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Glioblastoma
Karen L. Salzman, MD
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Pathology

          • Clinical Issues

            TERMINOLOGY

            • Synonyms

              • Glioblastoma (GBM), grade 4 astrocytoma, malignant astrocytoma, glioblastoma multiforme (outdated term)
            • Definitions

              • Rapidly enlarging malignant astrocytic tumor characterized by necrosis and neovascularity
              • Most common of all primary intracranial malignant neoplasms
              • GBM, IDH-wild-type is most common and most malignant (~ 90% of GBM)
              • GBM, IDH-mutant arises from lower grade astrocytic tumors (diffuse astrocytoma, grade 2 or anaplastic astrocytoma, grade 3) and has better prognosis

            IMAGING

            • General Features

              • CT Findings

                • MR Findings

                  • Angiographic Findings

                    • Nuclear Medicine Findings

                      • Imaging Recommendations

                        DIFFERENTIAL DIAGNOSIS

                          PATHOLOGY

                          • General Features

                            • Staging, Grading, & Classification

                              • Gross Pathologic & Surgical Features

                                • Microscopic Features

                                  CLINICAL ISSUES

                                  • Presentation

                                    • Demographics

                                      • Natural History & Prognosis

                                        • Treatment

                                          DIAGNOSTIC CHECKLIST

                                          • Consider

                                            • Image Interpretation Pearls

                                              Selected References

                                              1. Jackson C et al: A systematic review and meta-analysis of supratotal versus gross total resection for glioblastoma. J Neurooncol. ePub, 2020
                                              2. Shimizu T et al: Differentiating between glioblastomas with and without isocitrate dehydrogenase gene mutation by findings on conventional magnetic resonance images. J Clin Neurosci. 76:140-4, 2020
                                              3. Ohno M et al: Survival benefits of hypofractionated radiotherapy combined with temozolomide or temozolomide plus bevacizumab in elderly patients with glioblastoma aged ≥ 75 years. Radiat Oncol. 14(1):200, 2019
                                              4. Tixier F et al: Preoperative MRI-radiomics features improve prediction of survival in glioblastoma patients over MGMT methylation status alone. Oncotarget. 10(6):660-72, 2019
                                              5. Bae S et al: Radiomic MRI phenotyping of glioblastoma: improving survival prediction. Radiology. 289(3):797-806, 2018
                                              6. Hong EK et al: Radiogenomics correlation between MR imaging features and major genetic profiles in glioblastoma. Eur Radiol. 28(10):4350-61, 2018
                                              7. Lam S et al: Patient and treatment factors associated with survival among pediatric glioblastoma patients: a Surveillance, Epidemiology, and End Results study. J Clin Neurosci. 47:285-93, 2018
                                              8. Rowe LS et al: Differentiating pseudoprogression from true progression: analysis of radiographic, biologic, and clinical clues in GBM. J Neurooncol. 139(1):145-52, 2018
                                              9. Korshunov A et al: H3-/IDH-wild type pediatric glioblastoma is comprised of molecularly and prognostically distinct subtypes with associated oncogenic drivers. Acta Neuropathol. 134(3):507-16, 2017
                                              10. Liu X et al: The preliminary radiogenomics association between MR perfusion imaging parameters and genomic biomarkers, and their predictive performance of overall survival in patients with glioblastoma. J Neurooncol. 135(3):553-60, 2017
                                              11. Blasel S et al: Perfusion MRI in the evaluation of suspected glioblastoma recurrence. J Neuroimaging. 26(1):116-23, 2016
                                              12. Cui Y et al: Prognostic imaging biomarkers in glioblastoma: development and independent validation on the basis of multiregion and quantitative analysis of MR images. Radiology. 278(2):546-53, 2016
                                              13. Louis DN et al: The 2016 World Health Organization Classification of Tumors of the Central Nervous System: a summary. Acta Neuropathol. 131(6):803-20, 2016
