Very late frontal relapse of medulloblastoma mimicking a meningioma in an adult: usefulness of 1H magnetic resonance spectroscopy and diffusion-perfusion magnetic resonance imaging for preoperative diagnosis: case report.
OBJECTIVE
We present a rare case of very long-term medulloblastoma relapse in an adult patient and discuss the pattern of recurrence and metabolic imaging of the tumor.


METHODS
A 45-year-old man was referred for evaluation of a frontobasal midline tumor 21 years after treatment of a cerebellar medulloblastoma by surgery followed by chemotherapy and craniospinal radiotherapy. Magnetic resonance images were suggestive of a meningioma. Several hypotheses were discussed, such as other radio-induced tumors, sarcomas, high-grade gliomas, or lymphomas (previous chemotherapy) and even recurrence of medulloblastoma. Preoperative exploration included H magnetic resonance single-voxel spectroscopy (35 and 135 ms echo time), diffusion imaging, and perfusion magnetic resonance imaging.


METHODS
On magnetic resonance spectroscopy, N-acetyl-aspartate and an elevated choline/creatine ratio were retrieved, with a huge unidentified peak at 1.27 parts per million (ppm). Myoinositol signal was present at both echo times. On diffusion imaging, the tumor appeared hyperintense, with a low apparent diffusion coefficient value of 0.689. In the perfusion study, the maximal relative cerebral blood volume was 2. Metabolic imaging favored the diagnosis of medulloblastoma over the initially suspected diagnosis of meningioma. The patient underwent complete removal of the tumor that was confirmed to be a metastasis of his primary medulloblastoma. The postoperative course was uneventful, and complementary courses of radiotherapy and chemotherapy were planned.


CONCLUSIONS
Late relapse should be considered, even after several decades, on occurrence of a second intracranial tumor in this context. Our observation validates the clinical interest of preoperative metabolic imaging for brain tumors with distinctive pattern.
Neurosurgical Department, Neurological Hospital, University Claude Bernard Lyon, Lyon, France.
Emmanuel
E
Jouanneau
Rafael Alfonso
RA
Guzman Tovar
Claude
C
Desuzinges
Didier
D
Frappaz
Guy
G
Louis-Tisserand
Marie-Pierre
MP
Sunyach
Anne
A
Jouvet
Marc
M
Sindou
D002528:Cerebellar Neoplasms / Q000175:diagnosis* / Q000601:surgery; D003937:Diagnosis, Differential; D038524:Diffusion Magnetic Resonance Imaging / Q000379:methods; D006801:Humans; D009682:Magnetic Resonance Spectroscopy / Q000379:methods; D008297:Male; D008527:Medulloblastoma / Q000175:diagnosis* / Q000601:surgery; D008577:Meningeal Neoplasms / Q000175:diagnosis* / Q000601:surgery; D008579:Meningioma / Q000175:diagnosis* / Q000601:surgery; D008875:Middle Aged; D011300:Preoperative Care / Q000379:methods; D011522:Protons; D012008:Recurrence
D011522:Protons