Glioblastoma NOS

Case contributed by Dalia Ibrahim
Diagnosis almost certain



Patient Data

Age: 40 years
Gender: Male

Left deep insular fairly defined complex space-occupying lesion. It measures about 4.0 x 5.6 x 4.8 cm along its max TS, AP and CC dimensions. It elicits heterogeneous signal with cystic and solid components. It shows areas of blooming on SWI suggestive of hemorrhage/calcifications. No diffusion restriction. It shows heterogenous enhancement. It's surrounded by vasogenic edema and exerts positive mass effect on the left lateral ventricle.

Differential possibilities include:

  • metastatic lesion

  • grade 4 diffuse astrocytoma/glioblastoma

  • parenchymal ependymoma


The lesion appears complex on non contrast CT scan with hyperdense hemorrhagic areas and small calcific foci.

The patient went on to have a biopsy.


Sections revealed brain tissue infiltrated by malignant astrocytic tumor compromised of malignant astrocytes with pleomorphic nuclei, increased nuclear-cytoplasmic ratio, prominent nucleoli and frequent mitosis. Vascular proliferation was detected in the form of small blood vessel proliferation and endothelial proliferation with occasional glomeruloid morphology. Focal necrosis was observed.

Final diagnosis

WHO CNS grade 4 astrocytic tumor.


  • P53: negative staining

  • IDH1;Negative staining

  • GFAP:Diffuse positive staining

  • K167:Proliferation index 8%

Case Discussion

This is a highly aggressive complex cystic solid lesion. Differential possibilities according to the relatively young age of the patient included:

  • grade 4 diffuse astrocytic tumor, either an astrocytoma or glioblastoma

  • parenchymal extraventricular ependymoma

  • pilocytic astrocytoma with piloid features in NF patients

  • metastatic lesion

The immunostain was negative for IDH 1 mutation, however, for the diagnosis of IDH wild type in this young age (<55 years) the patient must have sequencing which is unfortunately not made for this patient. This makes the diagnosis (Glioblastoma NOS).

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