leptomeningeal carcinomatosis ( lc ) , also called carcinomatous leptomeningitis , neoplastic ( lepto)meningitis , leptomeningeal metastasis , or more commonly leptomeningeal seeding , is the dissemination and growth of cancer cells within the leptomeningeal space ; it is one of the most serious complications that can occur in cancer patients1 ) . lc is frequently found in patients with leukemia , breast cancer , lymphoma , and lung cancer2 ) . gastric cancer ( gc ) is one of the most common causes of cancer related death in asian countries including korea . kim , et al3 ) reported that the incidence of lc with gc was 0.06% of all cases of gastric cancer . lc is a more frequent manifestation of advanced or metastatic carcinoma rather than associated with early disease . we report a rare case with lc as the presenting symptom and review the medical literature . a 49-year - old woman was admitted to our hospital with headache , dizziness , easy fatigability , and melena for 10 days . her vital signs were as follows : a blood pressure of 130/75 mmhg , a pulse rate of 95 beats / min and a respiration rate of 21 breaths / min . the mri of brain showed no abnormalities , but the esophagogastroduodenoscopy showed thickening of the gastric folds on the greater curvature of the stomach and on the posterior wall of the stomach compatible with a borrman type iv gastric cancer ( figure 1 ) . the ct scan of abdomen and pelvis showed an advanced gastric cancer involving the posterior wall of the lower body of the stomach ; in addition , the angle and the antrum had extensive metastatic lymphadenopathy . the patient complained of an intractable persistent headache as well as nausea and vomiting on admission day 6 . a lumbar puncture and analysis of the cerebrospinal fluid ( csf ) there were many mucin - secreting cells and signet ring cell types , which were strongly positive for mucicarmin and alcian blue in the csf ( figure 4 ) . since the first report of leptomeningeal carcinomatosis ( lc ) in 1870 , the incidence of lc has been increasing . gastric cancer is the most common cancer in korea ; however , lc associated with gastric cancer ( gc ) is relatively rare . in the korean medical literature , the incidence of lc with gc has been reported to be 0.06% of all gastric cancers3 ) . among cases with lc , gc is reported as the most frequent cause of cancer in korea4 , 5 ) . however , these results are based on the experience of one institution , so these findings may not be generalized to the entire korean population . the clinical manifestations of lc are very variable and depend on the site of involvement . many patients complain of headache , nausea , vomiting , ataxia , and have a variety of neurological deficits . lc is usually a manifestation of advanced cancer discovered during follow - up after a cancer diagnosis ; it is rarely the presenting symptom as it was in this case . the median time to the diagnosis of lc , from the initial cancer diagnosis , is very variable ; reports have found a 76 day5 ) to 17 month4 ) time interval .. diagnosis is based on cytology examination of the csf and imaging studies ( especially , magnetic resonance imaging with gadolinium enhancement)8 ) . the csf findings include an increased opening pressure , elevated protein , the presence of tumor markers ( for example , cea , ca19 - 9 in gastric cancer ) , decreased glucose , and pleiocytosis . however , the diagnosis is frequently missed on the first trial but the diagnosis rate increases by 30% on a second one . in our case , reported on patients with breast cancer metastasized to the central nervous system over 20 years . out of five lc patients , only one ( 20% ) patient was confirmed cytologically9 ) . pathologically , poorly differentiated adenocarcinoma with signet ring cell features is the most frequent type of lc associated with gc in japan10 ) and this is likely true for korea3 ) . lc was a more frequent finding in advanced disease with or without distant metastases ; it is rarely reported with early gastric cancer11 ) . imaging studies ( mri with gadolinium enhancement ) show abnormalities in 67% of lc patients12 ) . there are several treatment options for patients with lc including intrathecal ( it ) chemotherapy with or without radiotherapy ( rt ) . most chemotherapeutic agents do not penetrate the blood - brain barrier ( bbb ) , and are given by direct intrathecal administration . agents that can be used for it chemotherapy include methotrexate ( mtx ) , cytarabine , thiotepa , and steroids . the benefit ( i.e. the prolongation of survival ) achieved by it chemotherapy ( single or multiple regimens ) in lc patients continues to be debated . the median survival of lc is reported to be four to six months even with aggressive therapy . in one study , the objective response rate and median survival of it mtx were 20% and 11 weeks ; with sustainedrelease cytarabine they were 25% and 15 weeks . therefore , the results did not confirm a definite benefit with the it chemotherapy13 ) . however , in a korean study , there was a favorable outcome with combination it chemotherapy , compared to the single it chemotherapy14 ) . mtx , one of most useful agents for it chemotherapy , penetrates the blood brain barrier poorly in low doses , but can penetrate in the higher dose range . high dose intravenous mtx ( 3.5 g / m ) injection showed a 28% partial response and stable disease and 44% progressive disease . the median survival of patients with lc ( with or without parenchymal disease ) was 12.6 weeks ; shorter than with isolated parenchymal disease ( 25.4 weeks)15 ) . the clinical risk factors that influence the survival of patients with lc are performance status , underlying malignant disease and previous responsiveness to anticancer therapy . the patients with disease that is more advanced , poor performance status ( ps ) , chemoresistant tumors , pronounced neurological clinical findings , and a heavy pretreatment status have a poor prognosis and additional management should be with conservative treatment16 ) . in our case , the patient had a poor ps , pronounced abnormal neurological clinical findings and a very rapidly deteriorating clinical course .