                                              14. Nikitović M et al: Pediatric glioblastoma: a single institution experience. Childs Nerv Syst. 32(1):97-103, 2016
                                              15. Andre JB et al: Cerebral blood flow changes in glioblastoma patients undergoing bevacizumab treatment are seen in both tumor and normal brain. Neuroradiol J. 28(2):112-9, 2015
                                              16. Bauer AH et al: Differentiation of solitary brain metastasis from glioblastoma multiforme: a predictive multiparametric approach using combined MR diffusion and perfusion. Neuroradiology. 57(7):697-703, 2015
                                              17. Harris RJ et al: MRI perfusion measurements calculated using advanced deconvolution techniques predict survival in recurrent glioblastoma treated with bevacizumab. J Neurooncol. 122(3):497-505, 2015
                                              18. Iagaru A et al: Glioblastoma multiforme recurrence: an exploratory study of 18F FPPRGD2 PET/CT. Radiology. 141550, 2015
                                              19. Ideguchi M et al: MRI findings and pathological features in early-stage glioblastoma. J Neurooncol. 123(2):289-97, 2015
                                              20. Kobayashi K et al: Prognostic value of volume-based measurements on (11)C-methionine PET in glioma patients. Eur J Nucl Med Mol Imaging. 42(7):1071-80, 2015
                                              21. Mabray MC et al: Modern brain tumor imaging. Brain Tumor Res Treat. 3(1):8-23, 2015
                                              22. Melguizo-Gavilanes I et al: Characterization of pseudoprogression in patients with glioblastoma: is histology the gold standard? J Neurooncol. 123(1):141-50, 2015
                                              23. Pope WB: Genomics of brain tumor imaging. Neuroimaging Clin N Am. 25(1):105-19, 2015
                                              24. Schmainda KM et al: Dynamic susceptibility contrast MRI measures of relative cerebral blood volume as a prognostic marker for overall survival in recurrent glioblastoma: results from the ACRIN 6677/RTOG 0625 multicenter trial. Neuro Oncol. 17(8):1145-56, 2015
                                              25. Smith TR et al: Use of preoperative FLAIR MRI and ependymal proximity of tumor enhancement as surrogate markers of brain tumor origin. J Clin Neurosci. 22(9):1397-402, 2015
                                              26. Stadlbauer A et al: Quantification of serial changes in cerebral blood volume and metabolism in patients with recurrent glioblastoma undergoing antiangiogenic therapy. Eur J Radiol. 84(6):1128-36, 2015
                                              27. Tietze A et al: Perfusion MRI derived indices of microvascular shunting and flow control correlate with tumor grade and outcome in patients with cerebral glioma. PLoS One. 10(4):e0123044, 2015
                                              28. Barajas RF Jr et al: Benefits of dynamic susceptibility-weighted contrast-enhanced perfusion MRI for glioma diagnosis and therapy. CNS Oncol. 3(6):407-19, 2014
                                              29. Das KK et al: Pediatric glioblastoma: clinico-radiological profile and factors affecting the outcome. Childs Nerv Syst. 28(12):2055-62, 2012
                                              30. Mahvash M et al: Glioblastoma multiforme in children: report of 13 cases and review of the literature. Pediatr Neurol. 45(3):178-80, 2011
                                              31. Perkins SM et al: Glioblastoma in children: a single-institution experience. Int J Radiat Oncol Biol Phys. 80(4):1117-21, 2011
                                              32. Koukourakis GV et al: Temozolomide with radiation therapy in high grade brain gliomas: pharmaceuticals considerations and efficacy; a review article. Molecules. 14(4):1561-77, 2009
                                              33. Martin V et al: Encountering and advancing through antiangiogenesis therapy for gliomas. Curr Pharm Des. 15(4):353-64, 2009
                                              34. McGirt MJ et al: Gliadel (BCNU) wafer plus concomitant temozolomide therapy after primary resection of glioblastoma multiforme. J Neurosurg. 110(3):583-8, 2009
                                              35. Miletic H et al: Anti-VEGF therapies for malignant glioma: treatment effects and escape mechanisms. Expert Opin Ther Targets. 13(4):455-68, 2009
                                              36. Oshiro S et al: Efficacy of temozolomide treatment in patients with high-grade glioma. Anticancer Res. 29(3):911-7, 2009
                                              37. Paldino MJ et al: Repeatability of quantitative parameters derived from diffusion tensor imaging in patients with glioblastoma multiforme. J Magn Reson Imaging. 29(5):1199-205, 2009
