Medical Image of the Month: Glioblastoma Multiforme

Figure 1. Non-contrast CT axial views of what was later identified as glioblastoma multiforme demonstrates heterogeneous left frontal lobe mass with foci of hemorrhage (black arrows, A), mass effect (gray arrow, A & B), central necrosis (gray arrowhead, C), invasion of the corpus callosum (gray arrowhead, C), and vasogenic edema (white arrow, D).

A patient in their 60's presented with headaches for approximately 2 weeks followed by acutely worsening mental status with confusion. CT of the head is shown (Figure 1). Glioblastoma multiforme was high on the differential diagnosis.

Glioblastoma multiforme (GBM) is classified as a grade IV astrocytoma and is the most common malignant primary brain tumor. It has an incidence of 3.19 cases per 100,000 persons per year. Astrocytomas are the most invasive type of glial tumor, directly reflecting the remarkably poor prognosis with a 5-year survival rate of approximately 4% and a 26-33% survival rate at 2 years in clinical trials. Symptoms develop relatively rapidly due to edema and mass effect of the tumor. Increased intracranial pressure and swelling manifests as nausea, vomiting, seizures and headaches that are typically worse in the morning. Neurological symptoms are dependent on the location of the cerebrum that is affected (ex. sensory, motor, visual changes, gait disturbances). Conventional gadolinium-enhanced MR imaging is the standard technique for the evaluation of GBM. GBM is characterized by a large, heterogeneous mass in the cerebral hemisphere exhibiting hemorrhage, necrosis and enhancement. In addition, magnetic resonance tomography (MRS) and positron emission tomography (PET) can be used to examine the chemical profile and assist in detecting tumor recurrence, respectively. The current gold standard treatment for GBM is temozolomide in combination with radiation therapy. Two potential new treatment modalities currently under investigation are gene therapy and immunotherapy.

Biopsy of the patient’s mass confirmed glioblastoma multiforme, which was successfully treated without recurrence on MRI 18 months later.

Cassandra Ann Roose and Michael Craig Larson MD, PhD

Medical Imaging Department

Banner University Medical Center/University of Arizona

Tucson, AZ UA

References

1. Stoyanov GS, Dzhenkov DL. On the Concepts and History of Glioblastoma Multiforme - Morphology, Genetics and Epigenetics. Folia Med (Plovdiv). 2018;60(1):48-66. [CrossRef] [PubMed]
2. Altman DA, Atkinson DS Jr, Brat DJ. Best cases from the AFIP: glioblastoma multiforme. Radiographics. 2007;27(3):883-888. [CrossRef] [PubMed]
3. American Association of Neurological Surgeons. Glioblastoma Multiforme. Available from: https://www.aans.org/en/Patients/Neurosurgical-Conditions-and-Treatments/Glioblastoma-Multiforme (accessed 8/24/20).

Cite as: Roose CA, Larson MC. Medical image of the month: glioblastoma multiforme. Southwest J Pulm Crit Care. 2020;21(3):64-5. doi: https://doi.org/10.13175/swjpcc046-20 PDF 

Medical Image of the Week: Typical Pulmonary CT Findings Following Radiotherapy

Figure 1. Panel A: CT chest, lung windows, demonstrating a spiculated nodule, biopsy proven adenocarcinoma in the right lower lobe (arrow). Panel B: Eight months post stereotactic radiation therapy, there has been development of focal consolidation, with air bronchograms, involving the right middle and lower lobes. Notice the volumetric appearance. The primary malignancy is no longer identified as such. Panel C: Thirteen months later the consolidation has evolved into an area of volume loss, containing bronchiectasis, and sharp contours as a result of organized fibrosis.

Radiation-induced lung disease (RILD) commonly develops in patients treated with radiation for intrathoracic and chest wall malignancies.

There are two distinct radiographic patterns:

1. Radiation pneumonitis which occurs within 4-12 weeks after completion of therapy, and is characterized by development ground-glass opacities and/or consolidation in and around the treated lesion. A somewhat nodular or patchy appearance may occur. Typically, the affected tissue conforms to the radiation ports and may cross fissures/lobes. There may be milder similar changes in the contralateral lung.
2. A chronic phase, known as radiation fibrosis, is noticeable about 6-12 months post treatment and may progress up to 2 years, after which the findings tend to stabilize. In this stage, the areas of consolidation undergo volume loss, architectural distortion and may contain traction bronchiectasis. Linear and band scarring may also be seen. In this phase, sharper demarcation between normal and irradiated lung parenchyma is commonly seen.

Special attention to the typical radiological characteristics and timeline, in most cases allows to distinguish RILD from potential superimposed infection, subacute inflammatory diseases, locally recurrent neoplasm and radiation-induced neoplasms.

