Presentation
Seizure
Patient Data
An intra-axial mass in the left frontal lobe with an indistinct margin. The mass appears as low intensity, heterogenous on T1-weighted images and high intensity, heterogenous on T2-weighted and FLAIR images. There is no evidence of diffusion restriction or dark signal on SWI, and there is no enhancement after gadolinium administration. The lesion extends into the corpus callosum and causes mild degree of midline shift to the right.
The MRS images shows a Choline/Creatine ratio of 2.3.
The MR perfusion (T2*) images shows no evidence of hyperproliferation of the mass.
DTI image were obtained for preoperative planning.
The patient went on to have a resection.
Histology
The specimen appeared opaque white and soft, measured 4 x 2.5 x 1.5 cm.
Microscopic description:
Brain tissue containing a tumor with a relatively high cell density. The tumor cells had large and irregular nuclei, coarse chromatin, and exhibited infiltrative growth into the adjacent normal brain tissue. Additionally, in the periphery of the tumor, there were multiple areas where tumor cells surrounded neurons, giving a "satellite" appearance. The connective tissue surrounding the tumor contained nerve stroma, with some areas exhibiting microcysts. No evidence of mitotic activity, necrosis, or vascular proliferation was found.
Conclusion:
Diffuse astrocytoma, not otherwise specified (NOS), WHO grade 2.
Case Discussion
On routine protocol sequences, the images show a mass in the left frontal area with no restriction diffusion , no contrast enhancement, no evidence of hyperproliferation on perfusion as indirect imaging features of lower grade IDH mutant diffuse glioma rather than wild-type glioblastoma. However, the definitive determining grading of the glioma depends on the molecular status rather than histology or radiological features.
The patient underwent surgery, and the pathology results confirmed.
IDH mutation status is not provided in this case and according to the (2021) WHO classification of CNS tumors, this tumor would, therefore, be designated as a diffuse astrocytoma NOS.
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