                                              38. Pirotte BJ et al: Positron emission tomography-guided volumetric resection of supratentorial high-grade gliomas: a survival analysis in 66 consecutive patients. Neurosurgery. 64(3):471-81; discussion 481, 2009
                                              39. Quinn JA et al: Phase II trial of temozolomide plus o6-benzylguanine in adults with recurrent, temozolomide-resistant malignant glioma. J Clin Oncol. 27(8):1262-7, 2009
                                              40. Saraswathy S et al: Evaluation of MR markers that predict survival in patients with newly diagnosed GBM prior to adjuvant therapy. J Neurooncol. 91(1):69-81, 2009
                                              41. Swanson KR et al: Complementary but distinct roles for MRI and 18F-fluoromisonidazole PET in the assessment of human glioblastomas. J Nucl Med. 50(1):36-44, 2009
                                              42. Wang W et al: Diffusion tensor imaging in glioblastoma multiforme and brain metastases: the role of p, q, L, and fractional anisotropy. AJNR Am J Neuroradiol. 30(1):203-8, 2009
                                              43. Laprie A et al: Proton magnetic resonance spectroscopic imaging in newly diagnosed glioblastoma: predictive value for the site of postradiotherapy relapse in a prospective longitudinal study. Int J Radiat Oncol Biol Phys. 70(3):773-81, 2008
                                              44. Louis DN et al: WHO Classification of Tumours of the Central Nervous System: Glioblastoma. IARC Press. 33-49, 2007
                                              45. Pivawer G et al: Perfusion MR imaging and proton MR spectroscopic imaging in differentiating necrotizing cerebritis from glioblastoma multiforme. Magn Reson Imaging. 25(2):238-43, 2007
                                              46. Calli C et al: Perfusion and diffusion MR imaging in enhancing malignant cerebral tumors. Eur J Radiol. 58(3):394-403, 2006
                                              47. Di Costanzo A et al: Spectroscopic, diffusion and perfusion magnetic resonance imaging at 3.0 Tesla in the delineation of glioblastomas: preliminary results. J Exp Clin Cancer Res. 25(3):383-90, 2006
                                              48. McMillan KM et al: Physiologic characterisation of glioblastoma multiforme using MRI-based hypoxia mapping, chemical shift imaging, perfusion and diffusion maps. J Clin Neurosci. 13(8):811-7, 2006
                                              49. Stenberg L et al: Dynamic susceptibility contrast-enhanced perfusion magnetic resonance (MR) imaging combined with contrast-enhanced MR imaging in the follow-up of immunogene-treated glioblastoma multiforme. Acta Radiol. 47(8):852-61, 2006
                                              50. Hakyemez B et al: Glioblastoma multiforme with atypical diffusion-weighted MR findings. Br J Radiol. 78(935):989-92, 2005
                                              51. Fan G et al: In vivo single-voxel proton MR spectroscopy in the differentiation of high-grade gliomas and solitary metastases. Clin Radiol. 59(1):77-85, 2004
                                              52. Maldaun MV et al: Cystic glioblastoma multiforme: survival outcomes in 22 cases. J Neurosurg. 100(1):61-7, 2004
                                              53. Principi M et al: Perfusion MRI in the evaluation of the relationship between tumour growth, necrosis and angiogenesis in glioblastomas and grade 1 meningiomas. Neuroradiology. 45(4):205-11, 2003
                                              54. Provenzale JM et al: Comparison of permeability in high-grade and low-grade brain tumors using dynamic susceptibility contrast MR imaging. AJR Am J Roentgenol. 178(3):711-6, 2002
                                              55. Lacroix M et al: A multivariate analysis of 416 patients with glioblastoma multiforme: prognosis, extent of resection, and survival. J Neurosurg. 95(2):190-8, 2001
                                              56. Lüdemann L et al: Comparison of dynamic contrast-enhanced MRI with WHO tumor grading for gliomas. Eur Radiol. 11(7):1231-41, 2001
                                              57. Castillo M et al: Correlation of myo-inositol levels and grading of cerebral astrocytomas. AJNR Am J Neuroradiol. 21(9):1645-9, 2000
                                              Related Anatomy
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                                              Related Differential Diagnoses
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                                              References
                                              Tables

