Glioblastoma

Case contributed by A.Prof Frank Gaillard

Presentation

Seizure

Patient Data

Age: 40 years
Gender: Male
Modality: CT

A large area of low attenuation, mostly confined to the white matter, is seen involving the right frontal lobe. Within it is embedded a relatively ill-defined area of hyperdensity with contrast enhancement. 

Hyperdensity implies high cellularity. 

Differential includes high grade glioma, cellular metastasis or CNS lymphoma. 

Modality: MRI

There are multiple intra-axial heterogeneously enhancing lesions the right cerebellar hemisphere:

  • Right inferior frontal gyrus opercular region. This lesion extends to involve the cortex and possibly the leptomeninges. Increased CBV.
  • Right thalamic hemorrhagic lesion protruding into the body of the right lateral ventricle, with predominantly acute stage blood product.
  • Right frontal deep white matter extending into body of corpus callosum. MRS- inc Cho. Increased CBV. Shows low ADC values suggesting high cellularity. 

Moderately extensive confluent white matter bright FLAIR/T2 signal around these lesions, with 1cm midline shift of the septum pellucidum to the left. Right uncal herniation with right cerebral peduncle compression.

Case Discussion

This is an interesting case, in that the contrast appearance and homogeneity of the largest periventricular mass are quite good for CNS lymphoma, especially in the presence of low ADC values and high density on non-contrast CT, which implies high cellularity. 

Presence of thalamic haemorrhage would be unusual for lymphoma however (unless immunocompromised). The differential is therefore essentially between a high grade glioma (GBM) or lymphoma. The location and appearance would be unusual for metastases. The high cellularity essentially excludes demyelination. 

The patient went on to have a craniotomy. 

Histology

MICROSCOPIC DESCRIPTION: The sections show features of a densely cellular astrocytic tumour. The tumour cells show elongated, angulated and hyperchromatic nuclei. Scattered large multinucleated tumour giant cells are noted. In some areas, the tumour cells have high N/C ratio with granular chromatin and nuclear moulding. They show patchy positivity for synaptophysin, consistent with PNET-like differentiation. Tumour cells are seen to extend into the cerebral cortex. Scattered mitotic figures are identified. There are foci of endothelial cell hyperplasia. Some of the blood vessels show perivascular lymphocytes. Areas of necrosis are present, some with pseudopalisading. The features are those of glioblastoma.

FINAL DIAGNOSIS: Glioblastoma (WHO Grade IV).

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Case Information

rID: 33365
Case created: 8th Jan 2015
Last edited: 1st Sep 2016
Inclusion in quiz mode: Included

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