Correlation of Leptomeningeal Disease on MRI Between the Brain and Spine in Patients Presenting to a Tertiary Referral Center Poster #: EP-47 Control #: 1681

1 Syed S. Hashmi, 2 J. Matthew Debnam, 3 Dima Suki, 4 Rory R. Mayer, 2 T Linda Chi, 2 Leena Ketonen, 3 Jeffrey S. Weinberg, 2 Nandita Guha-Thakurta 1 Department of Diagnostic Radiology, The University of Texas, Houston, TX; 2 Department of Diagnostic Radiology, Section of Neuroradiology, 3 Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX; 4 Department of Neurosurgery, Baylor College of Medicine, Houston, TX

The Institutional Review Board approved this study and waived the requirement for informed consent. Data acquisition was performed in compliance with all applicable Health Insurance Portability and Accountability Act regulations. No Disclosures

Leptomeningeal disease (LMD) Background Spread of cancer cells within the leptomeningeal space in brain and/or spine Associated with poor prognosis, increased mortality rates Incidence of LMD has been increasing – now occurring in 3-8% of patients with cancer

Leptomeningeal disease (LMD) Background Cytological evaluation remains the gold standard for diagnosis, however,... MRI is often used in the assessment of patients with suspected LMD involving the brain and spine

Purpose of Study To determine if there is a correlation between findings in the brain and spinal canal on MRI in patients with LMD

Materials & Methods Inclusion criteria MRI brain with contrast MRI spine with contrast CSF cytology documenting the presence of LMD

Materials & Methods Total cases reviewed – patients met the inclusion criteria MRI brain review –consensus by 4 neuroradiologists MRI of the spine review –consensus by 2 neuroradiologists

Materials and Methods MR imaging BRAIN assessment (10 categories) 1.Presence of leptomeningeal enhancement (T1 post-contrast) and FLAIR signal hyperintensity in the sulci of the brain cerebellum, frontal, parietal, temporal and occipital lobes. 2.T1 enhancement and FLAIR hyperintensity was evaluated and qualified as: absent equivocal <1/4 of the affected lobe >1/4 but <1/2 of the affected lobe, or >1/2 of the affected lobe

Materials and Methods BRAIN MR imaging assessment (10 categories) 3.Ependymal enhancement in the ventricular system linear nodular, or mixed 4.Number of parenchymal lesions solitary 2-5 lesions, or >5 lesions 5.Size of the largest parenchymal metastasis 6.± vasogenic edema 7.Related mass effect

Materials and Methods BRAIN MR imaging assessment (10 categories) 8.Cranial nerve enhancement CN III CN V Meckel’s cave CN VII/VIII 9. Basal cisterns enhancement 10. Pituitary stalk enhancement

Materials and Methods SPINE MR imaging assessment T1 enhancement was qualified as one or more of the following: 1.thin and linear 2.thick and linear 3.nodular 4.diffuse filling the spinal canal

Statistical Analysis Frequencies and descriptive statistics on the various entities under study were obtained. Chi square test or the Fisher exact test univariate and multivariate logistic regression analysis Odds ratios and their 95% confidence intervals were obtained A multivariate model was utilized if a critical p value was 0.05

Results Patient demographics 157 patients positive for LMD on cytology 88 women: 69 men age 9-82 (mean age 51 ± 13.2 years) For patients < 36.5 years: 11 (41%) patients were positive for spinal LMD 16 (59%) patients were positive for spinal LMD For patients ≥ 36.5 years 36 (28%) patients were positive for spinal LMD 94 (72%) patients were positive for spinal LMD

Results Primary Malignancy (n=157) breast (n=44) lymphoma (n=36) lung (n=23) melanoma (n=19) glioma (n=9) leukemia (n=5) other (n=21)

Results Brain –T1 post contrast enhancement in each lobe NoneEquivocal Less than one quarter one quarter to one half greater than one half Combined Right cerebellum Left cerebellum Right occipital Left occipital Right parietal Left parietal Right temporal Left temporal Right frontal Left frontal Axial T1 postcontrast: A, LMD in the sulci of the frontal and parietal lobes B, LMD in the cerebellar folia A B

Results Brain – T2/FLAIR hyperintensity in each lobe NoneEquivocal Less than one quarter one quarter to one half greater than one half Combined Right cerebellum Left cerebellum Right occipital Left occipital Right parietal Left parietal Right temporal Left temporal Right frontal Left frontal Axial T2/FLAIR A, LMD in the sulci of the frontal and parietal lobes B, LMD in the cerebellar folia A B

Results Brain LMD-Cranial nerve involvement right CN III (n=6), left CN III (n=5) right CNV (n=16), left CN V (n=14) right Meckel’s cave (n=15) left Meckel’s cave (n=12) A. CN IIIB. CN V C. Meckel’s cave A B C

Results Brain LMD-Cranial nerve involvement right CN VII/VIII (n=34), left CN VII/VII (n=28) basal cisterns (n=28) pituitary stalk (n=7) some patients exhibited more than one site involvement A. CN VII/VIII B, basal cisterns C. pituitary stalk C B A

Results Brain LMD-Other sites of disease involvement Ependymal enhancement: 28 patients (17.8%) linear (n=16), nodular (n=4), or mixed (n=8). Parenchymal metastasis: 61 patients (38.8%) Number: solitary (n=21), between 2-5 (n=25), or >5 (n=15) Size: <10 mm (n= 26), between 10 and <20 mm (n=18), greater or equal to 20 mm (n=17) Vasogenic edema present: 56 patients (35.7%) Mass effect present: 40 patients (25.5%) A. ependymal B. parenchymal met C. Vasogenic edema/ mass effect C B A

Results Spinal canal -Leptomeningeal enhancement 110 of 157 patients (70.1%) thin/linear (n=55) thick (n=36) nodular (n=15) diffuse (n=5) Patients may have exhibited more than one type of enhancement A. thin linear B, thick linear C. nodular D. diffuse A B C D

Results-Statistics gender (n=0.9) tumor type (0.85) ependymal enhancement (p=0.78) parenchymal mass presence of a mass (p=0.2) size (p=0.22) vasogenic edema (p=0.24) associated mass effect (p=0.68) No significant association was noted between spinal leptomeningeal enhancement and….

Results-Statistics No significant association was noted between brain parenhcymal enhancement and spinal leptomeningeal enhancement T1 post contrastT2/FLAIR p value Right cerebellum Left cerebellum Right occipital Left occipital Right parietal Left parietal Right temporal Left temporal Right frontal Left frontal T2/FLAIR hyperintensity in the occipital lobe closely approached and in the left parietal lobe was significantly associated with spinal canal leptomeningeal enhancement

Results-Statistics All cranial nerves combined: approached significance (p=0.09) right CN III (p=0.18) left CN III (p=0.32) right Meckel’s cave (p=0.56) left Meckel’s cave (p=0.51 pituitary stalk (p=0.43) Relation between cranial nerve involvement with LMD and spinal LMD

Results-Statistics All cranial nerves combined approached significance (p=0.09) Significant association right CNV (p=0.003) left CNV (p=0.01) right CNVII/VIII (p=0.01) left CN VII/VIII (p=0.01) Basal cistern (0.17) Relation between cranial nerve involvement with LMD and spinal LMD

Conclusion LMD can affect the brain at many locations Higher association of leptomeningeal enhancement in the spinal canal seen with the presence of the following: Leptomeningeal enhancement of the cranial nerves, particularly CN V and CN VII/VIII T2/FLAIR signal hyperintensity in the sulci of the parietal and occipital lobes Patients with these findings in the brain should undergo imaging of the spine to assess or spinal LMD