PMC3526147_01
Contrast-enhanced, axial, T1-weighted magnetic resonance images of the tumor.. Notes: Initial images showing a large, heterogeneously enhancing tumor in the right temporal lobe, extending to the choroid plexus of the right lateral ventricle and to the temporal horn, infiltrating the hippocampus (A). Images at 6 months after the first operation, documenting a gross total resection of the tumor without evidence of recurrences (B).
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Brain MRI had revealed a large, heterogeneously enhancing tumor in the right temporal lobe, and the tumor had extended to the choroid plexus of the right lateral ventricle and to the temporal horn, infiltrating the hippocampus (Figure 1A). He had undergone a right temporoparietal craniotomy with a gross total resection of the tumor (Figure 1B). Brain MRI performed at 3 and 6 months after surgery had not shown tumor recurrences (Figure 1B).
The patient's third ventricle nodular lesion.. Notes: Contrast-enhanced magnetic resonance images at the 11-month follow-up revealing the onset of an apparently solitary nodular lesion in the third ventricle, while the operative site was still disease-free (A). Postoperative computed tomography scan showing the resection of the nodular lesion in the third ventricle without complications (B).
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At an 11-month follow-up, a contrast enhanced MRI revealed the presence of an apparently solitary nodular lesion inside the third ventricle, while the operated site was still disease-free (Figure 2A). We removed the biggest subependymal lesion inside the third ventricle, performed a ventriculocisternotomy of the third ventricle, and placed an intraventricular catheter there, connecting the catheter to an Ommaya reservoir for locoregional intrathecal chemotherapy (Figure 2B).
Close-up endoscopic third ventricle views.. Notes: The nodule inside the third ventricle, just beneath the opened ependymal layer (A). Endoscopic view after tumor removal with the origin of the sylvian aqueduct (B). The floor of the third ventricle detecting a diffuse tumor infiltration composed of small adjacent nodules lying beneath the ependyma, unidentified by MRI and PET scan (C and D).
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Neuroendoscopic examination, beyond the MRI-detected nodule inside the third ventricle, surprisingly revealed a diffuse tumor infiltration, composed of small adjacent nodules lying beneath the ependyma, unidentified by MRI and PET scan (Figure 3).
H and E glioblastoma multiforme, World Health Organization grade IV, with evidence of nuclear pleomorphism, mitotic activity, endothelial hyperplasia, and areas of palisading necrosis.
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The histological diagnosis of GBM was confirmed (Figure 4).
PMC3526147_02
Preoperative, contrast-enhanced, axial, T1-weighted magnetic resonance images.. Notes: Multiple heterogeneously enhanced lesions, proximal to the choroid plexus of the right lateral ventricle, with mild associated perilesional edema and right ventricular enlargement due to occlusion of the foramen of Monro* (A and D). Contrast-enhanced, axial, T1-weighted magnetic resonance image at the 6-month follow-up showing the resolution of the obstructive hydrocephalus (B). At this time, MRI also documented the contralateral tumor infiltration along the anterior commissure (E), not detected at the preoperative MRI (D), although it was evident during the endoscopic procedure. Contrast-enhanced, axial, T1-weighted MR image at the 18-month follow-up showing a massive subependymal tumor infiltration of the left lateral and third ventricles with growth and diffusion of the tumor in the right lateral ventricle (C and F).. *The left ventricle looked normal.. Abbreviation: MRI, magnetic resonance imaging.
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The left ventricle appeared normal (Figure 5). The patient, with unknown primary cancer in anamnesis, underwent a neuroendoscopic procedure for the resection of the lesion at the level of the foramen of Monro in order to obtain a diagnosis and to address the hydrocephalus (Figure 5B and E). This finding, undetected by preoperative neuroimaging studies (Figure 5D), became evident during the second postoperative MR image (Figure 5E). The patient survived for 20 months after surgery, with uncontrollable massive diffusion of the disease 2 months before death (Figure 5C and F).
Diffuse yellowish coloration of the walls of the right lateral ventricle discovered during neuroendoscopic examination, with clusters of neoplastic cells embedding the choroid plexus and a thin sheet of tumor cells forming small nodules in the subependymal region (A-C). Endoscopic view of the septostomy with a contralateral apparently normal ependymal layer and choroid plexus (D and E). Close-up view of an initial, contralateral tumor infiltration evident through the fibers of the subependymal layer, situated along the anterior commissure (F). This finding was undetected by preoperative magnetic resonance imaging (see Figure 5D).
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A septostomy was performed for the same reason (Figure 6). This infiltration showed a perivascular pattern and spread beneath the normal ependyma (Figure 6A-C). Interestingly, via the septostomy (Figure 6D), the neuroendoscopic exploration suggested normal features of the left ventricular system (Figure 6E). However, on closer examination, an initial contralateral tumor infiltration was evident through the fibers of the subependymal layer, situated along the anterior commissure (Figure 6F).
H&E staining of neoplastic epithelial tubules and glands infiltrating the brain parenchyma.. Notes: The cells show aspects of mucosecretion (A). Immunohistochemistry was positive for cytokeratin 20 (B) and CEA (C).. Abbreviations: CEA, carcinoembryonic antigen; H&E, hematoxiline and eosin.
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The morphology of the lesion and the results of immunohistochemistry were consistent with metastasis from a gastrointestinal tumor (Figure 7).