A 70-year-old man presented with
dizziness,
headache and
hearing loss. He was admitted to our hospital because of increasing unsteadiness of gait. Magnetic resonance imaging of the brain revealed meningeal thickening with enhancement. The lumbar puncture revealed high opening pressure. The cerebrospinal fluid showed
pleocytosis, high
carcinoembryonic antigen (CEA) concentration, and presence of neoplastic cells, leading to the diagnosis of
leptomeningeal carcinomatosis. Systemic investigation for primary
neoplasm identified a Bormman type 3
gastric cancer (
papillary adenocarcinoma with micropapillary pattern). Except for the meninges, no metastatic lesions could be detected. A
ventriculoperitoneal shunt (Codman Hakim Programmable Valve) was placed for management of
intracranial hypertension and intrathecal chemotheray. He was started on oral S-1 (TS-1) combined with intrathecal
methotrexate injection using the VP shunt reservoir. In two weeks,
headache and
hearing loss completely disappeared and gait disturbances started to improve. CSF findings also improved remarkably with disappearance of neoplastic cells and almost normalization of CEA. For the next five months, he was well on oral S-1 and monthly intrathecal
chemotherapy, being able to walk using a walker and to stay at home. He subsequently developed posterior cortical symptoms such as
prosopagnosia and
cortical blindness and gradually lapsed into
coma. He died from
pneumonia one year after the onset of neurological symptoms. At autopsy, primary
gastric cancer was found but much reduced in size. No peritoneal
metastasis could be found. In the brain,
leptomeningeal carcinomatosis involved the occipital lobes, the base of the temporal lobe, and the cerebellum. We suggest that intrathecal
chemotherapy using
ventriculoperitoneal shunt with programmable valve system could be an effective method for the treatment of
meningeal carcinomatosis.