Presentation
Difficulty with speech represented by abrupt "switching" of words. Clinically interpreted by consulting neurologist as Wernicke's aphasia.
Patient Data
There is a large, heterogeneous (but predominantly decreased attenuation) mass with surrounding edema involving the left frontal, parietal, and temporal lobes. Mass effect results in near-complete effacement of the left lateral ventricle and nearby sulci. The left basal cisterns are effaced. There is a rightward midline shift.
On the CTA portion of the exam, there is arterial rim enhancement. Vessels course around the periphery and through the mass itself. There is no evidence of contrast extravasation to suggest active hemorrhage.
Irregular area of decreased T1 and increased T2-weighted signal with peripheral enhancement. The mass appears to be predominantly centered within the left temporal lobe.
There is significant surrounding vasogenic edema with associated mass effect as seen by a rightward midline shift and effacement of the adjacent sulci, left lateral ventricle, and third ventricle.
Case Discussion
This is a glioblastoma, IDH-wildtype.
The patient initially underwent a stereotactic biopsy which intraoperatively revealed cerebral tissue with rare atypical cells, suspicious for an infiltrating glioma.
The patient was then treated with four months of chemoradiation, but due to further decline in cognitive function, she underwent a left craniotomy for left temporal lobe tumor resection.
Gross pathology revealed irregular portions of tan-gray tissues. Histopathology was consistent with large areas of necrosis (>40%), likely on the basis of prior therapy. Viable glioma tissue and reactive cerebral tissue was seen in the remaining portions of the specimen. Immunohistochemical analysis demonstrated slightly elevated Ki-67 and low positivity for P53 (<5%). Further molecular testing was ordered which revealed the tumor was negative for MGMT promoter methylation. There was a mutated TERT promoter (-146C>G) and absence of IDH mutations. Together, these pathologic findings represented an infiltrating astrocytoma (IDH-wildtype, CNS WHO grade 4) with extensive necrosis consistent with therapy effects.
The patient did well post-operatively and was recommended for inpatient rehabilitation for her mixed aphasia and cognitive dysfunction. She was discharged and continued home PT/OT and speech therapy. To date, she continues chemotherapy and follows with oncology and neurosurgery.
Co-author:
Trevina Soliman