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Open Access 01-03-2021 | Glioblastoma | Clinical Case
Freiburg Neuropathology Case Conference
Contrast-enhancing Brain Lesion 6 Months after Resection and Combined Radiotherapy and Chemotherapy of an Unmethylated but IDH R132H-mutated Glioblastoma Multiforme
Published in: Clinical Neuroradiology | Issue 1/2021
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A 46-year-old woman complained of visual and gait disturbances and increasing headaches that had started some days earlier. Physical examination revealed a hemianopia to the right and restricted orientation to time without additional neurological deficits. A first magnetic resonance imaging (MRI) was performed, which revealed a large contrast-enhancing lesion within the left occipital lobe (Fig. 1). The patient was transferred to the department of neurosurgery at our university hospital. After interdisciplinary discussion in the neuro-oncological board, tumor resection was indicated and performed by use of intraoperative neuronavigation without any additional deficits. Neuropathological examination confirmed an unmethylated but isocitrate dehydrogenase 1 (IDH1) R132H-mutated glioblastoma with a high proliferation rate (MIB‑1: 15–20% immunopositive tumor cells). Combined radiotherapy and chemotherapy with adjuvant temozolomide (TMZ) (EORTC/-NCIC trial protocol [1]) was indicated according to our institutional guidelines. Subsequently, the patient developed steroid-induced psychosis and tapering of steroids along with pentoxifylline and boswellia treatment was recommended. At this time MRI showed significant contrast-enhancement and perilesional edema and dexamethasone was prescribed (Fig. 2). The patient recovered clinically and follow-up MRI displayed partial recovery of brain edema (Fig. 3). After discontinuation of steroids, the patient redeveloped symptoms of depression and MRI showed recurrence of brain edema. At this stage steroids were readministered while continuing with the intensified TMZ chemotherapy. After completion of the second cycle, the patient complained of mild hemiparesis graded as 4/5 on the medical research council (MRC) scale for muscle strength, hemiparesthesia, and constant fatigue. At this point in time MRI showed persisting signs of edema and contrast-enhancement suspicious of tumor progression (Fig. 4).
Fig. 1
time (t) = 0. Preoperative axial T2-weighted images (a) show a hyperintense space-occupying lesion (arrow) located in the left occipital lobe. In addition, hyperintense changes are displayed laterally to the thalami of both sides and the occipital forceps of the corpus callosum (a, arrowheads). After administration of gadolinium (b) the lesion shows marked rim enhancement (arrow) and central necrosis on T1-weighted images. On postoperative T2-weighted images a large resection defect is visible (c). The hyperintense signal intensity changes remain stable (arrowheads). On T1-weighted postcontrast images (d) at the same point in time complete tumor resection is shown (arrow)
Fig. 2
t = 7 weeks. On-going combined radiotherapy and chemotherapy. The hyperintense signal intensity changes have markedly increased on axial T2-weighted images (a, arrowheads). No signs of a solid residual tumor are on display (a, arrow). On contrast-enhanced T1-weighted images (b) a thick patchy rim of contrast enhancement along the margins of the tumor resection is visible (arrow) interleaved with smaller areas of regressive changes (arrowhead). On axial cerebral blood volume (CBV) maps of perfusion-weighted MR images (c) no hyperperfusion is visible in the areas of increased contrast enhancement (arrow)
Fig. 3
t = 14 weeks. Additional treatment with corticosteroids. The perifocal edema has clearly regressed on axial fluid attenuated inversion recovery (FLAIR) images (a, arrow). The signal intensity changes of the occipital forceps and the right sided perithalamic region have remained stable (a, arrowheads). On T1-weighted postcontrast images contrast (b) enhancement at the margins of the tumor resection has clearly regressed (arrow)
Fig. 4
t = 26 weeks. At the end of the second cycle of the intensified chemotherapy with temozolomide the patient complained of mild right-sided hemiparesis. Axial T2-weighted images (a) show an increasing perifocal edema (arrowheads) around the tumor resection (arrow). On axial T1-weighted images after administration of gadolinium (b) a thick patchy rim of enhancement can be seen along the margins of the initial tumor resection (arrow). Note the additional contrast-enhancing lesion located in the white matter adjacent to the right thalamus (arrowhead) most likely corresponding to additional manifestation of the underlying tumor. After reoperation a large resection defect can be seen on axial T2-weighted images (c, arrow). The perifocal edema is basically stable (c, arrowheads). On axial contrast-enhanced T1-weighted images (d) discrete enhancement is visualized along the borders of the tumor resection (arrow). Note the bulky contrast-enhancing portions infiltrating the occipital forceps of the corpus callosum and the white matter lateral to the left thalamus (arrowheads)
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