                                              Tables

                                              KEY FACTS

                                              • Terminology

                                                • Imaging

                                                  • Top Differential Diagnoses

                                                    • Pathology

                                                      • Clinical Issues

                                                        TERMINOLOGY

                                                        • Synonyms

                                                          • Glioblastoma (GBM), grade 4 astrocytoma, malignant astrocytoma, glioblastoma multiforme (outdated term)
                                                        • Definitions

                                                          • Rapidly enlarging malignant astrocytic tumor characterized by necrosis and neovascularity
                                                          • Most common of all primary intracranial malignant neoplasms
                                                          • GBM, IDH-wild-type is most common and most malignant (~ 90% of GBM)
                                                          • GBM, IDH-mutant arises from lower grade astrocytic tumors (diffuse astrocytoma, grade 2 or anaplastic astrocytoma, grade 3) and has better prognosis

                                                        IMAGING

                                                        • General Features

                                                          • CT Findings

                                                            • MR Findings

                                                              • Angiographic Findings

                                                                • Nuclear Medicine Findings

                                                                  • Imaging Recommendations

                                                                    DIFFERENTIAL DIAGNOSIS

                                                                      PATHOLOGY

                                                                      • General Features

                                                                        • Staging, Grading, & Classification

                                                                          • Gross Pathologic & Surgical Features

                                                                            • Microscopic Features

                                                                              CLINICAL ISSUES

                                                                              • Presentation

                                                                                • Demographics

                                                                                  • Natural History & Prognosis

                                                                                    • Treatment

                                                                                      DIAGNOSTIC CHECKLIST

                                                                                      • Consider

                                                                                        • Image Interpretation Pearls

                                                                                          Selected References

                                                                                          1. Jackson C et al: A systematic review and meta-analysis of supratotal versus gross total resection for glioblastoma. J Neurooncol. ePub, 2020
                                                                                          2. Shimizu T et al: Differentiating between glioblastomas with and without isocitrate dehydrogenase gene mutation by findings on conventional magnetic resonance images. J Clin Neurosci. 76:140-4, 2020
                                                                                          3. Ohno M et al: Survival benefits of hypofractionated radiotherapy combined with temozolomide or temozolomide plus bevacizumab in elderly patients with glioblastoma aged ≥ 75 years. Radiat Oncol. 14(1):200, 2019
                                                                                          4. Tixier F et al: Preoperative MRI-radiomics features improve prediction of survival in glioblastoma patients over MGMT methylation status alone. Oncotarget. 10(6):660-72, 2019
                                                                                          5. Bae S et al: Radiomic MRI phenotyping of glioblastoma: improving survival prediction. Radiology. 289(3):797-806, 2018
                                                                                          6. Hong EK et al: Radiogenomics correlation between MR imaging features and major genetic profiles in glioblastoma. Eur Radiol. 28(10):4350-61, 2018
                                                                                          7. Lam S et al: Patient and treatment factors associated with survival among pediatric glioblastoma patients: a Surveillance, Epidemiology, and End Results study. J Clin Neurosci. 47:285-93, 2018
                                                                                          8. Rowe LS et al: Differentiating pseudoprogression from true progression: analysis of radiographic, biologic, and clinical clues in GBM. J Neurooncol. 139(1):145-52, 2018
                                                                                          9. Korshunov A et al: H3-/IDH-wild type pediatric glioblastoma is comprised of molecularly and prognostically distinct subtypes with associated oncogenic drivers. Acta Neuropathol. 134(3):507-16, 2017
                                                                                          10. Liu X et al: The preliminary radiogenomics association between MR perfusion imaging parameters and genomic biomarkers, and their predictive performance of overall survival in patients with glioblastoma. J Neurooncol. 135(3):553-60, 2017
