Management of Grade IV Astrocytoma Diagnosed During Pregnancy

Purpose: To report a rare case of Grade IV astrocytoma diagnosed during pregnancy Methods: Case Report Results: Glioblastoma multiforme (GBM) is a highly malignant brain tumor derived from astrocytes. It is the most common malignant brain tumor, accounting for approximately 16% of all central nervous system neoplasms. Historically GBMs were clinically categorized by the decade of age they affect patients; primary glioblastomas are more frequent in patients in their 6th decade of life while secondary glioblastomas tend to affect patients in their 4th decade of life. However in 2016, the World Health Organization classified glioblastomas mainly on isocitrate dehydrogenase (IDH) mutation status: IDH-wildtype glioblastoma correlates with primary glioblastoma and IDH-mutant glioblastoma corresponds with secondary glioblastoma. Secondary glioblastomas arise from preexisting low-grade tumors such as diffuse or anaplastic astrocytomas and have mutations of IDH, p53 gene, or loss of chromosome 19q. Patients tend to have a short disease course with death occurring within weeks due to rapid tumor growth with symptoms of increased intracranial pressure, seizures, and focal neurologic symptoms. Early diagnosis and treatment are key, and positive prognostic factors include IDH-mutant glioma, lower patient age, and accessibility to surgical intervention. Patient is a 29-year-old G3P1112 with an intrauterine pregnancy at 21 weeks dated by 10 week ultrasound not consistent by last menstrual period who presented to the emergency department with a three day history of stroke like symptoms. Patient did not have any significant past medical history or family history of BRCA1/2 mutations. Her first pregnancy ended with a surgical abortion at 16 weeks. Her second pregnancy was a full term vaginal delivery without complications. In May 2023, the patient started having unremitting right-sided headaches managed symptomatically for approximately 3 months that started when she was 10 weeks pregnant. A month later at approximately 22 weeks gestation, she developed left-sided weakness which progressively worsened, and ambulation became difficult. In June 2023 when patient presented to the emergency department, she had a positive left sided pronator drift and flattening of the nasolabial fold on physical exam. Patient also reported episodes of time where she would stare off into space for thirty seconds to a minute. Imaging revealed a heterogeneous mass involving the right frontal lobe with minimal surrounding edema with marked mass effect with a subfalcine herniation and mild obstructive hydrocephalus. At that time, patient was subsequently seen by OB/GYN and neurosurgery. MRI showed a 3.2 x 2.4 x 3.1 cm lesion in the right frontal lobe with a second lesion nearby measuring 2.7 x 1.6 x 2.7 cm. Both lesions were heterogeneous with solid and cystic components associated with vasogenic edema with a leftward midline shift. Two weeks later, the patient had a right frontal craniotomy, and pathology revealed a high-grade glioma consistent with an IDH-1 mutation with a final histological diagnosis of a WHO Grade 4 astrocytoma. Follow-up brain imaging was consistent with a gross total resection. Patient delivered a viable 1740 gram infant via vaginal delivery at 32 weeks with APGARs 7/8. Her postpartum course was uncomplicated. Patient was discharged postpartum day two after meeting adequate milestones. After delivery, plans were made to proceed with definitive chemoradiotherapy in September 2023 with temozolomide and ivermectin per neurosurgery and hematology/oncology teams. Current goals of therapy are palliative with an attempt to approach from a curative intent standpoint with a guarded prognosis. Conclusion: GBM is a highly malignant neoplasm associated with a short disease course and a poor prognosis. There are variable reasons why GBMs are rarely associated with pregnancy, much less treated. It is pertinent to identify early symptoms of disease to decrease patient mortality, which in this case were simply headaches initially. GBM presenting during pregnancy carries unique challenges to the patient and fetus, and multidisciplinary care management is key. Survival rate was significantly better in patients who underwent chemotherapy plus radiotherapy treatment than patients who were under radiotherapy alone. In this patient, there was a delicate balance aimed to deliver not only a positive fetal outcome but also a positive maternal outcome. In conclusion, advanced GBM in pregnancy is not only a medical predicament but also an ethical one in which the delivery of multidisciplinary patient care is fundamental.