LMD-21. Headache Improvement Predicts Survival after CSF diversion in Leptomeningeal Disease

BACKGROUND: Leptomeningeal carcinomatosis (LMD) is a seeding of the leptomeninges by malignant cells. Clinical, treatment and patient-related factors have been described in patients with LMD. Current data are limited by small sample size, particularly in patients undergoing ventriculoperitoneal shunting (VPS) as part of the treatment regimen. OBJECTIVE: This study presents the largest cohort of LMD patients in the literature undergoing cerebrospinal fluid (CSF) diversion and seeks to identify prognostic factors related to survival. METHODS: A retrospective review of patients diagnosed with LMD between 2010 and 2016 at a quaternary referral center was performed. Cox proportional hazards modeling was utilized to identify variables associated with improved overall survival from LMD diagnosis. Overall survival was depicted using Kaplan-Meier methodology. Competing risk methodology was used to identify variables associated with VPS, considering death as a competing event. RESULTS: Of the 314 patients identified, 112 underwent VPS placement. The median overall survival from LMD diagnosis was 3.9 months (95% CI: 3.2–4.4). The presence of headaches, increased opening pressure, and gait difficulty increased the likelihood of VPS placement (all p<0.05). VPS, older age, lower Karnofsky Performance Status (KPS), higher opening pressure and CSF nucleated cell count (NCC) increased the risk of death (all p<0.05). Patients reporting headache improvement after VPS had better survival (p<0.05). CONCLUSIONS: Headache, increased opening pressure and gait instability were associated with higher rate of VPS placement and may portend more aggressive disease. Headache improvement following VPS is a favorable prognostic sign, suggesting survival advantage for patients with hydrocephalus undergoing VPS. Age, KPS, VPS, opening pressure, CSF NCC, concomitant visceral metastases and histology-specific molecular profile impact survival.