CASE N°23 – Glioblastoma (IV grade)

Clinical History:

Age: 39

Sex: Male

TAC-SCAN BRAIN : In the right temporal lobe is observed the presence of a voluminous expansive process of the maximum axial dimension of approximately 68×57 mm, characterized by marked hypodensity and peripheral impregnation  due to wide
intralesional necrotic component.  Marked mass effect compressing the right lateral ventricle and third ventricle, left displacement of the septum pellucidum about 13 mm. Marked dilatation of the left lateral ventricle, in particular of the horns occipital and temporal.

Cytological Images:

Cytological material:  Right temporal region cyst, fine-needle aspiration

Cytological Report:

Abbondante sostanza amorfa extracellulare in cui si repertano numerosi macrofagi e, piu’ raramente, cellule isolate, in parte con nucleo ipercromatico ed atipicoHistological

Images:

Histological material:  Right temporal region, neoformation

 MIB 1 – Ki67 %

Histological Report:

Morphological findings consistent with glioblastoma (grade IV sec. WHO).
Index of cell proliferation (MIB1): 35%

Discussion:

Gliomas can be slowly growing (low-grade, grades 1 and 2), or rapidly growing (high-grade, grades 3 and 4). This material will give important facts about the diagnosis and treatment of high-grade gliomas.High-grade gliomas are diagnosed by a biopsyOnce a brain tumor is detected on a CT or MRI scan, a neurosurgeon obtains tumor tissue for examination by a neuropathologist (a biopsy). The neuropathologist then gives the tumor a name and grade. The exact name and grade of the tumor determine treatment options, and also give important information about prognosis. 

Types of therapy

There are three standard types of treatment for patients with high-grade gliomas: surgery, radiation therapy, and chemotherapy. In addition to these standard therapies, major centers such as the MGH Brain Tumor Center may offer experimental treatments.

Because grade 3 and 4 tumors have a tendency to grow rapidly, treatment must be started as soon after surgery as is feasible, allowing time for the surgical incision to heal. Generally, this means that patients should be undergoing either radiation therapy or chemotherapy within 2 to 4 weeks after surgery. An algorithm that is commonly used for treatment of high-grade gliomas is presented on the following page.

While therapies for high-grade gliomas are helpful, at present these treatments cannot cure these tumors. The two major reasons for this are that tumor cells infiltrate into surrounding brain and thus cannot be completely removed by the surgeon, and that most glioma cells are at least partially resistant to radiation and chemotherapy.

The goals of treatment are to:

-remove as many tumor cells as possible (with surgery)

-kill as many as possible of the cells left behind (with radiation and chemotherapy)

-put remaining tumor cells into a nondividing, sleeping state for as long as possible (with radiation and chemotherapy)

High-grade glioma cells almost always start to grow again at some point in time. Patients receive aggressive treatment in order to delay this regrowth as long as possible. Regrowth does not necessarily imply loss of control of the tumor, but it does mean that a new series of treatments should be considered because the tumor is becoming more aggressive(1).

References:

1) Glioblastoma multiforme and anaplastic gliomas: A patient guide by John W. Henson, M.D., MGH Brain Tumor Center http://brain.mgh.harvard.edu/patientguide.htm

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