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| CASE REPORT |
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| Year : 2013 | Volume
: 61
| Issue : 6 | Page : 644-649 |
Recurrent meningeal inflammatory myofibroblastic tumor: A case report and literature review
Maria Pascual-Gallego1, Miguel Yus-Fuertes2, Manuela Jorquera2, Alfredo Gonzalez-Maté3, Luis Ortega4, Armando Martínez-Martínez4, Horacio Zimman1
1 Department of Neurosurgery, Clínico San Carlos University Hospital, Madrid, Spain
2 Department of Image Diagnosis, Clínico San Carlos University Hospital, Madrid, Spain
3 Department of Nuclear Medicine, Clínico San Carlos University Hospital, Madrid, Spain
4 Department of Anatomic Pathology, Clínico San Carlos University Hospital, Madrid, Spain
| Date of Submission | 27-Jun-2013 |
| Date of Decision | 28-Oct-2013 |
| Date of Acceptance | 03-Dec-2013 |
| Date of Web Publication | 20-Jan-2014 |
Correspondence Address:
Maria Pascual-Gallego
Department of Neurosurgery, Hospital Universitario Clínico San Carlos, Prof. Martín Lagos s/n, 28040, Madrid
Spain
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.125273
An inflammatory myofibroblastic tumor (IMT) is a rare lesion with an uncertain prognosis and a disorder difficult to classify. IMTs are a heterogeneous group of lesions, sometimes indistinguishable from meningiomas and other expanding or inflammatory lesions of the central nervous system. This report presents a patient with IMT, who presented with recurrent retroocular pain radiating to the occipital region and no neurologic deficits. He had early recurrence in spite of total resection of the lesion. The clinical profile of 18 patients with either progression or recurrence has been reviewed
Keywords: Inflammatory pseudotumor, meningeal inflammatory myofibroblastic tumor, plasma cell granuloma, somatostatin receptors
How to cite this article:
Pascual-Gallego M, Yus-Fuertes M, Jorquera M, Gonzalez-Maté A, Ortega L, Martínez-Martínez A, Zimman H. Recurrent meningeal inflammatory myofibroblastic tumor: A case report and literature review. Neurol India 2013;61:644-9 |
How to cite this URL:
Pascual-Gallego M, Yus-Fuertes M, Jorquera M, Gonzalez-Maté A, Ortega L, Martínez-Martínez A, Zimman H. Recurrent meningeal inflammatory myofibroblastic tumor: A case report and literature review. Neurol India [serial online] 2013 [cited 2023 Jun 2];61:644-9. Available from: https://www.neurologyindia.com/text.asp?2013/61/6/644/125273 |
| » Introduction | |  |
Inflammatory myofibroblastic tumor (IMT) is a rare lesion with uncertain prognosis and is difficult to classify. Recently, World Health Organization defined IMT as a soft tissue tumor. [1] This report presents a case of IMT with recurrence despite gross total removal.
| » Case Report | | |
The present case is about a 47-year-old woman who was admitted with a 1-year history of recurrent headaches, characterized by retroocular pain radiating to the occipital region. These attacks were associated with occasional nausea and visual disturbances. Neurologic examination was normal. Blood biochemistry and complete blood picture were normal. Brain magnetic resonance imaging (MRI) revealed a single extraxial mass in the left temporal-occipital lobe with features suggestive of meningioma [Figure 1]a-c. Cerebral single-photon emission computed tomography (SPECT) with 122 MBq of pentetreotide-I 111 showed a moderate uptake by the tumor, indicating somatostain receptors [Figure 1]d. A left temporal-occipital craniotomy revealed an extraxial and well-encapsulated mass adherent to the transverse sinus. Gross total resection of the lesion was done with coagulation of the implantation site (Simpson grade 2). Histological evaluation revealed a spindle cell monomorph neoplasm with sparse myxoid regions and collagenous stroma, intermingled with inflammatory infiltrate and numerous plasma cells [Figure 2]a. Inflammatory cells expressed CD45 [Figure 2]b with epithelial membrane antigen (EMA) negative reactivity [Figure 2]c, whereas spindle cells showed positive immunoreactivity for α-smooth muscle actin [Figure 2]d. Ki 67 labeling index was less than 1%. The pathological diagnosis was IMT. The post-operative course was uneventful and the immediate post-operative contrast computed tomography scan showed no residual tumor [Figure 2]e. MRI performed 4 months after surgery revealed a 23 mm recurrence adherent to the transverse sinus [Figure 2]f. The patient returned to her homeland and no subsequent follow-up exam was possible. | Figure 1: Pre-operative neuroradiological and single-photon emission computed tomography (SPECT) findings. (a) Axial basal T1-weighted magnetic resonance imaging (MRI) showing an isointense extraxial dural based temporal-occipital mass attached and (b) post-contrast which reveals an intense enhancement of the lesion, (c) Axial T2-weighted Fat-saturated Fast Spin Echo MRI coronal image with iso and hypointense areas with respect to the grey matter. Associated vasogenic edema found in the adjacent brain parenchyma. (d) Axial view of the cerebral SPECT with pentetreotide-I111 showing an uptake in the left temporal-occipital region matching the MRI location
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 | Figure 2: Histopathological findings. (a) Monomorphic spindle cells with bland nuclei, lying in a collagenous background containing plasma cell infiltrates (H and E) (b) CD45 positive immunostaining inflammatory cells with (c) epithelial membrane antigen negative reactivity. (d) Spindle cells showed positive immunoreactivity for alfa-smooth muscle actin staining. (e) Immediate post-operative contrast computed tomography scan showed no residual tumor. (f) Contrast T1-weighted magnetic resonance imaging 4 months later showed a recurrence adherent to the transverse sinus
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The literature review was based on a PubMed search for the key words "inflammatory myofibroblastic tumor", "inflammatory pseudotumor", "plasma cell granuloma" and further references cited in previous PubMed articles, including articles in English, French and Spanish.
