Tumor-like multiple sclerosis (MS) lesions: neuropathological clues

Diagnostic Challenges and Radiological Spectrum of Tumefactive Multiple Sclerosis: A Case Report Study

Multiple sclerosis (MS) is a chronic disease of the central nervous system (CNS). It has many types, which include tumefactive multiple sclerosis (TMS), one of the most uncommon types. We present the case of a 36-year-old woman who presented with right-sided numbness of the body. Magnetic resonance imaging (MRI) of the brain revealed a large mass (3 cm × 2.5 cm) in the deep white matter of the right frontal lobe along with smaller lesions of variable sizes. After considering the MRI features, the CSF results, and the improvement of the symptoms with a high dose of steroids, the diagnosis of tumefactive multiple sclerosis was made. A biopsy was not done on our patient as the symptoms resolved after treatment, although sometimes it is necessary for diagnosing tumefactive multiple sclerosis to rule out tumors or abscesses. The current study described the clinical presentation, the role of imaging, the differential diagnosis, and the treatment options. This case report aimed to report a rare presentation of TMS, which highlights the importance of differentiating TMS from other space-occupying lesions for prompt and proper management.

Differentiation of multiple sclerosis lesions and low-grade brain tumors on MRS data: machine learning approaches

Some multiple sclerosis (MS) lesions may have great similarities with neoplastic brain lesions in magnetic resonance (MR) imaging and thus wrong diagnoses may occur. In this study, differentiation of MS and low-grade brain tumors was performed with computer-aided diagnosis (CAD) methods by magnetic resonance spectroscopy (MRS) data. MRS data belonging to 51 MS and 39 low-grade brain tumor patients were obtained. The feature extraction from MRS data was performed by the help of peak integration (PI) and full spectra (FS) methods and the most significant features were identified. For the classification step, artificial neural network (ANN), support vector machine (SVM), and linear discriminant analysis (LDA) methods were used and the differentiation between MS and brain tumor was performed automatically. Examining the results, one can conclude that data which belong to MS and low-grade brain tumor cases were automatically differentiated from each other with the help of ANN with 100% accuracy, 100% sensitivity, and 100% specificity. Using of MR spectroscopy and artificial intelligence methods may be useful as a complementary imaging technique to MR imaging in the differentiation of MS lesions and low-grade brain tumors.

Tumor-Like Multiple Sclerosis: Report of Four Cases and Literature Review

Aims and background

Classical multiple sclerosis plaques usually have typical features on gadolinium-enhanced MRI scan. This non-neoplastic demyelinating process of the central nervous system generally does not produce focal space-occupying lesions associated with ring enhancement. However, atypical appearance of demyelinating lesions simulating a brain tumor is a possible well-known phenomenon.

Methods

We present our experience with 4 cases of multiple sclerosis indistinguishable clinically and neuroradiologically from a cerebral tumor. All patients underwent surgery.

Results

Histological examinations of all cases were positive for multiple sclerosis plaques.

Conclusions

The presented cases demonstrate the importance of considering a demyelinating disease in the differential diagnosis of a tumor-like brain lesion.

Inaugural tumor-like multiple sclerosis: clinical presentation and medium-term outcome in 87 patients

BACKGROUND

Tumefactive demyelinating lesions of the central nervous system can be the initial presentation in various pathological entities [multiple sclerosis (the most common), Balo's concentric sclerosis, Schilder's disease and acute disseminated encephalomyelitis] with overlapping clinical presentation. The aim of our study was to better characterize these patients.

METHODS

Eighty-seven patients (62 women and 25 men) from different MS centers in France were studied retrospectively. Inclusion criteria were (1) a first clinical event (2) MRI showing one or more large demyelinating lesions (20 mm or more in diameter) with mass-like features. Patients with a previous demyelinating event (i.e. confirmed multiple sclerosis) were excluded.

RESULTS

Mean age at onset was 26 years. The most common initial symptoms (67% of the patients) were hemiparesis or hemiplegia. Aphasia, headache and cognitive disturbances (i.e. atypical symptoms for demyelinating diseases) were observed in 15, 18 and 15% of patients, respectively. The mean largest diameter of the tumefactive lesions was 26.9 mm, with gadolinium enhancement in 66 patients (81%). Twenty-one patients (24%) had a single tumefactive lesion. During follow-up (median time 5.7 years) 4 patients died, 70 patients improved or remained stable and 12 worsened. 86% of patients received initial corticosteroid treatment, and 73% received disease-modifying therapy subsequently. EDSS at the end of the follow-up was 2.4 ± 2.6 (mean ± SD).

CONCLUSION

This study provides further evidence that the clinical course of MS presenting with large focal tumor-like lesions does not differ from that of classical relapsing-remitting MS, once the noisy first relapsing occurred.

