrexate in patients with neoplastic meningitis from solid tumors. Clin Cancer Res 5(11):3394–3402

    CAS  PubMed  Google Scholar 

  3. Kesari S, Batchelor TT (2003) Leptomeningeal metastases. Neurol Clin 21(1):25–66

    Article  PubMed  Google Scholar 

  4. Kaplan JG, DeSouza TG, Farkash A et al (1990) Leptomeningeal metastases: comparison of clinical features and laboratory data of solid tumors, lymphomas and leukemias. J Neurooncol 9(3):225–229

    Article  CAS  PubMed  Google Scholar 

  5. Jung T-Y, Chung W-K, Oh I-J (2014) The prognostic significance of surgically treated hydrocephalus in leptomeningeal metastases. Clin Neurol Neurosurg 119:80–83

    Article  PubMed  Google Scholar 

  6. Kumar A, Sardhara J, Singh G et al (2021) Malignant Meningitis Associated with Hydrocephalus. Neurol India 69(8):S429–S441

    Google Scholar 

  7. Moher D, Liberati A, Tetzlaff J, Althman D (2009) Preferred reporting items for systematic reviews and Meta-analyses: the PRISMA Statement. PloS Med 6(7):e1000097

    Article  PubMed  PubMed Central  Google Scholar 

  8. Lu VM, Abou-Al-Shaar H, Rangwala SD et al (2023) Neurosurgical outcomes of pediatric cerebral venous sinus thrombosis following acute mastoiditis: a systematic review and meta-analysis.J Neurosurg Pediatr.:1–9

  9. Begg CB, Mazumdar M (1994) Operating characteristics of a rank correlation test for publication bias. Biometrics 50(4):1088–1101

    Article  CAS  PubMed  Google Scholar 

  10. Egger M, Davey Smith G, Schneider M, Minder C (1997) Bias in meta-analysis detected by a simple, graphical test. BMJ (Clinical research ed) 315(7109):629–634

    Article  CAS  PubMed  Google Scholar 

  11. Duval S, Tweedie R (2000) Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics 56(2):455–463

    Article  CAS  PubMed  Google Scholar 

  12. Atkins D, Best D, Briss PA et al (2004) Grading quality of evidence and strength of recommendations. BMJ (Clinical research ed) 328(7454):1490

    Article  PubMed  Google Scholar 

  13. Wells G, Shea B, O’connell D et al (2009) The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Ottawa (ON): Ottawa Hospital Research Institute; Available in March 2016

  14. Su Y-H, Chiang C-L, Yang H-C et al (2022) Cerebrospinal fluid diversion and outcomes for lung cancer patients with leptomeningeal carcinomatosis. Acta Neurochir 164(2):459–467

    Article  PubMed  Google Scholar 

  15. Bander ED, Yuan M, Reiner AS et al (2021) Cerebrospinal fluid diversion for leptomeningeal metastasis: palliative, procedural and oncologic outcomes. J Neurooncol 154(3):301–313

    Article  PubMed  PubMed Central  Google Scholar 

  16. Yoshioka H, Okuda T, Nakao T et al (2021) Effectiveness of Palliative Cerebrospinal Fluid shunting for patients with Leptomeningeal Carcinomatosis-related Hydrocephalus. Anticancer Res 41(8):4169–4172

    Article  PubMed  Google Scholar 

  17. Kim HK, Lee HS, Heo MH et al (2021) Ventriculoperitoneal shunt for CNS metastasis in breast Cancer: clinical outcomes based on intrinsic subtype. Clin Breast Cancer 21(4):e402–e414

    Article  CAS  PubMed  Google Scholar 

  18. Kim HS, Park JB, Gwak H-S et al (2019) Clinical outcome of cerebrospinal fluid shunts in patients with leptomeningeal carcinomatosis. World J Surg Oncol 17(1):59

    Article  PubMed  PubMed Central  Google Scholar 

  19. Mitsuya K, Nakasu Y, Hayashi N et al (2019) Palliative cerebrospinal fluid shunting for leptomeningeal metastasis-related hydrocephalus in patients with lung adenocarcinoma: a single-center retrospective study. PLoS ONE 14(1):e0210074

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Burger MC, Wagner M, Franz K et al (2018) Ventriculoperitoneal shunts equipped with On-Off valves for Intraventricular Therapies in patients with communicating Hydrocephalus due to Leptomeningeal Metastases.J Clin Med.; 7(8)

