Glioblastoma (GBM) is the most common adult primary intracranial neoplasm (see brain tumours). It accounts for 12-15% of all intracranial neoplasms and ~50% of astrocytomas. Unfortunately, it also carries the worst prognosis (WHO grade IV).
They have a preferential spreading along the condensed white matter tracts such as corticospinal tracts and corpus callosum. They often spread across white matter commissural tracts such as the corpus callosum and can give rise to the so called butterfly glioma, to involve the contralateral hemisphere. Glioblastomas rarely involve the meninges. These tumours are multifocal in 20% of patients and are rarely multicentric.
Glioblastoma was previously known as glioblastoma multiforme. The WHO classification has dropped the 'multiforme' and thus it is best to refer to these tumours merely as glioblastomas, or grade IV astrocytomas. Somewhat confusingly the abbreviation GBM is still appropriate.
The original term was coined in 1926 by Percival Bailey and Harvey Cushing, and the suffix multiforme was meant to describe the various appearances of haemorrhage, necrosis and cysts.
A glioblastoma may occur at any age, however, they usually occur after the age of 40 years with a peak incidence between 65 and 75 years of age. There is a slight male preponderance with a 3:2 M:F ratio 5. Caucasians are affected somewhat more frequently than other ethnicities.
Glioblastomas are usually sporadic, although a proportion evolve from lower grade astrocytomas (these are usually IDH mutant - see below). Rarely they are related to prior radiation exposure (radiation-induced GBM).
They can also occur as part of rare inherited tumour syndromes, such as p53 mutation related syndromes such as neurofibromatosis type1 (NF1) and Li-Fraumeni syndrome. Other syndromes in which GBMs are encountered include Turcot syndrome, Ollier disease and Maffucci syndrome.
Typically patients present in one of three ways:
- focal neurological deficit
- symptoms of increased intracranial pressure (ICP)
Rarely (<2%) intratumoral haemorrhage occurs and patients may present acutely with stroke-like symptoms and signs.
Glioblastomas have traditionally been divided into primary and secondary.
De novo origin. These tumours are more aggressive than secondary glioblastomas and they tend to occur in older patients.
Primary glioblastomas tend to have amplification of EGFR and overexpression of MDM2, mutation of PTEN and/or loss of heterozygosity of chromosome 10p 7.
Secondary glioblastomas are those which arise from pre-existing lower grade gliomas. These tumours tend to be less aggressive than primary glioblastomas and they tend to occur in younger patients 7.
Characteristically, and unlike primary tumours, secondary glioblastomas tend to be IDH-1 mutant (positive), and demonstrate p53 mutations, amplification of PDGF-A, loss of heterozygosity of chromosomes 10q and 17p, loss of 19q and increased telomerase activity and hTERT expression 7.
Of this IDH1 mutation is most important in allowing separation of primary and secondary glioblastomas, and is present in over 80% of grade II and III astrocytomas 7,8.
Glioblastomas are typically poorly-marginated, diffusely infiltrating necrotic masses localised to the cerebral hemispheres. The supratentorial white matter is the most common location.
These tumours may be firm or gelatinous. Considerable regional variation in appearance is characteristic. Some areas are firm and white, some are soft and yellow (secondary to necrosis), and still other are cystic with local haemorrhage. GBMs have a significant variability in size from only a few centimetres lesions that replace a hemisphere. Infiltration beyond the visible tumour margin is always present.
Pleomorphic astrocytes with marked atypia and numerous mitoses are seen. Necrosis and microvascular proliferation are hallmarks of glioblastomas (see WHO grading of astrocytomas).
Microvascular proliferation results in and abundance of new vessels with poorly formed blood-brain barrier (BBB) permitting the leakage of iodinated CT contrast and gadolinium into the adjacent extracellular interstitium resulting in the observed enhancement on CT and MRI respectively 11.
Oedema and enhancement are however also seen in lower grade tumours that lack endovascular proliferation (anaplastic astrocytoma and other diffuse astrocytomas, for example, gemistocytic astrocytomas) and this is thought to be due to disruption of the normal blood-brain barrier by tumour produced factors. Vascular endothelial growth factor (VEGF) for example has been shown to both disrupt tight junctions between endothelial cells and increase the formation of fenestrations 12.
