Radiological features of cerebellar
glioblastoma multiforme
Dept. of Radiology and Neurosurgery
Ehime University School of Medicine
K. Kikuchi, Y. Hiratsuka, S. Ohue, T. Mochizuki
Introduction
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Glioblastoma (GBM) is the most common type of
malignant CNS tumor in adults; however, the
prevalence of GBM that arises in the cerebellum is
extremely low.
Malignant glioma is rarely considered in the
preoperative differential diagnosis of cerebellar
tumors. Although the possibility of cerebellar glioma
is noted primary consideration is given to metastatic
brain tumor, hemangioblastoma, and primary CNS
lymphoma (PCNSL).
Propose
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The purpose of this study was to
demonstrate the radiological features of
cerebellar GBMs, including CT, MRI, and
FDG - and MET - PET findings.
Materials and Methods
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We retrospectively reviewed patients with
glioma who underwent craniotomy or
stereotactic biopsy at our hospital from March
2003 to June 2014.
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The inclusion criterion was pathologically proven
cerebellar GBM in an adult patient. Patients with
supratentrial GBM were excluded.
Seven patients (six men and one woman:
mean age: 56 years, range: 18 - 73 years)
satisfied these criteria and were included in
the study.
Materials and Methods
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We reviewed the medical records and
radiological images.
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No-contrast CT (NCCT), MRI and PET.
NCCT and MRI (T2WI, FLAIR, T1WI and
Gd enhanced T1WI) were performed in all
patients.
FDG- and MET-PET examinations were
performed in three patients.
Materials and Methods
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MRI
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1.5-T (n = 3) or 3-T system (n = 4).
T2WI by fast SE
T1WI by SE or fast IR
Contrast medium at 0.1 mmol/kg body weight.
PET
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MET: A 21 minute static PET scan was begun 20 minutes
after MET injection (5 MBq/kg body weight)
FDG: After MET acquisition, FDG (3.5 MBq/kg body weight)
was injected. Rest for 90 minutes after injection, emission
data was acquired for 20 minutes.
Patients Summary
No.
Age/Sex
Symptom
1
33/M
Headache
2
71/F
None
3
70/M
Cerebellar ataxia
4
71/M
None
5
56/M
Dizziness, Cerebellar ataxia
6
18/M
Headache, Vomitting, Cerebellar ataxia, Nystagmus
7
73/M
Dizzienss, Vomitting
Image Findings: CT & MRI
No.
CT
MRI
1
iso~low
2
low
3
not evident
4
iso
irregular ring enhancement
5
slightly high
homogenous enhancement
6
low, hemorrhage
7
low
Lermitte-Duclos like
irregular ring enhancement
multiple patchy enhancement
hemorrhage, partially enhancement
homogenous enhancement with necrosis
SUVmax on PET
No.
FDG SUVmax
MET SUVmax
3
12.1
9.3
4
8.8
5.3
5
22.2
10.1
Case 1: 33/M

Case 1 had a “tiger-striped” appearance
with faint contrast enhancement on
MRI and was accordingly diagnosed
preoperatively as Lhermitte-Duclos
disease. However, the confirmed
pathological diagnosis was cerebellar
GMB. To our knowledge, this is the first
report of a case of cerebellar GBM with
a Lhermitte-Duclos disease like “tigerstriped” appearance. The reasons for
these imaging findings are unknown,
and the preoperative differential
diagnosis was therefore extremely
difficult.
Case 2: 71/F

