A rare gynecological case of paraneoplastic cerebellar degeneration discovered by FDG-PET

Gynecologic clear cell carcinoma and paraneoplastic cerebellar Degeneration: A literature review and case study

•Paraneoplastic cerebellar degeneration (PCD) is rare condition associated with gynecologic malignancy. •PCD presents with progressive cerebellar dysfunction in the setting of malignancy and confers a poor neurologic prognosis. •PCD associated with ovarian clear cell cancer may have more favorable neurologic outcomes versus other histologies. •The mainstay of PCD treatment is treatment of malignancy; symptom management may improve quality of life.

Paraneoplastic Cerebellar Degeneration: A Dilemma Resolved with Positron Emission Tomography/Computed Tomography

The case of a 39-year-old woman presented with symptoms of progressive cerebellar degeneration for few months preceding by the diagnosis and treatment of breast cancer. The causative association was revealed with the strong positivity of antineuronal antibody. Because of the multidisciplinary team approach with surgery and adjuvant endocrine treatment, the patient did improve symptomatically and she is alive without any evidence of disease after 22 months following the initial diagnosis of the neurological disorder. Interestingly, neurological symptoms regressed partially after surgery. Early recognition and appropriate combined modality treatment of this rare presentation of breast cancer are imperative as it may be crucial for the disease outcome.

Paraneoplastic neurological syndromes associated with ovarian tumors

Introduction

Paraneoplastic neurological syndromes (PNS) are neurologic deficits triggered by an underlying remote tumor. PNS can antedate clinical manifestation of ovarian malignancy and enable its diagnosis at an early stage. Interestingly, neoplasms associated with PNS are less advanced and metastasize less commonly than those without PNS. This suggests that PNS may be associated with a naturally occurring antitumor response.

Methods

We review the literature on the diagnosis, pathogenesis and management of PNS associated with ovarian tumors: paraneoplastic cerebellar degeneration (PCD) and anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis. An approach to the diagnostic workup of underlying tumors is discussed.

Results

PCD can precede the manifestation of ovarian carcinoma. Anti-NMDAR encephalitis in young women appears often as a result of ovarian teratoma. Since ovarian tumors and nervous tissue share common antigens (e.g., cdr2, NMDAR), autoimmune etiology is a probable mechanism of these neurologic disorders. The concept of cross-presentation, however, seems insufficient to explain entirely the emergence of PNS. Early resection of ovarian tumors is a significant part of PNS management and improves the outcome.

Conclusions

The diagnosis of PNS potentially associated with ovarian tumor indicates a need for a thorough diagnostic procedure in search of the neoplasm. In some patients, explorative laparoscopy/laparotomy can be considered.

Paraneoplastic Cerebellar Degeneration as Initial Presentation of Papillary Carcinoma of the Fallopian Tube: Evaluation and Usefulness of (18)F-FDG PET-CT. Case Report and Literature Review

The acquisition of an (18)F-FDG PET-CT scan in patients with suspected paraneoplastic cerebellar syndrome can be helpful in determining the origin of a neoplasm because of its high sensitivity and also helps guide the neurological development course depending on the degree of incorporation of (18)F-FDG to the cerebellar parenchyma when compared with the rest of the brain.

Screening for tumours in paraneoplastic syndromes: report of an EFNS task force

BACKGROUND

paraneoplastic neurological syndromes (PNS) almost invariably predate detection of the malignancy. Screening for tumours is important in PNS as the tumour directly affects prognosis and treatment and should be performed as soon as possible.

OBJECTIVES

an overview of the screening of tumours related to classical PNS is given. Small cell lung cancer, thymoma, breast cancer, ovarian carcinoma and teratoma and testicular tumours are described in relation to paraneoplastic limbic encephalitis, subacute sensory neuronopathy, subacute autonomic neuropathy, paraneoplastic cerebellar degeneration, paraneoplastic opsoclonus-myoclonus, Lambert-Eaton myasthenic syndrome (LEMS), myasthenia gravis and paraneoplastic peripheral nerve hyperexcitability.

METHODS

many studies with class IV evidence were available; one study reached level III evidence. No evidence-based recommendations grade A-C were possible, but good practice points were agreed by consensus.

RECOMMENDATIONS

the nature of antibody, and to a lesser extent the clinical syndrome, determines the risk and type of an underlying malignancy. For screening of the thoracic region, a CT-thorax is recommended, which if negative is followed by fluorodeoxyglucose-positron emission tomography (FDG-PET). Breast cancer is screened for by mammography, followed by MRI. For the pelvic region, ultrasound (US) is the investigation of first choice followed by CT. Dermatomyositis patients should have CT-thorax/abdomen, US of the pelvic region and mammography in women, US of testes in men under 50 years and colonoscopy in men and women over 50. If primary screening is negative, repeat screening after 3-6 months and screen every 6 months up till 4 years. In LEMS, screening for 2 years is sufficient. In syndromes where only a subgroup of patients have a malignancy, tumour markers have additional value to predict a probable malignancy.

Paraneoplastic cerebellar degeneration in ovarian carcinoma: case report with review of immune modulation

Paraneoplastic cerebellar degeneration (PCD) is a rare nonmetastatic complication of a carcinoma. It is typically mediated by antibodies generated against tumor antigens. These antigens are the same proteins as expressed on Purkinje cells within the cerebellum; immune activation in the central nervous system (CNS) results in the syndrome. A 56-year-old woman with stage IIIC serous ovarian carcinoma diagnosed 3 years prior developed progressive limb ataxia. Serum anti-Yo antibodies were positive, confirming the diagnosis of PCD. Treatment with plasmaphoresis, intravenous immune globulin, and immune modulation with corticosteroids and tacrolimus was unsuccessful. Although the syndrome can be debilitating and treatment options are limited, it may also be an example of a successful host immune response in certain cases.