PMC4263439_01
Gadolinium enhanced magnetic resonance imaging (MRI) scans and hematoxylin and eosin (HE)-stained sections before the first and second surgeries. (A) A pretreatment gadolinium-enhanced MRI scan showing a non-enhanced round tumor in the left frontal lobe. (B) Photomicrographs of HE-stained sections showing a fibrillary astrocytoma. (C) A gadolinium-enhanced MRI scan at 18 months after tomotherapy showing the cystic lesion with a well-enhanced cyst wall. (D) Photomicrograph of an HE-stained section of the specimen obtained at the second surgery showing the malignant transformation to an anaplastic astrocytoma.
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A 32-year-old woman presented with a left frontal brain mass, which was revealed using computed tomography (CT) and magnetic resonance imaging (MRI) (Fig. 1A). She underwent partial removal of the tumor, which was diagnosed as a fibrillary astrocytoma (Fig. 1B). Two years after the operation, the residual tumor re-grew (Fig. 1C), and she underwent a second surgery. The recurrent tumor was diagnosed as an anaplastic astrocytoma (Fig. 1D).
(A) Tomotherapy planning and findings confirming radiation necrosis. The yellow circle indicates the 56 Gy dosage. (B) An axial fluid attenuated inversion recovery image showing the left frontal lesion with broad brain edema extending to the contralateral hemisphere. (C) A methionine positron emission tomography scan showing only a small uptake of methionine. (D) A photomicrograph of the hematoxylin and eosin-stained section of the specimen obtained at the third surgery shows radiation necrosis.
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Postoperatively, she received intensity-modulated radiation therapy using tomotherapy with temozolomide at a marginal dose of 56 Gy (Fig. 2A). Enhanced MRI revealed a small lesion with extensive edema in the left frontal lobe (Fig. 2B). The positron emission tomography (PET) scan showed no uptake of fluorodeoxyglucose and low uptake of methionine (Fig. 2C). She underwent a third surgery to remove the lesion, which was pathologically confirmed as RN (Fig. 2D).
Changes in the cerebrospinal fluid protein level during bevacizumab therapy. The graph shows the changes in protein level in the cerebrospinal fluid during chemotherapy. Arrows show the timing of administration of the agents (bevacizumab and paclitaxel). In the second course, only bevacizumab was administered. Arrowhead shows the day of ventriculoperitoneal shunt. The figures on the arrows show the day, of which Day 1 shows the first day of administration. Bidirectional arrow indicates the period of ventricular drainage. The magnetic resonance imaging scans show the axial fluid attenuated inversion recovery images at days 0, 20, 37, and 183.
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Before and after administration of bevacizumab, we measured the changes in the protein level in the CSF obtained from the drainage system (Fig. 3). At day 210 (after 10 courses of treatment), the CSF protein level was 338 mg/dL (Fig. 3).