A 60-year-old male presented with progressive left hemiparesis and memory decline. Brain MRI revealed an enhancing mass within the right frontal lobe that was resected. Integrated diagnosis was consistent with glioblastoma WHO grade 4, IDH-wt, and MGMT unmethylated. There was significant postoperative improvement in symptoms. The patient was treated with pLDR as a part of a prospective phase II study (NCT04747145) to a total dose of 60 Gy in 30 fractions with concurrent TMZ followed by adjuvant TMZ. Adjuvant TTF were declined.
Follow-up brain MRI studies demonstrated progressively increasing enhancement around the resection cavity. At 13 weeks post-pLDR, FTB maps revealed 47.9% non-tumor, 19.2% tumor admixture, and 32.9% tumor within the contrast-enhancing tissue. Seven weeks later, brain MRI demonstrated increased enhancement, particularly at the superomedial resection cavity margin ( Figure 4A ). FTB maps were again obtained with increasing proportions of vascular tumor tissue suggesting progression: 42.9% non-tumor, 13.5% tumor admixture, and 43.6% tumor ( Figures 4B, D ).
At 30 weeks post-pLDR, redo-craniotomy was performed in the absence of FTB-guidance. Significant debulking was later confirmed by MRI ( Figure 4C ). Two tissue specimens revealed moderately cellular atypical glial proliferation, supportive of active tumor. At three weeks post-redo surgery, the patient progressed with gait dysfunction, dysphagia, expressive aphasia, and left facial droop.