Diagnostic Reliability of Leptomeningeal Disease Using Magnetic Resonance Imaging

Brain metastases are seen in 20%-50% of patients with metastatic solid tumors. On the other hand, leptomeningeal disease (LMD) occurs more rarely. The gold standard for the diagnosis of LMD is serial cerebrospinal fluid (CSF) analyses, although in daily practice, the diagnosis of LMD is often made by neuroimaging. Leptomeningeal metastases (LM) have been a relative contra-indication to radiosurgery. It can be noted that focal LMD can be difficult to distinguish from a superficially located/cortical-based brain metastasis which is not a contra-indication for radiosurgery. Hence, justifying the need of a reliable diagnosis method. The goal of this study was to determine the inter-observer reliability of contrast-enhanced magnetic resonance imaging (gdMRI) in the differentiation of focal cortical-based metastases from leptomeningeal spread. This is a retrospective review of a prospectively collected database of patients with brain metastases. A total of 42 cases with superficial lesions were selected for review. Additionally, eight control cases demonstrating deep and/or white-matter based lesions were included in the study. Three neuroradiologists and three radiation oncologists were asked to review each study and score the presence of LM. Inter-observer agreement was calculated using group-derived agreement coefficients (Gwet’s AC1 and Gwet's AC2). Pair-wise inter-observer agreement coefficients never reached substantial values for trichotomized outcomes (LMD, non-LMD or indeterminate) but did reach a substantial value in a minority of cases for dichotomised outcomes (LMD or non-LMD). The control subgroup analysis revealed substantial agreement between most pairs for both trichotomized and dichotomised outcomes. We observed low inter-observer agreement amongst specialists for the diagnosis of focal LMD by gdMRI. Neuroimaging should not be relied upon to make treatment decisions, notably to deny patients radiosurgery.