  21. Murakami Y, Ichikawa M, Bakhit M et al (2018) Palliative shunt surgery for patients with leptomeningeal metastasis. Clin Neurol Neurosurg 168:175–178

    Article  PubMed  Google Scholar 

  22. Yamashiro S, Hitoshi Y, Tajiri S et al (2017) Palliative lumboperitoneal shunt for leptomeningeal metastasis-related hydrocephalus: a case series. Palliat Med 31(1):93–96

    Article  PubMed  Google Scholar 

  23. Gonda DD, Kim TE, Warnke PC et al (2012) Ventriculoperitoneal shunting versus endoscopic third ventriculostomy in the treatment of patients with hydrocephalus related to metastasis. Surg Neurol Int 3:97

    Article  PubMed  PubMed Central  Google Scholar 

  24. Lin N, Dunn IF, Glantz M et al (2011) Benefit of ventriculoperitoneal cerebrospinal fluid shunting and intrathecal chemotherapy in neoplastic meningitis: a retrospective, case-controlled study. J Neurosurg 115(4):730–736

    Article  PubMed  Google Scholar 

  25. Blegvad C, Skjolding AD, Broholm H et al (2013) Pathophysiology of shunt dysfunction in shunt treated hydrocephalus. Acta Neurochir (Wien) 155(9):1763–1772

    Article  CAS  PubMed  Google Scholar 

  26. Mansoor N, Solheim O, Fredriksli OA, Gulati S (2021) Revision and complication rates in adult shunt surgery: a single-institution study. Acta Neurochir (Wien) 163(2):447–454

    Article  PubMed  Google Scholar 

  27. Yang TH, Chang CS, Sung WW, Liu JT, Lumboperitoneal Shunt (2019) : A New Modified Surgical technique and a comparison of the complications with Ventriculoperitoneal Shunt in a single Center.Medicina (Kaunas). ; 55(10)

  28. Menger RP, Connor DE Jr, Thakur JD et al (2014) A comparison of lumboperitoneal and ventriculoperitoneal shunting for idiopathic intracranial hypertension: an analysis of economic impact and complications using the Nationwide Inpatient Sample. Neurosurg Focus 37(5):E4

    Article  PubMed  Google Scholar 

  29. Grossman SA, Krabak MJ (1999) Leptomeningeal carcinomatosis. Cancer Treat Rev 25(2):103–119

    Article  CAS  PubMed  Google Scholar 

  30. Woo B, Gwak H-S, Kwon J-W et al (2022) Lumboperitoneal Shunt Combined with Ommaya Reservoir enables continued Intraventricular Chemotherapy for Leptomeningeal Metastasis with increased intracranial pressure. Brain tumor research and treatment 10(4):237–243

    Article  PubMed  PubMed Central  Google Scholar 

  31. Pentheroudakis G, Pavlidis N (2005) Management of leptomeningeal malignancy. Expert Opin Pharmacother 6(7):1115–1125

    Article  CAS  PubMed  Google Scholar 

  32. Sunderland GJ, Conroy EJ, Nelson A et al (2023) Factors affecting ventriculoperitoneal shunt revision: a post hoc analysis of the british antibiotic and silver impregnated catheter shunt multicenter randomized controlled trial. J Neurosurg 138(2):483–493

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Neurological Surgery, University of Miami, Miami, FL, US

    Victor M. Lu, Evan M. Luther & Carolina G. Benjamin

  2. Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, US

    Hussam Abou-Al-Shaar & Othman Bin-Alamer

  3. Department of Neurological Surgery, University of Miami Miller School of Medicine, 1095 NW 14th Terrace, Miami, FL, 33136, USA

    Victor M. Lu

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  1. Victor M. Lu
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  2. Hussam Abou-Al-Shaar
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  5. Carolina G. Benjamin
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Contributions

VML: Methodology, Software, Visualization, Investigation, Writing- Reviewing and Editing. All authors: Conceptualization, Data curation, Writing- Original draft preparation, Writing- Reviewing and Editing.

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Correspondence to Victor M. Lu.

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Lu, V.M., Abou-Al-Shaar, H., Bin-Alamer, O. et al. Postoperative course of cerebrospinal fluid diversion in the setting of leptomeningeal disease: a systematic review, meta-analysis, and meta-regression with an illustrative case. J Neurooncol 163, 29–37 (2023). https://doi.org/10.1007/s11060-023-04334-2

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  • DOI: https://doi.org/10.1007/s11060-023-04334-2

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