Journal of Postgraduate Medicine
 Open access journal indexed with Index Medicus & ISI's SCI  
Users online: 640  
Home | Subscribe | Feedback | Login 
About Latest Articles Back-Issues Article Submission Resources Sections Etcetera Contact
 
  NAVIGATE Here 
  Search
 
 :: Next article
 :: Previous article 
 :: Table of Contents
  
 RESOURCE Links
 ::  Similar in PUBMED
 ::  Search Pubmed for
 ::  Search in Google Scholar for
 ::  Article in PDF (122 KB)
 ::  Citation Manager
 ::  Access Statistics
 ::  Reader Comments
 ::  Email Alert *
 ::  Add to My List *
* Registration required (free) 

  IN THIS Article
 ::  References
 ::  Article Figures

 Article Access Statistics
    Viewed8990    
    Printed143    
    Emailed0    
    PDF Downloaded162    
    Comments [Add]    
    Cited by others 7    

Recommend this journal


 


 
LETTER TO EDITOR
Year : 2004  |  Volume : 50  |  Issue : 4  |  Page : 311-312

Carcinomatous meningitis occurring prior to a diagnosis of large cell neuroendocrine carcinoma of the uterine cervix


1 Departments of Neurological Sciences, Christian Medical College, Vellore - 632004, Tamilnadu, India
2 Departments of Pathology, Christian Medical College, Vellore - 632004, Tamilnadu, India

Correspondence Address:
Sudhir Kumar
Departments of Neurological Sciences, Christian Medical College, Vellore - 632004, Tamilnadu
India
Login to access the Email id


PMID: 15623983

Get Permissions




How to cite this article:
Kumar S, Nair S, Alexander M. Carcinomatous meningitis occurring prior to a diagnosis of large cell neuroendocrine carcinoma of the uterine cervix . J Postgrad Med 2004;50:311-2

How to cite this URL:
Kumar S, Nair S, Alexander M. Carcinomatous meningitis occurring prior to a diagnosis of large cell neuroendocrine carcinoma of the uterine cervix . J Postgrad Med [serial online] 2004 [cited 2014 Dec 19];50:311-2. Available from: http://www.jpgmonline.com/text.asp?2004/50/4/311/13660


Sir,



A 39-year-old lady presented with deviation of the angle of mouth to the right side, left-sided decreased hearing, dysphagia and dysarthria of three months duration associated with left-sided headache. There was no history of fever or ear discharge. On examination, optic fundi were normal. Left-sided lower motor neuron type of facial palsy, sensori-neural deafness, reduced pharyngeal sensations, impaired palatal movements and absent gag reflex were noted. The rest of the neurological examination was unremarkable.



Routine haemogram was normal and erythrocyte sedimentation rate was 130 mm/hour. Serum alkaline phosphatase was 208 U/L (normal range 40-125 U/L). Post-gadolinium magnetic resonance imaging (MRI) of the brain showed diffuse pachymeningitis [Figure - 1], without parenchymal lesions. Cerebrospinal fluid (CSF) analysis showed leucocyte count of 2/cmm, protein 44 mg% and sugar 67 mg%. Bacterial and fungal cultures, TB-PCR, and smear for acanthamoebae in the CSF were negative. CSF cytology showed a few atypical cells, however, malignant cells were absent. Therefore, bone marrow examination was done, which showed metastatic carcinoma [Figure - 2]. Gynaecological examination done as part of the search for possible primary showed features of carcinoma cervix. Histopathological examination confirmed the cervical tumour to be large cell neuroendocrine carcinoma.



Carcinomatous meningitis (CM) occurs in 5% of all adult cancer patients, often in the advanced stage.[1] Carcinoma cervix rarely leads to CM.[2] Our patient presented with multiple cranial nerve palsies, which is a relatively common neurological condition encountered in practice. MRI brain showed features of pachymeningitis, which is not specific for any particular aetiology. Diffuse meningeal enhancement on MRI can occur due to a wide variety of conditions, which include infectious (bacterial, fungal, tuberculous, etc.), inflammatory (sarcoidosis, collagen vascular diseases, etc.), carcinomatous (cancer-related), reactive (due to surgery, shunt or trauma), and chemical (due to ruptured cysts or intrathecal chemotherapy) causes.[3] Though the exact aetiology can often be determined on the basis of history, clinical examination, CSF analysis and other investigations, it could be challenging at times. However, it is vital to identify the aetiology in order to institute the correct treatment. CM usually occurs in patients with known cancer. Therefore, it should be suspected in patients with a history of malignancy, who present with an isolated neurological sign or symptom. However, confirming a diagnosis of CM might prove to be difficult. Repeated CSF analysis for detecting neoplastic cells is advised, as a single lumbar puncture might yield negative results.[4] Our patient did not show neoplastic cells even after three lumbar punctures. Though MRI findings are non-specific, it has been suggested that patterns of meningeal enhancement vary in different aetiologies. Infectious meningitis often results in leptomeningeal (pia and arachnoid) enhancement, when enhancement of the meninges follows the convolutions of the gyri and/or involves the meninges around the basal cisterns; whereas carcinomatous meningitis causes pachymeningeal (dura) enhancement, when the enhancement is thick and linear or nodular along the inner surface of the calvarium, falx, or tentorium without extension into the cortical gyri or basal cistern involvement.[3]



