Multiple sclerosis as differential diagnosis of radionecrosis for post-irradiation brain lesions: A case report

Abstract

Introduction: Demyelination can occur after brain radiotherapy in tissue adjacent to irradiated tumours. To date, no correlation has been found between conventional-dose radiotherapy and the development of multiple sclerosis, but radiotherapy could be a triggering factor among women with known multiple sclerosis. To the best of our knowledge, this is the first well-documented case of this association with a dosimetric analysis. Case presentation: The case we report here describes the development of multiple sclerosis in a 36-yearold woman without significant past medical history 3 months after the last session of fractionated stereotactic radiotherapy for a pituitary macroadenoma. Our dosimetric analysis suggests that all the multiple sclerosis lesions occurred in the brain regions irradiated with a mean biologically effective dose (BED 2) of 33.9 Gy (27.3-49.6 Gy). Conclusion: Consequently special caution towards radiotherapy is required among patients with demyelinating illnesses or for 35-45-year-old women who are at risk. In addition, multiple sclerosis lesions can look like metastases. We should therefore keep differential diagnoses in mind in order not to make mistakes that would delay treatment.

Multifocal and Multiphasic Demyelinating Lesions After Radiation for Ependymoma in a Pediatric Population

“…Scarce case reports have been described in the adult literature, including 2 involving radiation treatment for macroadenoma. 7,8 In one case, 7 weeks after radiotherapy, a 36-year-old female patient presented with temporal and spatial dissemination of T2/fluid-attenuated inversion recovery hyperintense lesions correlating with focal deficits. 7 Lumbar puncture yielded polyclonal IgG, negative myelin oligodendrocyte glycoprotein, and aquaporin-4 protein.…”

“…7,8 In one case, 7 weeks after radiotherapy, a 36-year-old female patient presented with temporal and spatial dissemination of T2/fluid-attenuated inversion recovery hyperintense lesions correlating with focal deficits. 7 Lumbar puncture yielded polyclonal IgG, negative myelin oligodendrocyte glycoprotein, and aquaporin-4 protein. 7 She was diagnosed with relapsing-remitting multiple sclerosis as per the 2017 McDonald criteria.…”

“…Treatment included methylprednisolone 1 g/d for 4 days, and then subsequently beta 1α interferon due to a relapsing course. 7 The authors hypothesized that women between ages 35 and 45 years undergoing radiotherapy may be at a higher risk of multiple sclerosis. This age hypothesis does not account for the occurrence in the pediatric population seen here, pointing to a common physiologic process.…”

“…Recently, there have been incidental case reports of multifocal, multiphasic demyelinating conditions presenting after ionizing radiation for cancer therapy. 7,8 No previous link between ionizing radiation and multiple sclerosis has been shown, although the proposed pathophysiology for radiation-induced brain injury and multiple sclerosis shares a common pathway. Furthermore, the immunogenic effects of tumor burden on peripheral inflammation serves as another mechanism to undermine the integrity of the blood-brain barrier, promoting vascular leak and a microclimate of inflammation, which may prompt demyelinating disorders.…”

“…To date, there have only been a small number of case reports in the adult literature on multiple sclerosis as a differential diagnosis of postradiation brain lesions. 7,8 Here we discuss 2 pediatric patients with multifocal and multiphasic demyelination concurrent and after radiation for ependymoma.…”