A challenging case of concurrent multiple sclerosis and anaplastic astrocytoma

Abstract

Background: Cases of gliomas coexisting with multiple sclerosis (MS) have been described over the past few decades. However, due to the complex clinical and radiological traits inherent to both entities, this concurrent phenomenon remains difficult to diagnose. Much has been debated about whether this coexistence is incidental or mirrors a poorly understood neoplastic phenomenon engaging glial cells in the regions of demyelination.

Case description: We present the case of a 41-year-old patient diagnosed with a left-sided frontal contrast enhancing lesion initially assessed as a tumefactive MS. Despite systemic treatment, the patient gradually developed signs of mass effect, which led to decompressive surgery. The initial microscopic evaluation demonstrated the presence of MS and oligodendroglioma; the postoperative evolution proved complex due to a series of MS-relapses and tumor recurrence. An ulterior revaluation of the samples for the purpose of this report showed an MS-concurrent anaplastic astrocytoma. We describe all relevant clinical aspects of this case and review the medical literature for possible causal mechanisms.

Conclusion: Although cases of concurrent glioma and MS remain rare, we present a case illustrating this phenomenon and explore a number of theories behind a potential causal relationship.

Keywords: Anaplastic astrocytoma; Gamma knife radiosurgery; Magnetic resonance imaging; Multiple sclerosis; Oligodendroglioma; Tumefactive multiple sclerosis.

Figure 1:

Re-evaluation (2017) of available samples from needle biopsy performed in 2008 (2 samples of <4 mm). (a) Hematoxylin and Eosin glial biopsy with a mild increase in astrocytes. (b) Inflammatory process dominated by foamy macrophages (confirmed by immunohistochemistry). (c+d) CD68 immunohistochemistry: presence of a large number of macrophages.

Figure 2:

T1-weighted magnetic resonance imaging, axial (top), and coronal (bottom) cross sections before biopsy (2008).

Figure 3:

First microsurgery (August 2010): T1-weighted magnetic resonance imaging, axial (top), and coronal (bottom) cross sections. Left column: preoperative images. Right column: postoperative images.

Figure 4:

T1-weighted magnetic resonance imaging (October 2010) before second resection (November 2010). Axial (left), coronal (center), sagittal (right) cross sections: tumor regrowth.

Figure 5:

Gamma knife treatment plan on stereotactic T1-weighted magnetic resonance imaging: Axial (left), coronal (Top, right), and sagittal cross sections (Bottom, right). Yellow line: prescription isodose at the margin (18Gy–50%). Green line: 10Gy-isodose.

Figure 6:

Re-evaluation (2017) of 25 mm sample collected from the second resection (November 2010). (a) Hematoxylin and Eosin glial biopsy with moderately increased atypical astrocytes with gemistocytic features and with few mitoses. (b) Smear from the same biopsy: moderate increase in astrocytes with variation in size and shape. (c) Glial fibrillary acidic protein immunohistochemistry: positive in glial cells with astrocytic features. (d) KI-67 proliferation index about 25%. Samples from the first resection were not made available.