Beyond the brain and barrier: high-grade astrocytoma with distant metastases in a young patient — a rare presentation

Abstract

Objective: High-grade astrocytic gliomas rarely spread outside the central nervous system, held back by the blood– brain barrier, the absence of CNS lymphatics, and short survival. We describe a young adult who developed osseous and hepatic metastases from an IDH-wildtype grade 4 astrocytic glioma.

Method: A 26-year-old man had maximal safe resection on 17 April 2025 (diffuse astrocytoma, NOS, CNS WHO grade 4, IDH-wildtype), at the Aga Khan University Hospital, Karachi, Pakistan. This was followed by chemoradiotherapy that finished on 16 July 2025, maintenance temozolomide, and later bevacizumab with irinotecan. On 28 May 2026 he reported new pain; whole-spine MRI found osseous metastases through the spine and pelvis and hepatic deposits, without leptomeningeal disease, and FDG PET/CT on 2 June 2026 showed these lesions were hypermetabolic. A liver biopsy was performed. Consent of the patient was obtained for publishing his case.

Results: The liver biopsy results showed a rhabdoid high-grade tumour whose profile matched the primary (GFAP positive, IDH1 negative, p53-mutant).

Conclusion: Immunophenotyping separates true metastasis from a second cancer.