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Radiologic findings. (A) Gd-enhanced axial T1-weighted MR images before first operation demonstrate a ring-enhanced mass in the left parietal region. (B, C) Gd-enhanced axial T1-weighted MR images show leptomeningeal spread of tumor, and subcutaneous scalp masses that are in continuity with the intracranial mass through the burr hole.
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F1
The last operation was performed before two months prior to this admission, and mass was confirmed as glioblastoma with malignant transformation from original anaplastic mixed glioma (Fig. 1A), which was consisting of ependymal and oligodendrogliomatous area with a small portion of astrocytic tumor in pathological finding. MRI demonstrated extensive leptomeningeal spread to the left temporo-occipital region and also noted subcutaneous scalp masses in continuity with the intracranial mass through the burr hole site (Fig. 1B, C).
Radiologic findings. (A, B) Gd-enhanced coronal T1-weighted MR images of the brain show multiple lymph adenopathies in deep cervical area (arrows). These lymph adenopathies are separated from extended scalp masses.
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F2
MR study also showed multiple lymph adenopathies in the deep cervical region without continuity with scalp mass (Fig. 2).
Pathologic findings of intracranial glioblastoma. (A, B) Biopsy specimen taken from the last surgery confirms as glioblastoma that had variable histologic features, mitosis, endothelial proliferation and necrosis (A; H&E, x40: B; H&E, x400). (C) Immunohistochemical stain demonstrates positive immunoreactivity for GFAP (GFAP immunostain, x200).
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F3
Pathological diagnosis was glioblastoma in the specimen from the last surgery (Fig. 3).
Fine needle aspiration smear from metastatic glioblastoma in cervical lymph node. (A) Photomicrograph reveals small atypical cells infiltrated into the fibroadipose tissue in cervical soft tissue (H&E, x200). (B) Immunohistochemical stain demonstrates positive immunoreactivity for GFAP (GFAP immunostain, x400).
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F4
Microscopically, small atypical cells infiltrated into the fibroadipose tissue of the cervical soft tissue and immunohistochemical stain showed positive immunoreactivity for glial fibrillay acid protein (GFAP) (Fig. 4).