                                                                                          11. Blasel S et al: Perfusion MRI in the evaluation of suspected glioblastoma recurrence. J Neuroimaging. 26(1):116-23, 2016
                                                                                          12. Cui Y et al: Prognostic imaging biomarkers in glioblastoma: development and independent validation on the basis of multiregion and quantitative analysis of MR images. Radiology. 278(2):546-53, 2016
                                                                                          13. Louis DN et al: The 2016 World Health Organization Classification of Tumors of the Central Nervous System: a summary. Acta Neuropathol. 131(6):803-20, 2016
                                                                                          14. Nikitović M et al: Pediatric glioblastoma: a single institution experience. Childs Nerv Syst. 32(1):97-103, 2016
                                                                                          15. Andre JB et al: Cerebral blood flow changes in glioblastoma patients undergoing bevacizumab treatment are seen in both tumor and normal brain. Neuroradiol J. 28(2):112-9, 2015
                                                                                          16. Bauer AH et al: Differentiation of solitary brain metastasis from glioblastoma multiforme: a predictive multiparametric approach using combined MR diffusion and perfusion. Neuroradiology. 57(7):697-703, 2015
                                                                                          17. Harris RJ et al: MRI perfusion measurements calculated using advanced deconvolution techniques predict survival in recurrent glioblastoma treated with bevacizumab. J Neurooncol. 122(3):497-505, 2015
                                                                                          18. Iagaru A et al: Glioblastoma multiforme recurrence: an exploratory study of 18F FPPRGD2 PET/CT. Radiology. 141550, 2015
                                                                                          19. Ideguchi M et al: MRI findings and pathological features in early-stage glioblastoma. J Neurooncol. 123(2):289-97, 2015
                                                                                          20. Kobayashi K et al: Prognostic value of volume-based measurements on (11)C-methionine PET in glioma patients. Eur J Nucl Med Mol Imaging. 42(7):1071-80, 2015
                                                                                          21. Mabray MC et al: Modern brain tumor imaging. Brain Tumor Res Treat. 3(1):8-23, 2015
                                                                                          22. Melguizo-Gavilanes I et al: Characterization of pseudoprogression in patients with glioblastoma: is histology the gold standard? J Neurooncol. 123(1):141-50, 2015
                                                                                          23. Pope WB: Genomics of brain tumor imaging. Neuroimaging Clin N Am. 25(1):105-19, 2015
                                                                                          24. Schmainda KM et al: Dynamic susceptibility contrast MRI measures of relative cerebral blood volume as a prognostic marker for overall survival in recurrent glioblastoma: results from the ACRIN 6677/RTOG 0625 multicenter trial. Neuro Oncol. 17(8):1145-56, 2015
                                                                                          25. Smith TR et al: Use of preoperative FLAIR MRI and ependymal proximity of tumor enhancement as surrogate markers of brain tumor origin. J Clin Neurosci. 22(9):1397-402, 2015
                                                                                          26. Stadlbauer A et al: Quantification of serial changes in cerebral blood volume and metabolism in patients with recurrent glioblastoma undergoing antiangiogenic therapy. Eur J Radiol. 84(6):1128-36, 2015
                                                                                          27. Tietze A et al: Perfusion MRI derived indices of microvascular shunting and flow control correlate with tumor grade and outcome in patients with cerebral glioma. PLoS One. 10(4):e0123044, 2015
                                                                                          28. Barajas RF Jr et al: Benefits of dynamic susceptibility-weighted contrast-enhanced perfusion MRI for glioma diagnosis and therapy. CNS Oncol. 3(6):407-19, 2014
                                                                                          29. Das KK et al: Pediatric glioblastoma: clinico-radiological profile and factors affecting the outcome. Childs Nerv Syst. 28(12):2055-62, 2012
                                                                                          30. Mahvash M et al: Glioblastoma multiforme in children: report of 13 cases and review of the literature. Pediatr Neurol. 45(3):178-80, 2011
                                                                                          31. Perkins SM et al: Glioblastoma in children: a single-institution experience. Int J Radiat Oncol Biol Phys. 80(4):1117-21, 2011
                                                                                          32. Koukourakis GV et al: Temozolomide with radiation therapy in high grade brain gliomas: pharmaceuticals considerations and efficacy; a review article. Molecules. 14(4):1561-77, 2009
                                                                                          33. Martin V et al: Encountering and advancing through antiangiogenesis therapy for gliomas. Curr Pharm Des. 15(4):353-64, 2009
                                                                                          34. McGirt MJ et al: Gliadel (BCNU) wafer plus concomitant temozolomide therapy after primary resection of glioblastoma multiforme. J Neurosurg. 110(3):583-8, 2009
