Glioblastoma
Introduction
Introduction to glioblastoma Glioblastoma is the most malignant glioma in astrocytic tumors and belongs to WHOIV class. The tumor is located under the cortex and grows invasively. It often invades several brain leaves and invades the deep structure. It can also affect the contralateral cerebral hemisphere through the corpus callosum. basic knowledge The proportion of illness: 0.003% - 0.006% Susceptible people: no special people Mode of infection: non-infectious Complications: intracranial hemorrhage
Cause
Glioblastoma etiology
(1) Causes of the disease
At present, studies have found that the primary molecular mechanism of primary glioblastoma and secondary glioblastoma is different. Primary glioblastoma is mainly composed of amplification and overexpression, while secondary glia. Maternal tumors are mainly characterized by mutations in p53.
(two) pathogenesis
Tumors occur in the cerebral hemisphere white matter, invasive growth, the appearance of hemispherical lobulated, most of the tumors are unclear, a small number of tumors due to rapid growth and surrounding tissue compression softening and edema, the performance of "false envelope" Phenomenon can be mistaken for a clear state of mind, in fact, the tumor has infiltrated and grow beyond the boundary.
The hardness of the tumor varies depending on whether the tumor has secondary changes. Generally, it is soft and hard, and the texture is uneven. The tumor can be in a variety of colors. The tumor often has cystic changes, necrosis and hemorrhage. Calcification is rare. The typical tumor surface can be seen in gray. Tumor, red fresh bleeding, purple bleeding block, yellow old bleeding and white interstitial hyperplasia, tumors can also have necrotic and cystic changes of different sizes, the fluid in the capsule can be bloody, brown, or yellow It can also be a plurality of small sacs scattered in the parenchyma of the tumor. The tumor is rich in blood supply, and the surrounding brain edema is obvious. It protrudes to the brain surface and ventricles. The tumor cells can be spread with the cerebrospinal fluid, and the individual can be transferred to the brain. Lung, liver, bone or lymph nodes.
Glioblastoma tissue is complex and different in morphology, and different parts of the same tumor are also inconsistent. According to the classification criteria proposed by WH0 (1990), glioblastoma is divided into the following two histological subtypes: 1 giant cell type Glioblastoma, 2 gliosarcoma, these subtypes are mainly based on some of the more prominent morphological features of the tumor, and there is no positive correlation with the patient's prognosis.
Tumor cells have a variety of histological morphology, and the proliferating tumor cells are often dominated by small, deeply stained round cells, with altered undifferentiated fibrosis, protoplasmic and obese astrocytes, and large. The weird tumor cells of unknown origin, the diameters of tumor cells are very different, the larger ones can reach more than 30m, the small ones may be less than 10m, some tumors are very rich in cytoplasm, and there are also cytoplasms that are completely absent and naked nuclei, nuclear polymorphism Sexuality has more divisions. The tumor necrosis area is surrounded by a pile of long and narrow tumor cell layers. The mitotic figures of tumor cells are quite common, and mononuclear or multinuclear giant cells can be seen. The blood vessels are rich in blood cells and proliferate in tumor cells. In the exuberant region, abnormal proliferation of vascular endothelial cells may occur, forming a surrounding glomus, similar to glomeruli, forming another feature of glioblastoma, derived from interstitial fibroplasia of adventitial cells. In severe cases, it can become a tumor component.
A small number of tumors can be disseminated in the subarachnoid space. Tumor cells can be found in the cerebrospinal fluid of 10% to 20% of patients with glioblastoma, about 10% with pia mater, 30% at autopsy, and craniotomy Very few patients with post-cranial metastases can occur.
Under electron microscope, the size and shape of tumor cells are different, the morphology is primitively poorly differentiated, the nucleus is large and the periplasm is less, the organelles are rare, but the polyribosome is abundant, the nucleus is irregular, the nucleoli are prominent, and the mitotic figures are common. The cell membrane of giant cells often folds. Sometimes a large amount of microvilli is visible, the organelles are not fixed, the nuclear deformity, polymorphism, or lobulation, and the height is irregular. The cytoplasm of giant cell glioblastoma is extremely broad, full of a large amount of gelatinous silk, indefinite, mature The degree is different, the mitochondria are scattered in it, the glycogen is abundant, the nuclear chromatin and nucleoli are prominent, the capillary and small vascular endothelium are globular, the vascular cavity is locked, the macrovascular endothelium is hyperplasia, and the multi-layer basement membrane is surrounded by a large number. Glial fibers are produced. Common tumor cells have varying degrees of necrosis, necrotic foci and common perivascular macrophages, fibroblasts and other inflammatory cells.