Andrew Erickson MS IV¹, Berndt Schmidt MD², Veronica Arteaga MD², Diana Palacio MD²

¹Midwestern University – Arizona College of Osteopathic Medicine

²Division of Thoracic Radiology, Department of Medical Imaging. University of Arizona, Tucson (AZ)

Reference

1. Choi YW, Munden RF, Erasmus JJ, Joo Park K, Chung WK, Jeon SC, Park CK. Effects of radiation therapy on the lung: radiologic appearances and differential diagnosis. Radiographics. 2004 Jul;24(4):985-97. [CrossRef] [PubMed]

Cite as: Erickson A, Schmidt B, Arteaga V, Palacio D. Medical image of the week: typical pulmonary CT findings following radiotherapy. Southwest J Pulm Crit Care. 2017;15(3):120-1. doi: https://doi.org/10.13175/swjpcc112-17 PDF

Medical Image of the Week: Malignant Spinal Cord Compression

Figure 1. MRI lumbar spine (sagittal image) demonstrating increased signal in the L1 and L2 vertebral bodies with tumor erosion of the posterior cortices. Encroachment upon the spinal canal is noted at L2.

Figure 2. MRI lumbar spine (sagittal image, post gadolinium infusion) demonstrating heterogeneous enhancement of L1 and L2 consistent with metastatic disease; spinal cord compression is noted at L2 (blue arrows). 

An 81 year-old man with metastatic bladder cancer was admitted to the hospital with back pain. The pain progressed over several weeks and interfered with ambulation. He had severe pain with any movement. Physical exam revealed pain with palpation of the lower back but no weakness or sensory deficits in the lower extremities. An MRI of the lumbar spine (with and without gadolinium contrast) revealed metastatic disease involving the L1 and L2 vertebral bodies, right sacrum and left iliac wing. At L2, moderate spinal canal stenosis due to tumor encroachment was noted (Figures 1 and 2). The patient was urgently treated with IV dexamethasone. He declined surgical intervention but agreed to radiation therapy.

Malignant spinal cord compression (MSCC) is an oncologic emergency that affects approximately 5% of cancer patients. It is most commonly seen in lung, breast, and prostate cancers (1). Neurologic complications are relatively uncommon in patients with bladder cancer. In a review of 359 patients with bladder cancer, only 2% had metastatic spinal cord compression (2). In MSCC, patients most commonly present with back pain. Weakness, sensory deficits, ataxia, paralysis, bowel and bladder dysfunction are later symptoms. The devastating effects of MSCC for patients make it imperative that clinicians consider the diagnosis in an oncology patient with back pain. The description of back pain can be vague and clinicians may overlook the insidious progression of symptoms. A crucial point related to the return of neurologic function in MSCC is the pretreatment neurological status. If treatment is started promptly, before significant weakness or other neurologic deficits develop, outcomes are notably improved. MRI of the total spine should be performed in any patient suspected of having MSCC. If MRI cannot be performed, CT with myelography is an alternative (3).

Treatment for MSCC includes steroids, radiotherapy, and surgery. The steroid doses vary widely and high dose steroids (dexamethasone 96 mg IV bolus with 24 mg four times daily for three days and taper over 10 days) are often initiated in patients with severe neurologic deficits. Lower dose steroids (dexamethasone 10 mg IV bolus, followed by 16 mg daily in divided doses) are also effective but there are no randomized controlled trials to compare efficacy of different doses. Radiation therapy is an important component of MSCC management, particularly in patients who are not surgical candidates. Both single dose radiation and longer course radiation have shown benefit, so decisions about dosing and duration can be based on the patient’s expected survival. Surgical decompression in addition to radiation therapy may provide quality of life benefits to a cohort of patients with MSCC. This avenue is reserved for patients with reasonable functional status and prognosis. A widely cited study published in 2005 showed improved functional outcomes after decompression plus radiotherapy versus radiotherapy only (4). If surgical intervention is considered, emergent consultation is critical to ensure the best possible outcome.

Katie Hawbaker MD, Michael Debo DO and Linda Snyder MD

Division of General Internal Medicine, Geriatrics and Palliative Medicine and Pulmonary, Allergy, Critical Care, & Sleep Medicine

Banner University Medical Center-Tucson

References

1. McCurdy M, Shanholtz C. Oncologic emergencies. Crit Care Med. 2012;40:2212-2. [CrossRef] [PubMed]
2. Anderson TS, Regine WF, Kryscio R, Patchell RA. Neurologic complications of bladder carcinoma. Cancer. 2003;97(9):2267-72. [CrossRef] [PubMed]
3. Carter BW, Erasmus JJ. Acute thoracic findings in oncologic patients. J Thorac Imaging. 2015;30:233-46. [CrossRef] [PubMed]
4. Patchell RA, Tibbs PA, Regine WF, Payne R, Saris S, Kryscio RJ, Mohiuddin M, Young B. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomized trial. Lancet. 2005; 366(9486):643-8. [CrossRef] [PubMed]

Cite as: Hawbaker K, Debo M, Snyder L. Medical image of the week: malignant spinal cord compression. Southwest J Pulm Crit Care. 2016;12(2):59-61. doi: http://dx.doi.org/10.13175/swjpcc160-15 PDF