- giant cell glioblastoma: accounting for 5% of glioblastomas, this histological variant has a mildly improved prognosis
- epithelioid glioblastoma: a new addition as of the 2016 update ot the WHO classification of CNS tumours
As with most other glial tumours, glioblastomas are positive for GFAP.
IDH1 is positive in many secondary GBMs 8.
Serum GFAP 4.
GBM's are typically large tumours at diagnosis. They often have thick, irregular-enhancing margins and a central necrotic core, which may also have a haemorrhagic component. They are surrounded by vasogenic-type oedema, which in fact usually contains infiltration by neoplastic cells.
Multifocal disease, which is found in ~20% of cases, is that where multiple areas of enhancement are connected to each other by abnormal white matter signal, which represents microscopic spread to tumour cells. Multicentric disease, on the other hand, is where no such connection can be seen.
- irregular thick margins: iso to slightly hyperattenuating (high cellularity)
- irregular hypodense centre representing necrosis
- marked mass effect
- surrounding vasogenic oedema
- haemorrhage occasionally seen
- calcification is uncommon
- intense irregular, heterogeneous enhancement of the margins is almost always present
- hypo to isointense mass within white matter
- central heterogeneous signal (necrosis, intratumoural haemorrhage)
T1 C+ (Gd)
- enhancement is variable but is almost always present
- typically peripheral and irregular with nodular components
- usually surrounds necrosis
- surrounded by vasogenic oedema
- flow voids occasionally seen
- susceptibility artefact on T2* from blood products (or occasionally calcification)
- Low-intensity rim from blood product 6
- incomplete and irregular in 85% when present
- mostly located inside the peripheral enhancing component
- absent dual rim sign
- solid component
- elevated signal on DWI is common in solid/enhancing component
- diffusion restriction is typically intermediate similar to normal white matter, but significantly elevated compared to surrounding vasogenic oedema (which has facilitated diffusion)
- ADC values correlate with grade 13
- WHO IV (GBM) = 745 ± 135 x 10-6 mm2/s
- WHO III (anaplastic) = 1067 ± 276 x 10-6 mm2/s
- WHO II (low grade) = 1273 ± 293 x 10-6 mm2/s
- ADC threshold value of 1185 x 10-6 mm2/s sensitivity (97.6%) and specificity (53.1%) in the discrimination of high-grade (WHO grade III & IV) and low-grade (WHO grade II) gliomas 13
- non-enhancing necrotic / cystic component
- the vast majority (>90%) have facilitated diffusion (ADC values >1000 x 10-6 mm2/s)
- care must be taken in interpreting cavities with blood product
- solid component
- MR perfusion: rCBV elevated compared to lower grade tumours and normal brain
- typical spectroscopic characteristics include
- choline: increased
- lactate: increased
- lipids: increased
- NAA: decreased
- myoinositol: decreased
- typical spectroscopic characteristics include
PET demonstrates accumulation of FDG (representing increased glucose metabolism) which typically is greater than or similar to metabolism in grey matter.
Treatment and prognosis
Biopsy and tumour debulking with post-operative adjuvant radiotherapy and chemotherapy (temozolomide) are the most commonly carried out treatment. Despite this, it carries a poor prognosis with an average survival of ~12 months 3.