Prevention
Glioblastoma prevention
Due to the high degree of malignancy of the tumor, postoperative recurrence, glioblastoma patients have a poor prognosis, 95% of untreated patients have a survival of no more than 3 months. The prognosis of patients is related to multiple factors. The patient's age is under 45 years old, and the preoperative symptoms are more than 6 months. The symptoms are mainly epilepsy rather than mental disorder. The tumor is located in the frontal lobe and the preoperative condition is better. The extent of tumor resection affects the patient's survival. Partial resection or biopsy of the tumor is half of the patients with gross tumor resection at 6 months and 2 years after surgery. Total resection of the gross eye tumor can help improve neurological symptoms in patients. Radiotherapy can prolong the patient's survival period of 4 to 9 months, and postoperative radiotherapy can make some patients survive for 18 months. However, although the comprehensive treatment of glioblastoma can temporarily alleviate the progress of the disease, it can not cure the tumor. The patient with glioblastoma has a 2-year survival rate of 10% after comprehensive treatment with gross tumor, radiotherapy and chemotherapy. Only less than 5% of patients can survive for a long time.
Complication
Glioblastoma complications Complications intracranial hemorrhage cerebral edema
If surgery is performed, the following complications may occur:
1. Intracranial hemorrhage or hematoma
It is not related to intraoperative hemostasis. With the improvement of surgical techniques, this complication has been less frequent. The wound is carefully hemostasis and repeated flushing before closing the skull can reduce or avoid postoperative intracranial hemorrhage.
2. Brain edema and postoperative high intracranial pressure
Dehydration drugs can be used to reduce intracranial pressure, and glucocorticoids can alleviate cerebral edema. For tumors with a wide range of lesions or high degree of malignancy, the tumors and non-functional areas of the brain tissue can be removed as much as possible, and the external decompression of the bone flap can be performed.
3. Loss of nerve function
It is related to the important functional area and important structure of the intraoperative injury. The injury should be avoided as much as possible during the operation.
Symptom
Glioblastoma Symptoms Common Symptoms Inability to Dementia Awareness Disorders Blind Sensory Disorders Increased intracranial pressure
Glioblastoma grows fast and has a short course of disease. 70% to 80% of patients have a disease course of 3 to 6 months, and only 10% of patients have a course of more than 1 year. The longer course may be caused by astrocytoma with low malignancy. However, individual cases may be stroke-like due to tumor hemorrhage, due to rapid tumor growth, extensive cerebral edema, and obvious symptoms of increased intracranial pressure. Almost all patients have headache, vomiting, optic disc edema, and headache (73%). Mental changes (57%), limb weakness (51%), vomiting (39%), disturbance of consciousness (33%) and speech disorder (32%), tumor invasive destruction of brain tissue, resulting in a series of focal symptoms, patients There are varying degrees of hemiplegia, partial sensory disturbances, aphasia and hemianopia, etc., neurological examination can detect hemiplegia (70%), cranial nerve damage (68%), partial sensory disturbance (44%) and hemianopia (39%), The incidence of epilepsy is less common than that of astrocytoma and oligodendroglioma. About 33% of patients have seizures, and about 20% of patients have mental symptoms such as apathy, dementia, and mental retardation.
Examine
Examination of glioblastoma
Lumbar puncture and more suggestive pressure increase, cerebrospinal fluid protein content and leukocytosis, a few cases of special staining can sometimes find shed tumor cells, patients with high intracranial pressure during lumbar puncture should pay attention to prevent the formation of cerebral palsy.
Radionuclide examination
The positive rate of diagnosis is higher than that of astrocytoma. The local area of the lesion shows radioactive concentration. The X-ray film of the skull only shows the increase of intracranial pressure. Occasionally, the displacement of the pineal calcification, cerebral angiography sees the displacement of blood vessels. About half of the blood vessels are shown in the pathology, and the blood vessels in the lesions are uneven in thickness and not distorted, and some are small dots or filaments.
2. CT scan
Tumors with mixed density lesions with unclear borders, many of which have high-density manifestations of intratumoral hemorrhage but less calcification, intratumoral necrosis and cystic changes show low density, and their morphology is pleomorphic, and most of the lesions The cerebral edema is heavier, the tumor has no obvious boundary with the brain tissue, the ventricle is often compressed and reduced, deformed or closed, and the midline structure is often shifted to the contralateral side. After the enhancement, 95% of the tumors are unevenly enhanced, often showing a central low density. The necrotic or cystic zone, the irregular hyperplasia of the surrounding proliferative vascular zone, the island shape or the spiral shape enhancement shadow, the necrotic zone is often located in the tumor parenchyma, and the low-density zone with irregular boundaries.
