Presentation
Memory disturbance and headache for two months. Worsening headache with abnormal behavior and abnormal gait for two days. No vomiting, convulsions, sensory/motor deficit, fever, or weight loss.
Patient Data
An oval-shaped, well-defined non-enhancing, solid heterogeneous hyperdense intracranial mass with few focal calcifications is seen in the subcortical posterior left temporal lobe. Mild edema in the surrounding brain, the mass effect over the left lateral ventricle, left uncal herniation & subfalcine herniation of about 8 mm are noted.
Possible differential diagnosis includes oligodendroglioma, GBM, and atypical meningioma.
A sizable lesion is seen in the left temporal lobe, which seems to originate from the inferior aspect of the left temporal lobe and is bulging superiorly along the temporal horn of the left lateral ventricle in to a subependymal location, displacing the left choroid plexus superomedially. The temporal horn itself appears entrapped and mildly dilated. The lesion is exerting mass effect with contralateral midline subfalcine herniation of about 8.5 mm as well as mild uncal herniation. The lesion matrix is heterogeneous showing intermediate signal intensity with subtle hyperintense foci on T1-weighted and mildly increased signal intensity on T2-weighted & FLAIR images with signal void foci which are likely calcifications. Mild diffusion restriction is noted at the periphery of the lesion. Extensive blooming (slightly sparing the periphery of the lesion) is noted in the susceptibility weighted images. Mild subtle enhancement is seen along the lesion periphery while no gross enhancement is seen centrally. The above described imaging features are impressive of left temporal lobe neoplastic lesion with prime differential diagnosis including oligodendroglioma and GBM.
Status post left temporoparietal craniotomy and surgical debulking of the left temporal tumor. Recent post-operative changes are seen in the surgical bed. Marked interval improvement is noted in the previously noted mass effect, and midline shift.
Case Discussion
Histopathology: Glioblastoma NOS, small cell type, Grade IV. The immunostain with the antibody anti-GFAP shows positivity in tumor cells in the perivascular areas. P53 is also strongly positive. Ki-67 labeling is very high. SOX 10, Synaptophysin, NSE and S100 are negative. ATRX is equivocal and IDH1/IDH2 by immunohistochemistruy is also negative.
Pathologist’s recommendation: Since this patient is young, the IDH1/IDH2 mutation by sequencing in order to classify the tumor as IDH mutant or wild-type, is recommended. However, unfortunately, this recommendation was not followed by the primary physician and the patient was referred to the oncologist for adjuvant chemoradiotherapy.
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