PMC4493308_01
Surgical pathological specimens from (a) initial craniotomy and (b-c) repeat craniotomy for recurrent intracranial disease. Histopathological analysis of the initial (a) right temporal lobe specimen demonstrated glioblastoma with small cell features. The pathological specimen after second resection (b) demonstrated active glioblastoma, almost entirely viable with <5% necrosis. Following the third and final (c) craniotomy for locally recurrent disease, predominantly viable (approximately 15% necrosis) active glioblastoma was identified. Molecular studies were negative for MGMT methylation and EGFR amplification was detected by FISH.
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He underwent right temporal craniotomy with postoperative pathology consistent with WHO grade IV astrocytoma (GBM) with small cell features (Figure 1(a)). MR imaging a month later revealed marked progressive enhancement and the patient underwent repeat resection with postoperative imaging indicating gross total resection and pathologic confirmation of recurrent GBM (Figure 1(b)). A third craniotomy was performed with pathology demonstrating mitotically active, recurrent GBM (Figure 1(c)).
(a) Whole body FDG PET imaging demonstrating hypermetabolic osseous and visceral metastases including bilateral pulmonary nodules and hilar adenopathy. (b) CT imaging demonstrating mediastinal adenopathy, multiple pulmonary nodules, and right pleural effusion. (c) Coregistered PET/CT imaging demonstrating intense FDG uptake within GBM lung metastases.
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FDG-avid, right middle lobe (SUV 11.5), two left upper lobe nodules (SUV 6.4 and 5.1), and right upper lobe (SUV 5.0) (Figure 2). Flexible bronchoscopy with biopsy was performed and demonstrated malignant spindle cell tumors with geographic necrosis consistent with metastatic GBM.
Intracranial imaging during final course of salvage therapy with bevacizumab and carboplatin. (a) FLAIR, (b) T1-weighted axial, and (c) T2-weighted axial magnetic resonance imaging demonstrating stable intracranial disease at time of respiratory decline. Postsurgical hyperintensity surrounds area of resection in the right temporal and occipital lobes communicating with the right occipital horn, unchanged with respect to prior imaging.
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Of note, synchronous brain MRI was stable at this time with no evidence of intracranial recurrence or progression (Figure 3).