PMC5178354_01
MRI and CT findings prior to surgery. (a) Sagittal T1-weighted imaging (T1WI) demonstrated a heterogeneous T1 hypointense mass involving a majority of the anterior temporal lobe with associated mass effect and surrounding vasogenic edema. Tumor extends through the greater wing of the sphenoid into the infratemporal fossa. (b) Sagittal postgadolinium T1WI demonstrates avid heterogeneous enhancement. The anterior portion in the soft tissues solidly enhances and intracranially has central necrosis. (c) 3D reconstruction from head CT demonstrates aggressive destruction of the greater wing of the sphenoid. (d) Axial FSE T2-weighted imaging demonstrates the mass to be heterogeneous iso/hypointense tumor with surrounding vasogenic edema suggesting increasing cellularity. (e) Axial postgadolinium T1WI demonstrates avid heterogeneous enhancement with central necrosis intracranially.
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The extracranial extension was better delineated with clear extension into the orbit, maxillary sinus, and invasion of the right pterygoid, masseter, and temporalis muscles (Figure 1).
Intraoperative photos of the firm, encapsulated tumor penetrating through the temporal bone and involving the temporalis muscle, (a) before and (b) after debulking the tumor extracranially.
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During exposure, a firm and encapsulated tumor invasive through the temporal bone was encountered below the temporalis muscle (Figure 2(a)), which was debulked extracranially throughout infratemporal fossa and dissected off the periorbita, isolating the intracranial components (Figure 2(b)).
Postoperative T1-weighted gadolinium-enhanced MRI of the brain. Both (a) coronal and (b) axial sequences confirm gross total resection of all enhancing tumor. New hyperintensity appreciated at the anterior right temporal pole identifies abdominal fat graft placed during reconstruction.
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Routine MRI performed on postoperative day one revealed no evidence of residual enhancing tumor (Figure 3), and the patient was dismissed from the hospital on postoperative day three.
(a) The hematoxylin and eosin-stained histological sections showed an infiltrating glioma containing microvascular proliferation (arrow) and foci of necrosis surrounded by vaguely pseudopalisading tumor cells ("N"), diagnostic of glioblastoma. (b) Other areas showed a malignant mesenchymal component admixed with the glioblastoma. (c) The GFAP stain highlights the glial component and is negative in the mesenchymal component. (d) In contrast, the reticulin stain demonstrates extensive pericellular deposition of collagen fibers in the mesenchymal component only and is negative in the glial component. These findings support the diagnosis of gliosarcoma (all images at 100x magnification; scale bar = 300 mum).
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Gliofibrillary cytoplasmic processes and cerebral parenchymal investment consistent with infiltrative glioma were widely observed, with foci of necrosis surrounded by vaguely pseudopalisading tumor cells (Figure 4(a)). The infiltrative glioma areas were also noted to alternate with mesenchymal-pattern areas of fibrotic stroma comprised of tumor cells with elongated, spindle-shaped nuclei (Figure 4(b)). Other characteristic GB features included positive immunohistochemical staining for glial fibrillary acid protein, which was notably absent from mesenchymal-predominant regions (GFAP, Figure 4(c)). In parallel, reticulin staining showed a dense pericellular deposition pattern in mesenchymal regions and was negative in GFAP-positive areas (Figure 4(d)).