                                                                                          35. Miletic H et al: Anti-VEGF therapies for malignant glioma: treatment effects and escape mechanisms. Expert Opin Ther Targets. 13(4):455-68, 2009
                                                                                          36. Oshiro S et al: Efficacy of temozolomide treatment in patients with high-grade glioma. Anticancer Res. 29(3):911-7, 2009
                                                                                          37. Paldino MJ et al: Repeatability of quantitative parameters derived from diffusion tensor imaging in patients with glioblastoma multiforme. J Magn Reson Imaging. 29(5):1199-205, 2009
                                                                                          38. Pirotte BJ et al: Positron emission tomography-guided volumetric resection of supratentorial high-grade gliomas: a survival analysis in 66 consecutive patients. Neurosurgery. 64(3):471-81; discussion 481, 2009
                                                                                          39. Quinn JA et al: Phase II trial of temozolomide plus o6-benzylguanine in adults with recurrent, temozolomide-resistant malignant glioma. J Clin Oncol. 27(8):1262-7, 2009
                                                                                          40. Saraswathy S et al: Evaluation of MR markers that predict survival in patients with newly diagnosed GBM prior to adjuvant therapy. J Neurooncol. 91(1):69-81, 2009
                                                                                          41. Swanson KR et al: Complementary but distinct roles for MRI and 18F-fluoromisonidazole PET in the assessment of human glioblastomas. J Nucl Med. 50(1):36-44, 2009
                                                                                          42. Wang W et al: Diffusion tensor imaging in glioblastoma multiforme and brain metastases: the role of p, q, L, and fractional anisotropy. AJNR Am J Neuroradiol. 30(1):203-8, 2009
                                                                                          43. Laprie A et al: Proton magnetic resonance spectroscopic imaging in newly diagnosed glioblastoma: predictive value for the site of postradiotherapy relapse in a prospective longitudinal study. Int J Radiat Oncol Biol Phys. 70(3):773-81, 2008
                                                                                          44. Louis DN et al: WHO Classification of Tumours of the Central Nervous System: Glioblastoma. IARC Press. 33-49, 2007
                                                                                          45. Pivawer G et al: Perfusion MR imaging and proton MR spectroscopic imaging in differentiating necrotizing cerebritis from glioblastoma multiforme. Magn Reson Imaging. 25(2):238-43, 2007
                                                                                          46. Calli C et al: Perfusion and diffusion MR imaging in enhancing malignant cerebral tumors. Eur J Radiol. 58(3):394-403, 2006
                                                                                          47. Di Costanzo A et al: Spectroscopic, diffusion and perfusion magnetic resonance imaging at 3.0 Tesla in the delineation of glioblastomas: preliminary results. J Exp Clin Cancer Res. 25(3):383-90, 2006
                                                                                          48. McMillan KM et al: Physiologic characterisation of glioblastoma multiforme using MRI-based hypoxia mapping, chemical shift imaging, perfusion and diffusion maps. J Clin Neurosci. 13(8):811-7, 2006
                                                                                          49. Stenberg L et al: Dynamic susceptibility contrast-enhanced perfusion magnetic resonance (MR) imaging combined with contrast-enhanced MR imaging in the follow-up of immunogene-treated glioblastoma multiforme. Acta Radiol. 47(8):852-61, 2006
                                                                                          50. Hakyemez B et al: Glioblastoma multiforme with atypical diffusion-weighted MR findings. Br J Radiol. 78(935):989-92, 2005
                                                                                          51. Fan G et al: In vivo single-voxel proton MR spectroscopy in the differentiation of high-grade gliomas and solitary metastases. Clin Radiol. 59(1):77-85, 2004
                                                                                          52. Maldaun MV et al: Cystic glioblastoma multiforme: survival outcomes in 22 cases. J Neurosurg. 100(1):61-7, 2004
                                                                                          53. Principi M et al: Perfusion MRI in the evaluation of the relationship between tumour growth, necrosis and angiogenesis in glioblastomas and grade 1 meningiomas. Neuroradiology. 45(4):205-11, 2003
                                                                                          54. Provenzale JM et al: Comparison of permeability in high-grade and low-grade brain tumors using dynamic susceptibility contrast MR imaging. AJR Am J Roentgenol. 178(3):711-6, 2002
                                                                                          55. Lacroix M et al: A multivariate analysis of 416 patients with glioblastoma multiforme: prognosis, extent of resection, and survival. J Neurosurg. 95(2):190-8, 2001
                                                                                          56. Lüdemann L et al: Comparison of dynamic contrast-enhanced MRI with WHO tumor grading for gliomas. Eur Radiol. 11(7):1231-41, 2001
                                                                                          57. Castillo M et al: Correlation of myo-inositol levels and grading of cerebral astrocytomas. AJNR Am J Neuroradiol. 21(9):1645-9, 2000