Presentation
Hemiplegia
Patient Data
A left-sided basal ganglia lesion with abundant surrounding edema is present exerting substantial localized mass effect.
A peripherally enhancing left basal ganglia lesion with blood product and central restricted diffusion is present surrounded by vasogenic edema. Inferolaterally a larger cystic component with thin peripheral enhancement demonstrates high T2 signal consistent with fluid and facilitated diffusion, with no hint of abnormally low diffusion restriction. MR spectroscopy demonstrates some elevation of choline lateral to the lesion with a very prominent lipid lactate peaks centrally. MR perfusion demonstrates elevation of cerebral blood volume in the enhancing components.
Conclusion: Left basal ganglia lesion most likely represents a glioblastoma. A necrotic/ hemorrhaging metastasis is though less likely, and if so it wouldn't be from prostate carcinoma but some other primary (e.g. melanoma or lung). Despite the presence of diffusion restriction within one component of the lesion, the minimal change over 2 weeks (prior MRI not shown), and presence of a blood product that can account for this appearance, makes this very unlikely to represent infection.
Case Discussion
The patient went on to have a biopsy.
Histology
Sections show fragments of an extensively necrotic hypercellular astrocytic glioma with a focal gemistocytic tumor cell morphology. Tumor cells show marked nuclear and cellular pleomorphism. Scattered mitotic figures are identified. There is focal microvascular proliferation with multilayering of atypical cells around vessel lumen.
Immunohistochemistry results show tumor cells stain:
- GFAP: Positive
- Nestin: Positive (high)
- NogoA: Negative
- IDH-1 R132H: Negative
- ATRX: Positive
- p53: Positive
- p16 CDKN2A: Positive
- Topoisomerase labeling index: 15%
FINAL DIAGNOSIS: glioblastoma, IDH wild-type (WHO Grade IV).
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