Glioblastoma: with a large cystic component

Case contributed by A.Prof Frank Gaillard

Presentation

2 week history of headaches not alleviated by analgesics.

Patient Data

Age: 66-year-old
Gender: Female

CT Brain (selected images)

Modality: CT

Selected pre and post-contrast images of brain showing a large cystic and well-defined lesion located in the right temporoparietal junction. Its content is homogeneously hypoattenuating and there is enhancement of the entire wall. The tumour promotes an expressive local mass effect characterised sulci effacement, peri-lesional oedema, right lateral ventricle partial collapse and midline shift to the left.

MRI Brain

Modality: MRI

Large intraaxial mass at right temporo-parietal junction. It measures 5.7 x 5.4 x 4.8cm  is largely cystic/necrotic, has ring enhancement and solid heterogenous enhancement posteroinferioly measuring 3.6 x 1.8 x 1.1cm. It extends to the subependyma of trigone and posterior temporal horn. Bright FLAIR signal extends into right anterior temporal pole and internal capsule posterior limb as well as the overlying cortex. Diffusion restriction and increased CBV of the thin enhancing rim and solid component. MRS suboptimal but shows increased choline at the margin (despite elevated baseline) and centre shows increased lactate.

There is transtentorial herniation with midbrain distortion. Midline shift to left 1.3cm.

Scattered foci of bright FLAIR signal in the rest of white matter (centrum semiovale) and periventricular deep white matter probably reflect chronic small vessel ischaemia.

Conclusion : Right temporoparietal lesion, with overall findings favouring a cystic high grade glioma.

Case Discussion

This case demonstrates yet another appearance of GBMs. Often the peripheral enhancement is nodular and irregular representing heterogenous necrosis of a solid tumour. In this case, the appearances are more those of a cystic tumour, with thin regular contrast enhancement. 

Pathology

MICROSCOPIC DESCRIPTION: The sections show features of a densely cellular astrocytic tumour. The tumour cells show elongated, angulated and hyperchromatic nuclei. Scattered tumour giant cells are identified. Mitoses are present. There is focal mild endothelial cell hyperplasia. One area of palisaded necrosis is present. The features are those of glioblastoma multiforme.

DIAGNOSIS: Glioblastoma (WHO Grade IV).

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Case Information

rID: 14564
Case created: 4th Aug 2011
Last edited: 9th Jan 2016
Tag: gbm
Inclusion in quiz mode: Included

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