Posterior Fossa Glioblastoma, Case Report, and Reviewed Literature
Gonçalo Januário1,2*
1Department of Neurosurgical, Policlínica Juaneda Miramar, Palma de Mallorca, Balearic Is-lands, Spain.
2Department of Neurosurgical, Policlínica Nuestra Señora del Rosario, Ibiza, Balearic Is-lands, Spain.
Abstract
Glioblastomas multiformes (GBMs), are the most common primary malignant tumors of the Central Nervous System. Frequently located in supratentorial topography, infratentorial location is rare, around 0-3.4% of primary GBMs. The diagnosis of these tumors is uncommon in adults, few cases have been reported, being even more infrequent in elderly patients. The most typical clinical presentation is a rapidly growing posterior fossa lesion, increased intracranial pressure, and cerebellar signs associated with the mass and perilesional edema. Clinical presentation, computed tomography (CT), and magnetic resonance imaging (MRI) provide useful information about the possible diagnosis but are not definitive. We describe a clinical case, 76 years old female with a clinical history of hypertension, depressive syndrome, and dyslipidemia. Started progressively with ataxy, imbalance, and vertigo. Brain CT shows an intra-axial, infiltrative lesion in the superior and middle vermis. MRI presents a heterogeneous lesion in the superior and median vermian region of the cerebellum with ring enhancement and central necrotic area. Was performed a middle suboccipital approach, corticectomy in the superior vermis. The intraoperative histological study reveal a high-grade malignancy astrocytoma, which was released through a subtotal resection. The histological result was a high-grade astrocytoma, grade IV in WHO classification. Four weeks after the surgery the patient started treatment with chemotherapy and radiotherapy. The main point of this case is the atypical location of the tumor. These lesions are rare in this location but they will do considering the differential diagnosis of posterior fossa tumors. However, the most frequent lesions with high percentages of incidence are metastatic lesions.
Keywords: Glioblastoma, Cerebellar tumor, Sub-occipital approach, Subtotal resection, Radiotherapy, Chemotherapy
With a frequency that ranges between 15 and 50%, glioblastoma multiforme (GBM) is the most common intracranial primary tumor in adults. GBM typically affects patients in their fifth or sixth decade of life and primarily develops within the cerebral hemispheres. Only 1% of cases of GBM in the posterior fossa, and more specifically in the cerebellar parenchyma, are reported.[1, 2]
Cerebellar glioblastoma in the elderly is uncommon; as far as we know, only 33 cases have been documented in the literature, which lends relevance to our work.[3]
A rapidly expanding posterior fossa tumor with increased intracranial pressure and cerebellar symptoms is the most common clinical presentation.[4]
Developing a viable treatment plan for cerebellar glioblastoma requires an accurate diagnosis. As always, it's important to combine the clinical manifestations with in-depth neurological testing and imaging studies. However, it can occasionally be challenging to diagnose these cancers. However, they might not result in a conclusive diagnosis. Clinical presentation, computed tomography (CT), and magnetic resonance imaging (MRI) might all offer significant information. Positron emission tomography/computed tomography (PET/CT) with fluorine-18-fluoro-deoxyglucose (FDG) is sometimes advised and may provide additional alternatives for differential diagnoses when accessible.[5]
Similar to PET/CT, Thallium-201 (Tl) single photon emission computed tomography (SPECT) imaging can be used to diagnose brain cancer if it is accessible. SPECT and PET both have the ability to identify biological processes at the cellular and molecular levels. They offer biochemical or molecular details on the tissues of brain tumors in this way. In most
Independent of the technique the radiological features are non-specific and the diagnosis was made only with histological examination, obtain with histological samples obtained during the surgery/biopsy.
It is useful to make the differential diagnosis between metastases, anaplastic astrocytomas, GBM, vascular lesions such as cerebellar infarction, and infectious lesions among other possible pathologies because their treatment modalities, prognosis, and evolution are different. Even the surgical approach could certainly be different.
The recommended treatment is radical resection if possible and without new neurological deficits after surgery, radiotherapy, and chemotherapy with temozolomide.[7]
With just 33 occurrences reported in the literature, we offer a clinical case of a primary cerebellar glioblastoma in an elderly woman. Describe clinical presentation, radiological diagnosis and pathological features, our management of the case, and review the literature.
A woman in her 76s who had a two-month history of intracranial pressure along with nausea, vomiting, and headaches was hospitalized to our hospital. She also had a history of hypertension, depressive syndrome, and dyslipidemia.
Cerebellar symptoms, including cerebellar ataxia, dysmetria, and dysdiadochokinesia, were seen during the neurologic examination. Bilateral papillary edema was visible in the fundus oculi.
In order to look for any intracranial lesions, a cerebral computed tomography (CT) and nuclear magnetic resonance (MRI) were carried out, focusing on the posterior fossa and taking into account the patient's symptoms. The CT revealed a lesion located in the upper part of the cerebellar vermis. The lesions were spontaneously hypodense with a mass effect on the roof of the fourth ventricle. The MRI showed a lesion in the upper vermis in the medial part, with irregular contours. After gadolinium administration, the lesion 3-4cm in size had ring enhancement and a central necrotic area (Figure 1).
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Figure 1. Brain MRI (a) axial, (b) sagittal, (c) coronal slices with midline superior vermis intraxial lesion, heterogeneous, ring enhancement and a central necrotic area. |
Before surgery, the diagnosis of cerebellar glioblastoma is infrequently made, despite the fact that the picture may show other types of lesions. Adults most frequently develop metastatic lesions in the posterior fossa. The systemic neoplastic search was unsuccessful in our situation.
It is important to think about the differential diagnosis before the surgery, being true that in many cases the form of surgical approach does not change.
Under general anesthesia, in the prone position. We used a midline incision and after displacing the occipital muscles we released a sub-occipital craniotomy. After opening the dura mater and performing the corticectomy, a white, infiltrating, friable, slightly hemorrhagic lesion was identified that did not present cleavage planes with the surrounding cerebellar parenchyma. The intraoperative histological study reveals a high-grade malignancy astrocytoma. A subtotal tumor resection was performed.
The patient presents a good evolution in the postoperative period, don´t present worst symptoms, and release a CT scan to control and exclude complication (Figure 2).
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Figure 2. CT, axial slices, status post middle sub-occipital craniectomy, without complications. |
The histological analysis revealed elongated spindle cells with irregular, somewhat pleomorphic, and large nuclei, proliferative blood vessels, and necrosis (Figure 3). These characteristics are compatible with glioblastoma (World Health Organization grade IV).
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