PMC9633940_01
Radiological and pathological images of the initial mass. (A-C) Preoperative Gd-enhanced T1-weighted MRI showing a heterogeneously enhanced mass in the left temporal region with leptomeningeal involvement. Note the lesion invading the transverse and sigmoid sinuses (arrow head). (D, E) Representative microphotos of the primary surgical sample with palisading tumor cell necrosis and GFAP immunopositivity, consistent with a diagnosis of glioblastoma. (F) The removed dural tissue is involved by glioblastoma (D, F: hematoxylin and eosin staining, original magnification x40, (E): GFAP immunohistochemistry, original magnification x200).
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Brain magnetic resonance imaging (MRI) showed a large contrast-enhancing (67x48x60 mm) lesion in the left temporal lobe, invading the transverse and sigmoid venous sinuses ( Figures 1A-C ). Tumor cell invasion of the dura was confirmed histopathologically ( Figures 1D-F ).
Radiological and treatment plan images for recurred lesions. (A, B) Gd-enhanced T1-weighted MRI showing two enhanced, dural based masses along the dura mater of remote site. Note that there is no definitive recurrence on the initial lesion. (C, D) Representative photos of dose plans for initial radiation (C, 60 Gy) and re-irradiation (D, 50 Gy) treatments. Note that there is no definitive overlap in radiation field in two dose plans.
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Unfortunately, two remote meningeal enhancing lesions in the left frontal and parietal convexity were found on follow-up MRI 5 months after surgery ( Figures 2A, B ) and the patient was treated with metronomic TMZ plus radiation therapy (RT, 50 Gy). Since there was no overlap of the radiation fields compared to the initial RT plan, there was little possibility of radiation necrosis ( Figures 2C, D ).
Radiologic images of extraneural metastasis (ENM). Whole spine MRI (A) and PET-CT (B) showing extensive ENM to multiple bones and lymph nodes.
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Due to progressive shoulder and back pain, systemic evaluations including spine MRI, positon emission tomography (PET)-CT, and chest and abdomen CT were done 9 months after surgery and revealed widespread metastases to the chest & cervical lymph nodes and multiple bones, including the vertebrae, scapula, and pelvis ( Figure 3 ).
Representative microphotos of a vertebral lesion with GFAP immunopositivity and high Ki-67 proliferation index, consistent with a diagnosis of metastatic glioblastoma. (A, B: hematoxylin and eosin staining, original magnification x100 & x400, C: GFAP immunohistochemistry, original magnification x200, D: Ki-67 staining, original magnification x400).
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The largest vertebral lesion was biopsied and diagnosed as metastatic glioblastoma as evidenced by glial fibrillary acidic protein (GFAP) immunopositivity ( Figure 4 ).