IS IT MULTICENTRIC OR MULTIFOCAL GLIOBLASTOMA ? DR AMIT KUMAR GHOSH GLOBAL HOSPITAL, CHENNAI

Clinical Profile 48 years, female, history of headache and few episodes of vomiting with few episodes of vacant look off and on over 10 days. On examination, no neurological deficit.

SURGICAL MANAGEMENT She underwent RIGHT FRONTO PARIETAL PARASAGGITAL CRANIOTOMY, INTERHEMISPHERIC APPROACH, TRANSCALLOSAL EXCISION OF TUMOUR LEFT FRONTAL SUPRAORBITAL CRANIOTOMY AND EXCISION OF LESION on 29.05.2015

PATHOLOGICAL DIAGNOSIS Histopathological examination Intraventricular lesion- Glioblastoma WHO grade IV Left basifrontal lesion-

Immunohistochemistry Intraventricular lesion- GFAP – strong diffuse positive EMA – Patchy positive paranuclear dot like Synaptophysin – Negative Chromogranin – Negative p53- 10% Left Basifrontal lesion- GFAP – Strong diffuse positive p53 – 10% G67 – 30%

Post operative period was uneventful,. She was covered with pre and post operative anticonvulsants and corticosteroids. EVD and surgical drain removed on POD 3 , Sutures removed on POD10 Advised Radiotherapy after 2 weeks

MULTICENTRIC / MULTIFOCAL Multifocal glioma consists of tumours separated by white matter tracts within the same hemisphere. Multicentric glioma consists of tumors in opposite hemispheres or separated by the tentorium.

PATHOLOGY Still there is no unified theory regarding the pathogenesis of multifocal and multicentric GBM, several hypotheses have been developed. The traditionally held view of the pathogenesis of multifocal/multicentric GBM is by three possible pathways. 1) First, a previously known primary high-grade glioma spreads through the cerebrospinal fluid or white matter tracts to other locations. 2) Second, multiple areas of high-grade glioma arise de novo from initially non-neoplastic cells that are influenced by genetic defect. 3) Third and last, initially diffuse low-grade glioma develops separate from separate areas of malignant transformation within itself, hence giving rise to multifocal/multicentric GBM. Some literature proposes that the pathogenesis of multiple and multicentric GBM may involve neural stem cells within the subventricular zone or could result from tumor dissemination along established CNS routes, such as white matter tracts and CSF pathways. Neural stem cells have been found to express matrix metalloproteinases, which are proteolytic enzymes implicated in tumor spread . Furthermore, the SVZ is thought to be a highly permissive environment for tumor growth and cellular migration.

TREATMENT MODALITIES Currently there is no clear guidelines regarding the optimal management of MF/MC GBM, role of surgery for MF/MC remains controversial. Aggressive resection of one tumor focus, biopsy alone followed by chemotherapy and radiation treatment, and multiple craniotomies during a single operation have all been described with no clear indication of which modality is superior  -

INCIDENCE Multiple glioma in the form of nultifocal or multicentric is uncommon entity. Incidence in literature varies from 0.15% to 25.4%

REFERENCES Andrea Arcos b, Lorena Romero b,∗, Ramón Serramito a, José M. Santína, Antonio Prieto a, Miguel Gelabert a, Miguel Ángel Arráez b: Multicentric glioblastoma multiforme. Report of 3 cases, clinical and pathological study and literature review: neuroc i rugia. 2 0 1 2;23(5):211–215 Zamponi N1, Rychlicki F, Ducati A, Regnicolo L, Salvolini U, Ricciuti RA.: Multicentric glioma with unusual clinical presentation.: Childs Nerv Syst. 2001 Jan;17(1-2):101-5. Sophia F. Shakur,1 Esther Bit-Ivan,2 William G. Watkin,2 Ryan T. Merrell,3 andHamad I. Farhat: Multifocal and Multicentric Glioblastoma with Leptomeningeal Gliomatosis: A Case Report and Review of the Literature: Case Reports in Medicine Volume 2013 (2013), Article ID 132679, 8 pages http://dx.doi.org/10.1155/2013/132679 Yusuf ZC, Do¤a GÜRKANLAR, Erdener T‹MURKAYNAK: Multicentric Gliomas: Still Remains a Controversial Issue: Turkish Neurosurgery 2005, Vol: 15, No: 2, 71-75

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