PMC9928596_01
Initial imaging presentation and histological studies of the tumor. (A). Imaging showed a cystic lesion with an enhancing mural nodule in the left occipital lobe; (B, C). H&E staining of the initial tumor revealed a low-grade astrocytic proliferation with scattered hyperchromatic nuclei and eosinophilic cytoplasm; (D-F). The second recurrent tumor displayed low-grade astrocytic features similar to the original tumor and some endothelial proliferation.
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Imaging studies revealed a cystic lesion with an enhancing mural nodule in the left occipital lobe ( Figure 1A ). As shown in  Figure 1B , the tumor was comprised of a low-grade astrocytic proliferation with scattered hyperchromatic nuclei. At the time, the tumor was thought to be most compatible with a pleomorphic xanthoastrocytoma (PXA), WHO grade 2 ( Figure 1B, C ). The tumor continued to show low-grade astrocytic features and was morphologically compatible with recurrent PXA ( Figure 1D-F ).
Clinical timeline.
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The patient underwent a subtotal resection 18.5 years ago, tolerating the procedure well with no neurological deficits (see  Figure 2  for timeline).
Imaging and microscopic studies of the newly recurrent tumor. (A), Imaging revealed a 6 cm irregular, contrast-enhancing mass with solid and cystic components associated with the prior tumor site causing significant mass effect.(B-F), H&E staining showed heterogeneous and poorly differentiated tumor cells with atypical mitotic figures (B), numerous bizarre multinucleated giant cells (C), clear cells change with eccentrical nuclei (D), fusiform and pleomorphic monstrous nuclei (E), and foci of palisading necrosis with tumor cells lining the ischemic edges (F). (G), Pleomorphic tumor cells were positive for GFAP staining. (H), Ki67 stain showed high mitotic index. (I), ATRX stain was retained. (J), Postoperative imaging demonstrated stable enhancing foci in the surgical bed.
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Imaging revealed a 6 cm irregular, contrast-enhancing mass with solid and cystic components associated with the prior tumor site causing significant mass effect ( Figure 3A ). A third resection was performed, showing a hypercellular glial neoplasm with marked atypia, palisading necrosis, and increased and atypical mitoses. ( Figure 3B-F ). Immunohistochemical stains were positive for GFAP ( Figure 3G ) and the MIB-1 index was approximately 50% ( Figure 3H ). Stains for BRAF V600E and IDH1 R132H were negative and ATRX was intact ( Figure 3I ). On clinical follow-up, the patient has done well with no new symptoms, and MRI has demonstrated stable enhancing foci in the surgical bed with no new abnormal enhancing foci on repeated imaging over the last 2.5 years since surgery ( Figure 3J ).