Glioblastoma Multiforme

Ashley Sanchez

Oct 16, 2019

Diagnostic Radiology 4001

Dr. Blair

McGovern Medical School

Clinical History

• 59 yo M• CC: “Personality changes, intermittent confusion, memory problems”

• Duration: several weeks

• Initial workup (7/23/19): • Non-contrast Brain CT

• Brain MRI w/ & w/o contrast

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Axial Non Contrast CTWhite Matter Hypodensities

White Matter

Grey Matter

Lateral Ventricle

s

Genu Corpus Callosum

Splenium Corpus Callosum

Falx

Cer

ebri

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T2 Axial HyperintensityEdema

ThirdVentricle

Basal Ganglia

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T1 Post Contrast

“Butterfly” Appearance

Central Necrosis

Peripheral Enhancement

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GREBlood

Products

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Imaging + History

CC: “personality/ memory changes”

Problem Area: Frontal Lobe

Imaging: B/l Frontal Lobe Mass

Executive Functioning

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Differential Diagnosis

• Brain lesion

• No systemic sx (fever)• No PMH/FHx of cancer• Crosses midline• Immunocompetent

• Primary Brain Tumors• Glioblastoma• Meningioma• Lymphoma

• Metastatic Brain Tumor• Infections- Abscess• Vascular Disease

• Cerebral hemorrhage• Stroke

• Gradual onset sx

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Characteristic Imaging Findings

Butterfly lesion (crosses midline)CT- Hypodensities +

Mass effect

MRI T2: Hyperintensities + Vasogenic Edema +

Central Necrosis

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Discussion- Glioblastoma Multiforme• Presenting Sx:

• executive function changes• Common presenting sx: headache, seizure, focal neuro deficit• Risk factors:

• ionizing radiation (therapeutic from childhood brain tumor)• Male, >50 yrs old, Caucasian or Asian ethnicity

• Pathophysiology: • not clearly understood• error w/ tumor regulator genes (EFGR, MDM2, PTEN, PDGFA, IDH)

• Biopsy to confirm dx: Glioblastoma, IDH- wildtype, WHO grade IV• Glial tumor type: Glioblastoma• IDH status: wildtype• WHO Grade: IV

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WHO Classification

Treatment

• Combo• Surgical Resection + Biopsy (histological dx)

• Max tumor resection ↔ Neurologic function• Adjuvant Post-op:

• Chemo (Temolozomide) • Radiation therapy

• Our patient:• craniotomy + partial resection x2 (7/24/19 &

8/22/19)• started chemotherapy: Temozolomide

(9/16/19)

Peripheral Enhancement

Partial Lobectomy

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Prognosis

• Extent of resection is a strong prognostic factor• 10 yr study of 20,000 adults w/ Glioblastoma looking at survival times with

different extent of resections• Gross total resection: 15 months • Subtotal resection: 12 months • No surgery 7 months

• Poor survival: < 1-2 yrs• High rate of recurrence

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ACR appropriateness Criteria

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Cost to Patient

Image Typical Charge Insured Uninsured

MRI Brain W-W/O Contrast $7431 $523 $2675

CT Head W/O Contrast $3157 $98 $1374

*Prices for imaging at MHH- TMC https://www.memorialhermann.org/patients-caregivers/pricing-estimates-and-information/

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Take Home Points

• Changes in personality/ memory• 1. Brain CT w/o Contrast• 2. Brain MRI w/ + w/o Contrast

• Brain lesion that crosses midline:• 1. Glioblastoma Multiforme• 2. CNS Lymphoma

• Glioblastoma • MC malignant primary brain tumor in adults

• most aggressive + fastest growing• Rarely metastasizes

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References

• https://radiopaedia.org/cases/normal-ct-brain-pre-and-post-contrast?lang=us• https://radiopaedia.org/cases/normal-brain-mri-6?lang=us• https://www.memorialhermann.org/patients-caregivers/pricing-estimates-and-information/• Noorbakhsh A, Tang JA, Marcus LP, McCutcheon B, Gonda DD, Schallhorn CS, Talamini MA,

Chang DC, Carter BS, Chen CC. Gross-total resection outcomes in an elderly population with glioblastoma: a SEER-based analysis. J Neurosurg. 2014 Jan;120(1):31-9. doi: 10.3171/2013.9.JNS13877. Epub 2013 Nov 8. PubMed PMID: 24205904.

• https://www.uptodate.com/contents/clinical-presentation-diagnosis-and-initial-surgical-management-of-high-grade-gliomas?search=glioblastoma%20prognosis&topicRef=5211&source=see_link#H2

• https://braintumor.org/wp-content/assets/WHO-Central-Nervous-System-Tumor-Classification.pdf• https://radiopaedia.org/articles/glioblastoma?lang=us• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5563115/

Questions?