PMC6744741_01
Axial fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI) demonstrating progression of the lesion over the patient clinical course. (a) The initial MRI before the first operation showing a hyperintense lesion in the right frontal lobe. (b) Postoperative MRI of the first surgery showing total removal of the FLAIR high lesion. (c) MRI of 5 years after the first operation demonstrating recurrence of the lesion around the removal cavity. (d) Postoperative MRI showing total removal of the recurring lesion. (e) MRI at 4 years after the second surgery showing another recurrent lesion in the right lower frontal lobe. (f) Postoperative MRI of the third surgery showing residual hyperintense lesion in the medial side of the temporal lobe. (g) MRI 2 years after the third operation showing hyperintense lesion reaching near the pyramidal tracts. (h) Carmustine wafers were placed in the removal cavity.
SNI-10-137-g001.jpg
PMC6744741_01_SNI-10-137-g001.jpg
F1
Fluid-attenuated inversion recovery (FLAIR) MRI of the brain showed a hyperintense lesion in the right frontal lobe suspicious for a low-grade glioma [Figure 1a]. Postoperative radiographic examination confirmed the total removal of the entire extent of hyperintense FLAIR signal [Figure 1b]. Radiographic reassessment at this point showed a lesion adjacent to the surgical cavity indicating recurrent tumor [Figure 1c]. Again, the entire extent of the FLAIR signal of the lesion was removed as confirmed on postoperative MRI [Figure 1d]. A recurrent lesion appeared enlarging the bottom of the right frontal lobe [Figure 1e], and once again, this was removed. Postoperative radiographic assessment showed partial removal of tumor with residual disease at the temporal lobe [Figure 1f]. Two years later, follow-up FLAIR MRI showed progression of the lesion extending toward the pyramidal tract [Figure 1g]. Postoperative MRI showed again subtotal removal of the tumor [Figure 1h] and temozolomide and procarbazine (100 mg for 10 days) were administered postoperatively.
Axial fluid-attenuated inversion recovery magnetic resonance imaging at (a) 3 days and (b) 1 month after administration of bevacizumab. Lesion was shrunk and edema decreased.
SNI-10-137-g002.jpg
PMC6744741_01_SNI-10-137-g002.jpg
F2
Radiological examination showed shrinkage of the lesion and decreased edema [Figure 2].
Microscopic finding of autopsy in hematoxylin and eosin staining. Histopathological patterns consistent with the World Health Organization (a) Grade II, (b) Grade III, and (c) Grade IV are confirmed extensively from each part of the brain. (d) Invasion also seen in the subarachnoid space at the specimen where the arachnoid membrane was removed together with the brain tissue.
SNI-10-137-g003.jpg
PMC6744741_01_SNI-10-137-g003.jpg
F3
Histopathological examination of various tumor sites revealed cells with atypically shaped nuclei [Figure 3a], anaplasia, and high proliferation [Figure 3b] corresponding to tumor areas of the WHO Grades II and III, respectively. The WHO Grade IV characteristics of palisading necrosis and mitoses were also identified [Figure 3c]. Tumor invasion was also observed in the subarachnoid space [Figure 3d].
Superimposition of the histopathological finding on the macroscopic photography of (a) coronal slice of the cerebrum, (c) axial slices of cerebellum and brainstem from the autopsy with corresponding T1 magnetic resonance imaging (MRI) (b and d, respectively) that taken 3 months after administration of bevacizumab. Within the superimposed images, red color indicating histopathological finding consistent with the World Health Organization (WHO) Grade IV. Blue color indicating histopathological finding consistent with the WHO Grade III. Gray color indicating histopathological finding consistent with the WHO Grade II. Green line indicating subarachnoid space. Histopathological analysis revealing widespread tumor invasion in cerebrum, cerebellum, brainstem, and pituitary region that is not seen on MRI. Around the WHO Grade IV lesion, the WHO Grade II and III lesions are widely identified, except in the superolateral part of the right temporal lobe that bordering with the right frontal lobe.
SNI-10-137-g004.jpg
PMC6744741_01_SNI-10-137-g004.jpg
F4
The Grade II and III lesions were widely identified around the Grade IV lesion, bilateral basal ganglia, insular cortex, and medial side of the right temporal lobe [Figures 4a and 4b]. When comparing autopsy results with MRI findings from the time after the patient had been treated with bevacizumab, it is suggested that tumor invaded areas could not be seen on MRI [Figure 4c and 4d].