Presentation
Seizures.
Patient Data
Multiple enhancing lesions are seen on the right extending from the amygdala, posteriorly along the hippocampus and temporal stem, into the peritrigonal white matter (which is the largest component) and anteriorly into the right thalamus. These are embedded in a continuous region of high T2 signal, some of which represents vasogenic edema and other components that represent non-enhancing tumor. The largest region, near the trigone, demonstrates central necrosis with some blood product centrally. The solid components have relatively low ADC values ranging from 830 to 950 x 10^-6 mm^2/s, consistent with high cellularity and these have high cerebral blood volume. Spectroscopy shows high choline, low NAA, and elevated lipid and lactate in the necrotic areas.
An incidental note is made of a small developmental venous anomaly in the right cerebellar hemisphere. Otherwise, the remainder of the brain is unremarkable.
Conclusion:
Features are those of a high-grade diffuse adult-type glioma (most likely a glioblastoma).
Case Discussion
The patient went on to have a biopsy.
Histology
Sections show pieces of a moderately-to-highly cellular diffuse glioma. The tumor cells have enlarged, angulated, hyperchromatic nuclei and are set in a fibrillary background. There are scattered mitotic figures identified. There is both palisaded and ischemic-type necrosis. There are foci suspicious of microvascular proliferation.
Immunohistochemistry:
GFAP: positive
OLIG2: positive
IDH1 R132H: negative (not mutated)
ATRX: positive (not mutated)
p53: wild-type staining (not mutated)
p16 CDKN2A: negative (probably lost)
Ki67: up to 30%
Final diagnosis:
Glioblastoma, IDH-wildtype (CNS WHO grade 4).
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