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Journal of Cancer Research and Therapeutics, Vol. 5, No. 1, January-March, 2009, pp. 43-45 Case Report Butterfly glioma of the corpus callosum Agrawal, Amit Department of Surgery, Datta Meghe Institute of Medical Sciences, Sawangi (Meghe), Wardha, India. Code Number: cr09010 Abstract The prognosis of glioblastoma multiforme (GBM) is poor even with aggressive first-line therapy, which includes surgery, radiation therapy, and adjuvant chemotherapy. Although the ideal course of treatment for elderly patients with newly diagnosed GBM is still undecided and requires further studies, the new chemotherapeutic agents administered with or without concomitant radiation therapy have shown promising results. However, in our setting, where resources are limited and newer treatment options are expensive, it is often difficult to deliver the best care to the patient.Keywords: Butterfly glioma, corpus callosum, glioma, glioblastoma Introduction The differential diagnoses of a mass lesion in the corpus callosum includes butterfly glioma [1],[2],[3],[4] and, rarely, lymphoma, metastasis, [2] toxoplasmosis, [5] demyelinating butterfly pseudoglioma, [6] and neuronal ceroid-lipofuscinosis (Kufs' disease). [7] In this article we report a case of butterfly glioma that had the characteristic imaging findings and discuss the role of the newer treatment modalities.Case Report A 70-year-old gentleman presented with a history of one episode of generalized tonic-clonic seizures followed by altered sensorium of 1 day's duration. Prior to the seizure he had complained of nausea, a sensation of uneasiness, and mild headache. He was a known case of hypertension but did not have diabetes. There was no history of fever, trauma, or any major systemic illness in the past. His general and systemic examination was unremarkable. On neurological examination, he was drowsy but rousable and obeyed commands on repeated requests. The pupils were equal and reactive to light bilaterally. There was no facial weakness. He was moving all four limbs. All deep tendon reflexes were exaggerated and the planters were extensor. Magnetic resonance imaging (MRI) of the brain showed a hypointense lesion on T1 imaging that was hyperintense on T2 and FLAIR images and enhanced after contrast administration. The lesion involved the splenium of the corpus callosum and extended on both sides into the occipital and temporal lobes [Figure - 1]. A diagnosis of corpus callosal butterfly glioma was suspected; a stereotactic biopsy of the lesion confirmed the diagnosis of high-grade glioma. We advised radiotherapy but his relatives did not give consent for any further interventions. One month later he was admitted with neurological deterioration and status epilepticus. He did not improve and succumbed to the ailment.Discussion Glioblastoma multiforme (GBM) is the most common diffuse astrocytic tumor in adults and is extremely aggressive. GBM most commonly spreads via direct extension along white matter tracts, including the corpus callosum; hematogenous, subependymal, and cerebrospinal fluid spread also occurs. As in the present case, when the corpus callosum is affected, GBM commonly displays a characteristic bihemispheric involvement, resulting in the classic butterfly pattern on imaging. [2] Because the corpus callosum is relatively resistant to infiltration, GBM should be considered whenever any lesion crossing the corpus callosum is encountered. [2],[8] On MRI, these tumors typically enhance solidly and intensely in the corpus callosum, although occasionally no enhancement may be seen. [2] Despite aggressive first-line therapy, consisting of surgery, radiation therapy, and adjuvant chemotherapy, GBM invariably recurs, and the median survival is only 9-12 months. [9] To make the issue gloomier, age has been recognized as a poor prognostic indicator in patients with high-grade glioma [10] and only a few studies have evaluated the outcome in patients up to age 70 years. [10],[11],[12] Treatment strategies for elderly patients with GBM remain a matter of debate; options range from palliative care to aggressive strategies, including surgery, radiation therapy, and chemotherapy. [10],[13],[14] In one study, the subgroup of elderly patients diagnosed to have GBM were recognized as a distinct population in terms of toxicity and treatment compliance, and the role of different management options for GBM in elderly patients were reviewed. [11] For example, radiation therapy requires particularly strict compliance in the elderly population and is also associated with significant cognitive impairments. [11] Recently, temozolomide a new, second-generation alkylating agent was used successfully in the management of GBM in the elderly. [11],[15],[16],[17] This drug can be given orally, crosses the blood-brain barrier readily, and has a favorable toxicity profile, with easily managed noncumulative myelosuppression. Temozolomide (without the use of concomitant radiation therapy) has been reported to be a safe first-line treatment for newly diagnosed GBM in elderly patients: it is effective as a single agent, convenient, and less invasive than other treatments. [11] The combination of Carmustine (BCNU) with temozolomide as neoadjuvant therapy in inoperable GBM has also exhibited promising activity and a good safety profile; however, further evaluation is recommended. [18] The ideal course of treatment for elderly patients with newly diagnosed GBM requires careful consideration, and further studies will be necessary to determine the role of the new chemotherapeutic agents, used with or without radiation therapy. [11],[15],[19] To summarize, in our setting, where resources are limited and newer treatment options prohibitively expensive, it often becomes difficult to deliver the best possible care to the patient. Nevertheless, urgent and definitive diagnosis of corpus callosal butterfly lesions is important, as the differential diagnoses of these tumors includes many benign and potentially treatable conditions [Table - 1], with the prognoses varying from favorable (e.g., for toxoplasmosis) to poor (e.g., for glioblastoma). References
Copyright 2009 - Journal of Cancer Research and Therapeutics The following images related to this document are available:Photo images[cr09010f1.jpg] [cr09010t1.jpg] |
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![[Figure - 1]](/showimage?cr/photo/cr09010f1.jpg){kind=link}
![[Table - 1]](/showimage?cr/photo/cr09010t1.jpg){kind=link}