PMC8769439_01
Preoperative axial T2-weighted (A) and axial T1-weighted MRI with gadolinium enhancement (B), showing a high-intensity area in the left inferior parietal lobule and enhancing parts at the superficial lesion. Generation of a 3D object representing the fiber bundles of white matter tracts (C). After segmentation of the fiber tract bundle, a 3D object (yellow) was generated, representing the left pyramidal tract. The green-colored area shows the SLF, the blue-colored area shows the IFOF, and the tumor area is highlighted in orange. Postoperative axial T2-weighted MRI (D) showing no tumors due to supratotal resection. Axial T1-weighted MRI with gadolinium enhancement (E) performed 9 years and 2 months after the surgery, showing no recurrent tumors. 3D: three-dimensional, IFOF: inferior fronto-occipital fasciculus, MRI: magnetic resonance imaging, SLF: superior longitudinal fasciculus.
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F1
T2-weighted images in the left inferior parietal lobule, with a maximum diameter of approximately 20 mm (Fig. 1A and 1B). The patient was transferred to our hospital for surgery. The white matter tracts, such as the pyramidal tract, superior longitudinal fasciculus (SLF), and inferior fronto-occipital fasciculus (IFOF), were computed from the preoperative diffusion tensor imaging (DTI) data set using BrainLAB iPlan Cranial version 3.0 (German HealthCare Export Group, Bonn, Germany) (Fig. 1C). Tumor resection included abnormalities on T2-weighted MRI, with subcortical mapping used to identify the deep functional boundaries (Fig. 1D). At a follow-up evaluation 9 years and 2 months after the surgery, the patient appeared healthy and showed no signs of relapse or recurrence (Fig. 1E).
Intraoperative photograph obtained before tumor resection, showing letter tags that indicate tumor boundaries (A-E). Postcentral gyrus stimulation induced convulsion around the mouth (tag: 1, 2). Posterior portion of the superior temporal gyrus stimulation induced phonemic paraphasia (tag: 3). Left superior parietal lobule stimulation induced a cessation in right upper limb movement (tag: 4-7). Oral reading and writing tasks did not induce any disturbances in the cortical mapping. Arrowhead: intraparietal sulcus, arrow: Sylvian fissure.
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F2
T2-weighted MRI that extends beyond the contrast-enhancing portion of the tumor, the patient underwent awake surgery, assisted by both cortical and subcortical functional mapping. The tumor margins were letter-tagged (A-F) using the neuro-navigation system before the brain shift occurred (Fig. 2). During cortical mapping using a biphasic current (pulse frequency, 60 Hz; single pulse phase duration, 0.5 ms) under a 4 mA stimulus with picture-naming tasks, a convulsion around the mouth was induced with postcentral gyrus stimulation (tags 1 and 2; Fig. 2).
Photomicrographs (magnification x40 or x200) of the current case. HE staining showed proliferation of atypical glial cells and necrosis. Abnormal proliferation of vessels was observed around necrosis (A). Microvascular proliferation was also observed, which strongly suggested glioblastoma pathology (B). Immunohistochemical staining of IDH1R132H yielded negative results (C). The absence of IDH1 and IDH2 mutations was also confirmed by Sanger sequencing. HE: hematoxylin-eosin, IDH: isocitrate dehydrogenase.
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F3
Histological examination of the tumor yielded a diagnosis of GBM, and Ki-67 expression was observed in 10% of the tumor cells (Fig. 3).