Glioblastoma with extracranial parotid, lymph node, and pulmonary metastases: a case report

Abstract

We present a rare case of an isocitrate dehydrogenase-wildtype glioblastoma with histologically proven parotid, cervical lymph node, and lung metastases. While recent therapy advances are likely to increase glioblastoma mid- and long-term survival, this will also increase the time window for extraneural glioblastoma spread. Radiologists should be aware of this risk, so they can accurately detect and interpret metastatic glioblastoma disease.

Keywords: Glioblastoma; Isocitrate dehydrogenase; Lung; Metastasis; Neoplasm; Parotid gland.

Fig. 1

(A-D) Iodine contrast-enhanced brain CT performed at an external imaging center showing a contrast-enhancing mass (red arrows) in the right temporal lobe abutting the tentorium cerebelli. Extensive perilesional edema (blue arrows) and secondary uncal (purple arrow) and subfalcine (green arrow) herniation were present. The mass was surrounded by multiple nodular satellite lesions (yellow arrows).

Fig. 2

MRI of the brain at initial presentation. (A) FLAIR image showing a slightly hyperintense mass (red arrows) compared to the surrounding parenchyma, with extensive perilesional edema (blue arrow). (B) T2* gradient echo image showing multiple hypointense dots (brown arrows) spread throughout the lesion, most likely corresponding hemosiderin or calcifications. (C) B1000 image demonstrating hyperintense areas in the mass (purple arrows). (D) ADC map showing corresponding areas of iso- to hypointensity (green arrows), suggestive of a hypercellular mass. (E) T1-weighted image showing a hypointense mass (orange arrows). (F-J) Gadolinium-enhanced T1-weighted images showing avid contrast enhancement of the temporal mass (blue arrows) with areas of central sparing. The mass was surrounded by multiple nodular satellite lesions (yellow arrows).

Fig. 2

MRI of the brain at initial presentation. (A) FLAIR image showing a slightly hyperintense mass (red arrows) compared to the surrounding parenchyma, with extensive perilesional edema (blue arrow). (B) T2* gradient echo image showing multiple hypointense dots (brown arrows) spread throughout the lesion, most likely corresponding hemosiderin or calcifications. (C) B1000 image demonstrating hyperintense areas in the mass (purple arrows). (D) ADC map showing corresponding areas of iso- to hypointensity (green arrows), suggestive of a hypercellular mass. (E) T1-weighted image showing a hypointense mass (orange arrows). (F-J) Gadolinium-enhanced T1-weighted images showing avid contrast enhancement of the temporal mass (blue arrows) with areas of central sparing. The mass was surrounded by multiple nodular satellite lesions (yellow arrows).

Fig. 2

MRI of the brain at initial presentation. (A) FLAIR image showing a slightly hyperintense mass (red arrows) compared to the surrounding parenchyma, with extensive perilesional edema (blue arrow). (B) T2* gradient echo image showing multiple hypointense dots (brown arrows) spread throughout the lesion, most likely corresponding hemosiderin or calcifications. (C) B1000 image demonstrating hyperintense areas in the mass (purple arrows). (D) ADC map showing corresponding areas of iso- to hypointensity (green arrows), suggestive of a hypercellular mass. (E) T1-weighted image showing a hypointense mass (orange arrows). (F-J) Gadolinium-enhanced T1-weighted images showing avid contrast enhancement of the temporal mass (blue arrows) with areas of central sparing. The mass was surrounded by multiple nodular satellite lesions (yellow arrows).

Fig. 3

Resection specimen of brain tissue and glioblastoma (GBM) (10×). (A) H&E stain showing GBM with palisaded highly atypical cells (yellow arrows) next to geographic necrosis (blue arrow) and high endothelial venules (green arrows). (B) Tumoral cells are diffusely GFAP positive (brown staining), indicating glial origin.

Fig. 4

Gadolinium-enhanced T1-weighted imaging 72 hours after resection. (A) At the level of the resection cavity, subtle nodular thickening of the right tentorium cerebelli was noted (red arrows), compatible with granulation tissue or residual tumor. Residual blood products were also present (brown arrow). (B) At the level of the right parotid gland (green arrows), no enhancing lymph nodes were present.

