PMC5884883_01
(A) Timeline of clinical course with dates of dietary treatments, magnetic resonance imaging (MRI), magnetic resonance spectroscopy (MRS), and hyperbaric oxygen therapy (HBOT). (B) Glucose/ketone index indicates the ratio of circulating glucose to urinary ketones at all eight clinical assessments during the 15 months period from February 2016 to April 2017.
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F1
A 38-year-old male presented on February 2016 with chronic headache, nausea, and vomiting with left partial motor seizures and weakness in the upper left limb (Figure 1A). The patient underwent a 72 h water-only fast immediately after preliminary diagnosis and before any medical or surgical treatment (Figure 1A). A KD (4:1, fat:protein + carbohydrate) was administered to the patient in restricted amounts for 21 days after the fast and before surgical tumor resection (Figure 1A). The patient's glucose-ketone index (GKI), a calculation that tracks the ratio of blood glucose to ketones as a single value, remained in the predicted therapeutic range (Figure 1B). Fasting blood glucose was around 70-75 mg/dL and urine ketone levels were + to ++ producing an approximate GKI of 5.0 (Figure 1B).
(A) Preoperative radiology, (A) magnetic resonance imaging (MRI) contrast enhanced images axial and sagittal view revealed cystic lesion with perifocal edema "blue arrow" and midline shift "red arrow"; (B) magnetic resonance spectroscopy (MRS) of the lesion revealed high choline value (28) and low N-acetylaspartate (NAA) value (2.7); (C) Functional MRI showed affection of motor and sensory functions; (D) MRI tractography showed displaced motor and sensory fibers. (B) 3 months postoperative radiology (A) MRI contrast enhanced images axial and sagittal view revealed reduction in tumor size and perifocal edema with less midline shift; (B) MRS of the lesion revealed reduction of choline value (21) and elevation of NAA value (3.5) compare to preoperative study. (C) 12 months postoperative radiology (A) MRI contrast enhanced images axial and sagittal view revealed stationary or slightly decrease in tumor size and less perifocal edema with less midline shift; (B) MRS of the lesion revealed reduction of choline value (19) and elevation of NAA value (4) compare to previous study. (D) Postoperative radiology at 20 months. MRI contrast enhanced images for axial, sagittal, and coronal views revealed further reduction in tumor size, with no perifocal edema or midline shift.
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F2
Enhanced magnetic resonance imaging (MRI) of the brain showed a solid cystic intra-axial occupying lesion in the right partial space (Figure 2A). Enhanced brain MRI and magnetic resonance spectroscopy (MRS) evaluated 3 months postoperative and before radiation or chemotherapy revealed a stationary course of disease regarding tumor size that persisted to 12 months (Figures 2B,C). Enhanced brain MRI and MRS revealed decrease in tumor size of about 1.5 cm in each diameter, with minimal perfusion and low metabolic activity assessed from the choline to creatine and choline to N-acetylaspartate (NAA) ratios on MRS (Figure 2D). Also seen were further decreases in choline and increase in NAA with no midline shift or brain edema (Figure 2D), A reduction in tumor size was correlated with a correction of the midline shift after 20 months of treatment (Figure 4B).
(A) Histopathological features of the patient glioblastoma multiforme (GBM). (A) Classic GBM area with pseudopalisading necrosis. (B) Regressive changes in the form of variable background fibrosis. (C) Glomeruloid thick-walled blood vessels. (D) Tumor edge showing limited brain infiltration (haematoxylin and eosin, 200x). (B) Immunohistochemical features of the patient GBM. (A,B) Diffuse positive staining for glial fibrillary acidic protein (100x and 200x, respectively). (C) Moderately high proliferative activity (Ki67, 200x). (D) Numerous blood vessels highlighted by cluster of differentiation 31 immunostaining (100x), negative staining for epithelial markers: CK [(E) 200x] and epithelial membrane antigen [(F) 200x], respectively.
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F3
Regressive and regenerative changes not typical of untreated GBM were noted, possibly reflecting a favorable response to preoperative ketogenic therapy (Figure 3A). Haematoxylin and eosin histological analysis revealed the classical patterns of GBM (Figure 3A). It is noteworthy that less aggressive forms of vascular proliferation and mitosis (namely, glomeruloid vascular proliferation and granular mitoses, respectively) were noted together with the more ominous type of vascular proliferation and irregular mitoses (3/10HPF), more typically associated with GBM (Figure 3A). The tumor tissue stained positive for GFA and highly positive for the Ki67 proliferative index and the cluster of differentiation 31 vascularization index, but was mostly negative for epithelial markers (Figure 3B).
(A) Comparison between tumor metabolism over 20 months. Choline indicates cell membrane turnover and reflects tumorigenesis. N-acetylaspartate (NAA) is a marker for neuronal integrity that decreases with brain malignancy and radio necrosis. Creatine is a marker for cellular energy that decreases significantly with malignancy and radio necrosis. Hunter angle (blue arrow) reflects the choline/NAA ratio. (B) Comparison between tumor size and midline shift (red line) over 20 months.
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The choline creatine ratio on MRS indicated significant reduction in tumor metabolism (Figure 4A). Also seen were further decreases in choline and increase in NAA with no midline shift or brain edema (Figure 2D), A reduction in tumor size was correlated with a correction of the midline shift after 20 months of treatment (Figure 4B).