A 56-year-old male presented with a history of seizure and expressive aphasia. Brain MRI revealed a left parietal mass with surrounding vasogenic edema and mass effect. Craniotomy and gross-total resection were performed, and integrated diagnosis was consistent with glioblastoma WHO grade 4, IDH-wt, and MGMT unmethylated. 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 and TTF.
At one week post-pLDR, there was clinical decline with MRI demonstrating significant vasogenic edema for which a bevacizumab infusion was provided every two weeks at 10 mg/kg. It was discontinued after two infusions due to a poor response and continued clinical decline. At five weeks post-pLDR, MRI demonstrated an increase in the left parietal peripherally enhancing lesion size ( Figure 2A ). FTB maps revealed predominantly treatment effect within the contrast enhancement surrounding the resection cavity with 84.0% non-tumor, 9.6% tumor admixture, and 6.4% tumor ( Figures 2B, D ).
At eight weeks post-pLDR, redo-craniotomy was performed in the absence of FTB-guidance. Reduced vasogenic edema and regions of enhancement around the resection cavity were later confirmed by MRI performed four weeks post-surgery ( Figure 2C ). Three tissue specimens were evaluated, two of which showed necrosis and hyalinized vessels, consistent with treatment effect, while the last sample revealed hypercellular high-grade glioma. The patient continued adjuvant treatment with TMZ and TTF. At nine weeks post-redo surgery, the patient's neurological symptoms included fatigue, right hemiparesis, and global aphasia. At 10 weeks post-redo surgery, he was restarted on bevacizumab at 10 mg/kg every 2 weeks, completing two infusions. Ultimately, he experienced a traumatic fall complicated by intraparenchymal hemorrhage and was transitioned to hospice.