| » Discussion | | |
IMTs include a heterogeneous group of lesions characterized by spindle shape cells and a variable amount of inflammatory cell infiltration and fibrosis. IMTs are divided into three subtypes: [2] (1) Compact spindle cells with inflammatory cells, (2) inflammatory areas resembling nodular fasciitis, (3) dense plate-like collagen resembling scar. Recurrence is infrequent and malignant transformation and metastases are even more uncommon. [3] IMTs were initially reported in the lung, [4] but can occur in any organ. IMTs have been described in the brain [5],[6],[7]] and spine. [8] Most importantly, the symptoms and imaging of IMTs are indistinguishable from meningiomas and other expanding or inflammatory lesions of the central nervous system (CNS). Only histopathology can help diagnose an IMT. As or our literature review, there had been approximately 100 cases of IMT of CNS reported and only 19, including our case, have shown either progression or recurrence. [5],[9],[10],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22]
IMTs of the brain are rare, with a small number of cases confirmed by histopathological diagnosis in children and adults. Pathology includes spindle cell proliferation with myofibroblastic differentiation, collagenous stroma and an inflammatory infiltrate of lymphocytes, eosinophils and plasma cells. [1] The CNS lesion location can be meningeal, [6] intraparenchymatous, [5] pineal, [23] hypothalmus [15] intraventricular. [7],[24] Lesions with sella turcica, [19] skull base, [25] orbit and external cranium including mastoid [6] and paranasal sinuses [26] have been reported. Clinically, IMTs are undistinguishable from other lesions of the brain and meninges. Clinical features of IMTs include headaches, seizures and focal deficits. [27]
This patient can be classified as meningeal tumor close to the transverse sinus. Meningeal IMT usually is a mass attached to the dura mater and sometimes in the vicinity of dural venous sinuses. On MRI imaging IMT presents an extraxial mass isointense to hypointense relative to brain parenchyma in both T1 and T2-weighted images with homogeneous uptake on postcontrast series. [20],[28] The radiologic features of IMT include: (1) Localized diffuse dural thickening, (2) dural based masses (3) single or multiple intraxial masses (4) intraventricular/choroid plexus masses. [12] Other findings include dural venous sinus thrombosis, leptomeningeal involvement, extracranial involvement (mastoid, orbit). Cranial bone involvement has also been described with focal neurological deficit. [29] These neuroimaging features are rather non-specific. SPECT with pentetreotide-In 111 shows a moderate uptake of radionucleide, which is less than the uptake observed in meningiomas, breast cancer metastasis and neuroendocrine tumors. There was only one report of pentetreotide-In 111 SPECT imaging in IMTs located in the pterygopalatine fossa. [15] These findings suggest for the potential role of somatostatin analogs in the treatment of IMTs. [30]
Surgical resection remains the treatment of choice for mass lesions and a total resection can be a cure. However, in this patient, total removal of the lesions did not prevent early tumor recurrence, suggesting the aggressive biological behavior of the lesion. Such early recurrence has been described in patients with IMT in other organs. Carswell and Chataway [31] in their study have reported the efficacy of long-term steroid therapy in controlling symptoms related to intracranial IMT.
Chemotherapy regimens used for IMT include carboplatin and paclitaxel [32] methotrexate and 6-mercaptopurine [28] Radiotherapy has also been tried in some case with variable degrees of success. [6],[20],[33] However, the determining factor for progression or recurrence of these tumors remains unclear and these lesions have been sometimes classified as inflammatory pseudotumors or plasma cell granulomas. [Table 1] describes the clinical profile of patients with recurrence or progression of the lesion. | Table 1: Literature review of 19 cases of recurrent/progressive intracranial inflammatory pseudotumors or plasma cell despite treatment
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Classification of different subtypes of IMT remains a challenge because of fewer numbers of cases and histological complexity of the tumor. In our patient the predominant pathological features spindle-shape cells and inflammatory infiltrates. Reactivity for α-smooth muscle actin was positive and EMA and anaplastic lymphoma kinase (ALK) was negative. These findings rule out other conditions, such as plasma cell meningioma, Rosai-Dorfman Disease More Details, pachimeningitis, tuberculosis and fungal disease. ALK is positive in nearly half of patients with extra-pulmonary IMT, particularly in children and is associated with local recurrence and distant metastasis. [5],[34] However, ALK was negative in our case and in all cases of the CNS-IMT reported by Kim et al., [20] whereas Clarke et al. [23] found a pineal IMT with positive ALK reactivity.
| » References | | |
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[Figure 1], [Figure 2]
[Table 1]
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