Fig. 5

MRI of the brain 3.5 months after presentation. (A) Gadolinium-enhanced T1-weighted image showing nodular recurrence (blue arrows) medial to the resection cavity. (B) Perfusion-weighted imaging showing an increased relative cerebral blood volume (white arrows) in the area of recurrence. (C) Gadolinium-enhanced T1-weighted image showing 3 enhancing nodules (yellow arrows) in the right parotid gland, suggestive of lymphadenopathy. (D) B1000 image demonstrating hyperintensity of the 2 largest parotid nodules (purple arrows). Nevertheless, the parotid nodules were missed on the initial report.

Fig. 6

MRI of the brain 5.5 months after presentation. (A) Gadolinium-enhanced T1-weighted image showing a volume increase of local recurrence. (B) Perfusion-weighted imaging demonstrating an increased relative cerebral blood flow (rCBF) in the area of recurrence. (C) Gadolinium-enhanced T1-weighted image showing a moderate volume increase of the parotid nodules. (D) On B1000 imaging, the parotid nodules had also grown in volume. On this examination, the parotid nodules were detected.

Fig. 7

Venous phase contrast-enhanced CT of the neck and chest 5.5 months after presentation. (A-C) CT of the neck demonstrating multiple suspect lymph nodes in the right parotid gland (yellow arrows) and right cervical levels 2-3 (blue arrows). (D) Lung window showing one of multiple millimetric solid lung nodules in the right upper lobe (orange arrow). (E) Chest CT maximum intensity projection (MIP) performed 3 days later showing bilateral solid lung nodules, not demonstrated on preoperative imaging (orange arrows). (F) 3D volume rendering reconstruction showing bilateral metastases (green nodules), predominantly in the right lung.

Fig. 8

Parotid, cervical lymph node and lung nodule tissue morphologic aspects and immunohistochemical staining. (A-C) Fine-needle aspiration cytology of a parotid lesion (20×). (A) H&E stain on tissue block showing atypical cells. (B) Atypical cells express GFAP (brown staining) (C) and are pankeratin negative, unusual for parotid gland neoplasm. (D-F) Biopsy of a cervical lymph node (20×). (D) H&E stain showing similar atypical cells (E) with expression of GFAP and (F) pankeratin negative staining. (G-I) Thoracoscopic biopsy of a lung nodule. (G) H&E (2.5×) stain showing a tumoral nodule. (H) Tumoral cells are GFAP positive (2.5×) and (I) pankeratin negative (pankeratin positive brown cells are entrapped alveoli) (10×).

Fig. 9

MRI of the brain 12.5 months after presentation. (A) Gadolinium-enhanced T1-weighted image showing local recurrence (blue arrow) and cystic encephalomalacia of the resection cavity (orange arrow). (B-C) Additionally, a contrast-enhancing mass (yellow arrows) was present in the right superior frontal gyrus and body of the corpus callosum. (D) Perfusion-weighted image showing an increased rCBF (white arrows) in the area of the frontocallosal mass. (E-F) T2-FLAIR-weighted images showing hyperintensity of the mass (red arrow) with significant perilesional edema (green arrows) extending to the precentral gyrus (purple arrow) and to a lesser extent to the postcentral gyrus (brown arrow), providing a possible explanation for the patient's progressive left-sided hemiparesis.

Fig. 9

MRI of the brain 12.5 months after presentation. (A) Gadolinium-enhanced T1-weighted image showing local recurrence (blue arrow) and cystic encephalomalacia of the resection cavity (orange arrow). (B-C) Additionally, a contrast-enhancing mass (yellow arrows) was present in the right superior frontal gyrus and body of the corpus callosum. (D) Perfusion-weighted image showing an increased rCBF (white arrows) in the area of the frontocallosal mass. (E-F) T2-FLAIR-weighted images showing hyperintensity of the mass (red arrow) with significant perilesional edema (green arrows) extending to the precentral gyrus (purple arrow) and to a lesser extent to the postcentral gyrus (brown arrow), providing a possible explanation for the patient's progressive left-sided hemiparesis.