Negative prognostic factors include:
- the degree of necrosis 10
- the degree of enhancement 10
- deep location (e.g. thalamus)
Response assessment criteria
Glioblastomas have been the subject of close trial scrutiny with many new chemotherapeutic agents showing promise. As such a number of criteria have been created over the years to assess response to treatment. Currently, the RANO criteria are most widely used. Other historical systems are worth knowing to allow interpretation of older data. These systems for response criteria for first-line treatment of glioblastomas include 9:
General imaging differential considerations include:
- may look identical
- both may appear multifocal
- metastases usually are centred on grey-white matter junction and spare the overlying cortex
- rCBV in the 'oedema' will be reduced
primary CNS lymphoma
- should be considered especially in patients with AIDS, as in this setting central necrosis is more common
- otherwise usually homogeneously enhancing
- central restricted diffusion is helpful
- hemorrhagic then assessment may be difficult
- presence of smooth and complete SWI low-intensity rim 6
- presence of dual rim sign 6
- should not have central necrosis
- consider histology sampling bias
- can appear similar
- often has an open ring pattern of enhancement
- usually younger patients
- subacute cerebral infarction
- history is essential in suggesting the diagnosis
- should not have elevated choline
- should not have elevated rCBV
- cerebral toxoplasmosis
- WHO classification of CNS tumours
- WHO grading of CNS tumours
- VASARI MRI feature set
- diffuse astrocytic tumours
- prognostic markers
- diffuse astrocytoma grading
- low grade astrocytoma
- anaplastic astrocytoma
- glioblastoma variant
- glioblastoma vs cerebral metastasis
- treatment response
- Stupp protocol
- glioma treatment response assessment in clinical trials
- multicentric glioblastoma
- multifocal glioblastoma
- radiation-induced gliomas
- gliomatosis cerebri (growth pattern)
- localised astrocytic tumours
- specific locations
- 1. Kumar V, Abbas AK, Fausto N et-al. Robbins and Cotran pathologic basis of disease. W B Saunders Co. (2005) ISBN:0721601871. Read it at Google Books - Find it at Amazon
- 2. Rees JH, Smirniotopoulos JG, Jones RV et-al. Glioblastoma multiforme: radiologic-pathologic correlation. Radiographics. 1996;16 (6): 1413-38. Radiographics (abstract) - Pubmed citation
- 3. Krex D, Klink B, Hartmann C et-al. Long-term survival with glioblastoma multiforme. Brain. 2007;130 (Pt): 2596-606. doi:10.1093/brain/awm204 - Pubmed citation
- 4. Jung CS, Foerch C, Schänzer A et-al. Serum GFAP is a diagnostic marker for glioblastoma multiforme. Brain. 2007;130 (Pt): 3336-41. doi:10.1093/brain/awm263 - Pubmed citation
- 5. Dähnert W. Radiology review manual. Lippincott Williams & Wilkins. (2003) ISBN:0781738954. Read it at Google Books - Find it at Amazon
- 6. Toh CH, Wei KC, Chang CN et-al. Differentiation of pyogenic brain abscesses from necrotic glioblastomas with use of susceptibility-weighted imaging. AJNR Am J Neuroradiol. 2012;33 (8): 1534-8. AJNR Am J Neuroradiol (full text) - doi:10.3174/ajnr.A2986 - Pubmed citation
- 7. Ohgaki H, Kleihues P. The definition of primary and secondary glioblastoma. Clin. Cancer Res. 2013;19 (4): 764-72. doi:10.1158/1078-0432.CCR-12-3002 - Pubmed citation
- 8. Osborns Brain. Lippincott Williams & Wilkins. ISBN:1931884218. Read it at Google Books - Find it at Amazon
- 9. Chinot OL, Macdonald DR, Abrey LE et-al. Response assessment criteria for glioblastoma: practical adaptation and implementation in clinical trials of antiangiogenic therapy. Curr Neurol Neurosci Rep. 2013;13 (5): 347. doi:10.1007/s11910-013-0347-2 - Free text at pubmed - Pubmed citation
- 10. Hammoud MA, Sawaya R, Shi W et-al. Prognostic significance of preoperative MRI scans in glioblastoma multiforme. J. Neurooncol. 1996;27 (1): 65-73. Pubmed citation
- 11. Zagzag D, Goldenberg M, Brem S. Angiogenesis and blood-brain barrier breakdown modulate CT contrast enhancement: an experimental study in a rabbit brain-tumor model. AJR Am J Roentgenol. 1989;153 (1): 141-6. doi:10.2214/ajr.153.1.141 - Pubmed citation
- 12. Zhao LN, Yang ZH, Liu YH et-al. Vascular endothelial growth factor increases permeability of the blood-tumor barrier via caveolae-mediated transcellular pathway. J. Mol. Neurosci. 2011;44 (2): 122-9. doi:10.1007/s12031-010-9487-x - Pubmed citation
- 13. Hilario A, Ramos A, Perez-Nuñez A et-al. The added value of apparent diffusion coefficient to cerebral blood volume in the preoperative grading of diffuse gliomas. AJNR Am J Neuroradiol. 2012;33 (4): 701-7. doi:10.3174/ajnr.A2846 - Pubmed citation