3. MRI examination
The tumor has a low signal on the T1-weighted image, and the T2W image is a tumor with unclear boundary of the high signal. It is not easy to distinguish from the adjacent brain tissue, and the occupancy effect is very obvious. If there is a large necrotic area in the tumor, it is lower. Signal, if there is a high signal of hemorrhage, the corpus callosum is often involved, the midline structure such as the longitudinal fissure pool can be deformed, narrowed or shifted, and the tumor is mixed signal in the T2-weighted image, with high signal, low dispersion and equal signal. After the injection of Gd-DTPA, the tumor has a significant contrast enhancement, which makes the tumor and the adjacent structure have a clear boundary, and it is well-developed in the deep brain, which is a characteristic feature.
Diagnosis
Diagnosis and diagnosis of glioblastoma
Diagnosis can generally be made based on medical history, clinical manifestations, and imaging studies.
Clinical manifestations: Glioblastoma has a fast growth rate and a short course of disease. 70% to 80% of patients have a disease course of 3 to 6 months, and only 10% of patients have a disease course of more than 1 year. Longer course of disease may evolve from a less aggressive astrocytoma. Individual cases may be stroke-like due to tumor bleeding. Due to rapid tumor growth, extensive cerebral edema, and increased symptoms of intracranial pressure, almost all patients have headache, vomiting, and optic disc edema. There were headaches (73%), mental changes (57%), weakness (51%), vomiting (39%), disturbance of consciousness (33%), and speech impairment (32%). Tumor invasive destruction of brain tissue, resulting in a series of focal symptoms, patients with varying degrees of hemiplegia, partial sensory disturbances, aphasia and hemianopia. Neurological examination revealed hemiplegia (70%), cranial nerve damage (68%), partial sensory disturbance (44%), and hemianopia (39%). The incidence of epilepsy is less common than astrocytoma and oligodendroglioma, and about 33% of patients have seizures. About 20% of patients show mental symptoms such as apathy, dementia, and mental retardation.
Laboratory examination: increased lumbar puncture pressure, increased protein content in cerebrospinal fluid and leukocytosis. In some cases, special staining can sometimes reveal shed tumor cells. Patients with high intracranial pressure during lumbar puncture should be careful to prevent the formation of cerebral palsy.
Other auxiliary inspections:
1. Radionuclide examination: The positive rate of diagnosis is higher than that of astrocytoma, and the lesion shows a radioactive rich area. The skull X-ray film only showed an increase in intracranial pressure, and occasionally the displacement of the pineal calcification. Cerebral angiography showed that the blood vessels were displaced by pressure, and about half of them showed pathological blood vessels. The blood vessels in the lesions were uneven in thickness and distorted, and some were small dots or filaments.
2. CT scan: The tumor has mixed density lesions with unclear borders. Most of them have high-density manifestations of intratumoral hemorrhage but less calcification. The intratumoral necrosis and cystic changes are low-density shadows, and their morphology is polymorphic. Sexuality, most of the brain edema around the lesion is heavier, and there is no obvious boundary between the tumor and the brain tissue. The ventricles are often compressed and become smaller, deformed or closed, and the midline structure is often displaced to the opposite side. After enhancement, 95% of the tumors showed uneven enhancement, often showing a central low-density necrotic or cystic zone, and irregular annular, island-shaped or spiral-shaped enhancement of the peripheral proliferative vascular zone. The necrotic area is often located in the parenchyma of the tumor, and is in a low-density area with irregular boundaries.
3. MRI examination: The tumor showed a low signal on the T1-weighted image, and the T2W image was a tumor image with a high signal boundary, which was not easily distinguished from the adjacent brain tissue, and the occupancy effect was very obvious. If there is a large necrotic area in the tumor, it will show a lower signal, and if there is bleeding, it will be a high signal. The carcass is often involved, and the midline structure, such as the longitudinal fissure pool, can be deformed, narrowed, or displaced. The tumor showed a mixed signal in the T2-weighted image, with high signal as the main signal and low dispersion and equal signal. After the injection of Gd-DTPA, the tumor has a very significant contrast enhancement, which makes the tumor and the adjacent structure have a clear boundary, and occurs well in the deep brain, which is a characteristic feature.
