PMC9484818_01
Radiological findings. (A) Magnetic resonance imaging (MRI) images taken before the first craniotomy. (B) MRI images taken after the second craniotomy. (C) Positron emission tomography-computed tomography (PET-CT) before systemic chemotherapy. (D,E) Contrast-enhanced MRI of the head during intracranial re-metastasis. (F) Comparison of PET-CT. The two images on the left were taken before the ICE therapy, whereas the two images on the right were taken after five courses of the ICE therapy. (G) Comparison of bone scintigraphy. The top image was taken before the ICE therapy, whereas the bottom image was taken after five courses of the ICE therapy.
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Magnetic resonance imaging (MRI) of the head revealed a mass lesion in the left temporal lobe with a ring-shaped contrast effect (Fig. 1A). Approximately 6 months after the initial operation, a local recurrent lesion, extramedullary in location, was detected in the left parietal region (Fig. 1B). About 6 months after the second surgery, positron emission tomography-computed tomography and bone scintigraphy revealed multiple metastases to the cervical lymph node and spine as well as multiple bone metastases (Fig. 1C). The chemotherapy was surprisingly effective, and remarkable shrinkage of the metastatic lesions was observed (Fig. 1F, G). Because ICE chemotherapy was no longer effective, procarbazine/ACNU/vincristine was administered; however, the lesion further progressed (Fig. 1D, E) and was subsequently treated with local radiation therapy.
Microscopic findings of the surgically resected sample from the first surgery. (A) Hematoxylin and eosin staining showed tumor cells with undifferentiated morphological features. The cells formed differently sized foci with cartilaginous metaplasia (*). Scale bars: 200 mum (left) and 50 mum (right). (B) Immunohistochemistry for Ki-67, ATRX, GFAP, and MGMT. Scale bar: 50 mum.
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The first postoperative pathological finding indicated growing atypical glial cells with a high nuclear-cytoplasmic ratio and increased chromatin content in large and small foci (Fig. 2A). As presented in Fig. 2B, the Ki-67 labeling index was high (>90%) in the tumor cells, ATRX staining was positive, glial fibrillary acidic protein (GFAP) staining was partially positive, MGMT staining was positive, and mutant isocitrate dehydrogenase1 (IDH1 R132H) was non-existent.
Pathological findings from the post-mortem autopsy. Hard, whitish nodules were detected in the (A) the skin around the neck and ears, (B) lungs, (D) left kidney, and (E) left temporal lobe and right midbrain. Ossification was observed in the (C) bone marrow. Tumor cells had proliferated and formed solid foci, and the cartilage was sporadically detected. The trabeculae were enlarged, and fibrosis was detected in the bone marrow. Scale bar: 50 mum.
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As presented in Fig. 2B, the Ki-67 labeling index was high (>90%) in the tumor cells, ATRX staining was positive, glial fibrillary acidic protein (GFAP) staining was partially positive, MGMT staining was positive, and mutant isocitrate dehydrogenase1 (IDH1 R132H) was non-existent. Autopsy was performed (Fig. 3A-E).