Programmable shunt valves with a “virtual off” for intrathecal chemotherapy delivery in children with high-grade CNS tumors and hydrocephalus

PURPOSE: Current chemotherapy protocols for treatment of embryonal brain tumors in children may recommend administration of intrathecal chemotherapy, either by a lumbar tap or via an Ommaya reservoir. Children with concurrent hydrocephalus and shunts may have subtherapeutic levels of chemotherapy in the CSF due to constant CSF drainage to extra-CNS compartments. We present our experience in delivery of chemotherapy to children via programmable valves. METHODS: A retrospective analysis of children with CNS malignancies together with hydrocephalus treated with a shunt and a programmable valve (CERTAS™ Plus Programmable Valves-Integra Life Sciences, proGAV®-Miethke) was conducted. RESULTS: Eighteen children up to 16 years of age (mean age 5 years) were included. Main pathologies included medulloblastomas (7) and atypical rhabdoid teratoid tumor (5). Each patient underwent 3-55 intrathecal injections (17 ± 14). One patient developed symptomatic hydrocephalus during the injection, which resolved with valve resetting. There were no infections, leaks, or major complications. One child required a wound revision due to exposure of the proximal catheter related to extremely thin skin. One patient experienced a "stuck" setting of the valve. Eight children are alive with no active disease, 25-80 months after shunt placement (52 ± 21). There were no late effects related to IT chemotherapy. CONCLUSIONS: Programmable ventriculoperitoneal valves are a safe method for delivery of intra-ventricular chemotherapy in children. This technique may potentially have an added value for children with concurrent shunts and may also obviate the need for an additional ventricular access device (such as an Ommaya reservoir).