Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA.
University of Massachusetts, Worcester, MA, USA.
J Investig Med High Impact Case Rep. 2021 Jan-Dec;9:23247096211033047. doi: 10.1177/23247096211033047.
The emergence of immunomodulators as effective cancer treatments has been an important advance in cancer therapy. The combination therapy of BRAF/MEK inhibition with or without anti-CTLA-4 treatment causes an immunostimulatory effect that has greatly reduced death from melanoma. In this article, we present the case of a patient with prior multiple sclerosis (MS) and who later developed metastatic malignant melanoma, had a marked increase of magnetic resonance imaging (MRI) findings after treatment with the combination of trametinib (MEK) and dabrafenib (BRAF), diagnostic question of metastatic disease versus new MS lesions without brain biopsy is discussed. A healthy 49-year-old man was diagnosed with MS in October 2012. He was stable with an oral disease modifying drug until March of 2016 when the patient discovered a lump in his right groin. Biopsy was positive for S100 and BRAF V600 mutation. Combination MEK/BRAF was given and after immunotherapy an MRI showed 25 new gadolinium-enhancing lesions thought to be metastases. A brain biopsy was recommended but neurology and neuroimaging consultation showed that the MRI was consistent with demyelination (oval/ovoid, homogeneous and open-ring enhancement, and predominance of the central vein sign within lesions) rather than metastasis. Treatment for MS has been successful and there has been no return of his melanoma in 4 years. New immunotherapies are lifesaving but the modulation of the immune system can cause unpredictable events such are markedly increased MS activity. The awareness of the diagnostic value of the central vein sign provided a better outcome for this patient and could be a model in the future for others.
免疫调节剂作为有效的癌症治疗方法的出现是癌症治疗的重要进展。BRAF/MEK 抑制联合或不联合抗 CTLA-4 治疗引起免疫刺激作用，大大降低了黑色素瘤的死亡率。在本文中，我们介绍了一例先前患有多发性硬化症（MS）的患者，后来发展为转移性恶性黑色素瘤，在接受 trametinib（MEK）和 dabrafenib（BRAF）联合治疗后，磁共振成像（MRI）发现明显增加，讨论了转移性疾病与无脑部活检的新 MS 病变之间的诊断问题。一位 49 岁健康男性于 2012 年 10 月被诊断为 MS。他口服疾病修正药物稳定，直到 2016 年 3 月，患者发现右腹股沟有肿块。活检显示 S100 和 BRAF V600 突变阳性。给予 MEK/BRAF 联合治疗，免疫治疗后 MRI 显示 25 个新的钆增强病变，被认为是转移。建议进行脑部活检，但神经病学和神经影像学咨询显示 MRI 与脱髓鞘一致（椭圆形/卵形，均匀和开环增强，病变内中央静脉征为主），而不是转移。MS 的治疗已取得成功，4 年来未出现黑色素瘤复发。新的免疫疗法是救命的，但免疫系统的调节会导致不可预测的事件，如 MS 活动明显增加。中央静脉征的诊断价值意识为该患者提供了更好的结果，并可能成为未来其他人的模型。
