The Study Of Clinical-pathology-¹H-MRS Imaging In Patients With Tumor-like Inflammatory Demyelinating Diseases And Low Grade Glioma

Objective: To investigating the similarities and differences betweentumor-like inflammatory demyelinating diseases（TIDD） and low gradeglioma（LGG） in clinical-pathology-¹H-MRS imaging for increasing theawareness of TIDD.Methods:12patients with TIDD confirmed by operation,biopsy orfollowed up on MRI after drug treatment were selected as patient group and10patients with LGG confirmed by operation as control group.The clinical,pathological and imaging data were compared between the two groups. Allpatients were performed with axial T1WI-FLAIR, FSE-T2WI, T2WI-FLAIR,1H-MRS and T1WI sequences on3.0T MR system before operation, biopsyand medication. The clinical and pathological data of the two groups werecompared.The anatomical structure, lesion site, morphology and signalcharacteristics were observed on the conventional magnetic resonance （cMRI）and enhanced scan.The absolute value of acetyl aspartate（NAA）, creatine（Cr）and choline（Cho） and the ratio change of N-acetyl aspartateleucine/creatine（NAA/Cr）, N-acetyl aspartic acid/choline （NAA/Cho）, choline/creatine（NAA/Cr） were measured in lesions area and lateral normal area by¹H-MRS.All the data were analyzed statistically by SPSS13.0statistical analysissoftware.Results:1Clinical results12patients in TIDD group,7cases were acute onset, accounting for theTIDD group58.3%,3cases were subacute onset, accounting for the TIDDgroup25.0%, and2cases were chronic onset, accounting for the TIDD group16.7%. Before the onset,10cases had not obvious incentive, only1case had cesarean section, accounting for the TIDD group8.3%,1case had symptomsof upper respiratory tract infection, accounting for the TIDD group8.3%.About the clinical manifestations,5cases onset epilepsy, accounting for theTIDD group41.7%,3cases onset limb weakness, accounting for the TIDDgroup25.0%, only1case onset headache, nausea and vomiting, accounting forthe TIDD group8.3%,1case onset unresponsive, accounting for the TIDDgroup8.3%,2cases onset epilepsy and limb weakness, accounting for theTIDD group16.7%. In TIDD group,4cases were misdiagnosed as gliomabefore operation, confirmed as the TIDD by pathology after operation;2caseswere confirmed as TIDD by brain biopsy; the clinical symptoms wereimproved by hormone therapy in6cases, and no recurrence followed up aftertwo months and six months. In the LGG group,3cases were subacute onset,accounting for the LGG group30%, seven cases were chronic onset,accounting for the LGG group70%. About the clinical manifestations,4casesonset headache, accounting for the LGG group40%,3cases onset epilepsy,accounting for the LGG group30%,2cases onset limb weakness, accountingfor the LGG group20%,1case onset nausea and vomiting, accounting for theLGG group10%.2Pathological resultsIn the TIDD group,6cases had pathological examination.the inflammatoryreaction were mainly observed by the ordinary HE staining.The lymphocytesand mononuclear-macrophages in the different stages rounded the vascularshowed a “sleeve-like” changes, with obesity astrocytosis.In the chronicphase,glial fiber was thicker and the cells were still arranged in certaindirection. By the myelin staining, a large number of myelin dropped out, butthe axons relatively reserved. In the immunohistochemistry, CD68, GFAP,LCA and lysozyme were diffuse positive. In the LGG group, a large numberof glial were proliferated with nuclei split irregularly and atypia obviously,accompaned with lymphocytic infiltration by the ordinary HE staining.In theimmunohistochemistry, the GFAP was strongly positive, Vimentin and S-100were mildly positive, Cytokeratin, and EMA were negative. 3cMRI resultsAll of the TIDD patients and LGG patients were performed withconventional magnetic resonance and enhanced scan. cMRI showed:（1）Lesion Site:12patients in TIDD group, the lesions of two cases were locatedin right frontal lobe, the lesion of one case was located in left frontal, thelesions of two cases were located in right temporal lobe, the lesion of one casewas located in right occipital lobe, the lesion of one case was located in corpuscallosum, the lesions of two cases were located in right parietal lobe, thelesions of three cases were located in basal ganglia.10patients in LGG group,the lesions of three cases were located in left basal ganglia, the lesions of twocases were located in right temporal lobe, the lesions of two cases werelocated in right occipital lobe, the lesions of two cases were located in leftfrontoparietal, the lesion of one case was located in right frontal.