Common sites of distant metastases in carcinoma cervix are liver and lung parenchyma. Brain metastases from cervical carcinoma are uncommon and occur in only 1% of all cervical carcinoma.[5] The median interval between the diagnosis of cervical cancer and documentation of brain involvement is 18 months,[5] however, occasionally, this can be as short as one week.[6] In our patient, the detection of neurological disease preceded the diagnosis of carcinoma cervix. To the best of our knowledge, this has not been reported before.



In conclusion, the present case highlights the difficulty in diagnosing CM, especially in a patient previously not known to have a malignancy. It also emphasizes the importance of simple procedures such as bone marrow biopsy and gynaecological examination in women presenting with features suggestive of pachymeningitis, in disclosing an unknown malignancy.

 
 :: References Top

1.Ferreira Filho AF, Cardoso F, Di Leo A, Awada A, da Silva VD, Tovar RB, et al. Carcinomatous meningitis as a clinical manifestation of pancreatic carcinoma. Ann Oncol 2001;12:1757-9.   Back to cited text no. 1    
2.Aboulafia DM, Taylor LP, Crane RD, Yon JL, Rudolph RH. Carcinomatous meningitis complicating cervical cancer: A clinicopathologic study and literature review. Gynecol Oncol 1996;60:313-8.  Back to cited text no. 2    
3.Kioumehr F, Dadsetan MR, Feldman N, Mathison G, Moosavi H, Rooholamini SA, et al. Postcontrast MRI of cranial meninges: Leptomeningitis versus pachymeningitis. J Comput Assist Tomogr 1995;19:713-20.  Back to cited text no. 3    
4.Wang VS, Tuch P, Wang CC. An unusual cause of headache. J Clin Neurosci 2003;10:612-6.  Back to cited text no. 4    
5.Cormio G, Pellegrino A, Landoni F, Regallo M, Zanetta G, Colombo A, et al. Brain metastases from cervical carcinoma. Tumori 1996;82:394-6.  Back to cited text no. 5    
6.Friedman M, Nissenbaum M, Lakier R, Browde S. Brain metastases in early cancer of the uterine cervix. A case report. S Afr Med J 1983;64:498-9.  Back to cited text no. 6    


    Figures

[Figure - 1], [Figure - 2]

This article has been cited by
1 The Cerebroespinal venous system: Clinical anatomy, physiology and implications | [El sistema venoso cerebroespinal: Anatomía, fisiología e implicaciones clínicas]
Tobinick, E.
Archivos de Medicina. 2010; 6(1)
[Pubmed]
2 Carcinomatous meningitis from adenocarcinoma of the uterine cervix: A case report and literature review
Yamauchi, N., Sameshima, H., Osato, K., Fukushima, K., Sato, Y., Ikenoue, T.
Journal of Obstetrics and Gynaecology Research. 2010; 36(2): 444-447
[Pubmed]
3 Leptomeningeal carcinomatosis presenting as bilateral sensorineural deafness and unilateral facial palsy
Mourgela, S., Sakellaropoulos, A., Ardavanis, A.
Journal of B.U.ON.. 2009; 14(2): 317-319
[Pubmed]
4 Meningeal carcinomatosis and uterine carcinoma: Three different clinical settings and review of the literature
Asensio, N., Luis, A., Costa, I., Oliveira, J., Vaz, F.
International Journal of Gynecological Cancer. 2009; 19(1): 168-172
[Pubmed]
5 Pachymeningeal metastasis from squamous cell carcinoma of the uterine cervix with involvement of the optic nerve: Case report and review of the literature
Balaji, R., Ramachandran, K., Kumar, A., Krishnakumar, A.S., Venugopal, M.
Cancer Imaging. 2007; 7(1): 138-140
[Pubmed]
6 The cerebrospinal venous system: Anatomy, physiology, and clinical implications
Tobinick, E.
MedGenMed Medscape General Medicine. 2006; 8(1)
[Pubmed]
7 Intramedullary spinal cord and leptomeningeal metastases in a patient with carcinoma of the uterine cervix
Kastritis E, Moulopoulos LA, Politi E, et al.
GYNECOLOGIC ONCOLOGY. 2006; 102 (1): 124-127
[Pubmed]



 

Top
Print this article  Email this article
Previous article Next article
Online since 12th February '04
© 2004 - Journal of Postgraduate Medicine
Official Publication of the Staff Society of the Seth GS Medical College and KEM Hospital, Mumbai, India
Published by Medknow