The appearances of GBM vary widely,
although the most important unifying
characteristic, which is recognized during
both radiologic and gross pathologic
examinations, is the presence of hemorrhage
or necrosis. The primary cellular component
of the tumor exhibits variable attenuation on
unenhanced CT and depending on tumor
cellularity, hypointensity on T1WI. The
presence of necrosis is clearly demonstrated
as a ring enhancement on Gd-enhanced T1WI
and serves as a key indicator of GBM
diagnosis.
Case 6: 18/M
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In this case, intra-tumoral hemorrhage was
depicted strong attenuation on unenhanced CT.
On T2WI, a hyperintense rim surrounding a
hypointense area, which was also suggestive of
hemorrhage, was exhibited. A ring enhancement
was also shown surrounding the hemorrhage.
In our patient series, an irregular ring
enhancement finding on MRI was evident in
three cases, and a solid tumor with necrosis was
evident in one case. These four cases could be
prospectively diagnosed as cerebellar GBM.
Case 3: 70/M

FGD
MET
Cases 3 and 5 exhibited strongly
increased FDG and MET uptake, and
PCNSL was assumed as a preoperative
diagnosis. In these cases, the MET
uptake area was larger than the Gd
enhancement area. Sasaki et al.
reported a larger area of MET uptake
than the areas of FDG uptake and Gd
enhancement in astrocytic tumors. In
contrast, Ogawa et al. reported that
the area of increased MET
accumulation was larger than those of
the enhancing lesions observed on CT
or MR images from patients with
PCNSL.
Case 5: 56/M
FDG
MET

FDG-PET has been reported as a
useful tool for differentiating
PCNSL from high-grade glioma.
Makino et al. and Okada et al.
reported that a FDG SUVmax of
≥12 indicated PCNSL, whereas a
value <12 suggested GBM;
however cases 3 and 5 of our
GBM patients had FDG SUVmax
values >12.
Discussions

GBM is the most common type of primary CNS tumor
and is located most frequently in the cerebral
hemispheres, with a peak age of onset during the
sixth or seventh decade of life. According to previous
reports, cases of GBM in the cerebellum are
extremely rare. The theory in which cerebellar GBM
originates from embrionarycells was altered following
the proposed anaplasic progression of mature
cerebellar astrocytic cells. Therefore, there is no
apparent explanation for the rarity of the
infratentorial compartment as a site of GBM origin.
Discussions
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MRI is the diagnostic method of choice for a
suspected intracranial tumor. Nevertheless, cerebellar
GBM can be easily misdiagnosed, even after
performing contrast-enhanced high-resolution MRI
because the imaging findings are often unspecific.
A discrepancy between the MET uptake area and
lesion enhancement area on MRI suggests a
diagnosis of glioma or PCNSL.
FDG SUVmax has been reported as a useful tool for
differentiating PCNSL from high-grade glioma. In our
patients series, however, the differential diagnoses
were difficult despite referring SUV max values.
Conclusion

We reviewed the radiological features of
seven cases of cerebellar GBM. Some of
these cerebellar GBM cases did not
exhibit common CT, MRI, and PET
findings. Therefore, the consideration of
CT, MRI, and PET findings in the
differential diagnosis of cerebellar GBM
remains challenging.
References
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Gopalakrishnan CV, Dhakoji A, Nair S, et al. J Clin Neurosci 2012;19:1684-1688
Grahovac G, Tomac D, Lambasa S, et al. Acta Neurochir (Wien) 2009;151:653-657
Gupta V, Goyal A, Sinha S, et al. J Neurosurg Sci 2003;47:157-164
Kuroiwa T, Numaguchi Y, Rothman MI, et al. American Journal of Neuroradiology
1995;16:583-589
Mattos JP, Marenco HA, Campos JM, et al. Arq Neuropsiquiatr 2006;64:132-135
Akimoto J, Fukami S, Tsutsumi M, et al. Brain Tumor Pathol 2009;26:59-68
Chiofalo M, Cappabianca P, Del Basso De Caro M, et al. Journal of Neuro-Oncology
2007;82:183-185
Thomas B, Krishnamoorthy T, Radhakrishnan VV, et al. Neuroradiology
2007;49:733-738
Sasaki M, Kuwabara Y, Yoshida T, et al. Eur J Nucl Med 1998;25:1261-1269
Ogawa T, Kanno I, Hatazawa J, et al. Radiographics 1994;14:101-110
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