Presentation
Motor vehicle accident.
Patient Data
Within the right frontal lobe there is a region of diffuse ill-defined hyperdensity with a small rim of surrounding edema and minor local mass effect with effacement of the overlying sulcal. No appreciable enhancement post-contrast. No midline shift. No hydrocephalus.
Right frontal region of cortical expansion and increased signal on the T2-weighted and FLAIR sequence is associated with reduced signal on the ADC map (692 x 10^-6 mm^2/s) and increased cerebral blood volume. Enhancement at the anterior aspect of the lesion is more nodular in appearance. No susceptibility artefact identified to suggest the presence of blood products. Spectroscopy demonstrates elevation of choline.
The remainder of the brain is normal in signal and contour. No hydrocephalus or extra-axial fluid collection identified.
A 7 mm left frontal meningioma is noted. Normal variant cavum septum pellucidum noted.
Conclusion: Right frontal lesion is most consistent with a high-grade glioma.
Case Discussion
The patient went on to have a resection.
Histology
Sections show fragments of a cellular tumor. The tumor is composed of enlarged and pleomorphic cells, that have oval to irregularly-shaped large nuclei, granular chromatin, occasional central nucleoli and clear to finely vacuolated eosinophilic cytoplasm. Abnormal mitotic figures are easily identified. There are also multiple foci of multi-layering around vessels, as well as some areas of palisaded necrosis.
IMMUNOHISTOCHEMISTRY:
- GFAP: positive
- IDH1: negative (not mutated)
- ATRX: positive (not mutated)
- NogoA: positive
- Nestin: positive
- p53: positive
- p16: negative
- Ki67: 40%
FINAL DIAGNOSIS: glioblastoma, IDH1 wild-type (WHO IV).
Note, although IDH status has only been investigated with immunohistochemistry (without sequencing) given the age of the patient is more than 65 years, this is deemed sufficient to establish wild-type status. This is due to the incidence of IDH mutations in this age group is very low.
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