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LETTER TO EDITOR
Year : 2013  |  Volume : 61  |  Issue : 3  |  Page : 325-326

Glioblastoma multiforme presenting as a fungating mass extending through previous craniotomy site


1 Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
2 Department of Neuroanaesthesia, All India Institute of Medical Sciences, New Delhi, India
3 Department of Surgery, All India Institute of Medical Sciences, New Delhi, India

Date of Submission15-Feb-2013
Date of Decision04-Mar-2013
Date of Acceptance30-May-2013
Date of Web Publication16-Jul-2013

Correspondence Address:
Pankaj Kumar Singh
Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.115094

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How to cite this article:
Verma SK, Kumar A, Singh PK, Bindra A, Sagar S, Sharma BS. Glioblastoma multiforme presenting as a fungating mass extending through previous craniotomy site. Neurol India 2013;61:325-6

How to cite this URL:
Verma SK, Kumar A, Singh PK, Bindra A, Sagar S, Sharma BS. Glioblastoma multiforme presenting as a fungating mass extending through previous craniotomy site. Neurol India [serial online] 2013 [cited 2019 Dec 7];61:325-6. Available from: http://www.neurologyindia.com/text.asp?2013/61/3/325/115094


Sir,

High grade gliomas are locally aggressive, but dural invasion is exceedingly rare as dura acts as a natural barrier to gliomas, [1] thereby, making calvarial erosion and destruction an extremely unusual phenomenon. [2] Dural invasion and calvarial destruction with these tumors can occur either spontaneously [3],[4],[5],[6],[7] or after surgery/radiotherapy. [8],[9],[10],[11] We report one such rare case.

A 25-year-old male was operated at another hospital for left frontal glioma 1 year before presenting to us. His presenting symptoms at that time were headache, progressive visual loss and focal seizures. The operative details were not available and histopathology report was suggestive of anaplastic astrocytoma (World Health Organization [WHO] grade III). At this admission patient presented with a large growth at the site of previous surgery, right hemiparesis and dysphasia, and recurrent generalized tonic-clonic seizures (GTCS). Patient was blind in right eye and vision in left eye was significantly reduced (6/60). Local examination revealed a large ulcerated, fungating mass measuring 5 cm × 5 cm over left frontal region [Figure 1]a and b. Magnetic resonance imaging revealed a large left frontal heterogeneously enhancing lesion with extracalvarial extension, suggestive of fungating high grade glioma [Figure 2]a-c. Patient underwent left fronto-temporal craniotomy and excision of fungating portion of tumor and decompression of intracranial portion. The bone defect was reconstructed using bone cement [Figure 2]d-f. Scalp was reconstructed using rotation flap and split skin grafting techniques [Figure 1]c and d. Post-operative course was uneventful. Histopathology revealed features suggestive of glioblastoma multiforme (GBM). Patient was planned for adjuvant radiotherapy and chemotherapy; however, he died 1 month after discharge at home following an episode of GTCS.
Figure 1: (a and b) Pre-operative photographs showing fungating mass in left frontal region. (c and d) Post-operative photographs showing closure of skin defect with rotation flap and split skin graft

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Figure 2: (a-c) Pre-operative contrast magnetic resonance imaging showing a large left frontal heterogeneously enhancing lesion extending extracalvarially. (d-f) The fungating portion was excised and intracranial part decompressed. The skull defect was reconstructed with bone cement

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Intracranial tumors, especially meningiomas are known to penetrate dura and bone. However, dural invasion and calvarial destruction by a glioma leading to an outward growth is extremely rare. [3] This unusual growth pattern of high-grade gliomas has been described in the literature only on few occasions. [2],[3],[4],[5],[6],[7],[8],[9],[10],[11] Dural invasion and calvarial destruction by gliomas can occur either after surgery/irradiation [8],[9],[10],[11] or spontaneously in the absence of any prior intervention. [3],[4],[5],[6],[7]

There are three potential routes for extradural extension of gliomas, (i) through the cranial or spinal nerves, (ii) along the perivascular/dural slits or by (iii) direct destruction of dura. [6] Iatrogenic violation of dura by surgery presents a possible route of spread for high-grade glioma as happened in this patient. Dural defect created as a result of surgery along with raised intracranial pressure consequent to progressive tumor growth direct the tumor to grow outwards, [7] leading to calvarial destruction and skin ulceration. In present case, patient had previously undergone surgery and histopathology was suggestive of anaplastic astrocytoma (WHO grade III). The patient presented 1 year later with rapid deterioration and extracalvarial extension of glioma. The tumor had progressed over a period of time from grade III to IV. This aggressive transformation presented with an unusual growth pattern. Our case highlights an unusual extrafugal growth pattern of GBM leading to dural invasion and calvarial destruction, due to the combined effect of disruption of dural barrier and rapid tumor growth. This case stresses the fact that GBM can, not only grow centripetally along white matter tracts, but also centrifugally beyond the dural barrier.

 
  References Top

1.Pedersen PH, Rucklidge GJ, Mørk SJ, Terzis AJ, Engebraaten O, Lund-Johansen M, et al. Leptomeningeal tissue: A barrier against brain tumor cell invasion. J Natl Cancer Inst 1994;86:1593-9.  Back to cited text no. 1
    
2.Osborn RE, Ley CE. Astrocytoma with calvarial erosion. AJNR Am J Neuroradiol 1986;7:178.  Back to cited text no. 2
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3.Woodruff WW Jr, Djang WT, Voorhees D, Heinz ER. Calvarial destruction: An unusual manifestation of glioblastoma multiforme. AJNR Am J Neuroradiol 1988;9:388-9.  Back to cited text no. 3
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4.Shuangshoti S, Kasantikul V, Suwanwela N. Spontaneous penetration of dura mater and bone by glioblastoma multiforme. J Surg Oncol 1987;36:36-44.  Back to cited text no. 4
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5.Rainov NG, Holzhausen HJ, Meyer H, Burkert W. Local invasivity of glioblastoma multiforme with destruction of skull bone. Case report and review of the literature. Neurosurg Rev 1996;19:183-8.  Back to cited text no. 5
[PUBMED]    
6.Kawano N, Yada K, Ogawa Y, Sasaki K. Spontaneous transdural extension of malignant astrocytoma. Case report. J Neurosurg 1977;47:766-70.  Back to cited text no. 6
[PUBMED]    
7.Sanerkin NG. Transdural spread of glioblastoma multiforme. J Pathol Bacteriol 1962;84:228-33.  Back to cited text no. 7
[PUBMED]    
8.Murphy MN, Korkis JA, Robson FC, Sima AA. Gliosarcoma with cranial penetration and extension to the maxillary sinus. J Otolaryngol 1985;14:313-6.  Back to cited text no. 8
[PUBMED]    
9.Houston SC, Crocker IR, Brat DJ, Olson JJ. Extraneural metastatic glioblastoma after interstitial brachytherapy. Int J Radiat Oncol Biol Phys 2000;48:831-6.  Back to cited text no. 9
[PUBMED]    
10.Horiuchi T, Osawa M, Itoh N, Kobayashi S, Nitta J, Hongo K. Extradural extension of glioblastoma multiforme into the oral cavity: Case report. Surg Neurol 1996;46:42-6.  Back to cited text no. 10
[PUBMED]    
11.Pompili A, Calvosa F, Caroli F, Mastrostefano R, Occhipinti E, Raus L, et al. The transdural extension of gliomas. J Neurooncol 1993;15:67-74.  Back to cited text no. 11
[PUBMED]    


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