PMC8504694_01
Preoperative brain MRI findings on May 7, 2017. The axial planes of preoperative MRI of the brain showing a 6-cm heterogeneous mass in the left superior temporal lobe. (A) T1-weighted MRI. (B) T2-weighted fluid-attenuated inversion recovery (FLAIR) MRI. (C) T2-weighted MRI. (D) Enhanced T1-weighted MRI. (E) Diffusion-weighted MRI.
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On May 7, 2017, craniocerebral magnetic resonance imaging (MRI) revealed space-occupying lesions in the left temporal lobe ( Figure 1 ).
Postoperative brain MRI findings on May 31, 2017. The axial planes of postoperative brain MRI showed that the tumor had been removed. (A) Enhanced T1-weighted MRI. (B) T2-weighted FLAIR MRI.
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O6-methylguanine-DNA-methyltransferase (MGMT) protein 80% positive, P53 10% positive, programmed cell death 1 (PD-1) scattered cells positive, programmed cell death-ligand 1 (PD-L1) partial positive, and Ki-67 30% positive in tumor cell nuclei, indicating high mitotic activity. On May 31, 2017, postoperative reexamination of brain MRI showed that the tumor had been removed ( Figure 2 ).
Brain MRI findings on August 13, 2019. Brain MRI showing a new focus in the postoperative residual cavity of the left temporal lobe. (A) The axial plane of T1-weighted MRI. (B-D) The axial planes of T2-weighted FLAIR MRI. (E) The axial plane of T2-weighted MRI. (F-H) The axial planes of enhanced T1-weighted MRI. (I, J) The sagittal and coronal planes of enhanced T1-weighted MRI. (K) The axial plane of diffusion-weighted MRI.
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On second admission (August 13, 2019), MRI demonstrated recurrence of the tumor in the postoperative residual cavity ( Figure 3 ).
Brain MRI findings after the second surgery on December 4, 2019. (A) The axial plane of T1-weighted MRI. (B-D) The axial planes of T2-weighted FLAIR MRI. (E) The axial plane of T2-weighted MRI. (F-H) The axial planes of enhanced T1-weighted MRI. (I, J) The sagittal and coronal planes of enhanced T1-weighted MRI.
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The intracranial conditions are shown in  Figure 4 .
Whole spinal MRI findings on December 12, 2019. Sagittal planes of T1-weighted MRI of the whole spine showed metastases of the T7 and T10 vertebrae. (A) T1-weighted MRI. (B) Enhanced T1-weighted MRI.
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T7 and T10 vertebrae and right posterior chest wall ( Figures 5 ,  6 ), while thoracic and abdominal computed tomography (CT) on December 6, 2019, showed the metastases of the ninth posterior ribs on the right, third anterior ribs on the left, and T7 and T10 vertebrae and their appendages ( Figure 7 ). To determine the nature of the ninth posterior costal mass, CT-guided fine needle biopsy of the ninth posterior costal mass was performed on December 6, 2019.
The coronal plane of MRI findings on December 6, 2019. (A-F) Metastasis of the thoracic vertebrae and chest wall on the coronal planes of enhanced T1-weighted MRI.
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T7 and T10 vertebrae and right posterior chest wall ( Figures 5 ,  6 ), while thoracic and abdominal computed tomography (CT) on December 6, 2019, showed the metastases of the ninth posterior ribs on the right, third anterior ribs on the left, and T7 and T10 vertebrae and their appendages ( Figure 7 ). To determine the nature of the ninth posterior costal mass, CT-guided fine needle biopsy of the ninth posterior costal mass was performed on December 6, 2019.
Thoracic and abdominal CT findings on December 6, 2019. Thoracic and abdominal CT revealed multiple metastases of the chest wall and thoracic vertebrae (A-D). Metastases of the third anterior ribs on the left, T7 vertebrae and its appendages, ninth posterior ribs on the right, and T10 vertebrae and its appendages.
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T7 and T10 vertebrae and right posterior chest wall ( Figures 5 ,  6 ), while thoracic and abdominal computed tomography (CT) on December 6, 2019, showed the metastases of the ninth posterior ribs on the right, third anterior ribs on the left, and T7 and T10 vertebrae and their appendages ( Figure 7 ). To determine the nature of the ninth posterior costal mass, CT-guided fine needle biopsy of the ninth posterior costal mass was performed on December 6, 2019.
Pathological and genetic tests results of the fibrous tissue obtained on December 10, 2019. Atypical cells in the fibrous tissue, necrosis, and obvious cell atypia, in accordance with GBM, WHO grade IV. (A) Glial fibrillary acidic protein (GFAP) positivity. (hematoxylin and eosin, original magnification x 400). (B) Genetic tests revealed that the 1p/19q genes were intact (x 1000).
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Postoperative pathology and IHC revealed the following: GBM ( Figure 8 ), WHO grade IV, Olig-2, ATRX and GFAP positive, IDH-1 wild-type, P53 revealed 10% positive, Ki-67 revealed 10% positive.