Tumefactive demyelinating lesions: A comprehensive review

Paraneoplastic tumefactive demyelination in a 47-year-old man with underlying seminoma

BACKGROUND

Tumefactive demyelination presents as an aggressive, fast progressive focal demyelinating lesion in the central nervous system, with often devastating clinical outcome if not acutely treated. Correct and early treatment is threatened by its real diagnostic challenge.

CASE REPORT

We describe a 47-year-old man with tumefactive demyelination and testicular seminoma. He presented with aphasia, cognitive impairment and right sided weakness of the arm and lower face. MRI revealed a lesion characteristic of tumefactive demyelination. Cerebral biopsy confirmed this diagnosis. In addition, a testicular seminoma was diagnosed. Temporal association of demyelination and malignancy was highly suggestive for a paraneoplastic syndrome. He responded well to corticosteroid therapy plus orchiectomy, but a behavioral disturbance remained.

DISCUSSION

A good knowledge of specific imaging characteristics of tumefactive demyelination can help in early diagnosis. Multiple underlying causes should be considered, including, but not limited to multiple sclerosis. A paraneoplastic syndrome should not be overlooked. This is the fifth case in which seminoma is associated with a paraneoplastic tumefactive demyelination lesion.

A tumefactive demyelinating lesion in a person with MS after five years of fingolimod

A 38-year-old man with relapsing remitting multiple sclerosis (RRMS) developed a tumefactive demyelinating lesion (TDL) after being clinically and radiologically stable on fingolimod for the last five years. TDLs in MS tend to occur early on in the disease and are uncommon in longstanding MS. Compared to other immune modifying drugs used in MS, there is a relatively high and still increasing number of reports describing the development of TDL under treatment with fingolimod, suggesting a causal relation.

Concurrence of multiple sclerosis, oligodendroglioma, and autosomal recessive cerebellar ataxia with spasticity in the same patient: A challenging diagnosis

Multiple sclerosis (MS) has been described in several case reports to coexist with brain tumors. This unusual concurrence has been the subject of research projects with a common question of whether these pathological entities share common roots. However, no clear association has proved that either of them could provoke the other, and mere chance is the only acceptable explanation. Along all reported cases, oligodendroglioma has been rarely reported to coexist with MS. In this paper, we report a unique case with a triad of MS, oligodendroglioma, and autosomal recessive cerebellar ataxia with spasticity and discuss possible theories that might have attributed to these three conditions. To our knowledge, this is the first case ever to have these three conditions present in one patient. The most likely explanation is believed to be that this patient was unfortunate to have three unrelated diseases.

Tumefactive multiple sclerosis which initially presented with brainstem encephalitis with a long-term follow-up

Tumefactive demyelinating lesions (TDLs) are rare in multiple sclerosis (MS). We herein report a case of tumefactive MS which initially presented with brainstem encephalitis with a long-term follow-up. The patient had experienced relapse mostly in the brainstem in the first twenty years, and then in the periventricular white matter afterwards. The patient responded well to steroid treatment recovered without sequalae. However, immunodeficiency due to the long-term use of oral prednisolone made aggressive therapy during the relapse impossible, so recovery after steroid therapy is incomplete. Our case is different from classical MS in clinical course and response to treatment. Our report offers rare information on long-term outcome of tumefactive MS.

Usefulness of [11C] Methionine PET in the Differentiation of Tumefactive Multiple Sclerosis from High Grade Astrocytoma

Tumefactive multiple sclerosis (tumefactive MS) is an atypical variant of MS characterized by a large isolated demyelinating lesion. Because tumefactive MS mimics high grade astrocytoma clinically and radiologically, it is difficult to distinguish between the two using only traditional diagnostic modalities, such as routine magnetic resonance imaging. [¹¹C] methionine positron emission tomography (MET PET) has been known as a useful diagnostic tool for glioma. However, it has not been established as a diagnostic tool for tumefactive MS yet. Therefore, the objective of this study was to evaluate the performance of MET PET in differentiating tumefactive MS from high grade astrocytoma. We studied patients with tumefactive MS [six patients (three men, three women), 7 lesions] and 77 patients with astrocytoma (World Health Organization grade II: 13 patients, grade III: 28 patients, and grade IV: 36 patients), and we compared MET uptake of tumefactive demyelinating lesions and astrocytoma. For MET PET analysis, Lesion/Normal region ratios (L/N ratios) were calculated and compared between tumefactive demyelinating lesions and astrocytoma. On MET PET, the L mean/N ratio of tumefactive MS was 1.18 ± 0.50, which was significantly lower than that of high-grade glioma (astrocytoma grade III: 1.95 ± 0.62, P = 0.006; grade IV: 2.35 ± 0.54, P <0.0001). The L maximum (L max)/N ratio of tumefactive demyelinating lesion was also significantly lower than that of high grade astrocytoma (tumefactive MS: 1.89 ± 0.55; astrocytoma grade III: 3.37 ± 1.36, P = 0.0232; astrocytoma grade IV: 4.35 ± 1.30, P <0.0001). In conclusion, MET PET can help differentiate tumefactive MS from high grade astrocytoma.