（2） LesionMorphology:12patients in TIDD group, nine cases showed focal and singlemass, three cases showed flaky and multiply lesions, all LGG patients showedfocal and singly mass.（3） Lesion Signal:12patients in the TIDD group, thelesion signal was close to edema in cMRI, it was difficult to distinguish. All ofthem showed low signal on T1WI, intensive signal on T2WI and FLAIR, onecase showed mixed signal on T2WI;10patients in LGG group, all of themshowed low signal on T1WI, intensive signal on T2WI and FLAIR, no mixedsignals appeared.（4） Enhanced Scan:12patients in TIDD group, eight casesshowed significantly strengthening, one case showed cystic, four casesshowed open-ring enhancement called "open-loop" sign, one case showedclosed-loop enhancement, two cases showed clumps nodular enhancement,one case showed flaming enhancement, four cases showed no obviousenhancement.10patients in LGG group, six cases showed mild enhancement,accounting for60%, four cases showed no obvious enhancement.（5） Perifocal:12patients in TIDD group, five cases were accompanied by edema,accounting for41.7%,10patients in LGG group, nine cases wereaccompanied by edema, accounting for90%,（6） Review the MRI: In TIDDgroup, the lesions of six cases were significantly reduced after hormone therapy.41H-MRS results3.1The difference in NAA, Cho, Cr, Lac value and Cho/Cr, NAA/Cr,NAA/Cho ratio between the lesions area and lateral normal area in TIDDgroup.12patients in TIDD group, compared with lateral normal area, the NAApeak declined30.7%（normal1.27±0.19; lesions0.88±0.21p<0.01）, Cho peakrose up36.4%（normal0.74±0.12; lesions1.01±0.09p<0.01）, of which ninecases showed a clear Lac peak（normal0.14±0.32; lesions1.98±0.29p<0.01）and Lip peak,There were significant difference in Cho/Cr、NAA/Cr andNAA/Cho（1.18±0.09,1.02±0.05,0.87±0.06;0.86±0.06,1.47±0.15,1.71±0.21）between leision area and lateral normal area in TIDD group （P=0.000<0.01）.3.2The difference in NAA, Cho, Cr, Lac value and Cho/Cr, NAA/Cr,NAA/Cho ratio between the lesions and its contra lateral normal area in LGGgroup.10patients in LGG group, compared with lateral normal area, the NAApeak declined37.6%（normal1.25±0.09; lesions0.78±0.11p<0.01）, Cho peakrose up69.4%（normal0.72±0.19; lesions1.22±0.31p<0.01）, Cr peakdecreased slightly（normal0.85±0.19; lesions0.77±0.43p>0.05）, of whichnine cases showed a low Lac peak（normal0.16±0.19; lesions0.48±0.52p>0.05）, no Lip peak, There were significant difference in Cho/Cr,NAA/Crand NAA/Cho（1.57±0.11,1.01±0.1,0.64±0.09；0.86±0.05,1.47±0.19,1.73±0.29）between leision area and lateral normal area in LGG group （P=0.000<0.01）.3.2The difference in NAA, Cho, Cr, Lac value and Cho/Cr, NAA/Cr,NAA/Cho ratio between lesions in TIDD group and lesions in LGG group.Compared with TIDD group, the Cho peak in the lesion area increasedobviously in LGG group, the rate increased from36.4%to69.4%, There weresignificant difference in Lac/Lip peak, Cho/Cr and NAA/Cho（1.98±0.29,0.48±0.52;1.18±0.09,0.87±0.06；1.57±0.11,0.64±0.09）between TIDD groupand LGG group,（P=0.000<0.01）;But there were no statistic difference inNAA/Cr （1.02±0.05;1.01±0.10） between TIDD group and LGG group.（P=0.75>0.01）Conclusions:1The TIDD patients are acute onset commonly, the epilepsy and limbweakness are major clinical performanec; The LGG patients are chronic onsetcommonly, the headache is major clinical performanec.However, the clinicalperformance. are similar.2The pathological performance of TIDD patients was mainlyinflammatory reaction, typical showed “sleeve-like”, LGG patients showedsignificant atypia changes, Myelin staining and immunohistochemistry candistinguish TIDD and LGG. Although the pathology is the gold standard toidentificating the two diseases, but the biopsy or surgery is invasive ways.3The cMRI performance is similar berween TIDD patients and LGGpatients, the “open-ring” and “flaming strengthen” were typical imagecharacteristics in TIDD. However, patchy enhancement showed in majoritypatients was no specificity to distinguish TIDD and LGG.4¹H-MRS can detect metabolite content of brain tissue without invasion.The Cho/Cr ratio increased but the Lac/Lip peak and NAA/Cho ratiodecreased in LGG patients than that in TIDD patients.it had statisticalsignificance.¹H-MRS has important clinical value in the diagnosis anddistinguish of the TIDD and LGG...