Leptomeningeal disease (LMD) confirmed by CSF cytology (positive malignant cells), CSF fl...

Deterministic view of the source YAML entity. Clinical authority remains with the cited source IDs and reviewer sign-off state.

ID	`RF-LEPTOMENINGEAL-DISEASE`
Type	Red flag
Status	reviewed 2026-04-27 \| pending_clinical_signoff
Diseases	None declared
Sources	`SRC-NCCN-BCELL-2025` `SRC-NCCN-CNS-2025`

Red Flag Origin

Definition	Leptomeningeal disease (LMD) confirmed by CSF cytology (positive malignant cells), CSF flow cytometry, or imaging (linear/nodular leptomeningeal enhancement on contrast MRI brain/spine). Triggers intrathecal chemotherapy (methotrexate, cytarabine, liposomal cytarabine), CSF-penetrant systemic therapy (HD-MTX, HD-cytarabine, pemetrexed, osimertinib at 160 mg, tucatinib), and consideration of craniospinal RT.
Clinical direction	intensify
Category	oncologic-emergency

Trigger Logic

{
  "any_of": [
    {
      "finding": "csf_cytology_positive",
      "value": true
    },
    {
      "finding": "leptomeningeal_enhancement_imaging",
      "value": true
    },
    {
      "finding": "leptomeningeal_disease",
      "value": true
    }
  ],
  "type": "composite_score"
}

Notes

EANO-ESMO 2017 LMD guideline (Le Rhun) classifies into Type I (CSF+) and Type II (imaging+) — both confirm. Solid tumors: outcomes poor, median OS 3-6 months untreated. Treatments: IT MTX 12-15 mg twice weekly induction; IT cytarabine 50 mg, IT liposomal cytarabine 50 mg q2wk (IRIS); IT topotecan investigational. Systemic options: HD-MTX 3-8 g/m² (lymphoma, breast), pemetrexed (NSCLC adeno), high- dose osimertinib 160 mg (BLOOM trial CNS-LM), tucatinib (HER2CLIMB LM subgroup), pembrolizumab (PMBCL, NSCLC). Hematologic LMD (DLBCL, ALL, Burkitt) carries CNS prophylaxis lessons — IT MTX 4 doses + HD-MTX systemic. Craniospinal RT 24-30 Gy for bulky LM unresponsive to IT/HD systemic. Symptom control: ventriculo- peritoneal shunt + Ommaya reservoir for hydrocephalus + IT access.

Used By

No reverse references found in the YAML corpus.