Glioblastoma pseudoprogression

Case contributed by A.Prof Frank Gaillard

Presentation

Patient presented with increasing headache and drowsiness and on the basis of CT went on to have resection. No pre-operative MRI available.

Patient Data

Age: 45 years
Gender: Female

Immediate Post-op

Modality: MRI

Recent right pterional craniotomy with underlying right temporal resection. Small amount of blood and gas in the right frontal temporal extra-axial space. Slither of T1 and FLAIR hyperintense fluid is also seen overlying the right cerebellar hemisphere with smooth asymmetric enhancement of the right tentorium. T1 hyperintense blood lies dependently with a fluid fluid level at the posterior resection margin where there is also a thin rim of diffusion restriction. Faint wispy enhancement remains at the postero supero medial aspect of the resection cavity. Peritumoural FLAIR hyperintensity extending superiorly to involve the right frontal parietal and temporal white matter, as well as internal capsule and thalamus.

Conclusion:  A small amount of faint wispy enhancement remains at the postero-superomedial aspect of the resection cavity in keeping with a small amount of residual enhancing tumour.

6 months post-op (3 months post Stupp)

Modality: MRI

There is an extensive high T2 and FLAIR signal abnormalities surrounding the resection cavity and extending superiorly throughout the frontoparietal white matter, as well as a thick linear and irregular contrast enhancement along the resection margins in the temporal lobe occupying the resection cavity. No areas of restricted diffusion; in fact there is strikingly facilitated diffusion. Spectroscopy traces reveal increased choline just within the transition of the enhancing margins to the adjacent brain parenchyma; elsewhere the trace is essentially hypometabolic with a dominant lactate peak. There are just a few scattered foci of increased perfusion, likely vascular. Ventricles and basal cisterns are normal in appearance. No midline shift. The remainder brain is unremarkable.

Conclusion: Although residual tumour no doubt is present, in this treatment context, the features suggest pseudoprogression as the dominant process.

9 months post-op (6 months post Stupp)

Modality: MRI

FLAIR hyperintensity and enhancement have both decreased since the prior study and there is new ex vacuo dilatation of the right lateral ventricle. No new areas of involvement. Spectroscopy fails to show any significant tumoral trace. No diffusion restriction. No elevated CBV

Conclusion: Improved appearances, suggesting a component of response and/or resolving pseudoprogression.

Case Discussion

This case was confirmed to be GBM, MGMT methylated. This case demonstrates fairly typical features of pseudoprogression at a typical time - around 3 months following completion of postoperative Stupp protocol

Histology

MICROSCOPIC DESCRIPTION: The sections show features of a moderately cellular astrocytic tumour. Most of the tumour cells are astrocytic. They have elongated, angulated and pleomorphic
nuclei. A second very minor population of neoplastic oligodendroglial cells is also present. These cells have round nuclei and perinuclear haloes. Scattered mitotic figures are identified. There
are foci of microvascular proliferation. Areas of necrosis with focal palisading are present. There are perivascular lymphocytes.

The tumour cells are:

  • focally p53 positive.
  • IDH-1 negative (IDH1 wildtype)
  • MGMT negative (methylated) 
  • no loss of staining for ATRX
  • topoisomerase index is about 15%.

FINAL DIAGNOSIS: Glioblastoma (WHO Grade IV). 

 

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Case Information

rID: 45131
Case created: 16th May 2016
Last edited: 20th May 2016
Inclusion in quiz mode: Excluded

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