CNS tumor
Astrocytic tumors
Glioblastoma multiforme, NOS

Topic Completed: 1 March 2012

Minor changes: 1 February 2020

Copyright: 2002-2020,, Inc.

PubMed Search: Glioblastoma multiforme [title] NOS

Eman Abdelzaher, M.D., Ph.D.
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Cite this page: Abdelzaher, E. Glioblastoma multiforme, NOS. website. Accessed June 3rd, 2020.
Definition / general
  • See glioblastoma-IDH wildtype and glioblastoma-IDH mutant
  • NOS (not otherwise specified) suffix was introduced in the 2016 WHO classification for cases in which molecular information is not available or is insufficient for a more specific diagnosis (Louis: WHO Classification of Tumours of the Central Nervous System, 4th Edition, 2016)
  • Since this entity definition requires the presence of both IDH mutation and 1p / 19q codeletion, NOS can be used whenever one or both are not known, in a tumor that morphologically shows classical features of glioblastoma
  • A subsequent consensus paper from a group of experts named cIMPACT-NOW clarifies that this NOS designation should be used only when results are not available (i.e. they cannot or will not be performed or they were performed but results were not obtainable after a technical failure) and not when testing was performed but did not show the typical or expected alterations (Acta Neuropathol 2018;135:481)
  • A detailed report describing the histological and molecular findings should always be provided when using this terminology
  • Given the uncertainty of the term NOS, which presents the treating physicians with challenges in deciding adequate treatment, the recommendation is to avoid its use and to seek as much precision as possible in the diagnosis of brain tumors

Note: *** this topic is in the process of being updated ***
  • Malignant primary brain tumor with predominant astrocytic differentiation
  • WHO grade IV
  • "Multiforme" due to variegated gross appearance (firm white areas, yellow necrotic areas, hemorrhagic areas and cystic areas) as well as diverse histological features
  • Sites
    • Usually supratentorial; uncommon in cerebellum, rare in spinal cord
    • Glioblastoma of brain stem is infrequent and often affects children
    Clinical features
    • 12 - 15% of adult intracranial tumors, 50 - 60% of astrocytic neoplasms
    • Either primary (denovo, without recognizable precursor lesions, with p53 mutation) or secondary (develops slowly from grade II or III astrocytoma, often with partial #10 deletion)
    • May be under graded on small stereotactic biopsies due to regional heterogeneity
    • Median survival is 1 year; 5 year survival < 5%; survival may be overstated due to low grade tumors that dedifferentiate to glioblastoma (Cancer 2003;98:1745)
    Radiology description
    • Contrast enhancing (ring pattern is characteristic), large, surrounded by peritumoral edema, mass effect
    Radiology images

    Images hosted on other servers:

    MRI sagittal view

    With ring enhancement

    Case reports
    Gross description
    • Fast growing tumors may have apparent pseudocapsule
    • Large tumors are poorly delineated
    • Usually solitary but may cross midline through corpus callosum, massa intermedia or anterior commissure to produce a "butterfly" lesion
    • Often peritumoral edema
    • Cut section is variegated (yellowish necrotic central area, grayish peripheral rim, recent and old hemorrhage, cysts due to liquefied necrotic tumor tissue)
    • Usually intraparenchymal
    • Infrequently superficial, may grossly / radiologically resemble metastatic carcinoma or meningioma
    Gross images

    Images hosted on other servers:

    Variegated tumor

    Microscopic (histologic) description
    • High grade astrocytoma (anaplastic, nuclear atypia, cellular pleomorphism, mitotic activity) with either coagulation necrosis or microvascular proliferation (formerly "endothelial proliferation") with thickened vascular walls due to endothelial cell hyperplasia (increase in nuclei in vessel wall) and hypertrophy; also formation of multiple lumina resembling glomerulus
    • Usually hypercellular with mitotic figures (some atypical), multinucleated tumor cells, bizarre nuclei, karyorrhectic cells
    • May have pseudopalisading necrosis (tumor cells around necrotic zones), secondary structures of Scherer
    • Other less common features: epithelial structures (glandular or ribbon-like), epithelioid cells with well delineated cytoplasmic membranes, granular cells, lipidized cells, macrophages (Arch Pathol Lab Med 2001;125:637)
    • Small cell glioblastoma:
      • Densely packed small cells, resembles anaplastic oligodendroglioama on low power, may be calcification, perivascular pseudorosettes
      • May have a better prognosis than standard glioblastoma
      • Note: examine carefully to determine if low grade tumor also present, suggesting dedifferentiation
      • Glioblastoma with oligodendroglioma component: according to WHO classification (2007), anaplastic oligoastrocytoma associated with necrosis should be classified as "glioblastoma with oligodendroglial component"
    Microscopic (histologic) images

    Images hosted on other servers:

    Prominent anaplasia, vascular proliferation and palisading of tumor cells around necrosis

    Various vascular patterns

    H&E and HAM56+ macrophages

    Previous resection and radiation therapy

    Various images

    Positive stains
    Negative stains
    Molecular / cytogenetics description
    • Amplification of EGFR (particularly in small cell variant, Clin Neuropathol 2005;24:163), mutations of p16, p53 and PTEN; loss of heterozygosity at 10q
    Differential diagnosis
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