EPID-13CONCOMITANT GLIOBLASTOMA MULTIFORME IN PATIENTS DIAGNOSED WITH MULTIPLE SCLEROSIS: A REPORT OF TWO CASES

Abstract

Multiple sclerosis (MS) and glioblastoma multiforme(GBM)aretwo neuropathologies at the opposite ends of the immune spectrum. The incidence of MS with concomitant GBM is rare and only a number of case reports have been described in the literature. MS is an immune-mediated disease characterized by inflammation, demyelination, gliosis and neuronal loss while GBM is a primary malignant brain neoplasm that arises either from cancer stem cells or dysregulated astrocytes that result in uncontrolled tumor growth that escaped immune surveillance. We describe two cases that illustrate the challenges of timely diagnosis and management of GBM in patients with preexisting MS. The first case is a 59-year-old female with an 18-year history of MS, who is JC virus positive and previously received Rebif and Tysabri. She presented to the emergency department with headache and altered mental status; MRI revealed a hemorrhagic left temporal lesion. She underwent hematoma evacuation and a second craniotomy for tumor debulking and received a diagnosis of anaplastic oligodendroglioma. She received standard of care Temozolomide and radiation therapy. Six months later, the patient had tumor recurrence which required a third resection, pathology was read as GBM. Second-line therapy with Bevacizumab and Irinotecan were added due to temozolomide intolerance and clinical progression. The second case is a 48-year-old female with a 24-year history of mild MS on Copaxone, who presented with improving left sided numbness and tingling of 2 months duration. She was treated with oral steroids and an MRI of the brain was done to evaluate disease activity and showed a large, acute ring-enhancing lesion atypical for MS. She underwent a biopsy that was consistent with GBM and proceeded with oncologic treatment at another facility. Although rare, these two cases illustrate the diagnostic and treatment challenges of primary brain tumors in patients with pre-existing neurological disease.