Glioblastoma NOS

Case contributed by Frank Gaillard


Increasing headaches and unsteadiness. History of breast cancer 2 years ago treated with lumpectomy and radiotherapy.

Patient Data

Age: 65 years
Gender: Female

A large heterogeneous mass is centered into the right temporal lobe, elevating the MCA vessels in the Sylvian fissure and resulting in uncal herniation which in turn pushes the midbrain towards the left. 

The mass has central non-enhancing liquid density components, and irregular peripheral enhancement. It is surrounded by vasogenic pattern edema. 

Annotated image

The mass in the right temporal lobe has a liquid (necrotic) center ( blue * ) surrounded by a slightly hyperdense irregular rim (yellow arrows) which enhances following contrast administration. The whole mass is surrounded by low density change in the white matter (red * ) consistent with edema. 

There is significant mass effect with shift of the brain's midline to the left (dotted green line). 

The patient went on to have an MRI (not shown) which favored a high grade glioma, and soon after had a craniotomy and de-bulking of the tumor. 


MICROSCOPIC DESCRIPTION: Paraffin sections show fragments of a densely hypercellular astrocytic glioma.  Tumor 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

Case Discussion

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. 

Note: This case predates the recent (2016) revision WHO classification of CNS tumors and IDH status is not available. As such, this tumor would now be classified as a glioblastoma NOS.

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