Images in Clinical Medicine
Neoplastic Meningitis
N Engl J Med 2001; 344:494February 15, 2001
- Article
Figure 1 A 24-year-old man presented with headaches, polyuria, and a tumor in the region of the optic chiasm. An open biopsy was nondiagnostic, and he was treated empirically with radiation therapy for a presumed astrocytoma or germ-cell tumor of the central nervous system. Fourteen months later, he had pain in the neck and left arm and was found to have an intradural mass at the level of T5 on contrast-enhanced magnetic resonance imaging. Surgical exploration revealed a metastasis in the subarachnoid space, which proved to be from a yolk-sac tumor with a reticular pattern. The tumor was strongly immunoreactive to alpha fetoprotein. The patient's serum alpha fetoprotein level was elevated (474 ng per milliliter) and remained abnormal after he completed total spinal irradiation. A year later, after four cycles of systemic chemotherapy with cisplatin, etoposide, and ifosfamide, magnetic resonance imaging demonstrated new periventricular enhancement (Panel A) and a persistent T5 lesion consistent with the presence of progressive leptomeningeal involvement. One month later, increasing headache, nausea, and vomiting developed, and neuroimaging studies demonstrated a dramatic increase in the size of the periventricular tumor (Panel B).
Stuart A. Grossman, M.D.
Johns Hopkins Oncology Center, Baltimore, MD 21231Paul Celano, M.D.
Greater Baltimore Medical Center, Baltimore, MD 21204
