PMC5655759_01
(a) MRI brain with contrast demonstrated 4.7 cm multiloculated rim enhancing cystic lesion with additional smaller projections invading the right frontal lobe with associated vasogenic edema and midline shift. (b) MRI brain with contrast demonstrating resection of right frontal mass with expected postoperative changes. (c) MRI brain with contrast demonstrating enhancing foci within left frontal lobe adjacent to prior surgical cavity. (d) MRI brain with contrast demonstrating resection of left frontal foci with expected postoperative changes
SNI-8-243-g001.jpg
PMC5655759_01_SNI-8-243-g001.jpg
F1
MRI brain [Figure 1a] revealed a large right frontal lobe neoplasm consistent with high-grade glial neoplasm. Craniotomy was performed and postoperative imaging demonstrated gross total resection with marginal enhancement along the posterior margin of the surgical cavity thought to imply postoperative blood and hemostasis product [Figure 1b]. Twelve weeks after the initial resection and post radiation therapy/temozolomide, surveillance MRI scan revealed multiple new enhancing foci within the left frontal lobe [Figure 1c]. Due to the MGMT unmethylated status and the areas of new enhancement, open resection was performed, with pathology demonstrating cortex and white matter with very mild hypercellularity; no obvious tumor was recognized [Figure 1d].
Histologic features of glioblastoma with PNET-like components. (a) Glioblastoma. (b) Small round blue cell component. (c) GFAP stain. (d) PNET-like components are strongly positive for synaptophysin
SNI-8-243-g002.jpg
PMC5655759_01_SNI-8-243-g002.jpg
F2
IV with primitive neuroectodermal tumor-like components (MG-PNET) [Figure 2a-d]. Immunohistochemical staining demonstrated abundant GFAP immunoreactivity and frequent p53 nuclear staining.
(a) MRI with contrast; (b) MRI T2WI; (c) DWI; (d) ADC. MRI Head demonstrating right frontoparietal subdural collection with associated vasogenic edema and restriction on DWI and ADC maps
SNI-8-243-g003.jpg
PMC5655759_01_SNI-8-243-g003.jpg
F3
MRI brain revealed a diffusion restricting subdural collection overlying the prior craniotomy site [Figure 3a-d].
Histologic features of PNET-like subdural collection. (a) H and E stain. (b) Synaptophysin stain. (c) Reticulin stain. (d) p53 stain. (e) MIB-1 stain
SNI-8-243-g004.jpg
PMC5655759_01_SNI-8-243-g004.jpg
F4
Biopsy results demonstrated PNET-like only recurrence of the previously treated MG-PNET [Figure 4].
(a) MRI T1W with contrast four-weeks post-surgical evacuation of subdural collection and initiation of platinum-based chemotherapy demonstrating marked improvement. (b) MRI T1W with contrast eight-weeks following initiation platinum-based chemotherapy demonstrating marked progression of invasive tumor in the right parietal and posterior frontal lobes, extensive vasogenic edema extending to the atrium of the right lateral ventricle and midline shift
SNI-8-243-g005.jpg
PMC5655759_01_SNI-8-243-g005.jpg
F5
Initially, the patient responded well both clinically and radiographically to therapy; however, surveillance imaging at 8 weeks demonstrated significant tumor progression [Figure 5].