Central nervous system vasculitis in adults and children

Primary angiitis of the central nervous system (PACNS) is an inflammatory brain disease targeting the cerebral blood vessels, leading to a wide spectrum of signs and symptoms, including neurologic deficits, cognitive dysfunction, and psychiatric symptoms. The inflammation could be reversible if diagnosed and treated early. The diagnosis requires the careful consideration and rapid evaluation of systemic underlying conditions and disease mimics. The differential diagnosis is distinctly different for angiography-positive and -negative PACNS subtypes and differs depending on age, so there is childhood PACNS or adult PACNS. Distinct disease subtypes have been described, with characteristic disease course, neuroimaging findings, and histopathologic features. Novel and traditional biomarkers, including von Willebrand factor antigen and cytokine levels, can help diagnose, and define subtype and disease activity. Treatment of PACNS should be tailored to the disease subtypes and clinical symptoms. Beyond immunosuppression it should include medications to control symptoms in order to support and enhance the child's or adult's ability to actively participate in rehabilitation. The mortality of PACNS has decreased; studies determining the morbidity and its determinants are urgently needed.

Benign course of tumour-like multiple sclerosis. Report of five cases and literature review

BACKGROUND

Multiple sclerosis (MS) with initial neuroradiological features suggestive of brain tumour (tumour-like MS) may represent a challenging diagnosis.

METHODS

Among the patients seen at the MS centre of our Institution between 2000 and 2010, we identified cases presenting with a large (diameter>2 cm), well-defined lesion, suggestive of brain tumour on initial brain magnetic resonance imaging (MRI). Only patients with at least 10 years follow-up were included.

RESULTS

Five young women with MS who presented with a tumour-like lesion on initial brain MRI are described. All cases presented with sudden-onset neurological deficits due to a single large brain lesion compatible with neoplasm at MRI. Two cases underwent brain stereotactic biopsy, both misdiagnosed as astrocytoma. However, the subsequent clinical and MRI follow-up was consistent with MS in all cases. Unnecessary surgery and radiotherapy were responsible for disability in two cases. In three cases, the course of the disease remains benign after more than 13 years from symptoms onset.

CONCLUSIONS

Our report of clinical, radiological and pathological features of five tumour-like MS cases confirms that it is mandatory to consider a demyelinating process in the differential diagnosis of tumour-like brain lesions. Many tumour-like MS cases may have a favourable long term prognosis.

The pathological spectrum of CNS inflammatory demyelinating diseases

Inflammatory demyelinating diseases of the central nervous system (CNS) occur throughout the world and are the leading cause of nontraumatic neurological disability in young adults. They represent a broad spectrum of disorders that vary in their clinical course, regional distribution, and pathology. However, there can be a considerable overlap between at least some of these disorders, leading to misdiagnoses or diagnostic uncertainty. Multiple sclerosis (MS), the most common inflammatory demyelinating CNS disease affecting approximately one million adults, shares the basic pathological hallmark of CNS inflammatory demyelination. Advances based on recent systematic clinicopathologic-serologic correlative approaches have led to novel insights with respect to the classification of this disorder, the pathologic substrate of disability, a better understanding of the underlying pathogenic mechanisms involved in lesion formation, as well as the clinical relevance of cortical demyelination and normal appearing white matter pathology. In addition to prototypic MS, these diseases include Marburg variant of acute MS, Balo's concentric sclerosis, neuromyelitis optica, acute disseminated encephalomyelitis, and tumefactive MS. The last decade has seen a resurgence of interest in examining the lesions of these inflammatory demyelinating CNS disorders with newer and more sophisticated immunological and molecular tools. Herein, we review the clinicopathologic features of these CNS inflammatory demyelinating disorders and discuss recent advances in understanding their immunopathogenesis.

Demyelinating disease masquerading as a surgical problem: a case series

INTRODUCTION

We report three cases of demyelinating disease with tumor-like presentation. This information is particularly important to both neurosurgeons and neurologists who should be aware that inflammatory demyelinating diseases can present as a mass lesion, which is indistinguishable from a tumor, both clinically and radiologically, especially when there is no evidence of temporal dissemination of this disease.

