CAS E REP O R T Open Access
Extracranial propagation of glioblastoma with
extension to pterygomaxillar fossa
Damir Tomac
1
, Darko Chudy
1
, Smiljka Lambaša
2
, Iva Topić
3
, Gordan Grahovac
1*
and Arijana Zoric
4
Abstract
Background: Glioblastoma multiforme is a highly malignant primary brain tumor that shows marked local
aggressiveness, but extracranial spread is not a common occurrence. We present an unusual case of recurrent
glioblastoma in 54-year old male that spread through the scull base to the ethmoid and sphenoid sinuses, to the
orbita, pterygomaxillar fossa, and to the neck.
Methods: A 54-year old male underwent left temporal resection because of brain tumor of his left temporal lobe.
Operation was followed by external beam radiation combined with temozolomide. The tumor recurred eight
months after first surgery. The patient developed swelling of left temporal region, difficult swallowing and
headache. MRI of head showed recurrent tumor, which invaded orbita, ethmoid and sphenoid sinuses, nasal cavity,
pterygomaxillar fossa.
Results: The patient died ten months after initial diagnosis of glioblastoma multiforme, and two months after his
second operation.
Conclusions: The aggressive surgical operation helped to downsize the tumor mass as much as possible, but did
not prolonged significantly the life or improved the life quality of the patient. The current literature is reviewed,
and the diagnostic approaches as well as therapeutic options are discussed.
Background
Glioblastoma multiforme is a highly malignant primary
brain tumor. The median survival with therapy is
approximately 9-12 months[1].Glioblastomashows
marked local aggressiveness, but extracranial spread is
not a common occurrence. It is believed that dura pro-
vides excellent protection against infiltration by malig-
nant tumors. Improvement of treatment options and
survival time led to increase of extracranial recurrence
of glioblastoma. Most commonly glioblastomas metas-
tases are to the lungs, lymph nodes, liver, and bones [2].
We report an exceptional case of glioblastoma multi-
forme spreading extracranially to the orbita, ethmoid
and sphenoid sinuses, nasal cavity, pterygomaxillar fossa,
and neck.
Case Report
A 54-year old Caucasian male presented to Department
of Neurosurgery complaining of severe headaches,
dizziness, and dysarthria that lasted for 2 weeks. His
personal and family history was unremarkable, and his
Karnofsky score was 90. Upon admission MSCT showed
a hypodense lesion in the left temporal lobe. After initial
analysis MRI of the head was scheduled, which showed
a ring-enhancing lesion in the left temporal lobe.
(Figure 1) We preformed left temporal osteoplastic
craniotomy, and tumor was removed along with the sur-
rounding normal brain tissue (Figure 2). Regression of
dysarthria was noticed after the operation, and his Kar-
nofsky score was 100 at discharge. Histopathological
analysis confirmed diagnosis of glioblastoma, gradus IV
according to WHO. After discharge patient was sent for
oncological evaluation.
The patient received radiotherapy in daily factions of 2
Gy given 5 days per week for 6 weeks, for total 60 Gy
plus continuous daily temozolomide (75 mg per square
meter of body-surface area per day). Following with the
six cycles of the adjuvant temozolomide therapy (150 to
200 mg per square meter for 5 days).
Three months after operation control MSCT showed
no signs of tumor. Eight months after the first operation
* Correspondence: ggrahov@mef.hr
1
Department of Neurosurgery, Clinical Hospital Dubrava, Zagreb, Croatia
Full list of author information is available at the end of the article
Tomac et al.World Journal of Surgical Oncology 2011, 9:53
http://www.wjso.com/content/9/1/53 WORLD JOURNAL OF
SURGICAL ONCOLOGY
© 2011 Tomac et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creative commons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, pro vided the original work is properly cited.
MRI was performed and revealed a tumor that involved
middle cranial fossa with extension to the left orbita,
ethmoid and sphenoid sinuses, nasal cavity, and pterygo-
maxillar fossa (Figure 3, Figure 4). The patient had Kar-
nofsky score of 70 at second admission when he was
transferred to Department of Neurosurgery. Left tem-
poral recraniotomy and reduction of intracranial tumor
and tumor in pterygomaxillar fossa was performed.
Zygoma and left side of the mandible were resected.
Parotid gland and masseter muscle were used for defect
Figure 1 Axial T1 weighted contrast enhanced MRI image demonstrating ring-enhanced lesion of the left temporal lobe
Tomac et al.World Journal of Surgical Oncology 2011, 9:53
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Page 2 of 6
reconstruction. Histological analysis showed glioblas-
toma multiforme with invasion of bone, muscles, and
blood vessels (Figure 5, Figure 6 and Figure 7). The
patient died two months after second operation. The
patient and the family declined any other oncology
treatment because the Karnofsky score at discharge was
40, which rapidly deteriorated after discharge form the
hospital. Autopsy was not performed.
