An MRI scan showed a large heterogeneously enhancing mass lesion in the right frontal region that crossed over to the left frontal region through the corpus callosum, causing mass effect on the lateral ventricles. Features were consistent with glioblastoma multiforme involving both frontal lobes. Glioblastoma multiforme is the most common and most aggressive form of brain cancer, typically occurring in adults between 45-60 years old. Treatment may include surgery, radiation therapy, chemotherapy and experimental therapies, but the cancer often recurs and median survival is less than one year.

1. By DR TEFFY JOSE M1 UNIT PROF RUCKMANI’S UNIT

5. CT scan brain plain study : An illdefined large hypodense area is seen in the right frontal region & extending across the midline along the genu of the corpus callosum. There is mild mass effect in the form of subfalcine herniation & squashing of the frontal horn of right lateral ventricle. Left lateral ventricle is prominent. Midline shift of 4.7mm to left is seen. Rest of cerebral parenchyma shows normal attenuation. All other areas appear to be normal.

6. Impression : Illdefined large hypodense SOL in the right frontal region causing mass effect & midline shift to left. Suggested CECT / MRI for further evaluation.

13. MRI scan of brain : Well defined heterogenously enhancing mass lesion noted in the right frontal region basal aspect crossing over to the left frontal region through the corpus callosum with areas of necrosis & hemorrhage. The lesion causing mass effect on the frontal horn of both lateral ventricles.The mass lesion measures about 7.8 * 5.6 *4.65 cm. MR spectroscopy shows increased lactate,choline peak & reuced NAA levels. All other areas appear to be normal.

14. Impression : Features highly s/o GLIOBLASTOMA MULTIFORME ( butterfly glioma ) involving both frontal lobes ( Rt > Lt )

15. Glioblastoma multiforme A diffusely infiltrating astrocytoma ( WHO 2000 classification Grade IV) Most common form of cerebral glioma accounting for 12-15 % of all intacranial neoplasms & 50-60% of all astrocytic tumors

16. Pathogenesis Cell of origin Cell of origin EGFR amp LOH 10 (PTEN) CDK4 amp MDM2 amp Other LOH (eg DCC) Other amp (eg PDGFR) DENOVO :GBM WHO grade IV LOH17p(p53) Astrocytoma WHO grade II LOH19q LOH9p(INK4a) Astrocytoma WHO grade III LOH 10 q(PTEN) Secondary : GBM, WHO gradeIV

17. Rapidly growing tumors, highly cellular,often provoke a large amount of edema & usually contain areas of necrosis,& do not have a clearly defined margin. Supratentorial, frontal lobes are a common site of involvement & extension contralaterally through corpus callosum may give rise to a butterfly pattern. May become adherent to the overlying dura , but seldom penetrate it. Infiltration of ependyma & dissemination through CSF pathway may occur in late cases. Multicentricity can be seen in 4-10% of cases. Extraneural metastasis are rare.

18. Seen late in adult life, with a peak occurrence b/w 45 – 60 yrs. May present with Seizure Subacute progression of a focal neurologic deficit Nonfocal neurologic disorder such as headache,dementia, personality change or gait disorder Median survival is < 1 yr.

19. MRI features: High signal intensity on T2 weighted images & low signal intensity on T1 weighted images Infiltrate along white matter tracts & deeper lesions have a propensity to extend across the corpus callosum to opposite hemisphere Often have considerable mass effect, vasogenic edema& more commonly show evidence of haemorrhage Irregular ring enhancement with nodularity & nonenhancing necrotic foci is typical of glioblastoma Microscopic fingers of tumour usually extend for variable distances beyond the area of enhancement

20. Management: Dexamethasone – administered at the time of diagnosis & continued for the duration of radiotherapy Accesible astrocytomas are generally resected aggressively, even though total surgical resection is not possible Post op RT – prolongs survival & improve quality of life ( 5000-7000 cGy to tumor mass in 25-35 fractions, 5days/wk) Role of stereotaxic radiosurgery & interstitial brachytherapy in glioma trt is uncertain

21. Chemotherapy Is marginally effective & is used as an adjuvant therapy following surgery & RT Temozolomide , an oral alkylating agent has replaced nitrosoureas - 2½ mths longer survival in pts with methylation & silencing of the promoter for the MGMT gene Surgical implantation directly into tumor resection cavity of polymer wafers that releases BCNU locally into surrounding brain

22. Experimental approaches include - Bypassing BBB using local injections into tumor mass - Intraarterial injection of chemotherapy following osmotic disruption of BBB Molecular targeted therapies – EGFR antagonists or inhibitors of its signalling pathways ( Gefitinib /Erlotinib) , Bevacizumab

23. Prognosis: - age, functional status,extent of surgical resection. - survival ≈ 3 mths (without therapy) , 12 mths (with therapy). - recurrence is common.