Glioblastoma IDH wild-type

Case contributed by Dr Derek Smith

Presentation

New development of speech disturbance, dysphasia. Clinical team wanted to exclude any contraindications to thrombolysis for ischemic stroke.

Patient Data

Age: 60 years
Gender: Male
CT

No hemorrhage, recent infarct or hyperdense vessel.

Small cystic structure in left temporal lobe.

MRI

Solitary left temporal cystic lesion, centered on grey/white matter junction.

Faint peripheral enhancement. No nodule.

Surrounding cortical thickening, hyperintense on T2w. High local FLAIR signal.

No infarct or DWI abnormality.

Four week follow up

MRI

Increase in size of left temporal lesion, including the internal cystic component, surrounding enhancement with a posterior nodule, and white matter FLAIR abnormality. Some SWI abnormality compatible with blood products.

Some imaging features shared with ganglioglioma or DNET, but the rapid increase, enhancement pattern and blood products are more concerning for a more aggressive process such as metastasis or glioblastoma.

Case Discussion

Histology findings:

Microscopy: pleomorphic astrocytic tumor which diffusely infiltrates surrounding brain tissue. Predominantly composed of gemistocytic cells although some regions or more cohesive small cell apearance. Microvascular proliferation and intrinsic tumor necrosis identified.

Immunohistochemistry:
GFAP positive
MIB1 high index proliferation
ATRX positive (not mutated)
IDH1 negative (not mutated)
H3K27M negative
P53 focal upregulation
NeuN and synapthophysin in surrounding cortical tissue but negative within the tumor
MGMT 1.1% (unmethylated)

Comment: left temporal glioblastoma, WHO grade 4, IDH1 wild-type, unmethylated

Discussion:

New onset seizures in adults >40 years old merit neuroimaging with trauma, vascular disease and tumors common causative conditions.

Although there are a variety of smaller low grade tumors typically considered epileptogenic, high grade tumors such as glioblastoma should be in consideration. Small cortical lesions can initially present with seizures rather than the headaches or focal neurological deficits larger lesions elicit.

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