Glioblastoma: right frontal

Case contributed by Dr Sara Wein

Presentation

Delirium

Patient Data

Age: 58
Gender: Female
Modality: CT

There is a large intracranial mass lesion centred on the right frontal lobe measuring approximately 45 mm in maximum diameter with a large amount of surrounding vasogenic oedema. The lesion leads to a mass effect with effacement of the frontal horn of the right lateral ventricle and is approximately 13 mm of right-to-left subfalcine herniation and midline shift. No other parenchymal lesions. No acute intra orextra-axial haemorrhage.

Modality: CT

Multiple peripherally enhancing lesions with central hypodensity in the right frontal lobe. The largest lesions measures 2.9 x 2.2 x 1.7cm (AP x trans x CC) with multiple smaller lesions superiorly. Significant surrounding vasogenic oedema. There is effacement of the frontal horn of the right lateral ventricle, subfalcine herniation and right-to left midline shift of 13mm at the level of the septum pellucidum. No tonsillar or uncal herniation. The left ventricle is not dilated

No other areas of abnormal contrast enhancement. Mastoid air cells and paranasal sinuses are clear.

Conclusion:

Multiple peripherally enhancing lesions in the right frontal lobe resulting in significant mass effect. In the setting of fever, the findings are suspicious for cerebral abscesses. The differential includes metastatic lesions and a primary brain tumour. MRI is recommended to further evaluate.

Modality: MRI

Within the right frontal lobe, there is a cluster of multiple adjacent peripherally enhancing lesions which together measure 3.4 x 3.5 x 4.0cm (cc x trans x AP). This is surrounded by a large amount of FLAIR hyperintensity which extends across the genu of the corpus callosum into the left frontal lobe, and involves the right internal capsule, lentiform nucleus and thalamus. The signal abnormality and enhancement involve the right frontal cortex as well as white matter. Within the right frontal lobe just superior to the sylvian fissure, there is a separate 10 mm nodule of enhancement.

There is a large amount of mass effect, characterised by right frontal cortical sulcal effacement, compression of the right lateral and third ventricles and 11 mm of right to left shift and subfalcine herniation.

There is a slight dilatation of the left lateral ventricle consistent with early hydrocephalus. Within the right frontal lobe, there is mild diffusion restriction.

Conclusion:

Findings are strongly favoured to represent a high-grade glioma.

Case Discussion

Pathology report:

Paraffin sections show exstensive replacement of white matter by a densely hypercellular glial tumour. This is composed predominantly of fibrillary and gemistocytic astrocytes which show moderate nuclear and cellular pleomorphism. In adition there is a minor oligodendroglial component. Frequent mitotic figures are identified. There is prominent microvascular proliferation with multilayering of atypical cell around vascular lumena. Several areas of palisaded necrosis are also noted. These incorporate thin-walled necrotic and thrombosed blood vessels. Tumour extensively involves cerebral cortex and there is prominent peri-neuronal, perivascular and sub-pial secondary structuring. The features are of glioblastoma multiforme with a minor oligodendroglioma component (WHO Grade IV).

Diagnosis: Right frontal brain tumour: Glioblastoma with a minor oligodendroglioma component

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Case Information

rID: 33414
Case created: 12th Jan 2015
Last edited: 20th Feb 2016
Inclusion in quiz mode: Included

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