Presentation
Several weeks of increasing confusion, agitation, memory difficulties and headache. GCS 14 (E4V4M6). Nil other focal neurological deficits.
Patient Data
There are two distinct intracranial masses. Firstly, a 25 x 25 mm (trans) mass in the right superior frontal gyrus that involves the cortex. There is predominantly thick rim enhancement, with a more solid component superiorly.
Associated vasogenic edema extends through much of the left frontal lobe, and involves the genu of the corpus callosum. A high-grade glioma is most likely.
There is a second 25 x 22 mm (trans) mass centered along the anterior falx cerebri, slightly hyperattenuating precontrast, and largely homogeneous contrast enhancement, compatible with a meningioma. Right frontoparietal sulcal effacement, subfalcine herniation, 10 mm midline shift to the left, without descending trans tentorial or tonsillar herniation.
Direct correlation is made with the CT scan performed above. In the right frontal lobe, there is a large area of abnormal signal intensity with two areas of enhancement. The superior lesion near the vertex measures 2 cm x 2 cm.. It is intra-axial and situated in the superior frontal gyrus. It is iso-intense to grey matter on T1, has heterogeneous intensity on T2 weighted images and demonstrates peripheral enhancement. Hypointensity within the lesion on the EPI is consistent with blood products. The second area of enhancement measures 2 cm x 2.3 cm and is situated adjacent to the falx has a subfalcine extension to the left. It is likely to be intra-axial rather than a separate extra-axial lesion. It is hypointense on T1 and isointense to grey matter on T2 and demonstrates patchy enhancement. There is significant vasogenic edema. There is at least 1 cm of midline shift with subfalcine herniation and effacement of the frontal horns of both lateral ventricles. In the right basal ganglia, a small lesion of hyperintense T2 signal is seen. This is consistent with an old lacunar infarct. There are several other small foci in the white matter which are non-specific. No other intraparenchymal abnormality is seen. No other abnormal enhancement. Ventricular size is normal.
Conclusion: Large right frontal lesion described is likely to be one lesion with two areas of enhancement. The most likely diagnosis is a glioma (glioblastoma multiforme) with multifocal enhancement. The inferior abnormality has an unusual appearance that is abutting the falx, there is a possibility that the patient has two pathology with the superior one being a glioma and the inferior on being a meningioma. However, this is thought to be unlikely.
The patient underwent a right frontal craniotomy and tumor debulking.
HISTOPATHOLOGY: Paraffin sections show fragments of a densely hypercellular astrocytic glioma. Tumor cells show marked nuclear and cellular pleomorphism. Moderate numbers of multinucleated tumor giant cells are noted. There are frequent mitotic figures and prominent vascular endothelial cell hyperplasia. In addition, there are areas of both palisaded and confluent necrosis incorporating thin walled thrombosed and necrotic blood vessels. The features are of glioblastoma multiforme.
DIAGNOSIS: glioblastoma WHO grade IV
Note: IDH mutation status is not provided in this case and according to the current (2016) WHO classification of CNS tumors, this tumor would, therefore, be designated as a glioblastoma NOS.
Case Discussion
This case illustrates the characteristic imaging findings in glioblastoma (GBM). The most common imaging appearance of GBM is a large mass located in the supratentorial white matter. On CT it is typically a heterogeneous mass, with central areas of necrosis delineated by a thick irregular wall. There is surrounding extensive vasogenic edema with resultant mass effect. On MRI, the lesions are usually hypointense on T1-weighted imaging, and hyperintense on proton density and T2-weighted images.
The patient was offered further treatment with radiotherapy and chemotherapy, although declined, dying within six months of his diagnosis.
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