Molecular imaging of multiple sclerosis: from the clinical demand to novel radiotracers

Background

Brain PET imaging with different tracers is mainly clinically used in the field of neurodegenerative diseases and brain tumors. In recent years, the potential usefulness of PET has also gained attention in the field of MS. In fact, MS is a complex disease and several processes can be selected as a target for PET imaging. The use of PET with several different tracers has been mainly evaluated in the research setting to investigate disease pathophysiology (i.e. phenotypes, monitoring of progression) or to explore its use a surrogate end-point in clinical trials.

Results

We have reviewed PET imaging studies in MS in humans and animal models. Tracers have been grouped according to their pathophysiological targets (ie. tracers for myelin kinetic, neuroinflammation, and neurodegeneration). The emerging clinical indication for brain PET imaging in the differential diagnosis of suspected tumefactive demyelinated plaques as well as the clinical potential provided by PET images in view of the recent introduction of PET/MR technology are also addressed.

Conclusion

While several preclinical and fewer clinical studies have shown results, full-scale clinical development programs are needed to translate molecular imaging technologies into a clinical reality that could ideally fit into current precision medicine perspectives.

Brazilian Consensus for the Treatment of Multiple Sclerosis: Brazilian Academy of Neurology and Brazilian Committee on Treatment and Research in Multiple Sclerosis

The expanding therapeutic arsenal in multiple sclerosis (MS) has allowed for more effective and personalized treatment, but the choice and management of disease-modifying therapies (DMTs) is becoming increasingly complex. In this context, experts from the Brazilian Committee on Treatment and Research in Multiple Sclerosis and the Neuroimmunology Scientific Department of the Brazilian Academy of Neurology have convened to establish this Brazilian Consensus for the Treatment of MS, based on their understanding that neurologists should be able to prescribe MS DMTs according to what is better for each patient, based on up-to-date evidence and practice. We herein propose practical recommendations for the treatment of MS, with the main focus on the choice and management of DMTs, as well as present a review of the scientific rationale supporting therapeutic strategies in MS.

Using germline variants to estimate glioma and subtype risks

BACKGROUND

Twenty-five single nucleotide polymorphisms (SNPs) are associated with adult diffuse glioma risk. We hypothesized that the inclusion of these 25 SNPs with age at diagnosis and sex could estimate risk of glioma as well as identify glioma subtypes.

METHODS

Case-control design and multinomial logistic regression were used to develop models to estimate the risk of glioma development while accounting for histologic and molecular subtypes. Case-case design and logistic regression were used to develop models to predict isocitrate dehydrogenase (IDH) mutation status. A total of 1273 glioma cases and 443 controls from Mayo Clinic were used in the discovery set, and 852 glioma cases and 231 controls from UCSF were used in the validation set. All samples were genotyped using a custom Illumina OncoArray.

RESULTS

Patients in the highest 5% of the risk score had more than a 14-fold increase in relative risk of developing an IDH mutant glioma. Large differences in lifetime absolute risk were observed at the extremes of the risk score percentile. For both IDH mutant 1p/19q non-codeleted glioma and IDH mutant 1p/19q codeleted glioma, the lifetime risk increased from almost null to 2.3% and almost null to 1.7%, respectively. The SNP-based model that predicted IDH mutation status had a validation concordance index of 0.85.

CONCLUSIONS

These results suggest that germline genotyping can provide new tools for the initial management of newly discovered brain lesions. Given the low lifetime risk of glioma, risk scores will not be useful for population screening; however, they may be useful in certain clinically defined high-risk groups.

Silent Tumefactive Demyelinating Lesions and Radiologically Isolated Syndrome

Demyelinating lesions larger than 2 cm in diameter, with or without edema, are known as tumefactive demyelinating lesions (TDLs). They constitute a rare inflammatory demyelinating disorder of the central nervous system. TDLs are typically characterized by headaches, cortical symptoms such as aphasia, hemiparesis, hemisensory deficits, seizures, and changes in consciousness. TDLs may occur in patients with or without an established diagnosis of MS or may occur as the initial demyelinating event. They may also be observed during follow-up in patients with MS, neuromyelitis optica, acute disseminated encephalomyelitis, or other autoimmune diseases. Differential diagnosis includes brain tumors, abscess, granulomatous diseases, and vasculitis. In some cases, it may be very difficult to distinguish TDLs from a tumor, such that biopsy might be needed. However, no cases of asymptomatic TDLs have yet been reported in the literature. Hence, in this report, we present a case involving an asymptomatic TDL detected incidentally during magnetic resonance imaging in an 18-year-old man. The patient did not develop any symptoms during the 1-year follow-up period. During follow-up, the patient was diagnosed with a radiologically isolated syndrome. TDLs have not previously been identified as radiologically isolated syndrome. Thus, reporting similar cases in the future will help in further understanding this phenomenon.

