PMC6745105_01
Preoperative post contrast-enhanced axial cut of the CT scan of the brain showing tumor masses located parieto-occipitally in the right hemisphere surrounded by perifocal edema and a 54 x 31 mm intraparenchymatous bleeding with affection of midline structures.
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A contrast-enhanced CT scan of the brain revealed a tumor-suspected mass in the right parieto-occipital region surrounded by hemorrhage and edema, which caused mass affection of midline structures, basal cisterns, and sulci of the brain (Figure 1).
Histology showing a pleomorphic glial tumor, with numerous mitoses, malignant vascular proliferation with vascular thromboses, necrosis, and pseudopalisading tumor cells (HE, x200).
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PCR sequencing showed a 2% methylation of the O6-methylguanine-DNA methyltransferase (MGMT) gene, which with a cutoff value of 10% methylation, was concluded to be negative (Figures 2 and 3).
GFA staining (x200) of the same glial tumor showing biphasic tumor tissue with the mesenchymal component being negative and the more obvious glial component being positive in GFA, compatible with gliosarcoma, WHO grade IV.
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PCR sequencing showed a 2% methylation of the O6-methylguanine-DNA methyltransferase (MGMT) gene, which with a cutoff value of 10% methylation, was concluded to be negative (Figures 2 and 3).
Histology from the reoperation (GFA, x200) revealing a glial tumor with extensive sarcomatous components and more sparse astrocytic tumor cells being positive in GFA, compatible with regrowth of gliosarcoma, WHO grade IV.
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IDH-mutation was negative (Figure 4).
Sagittal T1-weighted MRI of the vertebral column without contrast enhancing showing tumor masses in the 3rd lumbar vertebrae (L3) with partial collapse of the corpus of L3 and tumor growth to the right paravertebral muscle.
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A whole body FDG/PET-CT scan (fluorodeoxyglucose/positron emission tomography-computed tomography) was performed which besides the known mass in the lumbar spine revealed a round infiltrate in the right lung, enlarged lymph nodes around both lungs and in the mediastinum, and embolisms to all three lobes of the right lung (Figures 5-7).
Fused FDG/PET-CT scanning at level of L3/L4 7 months after diagnosis of GBM showing substantial metabolically active metastases in and around L3 and surrounding paravertebral muscle.
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A whole body FDG/PET-CT scan (fluorodeoxyglucose/positron emission tomography-computed tomography) was performed which besides the known mass in the lumbar spine revealed a round infiltrate in the right lung, enlarged lymph nodes around both lungs and in the mediastinum, and embolisms to all three lobes of the right lung (Figures 5-7).
Frontal maximum intensity projection (MIP) image of whole body FDG PET scanning identifying disseminated metastatic spread to mediastinal lymph nodes, right lung, vertebral bone, and right paravertebral muscle. Physiological excretion to the intestines, kidneys, and bladder.
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A whole body FDG/PET-CT scan (fluorodeoxyglucose/positron emission tomography-computed tomography) was performed which besides the known mass in the lumbar spine revealed a round infiltrate in the right lung, enlarged lymph nodes around both lungs and in the mediastinum, and embolisms to all three lobes of the right lung (Figures 5-7).
Histology from tumor tissue in the lumbar column confirmed a pleomorphic biphasic glial tumor as diagnosed earlier, compatible with metastases from gliosarcoma, WHO grade IV (GFA, x200).
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MGMT gene. Morphologically and immunohistochemically, these findings were compatible with relapse of GS, with no evidence of metastases from the previous NET or colon cancer (Figure 8).
Coronal cut of CT scan of the brain showing tumor masses infiltrating the skull, subcutaneous soft tissue, and skin overlying the previous surgical cavity in which perifocal edema is causing midline shift towards the left hemisphere.
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The scan confirmed pervasive expanding tumor growth through the titanium net, penetrating the skull, and reaching the subcutaneous soft tissue (Figure 9).