Presentation
Right sided weakness
Patient Data
The mass is in the left frontal lobe, measuring about 64 x 83 x 67 mm (width x length x height). It contains mixed signals, including both solid and cystic lesions. The solid portion shows isointense signal on T1W, hyperintense signal on T2W and FLAIR, and mild restricted diffusion, with heterogeneous enhancement. The cystic portion shows hypointense signal on T1W, hyperintense signal on T2W and incomplete suppression on FLAIR (mismatch sign) , with no restricted diffusion. There are some areas of dark signal on SWI within.
The mass compresses the left lateral ventricle, shifting the midline to the right by about 11 mm, and there is brain edema surround the mass.
On the MRS images, the ratio of Cho/ Creatinin:2.75 and Cho/ NAA: 1.68.
On the perfusion images, there is hyperproliferation of the mass on CBV images.
Gross Description:
The biopsy fragments measure 3 x 2.5 x 0.8 cm, gray in color, and soft. They are divided into multiple pieces and transferred into 03 cassettes.
Microscopic Description:
On 03 slides stained with HE from the received specimen, it is observed: The sections from brain tissue show a tumor. The tumor cells have high cell density, large nuclei, pleomorphism, alkaline staining, bizarre nuclei, and numerous mitoses, including atypical mitoses. The tumor cells are situated on a background of fibrous stroma, with many areas of necrosis, pseudopalisading, and vascular proliferation in a rolled pattern.
Conclusion:
Astrocytoma, NOS, WHO grade 4
Case Discussion
In this case, based on these imaging findings and the presence of a mismatch sign, we can easily diagnose diffuse astrocytoma and suspect it as high-grade due to the dark signal on SWI within the tumor, the high ratio of Cho/Cre, and the hyperproliferation of the mass on CBV images.
However, the definitive determination of the glioma grading depends on the molecular status rather than histology or radiological features.
In this case, the IDH mutation status is not provided, and according to the WHO classification of CNS tumors, this tumor would therefore be designated as a diffuse astrocytoma, not otherwise specified (NOS).
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