Glioblastoma NOS (documented rapid growth)

Case contributed by Dr Bruno Di Muzio

Presentation

Left temporal seizure.

Patient Data

Age: 70-75 years
Gender: Female

T2/FLAIR hyperintensity and cortical expansion involving the left middle temporal gyrus is demonstrated. Although the most focally expanded region measures 15 x 16 mm, cortical signal abnormality extends over an AP distance of at least 46 mm (this is better appreciated on recent external MRI). No associated contrast enhancement, diffusion restriction or elevated cerebral blood volume (not shown). Spectroscopy is non-contributory due to wandering baseline (not shown).

MRI

MRI Brain (2 months later)

A comparison is made to the previous MRI.

FLAIR hyperintensity and expansion of the left middle temporal gyrus have increased, associated with the development of vivid contrast enhancement in this region. The contrast-enhancing mass measures 31 x 21 x 27 mm (AP x LR x SI). The mass is peripherally based, involving cortex and abutting dura which is smoothly thickened. There is further diffuse bilateral supratentorial pachymeningeal enhancement more prominent on the left, a new finding. Mild diffusion restriction has developed at the medial margin of the mass. The mass demonstrates elevated cerebral blood volume. On spectroscopy, a voxel anterior to the contrast enhancement demonstrates elevated choline to creatine and increased lactate. 

Conclusion: Left temporal tumour progression. The development of contrast enhancement and elevated cerebral blood volume indicate dedifferentiation into a glioblastoma. 

MRI

MRI Brain (follow-up post resection)

Postsurgical appearance with no evidence of enhancing tissue. Minimal enhancement at the operative site is most likely post-operative in nature, although further follow-up is required to clarify this.

MICROSCOPIC DESCRIPTION: 1&2. Paraffin sections show fragments of a densely hypercellular astrocytic glioma. Tumour cells show moderate nuclear and cellular pleomorphism. Scattered mitotic figures are identified. There are foci of microvascular proliferation with multilayering of atypical cells around vessel lumena. In addition there are several foci of tumour necrosis incorporating thin-walled thrombosed blood vessels. The features are of glioblastoma multiforme (WHO Grade IV). Separate fragments of brain parenchyma uninvolved by tumour show reactive changes.

DIAGNOSIS: 1&2. Brain tissue: Glioblastoma.

Case Discussion

This case illustrates the rapid progression of a high-grade tumour.

Due to a left temporal seizure, the patient was submitted to an MRI scan that revealed a left middle temporal gyrus T2/FLAIR hyperintense cortical lesion with mild expansion. Those findings were favoured to represent a low-grade glioma, with post-seizure change being the less likely differential. A new scan follow-up was performed in two months and then showed important progression, acquiring typical features of a glioblastoma: rapid growth, contrast enhancement, necrosis, diffusion restriction, choline peak and high rCBV values. 

The patient was treated with the Stupp protocol: maximum resection on surgery followed by radiotherapy and temozolamide. 

Note: IDH mutation status is not provided in this case and according to the current (2016) WHO classification of CNS tumours, this tumour would, therefore, be designated as a glioblastoma NOS.

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Case information

rID: 38605
Case created: 27th Jul 2015
Last edited: 30th May 2017
Tag: rmh
Inclusion in quiz mode: Included

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