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Glioblastoma Multiforme

George M Wu, MD
Liangge Hsu, MD

August 1, 1994

Presentation

A 36-year-old woman presented to the emergency room with new onset seizures.

Imaging Findings

Initial non-contrast T1-weighted MRI
T2-weighted MRI
Second T1-weighted MRI
With Contrast

Initial non-contrast T1-weighted MRI shows a large, heterogeneous, hypointense mass in the white matter of the right temporal lobe and extending into the parietal and occipital lobes. The lower signal area within the mass suggests tissue necrosis (arrow).

On T2-weighted MRI, the mass is much brighter than the surrounding tissue. The mass appears larger than on T1 because the surrounding edema is also high intensity on T2. There is effacement of the right temporal horn and a mild midline shift to the left (arrow).

A second T1-weighted MRI nine months later shows, again, the large mass with slightly more mass effect and midline shift. No enhancement with gadolinium-DTPA is seen in this study.

Differential Diagnosis

Glioblastoma multiforme is the most likely diagnosis given the irregular shape of the mass, the central necrosis, and the extensive surrounding edema and mass effect. Metastasis should be considered but is less likely given that the patient is young and has no history of a primary tumor. Brain abscess should also be mentioned but it is typically identifiable as a thin, regular rim of enhancement around a central cavity.

Diagnosis

Glioblastoma multiforme

Discussion

Forty to fifty percent of primary central nervous system tumors are gliomas. Approximately 50% of these are glioblastoma multiforme and 7% are astrocytomas. Astrocytic tumors can be divided into grades I through IV, with grade I being the most benign and grade IV being the most malignant. Grade I and II astrocytomas have a relatively benign appearance with homogeneous grouping of cells and little atypia or anaplasia. Grade III and IV astrocytomas have a greater degree of anaplasia than the benign forms but do not contain focal necrosis as seen with glioblastoma.

Glioblastoma multiforme refers to a malignant neoplasm with abundant glial pleomorphism, numerous mitotic figures and giant cells, vascular hyperplasia, and focal areas of necrosis. Occurring most commonly in the fifth through seventh decades, glioblastoma multiforme usually develops in the cerebral hemispheres (more often in the frontal lobes than the temporal lobes or basal ganglia) but almost never in the cerebellum. It grows as an irregular mass in the white matter and infiltrates the surrounding parenchyma by coursing along white matter tracts, frequently involving the corpus callosum and crossing the midline to produce the characteristic "butterfly" appearance.

MRI is particularly useful in evaluating tumor extension and subacute and chronic hemorrhage collections. Gadolinium-DTPA enhancement is almost always present and usually appears ring-like around the tumor with thick, irregular walls. Enhanced MRI also helps to distinguish the tumor nidus from the surrounding edema. However, as this particular case demonstrates, the lack of enhancement with gadolinium-DTPA does not preclude the diagnosis of glioblastoma multiform.

The prognosis is very poor. Mean survival length after diagnosis is eight to ten months with less than 10% survival after two years.

References

1. Dean BL, et al. Gliomas: classification with MR imaging. Radiology 174, 1990: 411-415.

2. Kieffer SA, et al. Multifocal glioblastoma: diagnostic implications. Radiology 143, 1982: 709-710.

3. Latchaw RE, editor. MR and CT imaging of the head, neck and spine. In: Mosby Yearbook. St. Louis, 1991:449-471.

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