CASE PRESENTATION

The first patient was a 42-year-old Malay woman who developed subacute onset of progressive quadriparesis with urinary incontinence. Magnetic resonance imaging of her spine showed an intramedullary lesion at the C5-C7 level. She was operated on and biopsy was suggestive of a demyelinating disease. Retrospective history discovered two episodes of acute onset of neurological deficits with partial recovery and magnetic resonance imaging of her brain revealed demyelinating plaques in the centrum semiovale. The second patient was a 16-year-old Malay boy who presented with symptoms of raised intracranial pressure. A computed tomography brain scan revealed obstructive hydrocephalus with a lesion adjacent to the fourth ventricle. An external ventricular drainage was inserted. Subsequently, a stereotactic biopsy was taken and histopathology was reported as demyelination. Retrospective history revealed similar episodes with full recovery in between episodes. The third case was a 28-year-old Malay man who presented with acute bilateral visual loss and confusion. Magnetic resonance imaging of his brain showed a large mass lesion in the right temporoparietal region. Biopsy was consistent with demyelinating disease. Reexamination of the patient revealed bilateral papillitis and not papilledema. Visual evoked potential was prolonged bilaterally. In all three cases, lumbar puncture for cerebrospinal fluid study was not carried out due to lack of patient consent.

CONCLUSIONS

These cases illustrate the importance of considering a demyelinating disease in the differential diagnosis of a mass lesion. Critical analyses of clinical presentations coupled with good physical examination are vital in assisting clinicians to reach the correct diagnosis.

Clinical and radiographic spectrum of pathologically confirmed tumefactive multiple sclerosis

Atypical imaging features of multiple sclerosis lesions include size >2 cm, mass effect, oedema and/or ring enhancement. This constellation is often referred to as ‘tumefactive multiple sclerosis’. Previous series emphasize their unifocal and clinically isolated nature, however, evolution of these lesions is not well defined. Biopsy may be required for diagnosis. We describe clinical and radiographic features in 168 patients with biopsy confirmed CNS inflammatory demyelinating disease (IDD). Lesions were analysed on pre- and post-biopsy magnetic resonance imaging (MRI) for location, size, mass effect/oedema, enhancement, multifocality and fulfilment of Barkhof criteria. Clinical data were correlated to MRI. Female to male ratio was 1.2 : 1, median age at onset, 37 years, duration between symptom onset and biopsy, 7.1 weeks and total disease duration, 3.9 years. Clinical course prior to biopsy was a first neurological event in 61%, relapsing–remitting in 29% and progressive in 4%. Presentations were typically polysymptomatic, with motor, cognitive and sensory symptoms predominating. Aphasia, agnosia, seizures and visual field defects were observed. At follow-up, 70% developed definite multiple sclerosis, and 14% had an isolated demyelinating syndrome. Median time to second attack was 4.8 years, and median EDSS at follow-up was 3.0. Multiple lesions were present in 70% on pre-biopsy MRI, and in 83% by last MRI, with Barkhof criteria fulfilled in 46% prior to biopsy and 55% by follow-up. Only 17% of cases remained unifocal. Median largest lesion size on T2-weighted images was 4 cm (range 0.5–12), with a discernible size of 2.1 cm (range 0.5–7.5). Biopsied lesions demonstrated mass effect in 45% and oedema in 77%. A strong association was found between lesion size, and presence of mass effect and/or oedema (P< 0.001). Ring enhancement was frequent. Most tumefactive features did not correlate with gender, course or diagnosis. Although lesion size >5 cm was associated with a slightly higher EDSS at last follow-up, long-term prognosis in patients with disease duration >10 years was better (EDSS 1.5) compared with a population-based multiple sclerosis cohort matched for disease duration (EDSS 3.5; P< 0.001). Given the retrospective nature of the study, the precise reason for biopsy could not always be determined. This study underscores the diagnostically challenging nature of CNS IDDs that present with atypical clinical or radiographic features. Most have multifocal disease at onset, and develop RRMS by follow-up. Although increased awareness of this broad spectrum may obviate need for biopsy in many circumstances, an important role for diagnostic brain biopsy may be required in some cases.

Demyelinating diseases

A diagnosis of demyelination carries important therapeutic and prognostic implications. In most cases the diagnosis is made clinically, and involvement of the histopathologist is largely confined to postmortem confirmation and clinicopathological correlation. However, every now and then, accurate diagnosis of the presence or cause of demyelination before death hinges on the histopathological assessment. Recognition of demyelination depends on an awareness of this as a diagnostic possibility, and on the use of appropriate tinctorial and immunohistochemical stains to identify myelin, axons and inflammatory cells. In biopsy specimens, the critical distinction is usually from ischaemic or neoplastic disease, and the types of demyelinating disease most likely to be encountered are multiple sclerosis, acute-disseminated encephalomyelitis, progressive multifocal leucoencephalopathy and extrapontine myelinolysis. Interpretation of the pathology has to be made in the context of the clinical, radiological and biochemical findings. Freezing of a small amount of fresh tissue allows for later virological studies, and electron microscopy is occasionally helpful for demonstration of viral particles.