Glioblastoma

Case contributed by Dr Derek Smith

Presentation

New onset headache and vertigo. Previously well. No focal deficit on examination.

Patient Data

Age: 35 years
Gender: Male
CT

3.5 cm centrally located tumor within the right corpus callosum. Low internal density compatible with necrosis. Surrounding mild perilesional edema.

Encroachment of the foramina of Monro with distended temporal and occipital horns, particularly on the right, consistent with entrapment / hydrocephalus. This lesion also displaces the internal cerebral veins to the left.

Incidental small calcified left frontal mass likely meningioma. No other intracranial abnormality. Normal skull and soft tissues.

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High-grade central tumor, likely GBM.
Lateral ventriclar hydrocephalus

MRI

Heterogeneous tumor (largest dimension 35 mm) centered in right body of the corpus callosum, showing a thick rind of enhancement with central necrosis. Adjacent ependymal enhancement involving the frontal horns and the roof of the right trigone. Non-enhancing white matter abnormality extending along the rest of the corpus callosum and superiorly into the right posterior frontal lobe.

Dilatation of the lateral ventricles, particularly right temporal horn. As on CT the mass encroaches the foramen on Monro on the right but is currently patent, with some mass effect to the left also. Minor but definite periventricular hyperintensity around the right temporal horn which in this case represents transependymal CSF shift. Mild sulcal effacement in the right cerebral hemisphere but no transcompartmental herniation.

No other abnormal parenchymal or extra-axial sites of enhancement within scanned limits. The region of left frontal extra-axial calcification on CT does not enhance, with low signal on all sequences, probable small burnt out meningioma.

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Right corpus callosal high grade tumor, likely GBM.
Contiguous ependymal extension.
Lateral ventricular hydrocephalus.

Case Discussion

PATHOLOGY

Biopsy: 20 x 5 x 3 mm brown tissue aggregate. Hemorrhagic brain barenchyma with diffuse infiltration of large cells with nuclear pleomorphism (including multinucleated and bizzare looking cells). Intrinsic necrosis and microvascular proliferation.

GFAP: strongly positive
IDH1: negative (wildtype)
ATRX: weak staining (mutated)
MGMT: negative
p53: positive
H3 K27M: negative
S100: occasional
NeuN: negative
CD34: present
MIB1: very high

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Diagnosis

Glioblastoma WHO grade 4; IDH1 wildtype; MGMT unmethylated

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Case information

rID: 67950
Published: 2nd May 2019
Last edited: 2nd May 2019
Inclusion in quiz mode: Included

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