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LETTER TO EDITOR
Year : 2010  |  Volume : 58  |  Issue : 6  |  Page : 978-979

Mirror-image insular glioma


Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi - 110 029, India

Date of Acceptance17-Sep-2010
Date of Web Publication10-Dec-2010

Correspondence Address:
A K Mahapatra
Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.73767

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How to cite this article:
Borkar SA, Tandon V, Kale S S, Mahapatra A K. Mirror-image insular glioma. Neurol India 2010;58:978-9

How to cite this URL:
Borkar SA, Tandon V, Kale S S, Mahapatra A K. Mirror-image insular glioma. Neurol India [serial online] 2010 [cited 2020 Dec 4];58:978-9. Available from: https://www.neurologyindia.com/text.asp?2010/58/6/978/73767


Sir,

A 35-year-old man presented to our outpatient services with 2-year history of complex partial seizures, mild holocranial headache and cognitive impairment. Neurological examination did not reveal any focal neurological deficit. His mini-mental examination score (MMSE) was 28/30. Non-contrast cranial computerized tomography (CT) revealed hypodense space occupying lesion in bilateral insular region in a mirror-image fashion [Figure 1]a. Magnetic resonance imaging (MRI) brain confirmed the CT findings. The lesion was hypointense on T1-weighted image, hyperintense on T2-weighted image and fluid attenuated inversion recovery [FLAIR] images with minimal inhomogeneous post-contrast enhancement [[Figure 1]b-d]. MR spectroscopy showed choline peak and elevated choline/N-acetylaspartate ratio [Figure 1]e. A preoperative diagnosis of glial tumor was considered. Right fronto-temporal craniotomy with subtotal excision of right insular glioma was carried out via trans-sylvian approach. The insular and opercular branches of middle cerebral artery were preserved. The patient had an uneventful postoperative course and was discharged on 7 th postoperative day. Histopathological examination revealed a moderately cellular tumor with microcystic change, moderate pleomorphism and occasional mitosis. No endothelial cell proliferation or necrosis was seen. MIB-1 labeling index was 8%. The tumor was p53 negative. Overall features were suggestive of anaplastic astrocytoma (WHO grade III). The patient was referred for radiotherapy and chemotherapy and was doing well at the last follow-up.
Figure 1: (a-d) Bilateral insular glioma in a mirror-image fashion. The lesion was hypointense on T1WI, hyperintense on T2WI with minimal inhomogeneous post-contrast enhancement. Magnetic resonance spectroscopy showed choline peak and elevated choline: NAA ratio (e)

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Multicentric gliomas are well-separated lesions, localized in different lobes or hemispheres, which cannot be ascribed to dissemination through commissural pathways; cerebrospinal fluid (CSF), blood or local extension. [1] Multicentric glioma is a rare entity, and very few cases have been reported in the literature till date [2],[3],[4],[5],[6] and the incidence ranges from 2.3% to 9.1%. [1] Pathak et al[2] quoted the incidence of multicentric gliomas as low as 0.4% amongst 500 glial tumors over a period of 8 years. These tumors may be synchronous or metachronous in clinical presentation. In some studies, metachronous lesions have been reported to be associated with better prognosis. [6] These tumors are usually high-grade lesions (WHO grade III, IV). [2],[3],[4],[5],[6] To the best of the authors' knowledge, multicentric anaplastic astrocytoma presenting as bilateral mirror-image insular masses has not been reported previously.

Lack of direct continuity or subarachnoid enhancement on CT scan and MRI brain suggests its primary multicentric origin. Despite advances in neuroradiological techniques, in case of multicentric cerebral lesions, differential diagnosis may require biopsy or surgical excision. [1] The diagnosis is best made by biopsy or surgery. [5]

 
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1.Zamponi N, Rychlicki F, Ducati A, Regnicolo L, Salvolini U, Ricciuti RA. Multicentric glioma with unusual clinical presentation. Childs Nerv Syst 2001;17:101-5.  Back to cited text no. 1
    
2.Pathak A, Sharma BS, Kak VK, Vasista RK, Banerjee AK. Multicentric gliomas: Report of 2 cases. Indian J Cancer 1993;30:205-8.  Back to cited text no. 2
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3.Kasliwal MK, Gupta DK, Mahapatra AK, Sharma MC. Multicentric cerebellopontine angle glioblastoma multiforme. Pediatr Neurosurg 2008;44:224-8.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Khongkhatithum C, Visudtibhan A, Chiemchanya S, Visudhiphan P, Sanvivad P, Larbcharoensub N, et al. Multicentric anaplastic astrocytoma in a child. J Clin Neurosci 2007;14:176-9.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Hashimoto H, Yonezawa T, Sakaki T, Tsunoda S. A multicentric glioma exhibiting three supratentorial lesions. No Shinkei Geka 1994;22:81-4.  Back to cited text no. 5
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6.Iza B, Mateo-Sierra O, Ruiz-Juretszke F, Garbizu J, Guzmαn de Villoria J, Carrillo R. Familiar glioblastoma presenting as a true multicentric tumor: Etiopathogenic and prognostic features. Neurocirugia (Astur) 2006;17:340-6.  Back to cited text no. 6
    


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