The patient went on to have an MRI (not shown) which favoured a high grade glioma, and soon after had a craniotomy and de-bulking of the tumour.
MICROSCOPIC DESCRIPTION: Paraffin sections show fragments of a densely hypercellular astrocytic glioma. Tumour cells show moderate nuclear and cellular pleomorphism and are a mixture of fibrillary and gemistocytic forms. Many cells also show lipidisation of their cytoplasm. Frequent mitotic figures are identified and there are numerous areas of both confluent and palisaded necrosis. Many of these include thin walled thrombosed and necrotic vascular channels. There is also prominent vascular endothelial cell hyperplasia. The features are of a glioblastoma.
FINAL DIAGNOSIS: Glioblastoma - WHO grade IV
This case illustrates typical appearances of a high grade glioma (WHO IV, glioblastoma). The differential, especially in this patient, should almost always include a solitary metastasis which can appear very similar. MRI should thus be obtained whenever possible pre-operatively, as often it is able to distinguish between the two - for example, if there are typical features on MRS of glioma, or multiple smaller lesions consistent with other metastases.
features images from this case