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Glioblastoma grade IV

 

Clinical history
The clinical history of this 26-year-old patient began with a rapidly progressing paresis of the right leg, with paresis of the left leg and sphincter dysfunction. For these reasons, the patient underwent the first MRI.

Preoperative MRI
Image 1: Sagittal T1WI. There is focal enlargement of the conus medullaris with no signal abnormalities.
Image 2: Sagittal Gd T1WI. After contrast injection, heterogeneous contrast enhancement is observed within the enlarged conus medullaris.
Image 3: Axial Gd T1WI. Abnormal heterogeneous enhancement within the enlarged conus predominantly on the right side is confirmed.
Image 4: Axial T2WI. Tumor infiltration appears hyperintense on this pulse sequence.

Conclusion
The radiological diagnosis at this time is: ill defined infiltrating, probably malignant tumor of the conus with no cystic components.

Surgery
At surgery, only focal biopsy was attempted as the surgeon could not identify a cleavage plane.

Histology
Glioblastoma grade IV according to the WHO.

Clinical follow-up
Adjuvant radiotherapy was given. At this time, the patient can still walk without help.
Eight months later, the patient complained of recurrence of pain of the lower limbs and both urinary and fecal retention. The patient redeveloped left lower limb paresis as well as right knee and foot paresis.

Postoperative control MRI
Image 5: Postoperative changes are obvious with a TH11-TH12 laminectomy and persistent opening of the dura allowing free growing of the tumor. Again, on these T1WI, no clear delineation can be found between tumor infiltration and normal cord.
Image 6: Sagittal T2WI. In comparison, on these T2WI, the tumor appears hyperintense allowing a better delineation of the tumor infiltration.
Image 7: Sagittal Gd T1WI. After Gadolinium injection only partial, irregular patchy contrast enhancement is seen within the lesion.

Second surgery
The patient was referred to our surgical department and another attempt to achieve partial resection was made. About 20 to 25% of the tumor was resected. Histopathology confirms the diagnosis of glioblastoma grade IV.

Adjuvant chemotherapy was now given. At this time, the patient showed temporary improvement, but after a few weeks paraparesis redeveloped. There was unfavorable clinical progression and a new follow-up MRI was performed.

Image 8: Sagittal T1WI. In spite of recent surgery, tumor progression is evident. Similar signal behavior is observed compared to the previous studies. The tumor remains isointense with the normal cord.
Image 9: Sagittal proton density and image 10: sagittal T2WI. The growth of the tumor is partially exophytic due to the presence of a laminectomy.
Image 11: Sagittal Gd T1WI. Only moderate contrast enhancement is shown within the tumor. There is evidence of sub-ependymal metastatic tumor spread superiorly.
Image 12: Axial Gd T1WI and image 13: axial T2WI confirm the exophytic growth of the tumor both anterior and posterior to the conus.

Clinical evolution
Clinical signs of metastatic spread occured despite chemotherapy. The patient died one and a half years after the diagnosis.

Search also:
- Anaplastic astrocytoma and glioblastoma

 

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Fig. 1

Glioblastoma grade IV, Fig. 1
Glioblastoma grade IV, Fig. 2
Glioblastoma grade IV, Fig. 3
Glioblastoma grade IV, Fig. 4
Glioblastoma grade IV, Fig. 5
Glioblastoma grade IV, Fig. 6
Glioblastoma grade IV, Fig. 7
Glioblastoma grade IV, Fig. 8
Glioblastoma grade IV, Fig. 9
Glioblastoma grade IV, Fig. 10
Glioblastoma grade IV, Fig. 11
Glioblastoma grade IV, Fig. 12
Glioblastoma grade IV, Fig. 13