Despite malignant nature of glioblastoma multiforme,
extracranial metastases are rare [3]. Glioblastoma are
prevented from metastasing by the relatively impassable
dura, tough basal membrane around intracerebral blood
vessels, and lack of true lymphatics in the brain[4].
Local dissemination to the scalp, face, and neck usually
occurs after operations and failure of closure of the
dura, or after shunt operations. Such procedures can
facilitate tumor cells to enter vascular system, extracra-
nial lymphatic system, or directly enter the peritoneum
in the setting of a ventriculoperitoneal shunt. Direct
bone invasion, which might interfere with local dural
blood supply resulting in dural necrosis, is also possible.
According to pathohistological findings in our patient,
Figure 2 Axial contrast enhanced MSCT of the head showing no signs of tumor.
Tomac et al.World Journal of Surgical Oncology 2011, 9:53
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we believe that extracranial spread was caused by
angioinvasion and invasion of the bone of the scull base.
Similarly, surgery may also have made metastases more
likely by simply prolonging the life of the patient [5].
Although rare, there are cases of glioblastoma multi-
forme with extracranial metastases in the absence of
previous craniotomies [2,6]. Various mechanisms of
spontaneous transdural spread have been described. The
tumor can extend through the perivascular or dural slit,
the increase of the intracranial pressure over a long per-
iod of time will allow the cerebral cortex to insinuate
itself wherever possible through the dura, or transdural
extension may originate by infiltration of tumor cells
into the previously herniated normal brain substance
[7]. The tumor can also pass through the dura mater by
way of cranial or spinal nerves [8], or the dura can be
directly destroyed by the tumor.
Conclusions
In summary, the extra cranial spread of glioblastoma
multiforme is a rare occurrence. In this report we pre-
sented unusual case of extra cranial spread of glioblas-
toma multiforme after resection and concomitant
radiotherapy with chemotherapy. The tumor showed
Figure 3 Axial T1-weighted contrast enhanced MRI image demonstrates extra cranial portion of the tumor extended to the sphenoid
and ethmoid sinuses, nasal cavity, and orbit.
Tomac et al.World Journal of Surgical Oncology 2011, 9:53
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aggressive clinical behavior after standard treatment in
very short period of time. The recurrent tumor extended
to the orbit, ethmoid and sphenoid sinuses, and to the
pterygomaxillar fossa. During second surgery we could
observe the adherent brain tumor mass to the temporal
dura. The tumor destructed the floor of the skull base;
the dura mater was absent from the floor of the skull
base. The pathological findings revealed invasion of the
bone of the skull base, and underlying masticator mus-
cles in the infratemporal fossa. Due to intraoperative
and histological findings we believe that the tumor
spread with direct invasion of the dura and underlying
scull base and mastication muscles. In the later stage of
disease tumor showed angioinvasion. Aggressive opera-
tion can downsize the tumor mass but the life quality
may not be improved significantly.
Consent
Written informed consent was obtained from the patient
for publication of this Case report and any accompanying
Figure 4 Sagittal T1-weighted contrast enhanced MRI image demonstrates intracranial and extra cranial portion of the tumor
extended to the sphenoid and ethmoid sinuses, nasal cavity, orbit, pterygomaxillar fossa, and neck.
Tomac et al.World Journal of Surgical Oncology 2011, 9:53
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Page 5 of 6
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
List of abbreviations
MRI: magnetic resonance imaging; MSCT: multi slice computed tomography;
WHO: World health organization
Author details
1
Department of Neurosurgery, Clinical Hospital Dubrava, Zagreb, Croatia.
2
Department of Pathology, Clinical Hospital Dubrava, Zagreb, Croatia.
3
Department of Otorhinolaryngology, Head and Neck Surgery, Clinical
Hospital Center Zagreb, Croatia.
4
Rudjer Boskovic Institute, Division for
Molecular Medicine, Laboratory of Molecular Oncology, Zagreb, Croatia.
Authors’contributions
DT collected the data, analyzed data and wrote the paper, DC gave
conceptual design and edited the paper, SL gathered pathological pictures
and interpreted them, IT supervised and edited the paper, GG wrote the
paper, AZ supervised the paper end edited the paper. All authors read and
approved the final manuscript.
Competing interests
All authors declare that they do not have any financial or non-financial
competing interests in relation in relation to this manuscript.
Received: 20 December 2010 Accepted: 19 May 2011
Published: 19 May 2011
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doi:10.1186/1477-7819-9-53
Cite this article as: Tomac et al.: Extracranial propagation of
glioblastoma with extension to pterygomaxillar fossa. World Journal of
Surgical Oncology 2011 9:53.
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Figure 5 Tissue sections showing a glioblastoma multiforme
with invasion in muscle tissue (hematoxylin-eosin stain, ×400).
Figure 6 Tissue sections showing a glioblastoma multiforme
with bone invasion (hematoxylin-eosin stain, ×400).
Figure 7 Tissue sections showing a glioblastoma multiforme
with angioinvasion (hematoxylin-eosin stain, ×400).
Tomac et al.World Journal of Surgical Oncology 2011, 9:53
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