A 30-year-old man presented with weeks of progressive headaches, imbalance, and aphasia. Brain MRI revealed an enhancing left frontal mass (figure 1, A and B). Chest imaging revealed mediastinal and hilar adenopathy (figure 1, C and D). Metastatic cancer was initially suspected, but pulmonary lymph node aspiration revealed sarcoidosis (figure 2A). Subsequent brain biopsy revealed glioblastoma (figure 2B).
Coronal contrasted T1 (A) shows heterogeneously enhancing, multifocal mass. Axial fluid-attenuated inversion recovery (B) shows vasogenic edema. Chest x-ray (C) and CT (D) demonstrate lymphadenopathy (arrows).
Lymph node biopsy (A) reveals sarcoid, with noncaseating granuloma (asterisk) surrounded by lymphocytes (arrow). Brain biopsy (B) reveals glioblastoma, with pseudopalisading necrosis (asterisk) and vascular proliferation (arrow).
This case emphasizes the importance of histologic diagnosis before initiating therapy. One study demonstrated nearly 50% variation in diagnosis following brain biopsy, 27% leading to a change in treatment.1 Sarcoid is associated with increased risk of certain cancers, though this has not been demonstrated for gliomas.2
AUTHOR CONTRIBUTIONS
Analysis and interpretation of data: Drs. Jordan, Yang, Narendra, and Plotkin. Drafting of the manuscript: Drs. Jordan, Yang, and Plotkin. Critical revision of the manuscript for important intellectual content: Drs. Jordan, Yang, Narendra, and Plotkin.
STUDY FUNDING
No targeted funding reported.
DISCLOSURE
The authors report no disclosures relevant to the manuscript. Go to Neurology.org for full disclosures.
ACKNOWLEDGMENT
The authors thank Dr. Maria Cobos Sillero, fellow in the Department of Neuropathology at the Massachusetts General Hospital, for her assistance in obtaining pathologic photographs.
Footnotes
Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
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- © 2014 American Academy of Neurology
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