Glioblastoma - solitary ring enhancing lesion

Case contributed by Dr Ammar Ashraf

Presentation

Headache and seizures. No history of trauma, fever, neurological deficit, or weight loss.

Patient Data

Age: 40 years
Gender: Male

FINDINGS: A space-occupying lesion with enhancing thick irregular walls and central necrotic core is seen in the left frontal lobe white matter. Marked surrounding vasogenic edema, effacement of the underlying ipsilateral lateral ventricle, and contralateral midline shift of 8 mm are noted. No other focal space-occupying lesion is seen.

CONCLUSION: Left frontal lobe ring-enhancing space-occupying lesion with mass effect, which is likely a primary brain tumor; other possible differential includes brain abscess & solitary brain metastasis.

FINDINGS: A solitary irregular heterogeneous mass lesion, measuring approximately 30 X 25 mm, is seen in the left frontal lobe. Its peripheral part is isointense on both T1 & T2-weighted images, shows mild restriction on diffusion-weighted images and thick irregular enhancement on post-contrast images. It has a central cystic/necrotic non-enhancing component.  Associated significant surrounding vasogenic edema and mass effect in the form of the effacement of the frontal horn of the left lateral ventricle as well as mild midline shift towards the right side is also noted.  The imaging differential diagnosis for this lesion remains the same (primary brain tumor, metastasis,  and less likely an abscess).

MRI brain two weeks after biopsy

MRI

Residual ring-enhancing lesion and recent postoperative changes are seen in the left frontal lobe.

A few well-defined focal hyperechoic lesions are noted in the right hepatic lobe (segments VI, VII & VIII). No significant internal vascularity is seen in these lesions on the color Doppler ultrasound examination. These hepatic lesions are likely hemangiomas. However, in view of the history of cerebral lesion, the possibility of metastases (though less likely) cannot be excluded.

After the ultrasound examination, a contrast-enhanced CT abdomen was performed (not shown here) which was suboptimal in the characterization of these hepatic lesions due to technical issues and a radionuclide RBC scan was recommended for further evaluation.

Tc-99m labeled RBC scan

Nuclear medicine

Multiple focal areas of increased isotope concentration, (which increased with passage of time in 2 hours delayed images), are noted in the segment VI, VII and VIII of the liver. These lesions are consistent with hepatic hemangiomas.

Follow-up MRI brain after two years

MRI

An irregular focal lesion having peripheral enhancing walls and necrotic non-enhancing center is seen in the left frontal lobe. Lesion extension into the genu of corpus callosum, marked perilesional edema and mass effect over the ipsilateral lateral ventricle are noted; however, no midline shift is seen. In comparison with the previous brain imaging; the current MRI features are suggestive of progressive disease.

Case Discussion

Craniotomy and biopsy of the left frontal lobe tumor.

Histopathology: Glioblastoma (WHO grade IV). 

The tumor is very cellular comprising epithelioid and spindle cell sarcomatous components as well as striking giant cells often with bizarre features together with extensive necrosis. Immunohistochemistry shows a negative reaction to cytokeratin AE1/AE3 and strong reactivity of tumor and brain tissue to vimentin.  CD34 is also negative. Glial fibrillary acidic protein (GFAP) shows focal immunoreactivity of viable as well as a necrotic tumor but the vast majority of the giant cells are nonreactive or only weakly reactive.

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