Tumefactive Multiple Sclerosis, A Rare Variant Presenting as Multiple Ring-enhancing Lesions in an Immunocompetent Patient: A Case Report

Tumefactive multiple sclerosis (TMS) is a rare entity which can be difficult to diagnose unless definitive diagnostic measures are taken. TMS is characterized by solitary or multiple lesions that are sized > 2 cm, with/without mass effect, edema, and ring enhancement on magnetic resonance imaging (MRI). The demyelinating lesion can mimic infections, vascular lesions, and inflammatory lesions. The clinical presentation is highly dependent on the area of the brain which is affected, and this can lead to a variety of signs and symptoms. Herein, we present the case of a 40-year-old immunocompetent female with a history of right-sided numbness of her face, arm, and leg associated with muscle weakness for about a week. Workup included an MRI showing ring-enhancing lesions in the white matter of the brain, zero oligoclonal bands in the CSF, a normal immunoglobulin G (IgG) index, and an elevated myelin basic protein (MBP) in the CSF. A biopsy was obtained that showed predominant macrophage infiltrate with loss of myelin but the preservation of axons. Suspecting a demyelinating pathology, the patient was informed that she would be started on intravenous dexamethasone for an eight-day course. With subsequent completion of this course in the hospital, the patient was discharged on oral prednisone daily for a month and a referral leading to a definitive diagnosis of TMS. The patient was started on interferon beta-1a and subsequently relapsed due to noncompliance. However, further workup showed a reduction in the mass-like lesions and a response to therapy. If suspicion for TMS is high despite workup, steroids can be used with immunomodulators in the interim to combat symptoms and potentially reduce lesions and potentially subvert the need for biopsy.

Frontal Tumefactive Demyelinating Lesion Mimicking Glioblastoma Differentiated by Methionine Positron Emission Tomography

BACKGROUND

Tumefactive demyelinating lesion (TDL) is often reported as a rare variation of multiple sclerosis (MS). TDL is difficult to diagnose solely by magnetic resonance imaging (MRI) in patients with no history of MS. This is because the lesion often shows ring enhancement with perifocal brain edema on gadolinium MRI, thus mimicking glioblastoma multiforme (GBM).

CASE DESCRIPTION

A 54-year-old healthy woman complained of headache 1 month before admission. She developed a decline in cognitive function, decreased attention, and executive function disorder 10 days before admission. Gadolinium magnetic resonance imaging showed a ring-shaped enhancement accompanied by massive brain edema in the left frontal lobe. This suggested GBM, but methionine positron emission tomography (MET PET), surprisingly, showed no uptake with a tumor-to-normal brain ratio of 1.18. Accordingly, we eliminated GBM and suspected brain abscess because diffusion-weighted images showed high signal intensity in the lesion. Although we performed drainage, we could not demonstrate the presence of pus. Pathologic analysis of a specimen obtained by needle biopsy revealed broad necrosis and a small number of inflammatory cells. We therefore prescribed steroid therapy, by which symptoms gradually improved. No relapse occurred for 2 years. We finally diagnosed the patient as having TDL.

CONCLUSIONS

MET PET is considered a possible diagnostic modality for demyelinating disease as it can appropriately reflect pathologic findings. MET PET will facilitate decision making regarding surgery in patients with TDL.

Tumefactive multiple sclerosis lesions associated with fingolimod treatment: Report of 5 cases

BACKGROUND AND OBJECTIVE

Fingolimod is a sphingosine 1-phosphate receptor modulator, which sequesters lymphocytes in lymph nodes and prevents them from entering the central nervous system. There have been increasing reports of severe rebounds with tumefactive demyelinatinglesions (TDLs) in patients with multiple sclerosis under fingolimod treatment, as well as following therapy discontinuation. Our objective is to review the clinico-radiological characteristics of patients with TDLs associated with fingolimod.

METHODS

Retrospective review of medical records of MS patients from our center, who were treated with fingolimod and developed TDLs. We review the literature.

