PMC6339752_01
Magnetic resonance images (MRIs) of the patient before biopsy. (a-d) Gd-enhanced T1-weighted images (Gd-T1WI) showing three separate lesions in the cerebellum: the lesion in the left cerebellum near the vermis with relatively regular enhancement (a), the lesion with the similar size in the right cerebellum with ring enhancement (b, arrowhead), and the tiny lesion in right cerebellum located far from two lesions (b, c, d, arrow). T2-weighted images (T2WI) showing peritumoral edema around two lesions (e, f, g), but no edema around the tiny lesion (f, arrow). FLAIR showing no clear connection of the tiny lesion to other two lesions (h, arrow).
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Head MRI revealed three separate lesions in the cerebellum: the largest lesion of approximately 15 mm in diameter in the left cerebellum near the vermis with relatively regular enhancement (Figure 1(a)), the lesion of slightly smaller size in the right cerebellum with ring enhancement (Figure 1(b)), and the tiny lesion in the upper right cerebellum located far from the two lesions (Figures 1(b)-1(d)). The smallest lesion was not connected to any other lesions on T2/FLAIR (Figures 1(e)-1(h)).
Photomicrographs displaying pathognomonic histopathological features of malignant glioma. (a) H&E staining showed tumor cells with eosinophilic cytoplasm and pleomorphism characterized by dense proliferation and diffuse infiltration in the granular cell layer. (b) Nuclear pleomorphism and mitotic figures were observed, but no microvascular proliferation and micronecrosis were detected. (c) Immunohistochemical staining showed positivity for GFAP. (d) The majority of the tumor cells are positive for p53. (e) P53 staining also revealed infiltrating tumor cells in the granular layer of the cerebellum away from the area of dense tumor cells. (f) The MIB-1 labeling index was 21.3%.
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Histopathological examination revealed tumor cells with eosinophilic cytoplasm and pleomorphism, which were characterized by dense proliferation and diffuse infiltration in the granular cell layer of the cerebellum (Figure 2(a)). Nuclear pleomorphism and mitotic figures were observed, but microvascular proliferation and micronecrosis were not detected (Figure 2(b)). Immunohistochemistry revealed the tumor cells were diffusely positive for glial fibrillary acidic protein (GFAP) (Figure 2(c)) and positive for p53 in large part (Figure 2(d)). In particular, p53 clearly showed infiltrating tumor cells at distant area (Figure 2(e)). MIB-1 labeling index was 21.3% (Figure 2(f)).
MRIs of the patient after biopsy. (a, b, c) MRIs taken at the midpoint of the treatment with chemoradiotherapy. The enlargement of all lesions and the worsening of the peritumoral edema were observed. (d, e, f) MRIs taken at discharge. Shrinkage of all the tumors and the improvement of the peritumoral edema were observed.
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Although the lesions were enlarged during the treatment (Figures 3(a)-3(c)), the patient was discharged in an independent state; the patient was unexpectedly transferred to our hospital due to sudden loss of consciousness and was in the state of cardiopulmonary arrest on arrival.