RESULTS

We found 5 cases: 4 developed TDLs as rebounds after treatment cessation and 1 under treatment. The 4 rebound cases were women, with a mean age of 34.7 years (SD = 3.6) and a mean disease duration of 10.2 years (SD = 4.1). The mean duration of fingolimod treatment before discontinuation was 36.2 months (SD = 22.4) and the mean time lapse between treatment withdrawal and rebound was 9.75 weeks (SD = 7.4). The total pre-rebound lymphocyte count (cells/mm3) was 482.5 (SD = 325.7) and1017.5 (SD = 364.8) during rebound. The TDL patient under fingolimod was a 36-year-old man who had been on fingolimod for 32 months after switching from glatiramer acetate. TDLs were multiple in 2 cases and solitary in 3. Acute treatment for rebound included high dose steroids (5/5), plasma exchange (3/5) and rituximab (2/5). Treatment after fingolimod included rituximab (2/5), alemtuzumab (2/5) and glatiramer acetate (1/5).

CONCLUSIONS

Our study, along with similar reports in literature, highlights the need for close monitoring in patients who plan to switch from fingolimod to other treatments because of the risk of severe rebound. The etiopathogenic association between fingolimod and TDLs is not clear, but given the increasing reports of cases it should be taken into account for treatment selection in patients with this type of lesions.

Pediatric multiple sclerosis and fulminant disease course: Features and approaches to treatment - A case report and review of the literature

Multiple sclerosis (MS) is the autoimmune, neurodegenerative disease of the central nervous system (CNS). Typically, it affects the young adult population, however, up to 10% of the cases, it can develop in childhood. Atypical manifestations, such as the tumefactive variant (tMS) or acute disseminated encephalomyelitis (ADEM), especially coupled with fulminant disease course, are even more rare and pose a considerable differential diagnostic and therapeutic challenge. Recently, the therapeutic strategy on the use of disease modifying therapies (DMTs) in MS has shifted to the direction of a more individualized approach, that takes the personal differences heavily into account, in particular regard to the activity and prognosis of the disease. Despite this change has only been applied to adults yet, it is plausible to predict, that it will soon be applied to pediatric patients as well, particularly, as several randomized studies are under way concerning DMTs in pediatric populations. To our best knowledge, we are the first to report a successful natalizumab treatment of pediatric fulminant tMS, in case of a 13.5 years old girl. We feel that this report demonstrates the need of early and adequate treatment in such an aggressive case, because it can reverse the course of a possibly fatal disease.

Potential neuroprotective effect of Fingolimod in multiple sclerosis and its association with clinical variables

INTRODUCTION

Multiple sclerosis (MS) is a chronic inflammatory, demyelinating disease of the central nervous system affecting both white matter and grey matter in the earliest phases of its course. The crucial role of neurodegeneration in disability progression in MS, regardless of white matter damage, has been confirmed by several imaging and neuropathological studies. Fingolimod is an effective immunomodulator of the sphingosine 1-phosphate receptor, approved in relapsing remitting MS and able to cross the blood-brain barrier and to slow disability progression and brain volume loss. However, it remains unclear whether this neuroprotective action is due to a peripheral anti-inflammatory effect and/or to a direct effect on neuronal cells.

AREAS COVERED

In this review, the authors summarize the published preclinical and clinical studies on the effect of Fingolimod in limiting the focal and diffuse grey matter damage in MS.

EXPERT OPINION

Fingolimod might have a significant neuroprotective effect on relapsing remitting MS based on its modulatory effect on oligodendroglial cells and astrocytes, and on its direct effect on cortical neurons. Future clinical studies including measures of grey matter damage are required to confirm in vivo such neuroprotective effect.

Pattern Recognition of the Multiple Sclerosis Syndrome

During recent decades, the autoimmune disease neuromyelitis optica spectrum disorder (NMOSD), once broadly classified under the umbrella of multiple sclerosis (MS), has been extended to include autoimmune inflammatory conditions of the central nervous system (CNS), which are now diagnosable with serum serological tests. These antibody-mediated inflammatory diseases of the CNS share a clinical presentation to MS. A number of practical learning points emerge in this review, which is geared toward the pattern recognition of optic neuritis, transverse myelitis, brainstem/cerebellar and hemispheric tumefactive demyelinating lesion (TDL)-associated MS, aquaporin-4-antibody and myelin oligodendrocyte glycoprotein (MOG)-antibody NMOSD, overlap syndrome, and some yet-to-be-defined/classified demyelinating disease, all unspecifically labeled under MS syndrome. The goal of this review is to increase clinicians’ awareness of the clinical nuances of the autoimmune conditions for MS and NMSOD, and to highlight highly suggestive patterns of clinical, paraclinical or imaging presentations in order to improve differentiation. With overlay in clinical manifestations between MS and NMOSD, magnetic resonance imaging (MRI) of the brain, orbits and spinal cord, serology, and most importantly, high index of suspicion based on pattern recognition, will help lead to the final diagnosis.