A 55-year-old male presented with a seizure, visual impairment and personality changes. Brain MRI revealed an enhancing left occipital mass surrounded by diffuse FLAIR hyperintensity signal. Craniotomy and gross-total resection were performed and integrated diagnosis was consistent with glioblastoma WHO grade 4, IDH-wt, and MGMT unmethylated. Following surgery, his symptoms included right hemiparesis, global aphasia, and a right homonymous hemianopsia. The patient was enrolled in a prospective phase II study (NCT04747145) to be treated with pLDR to a total dose of 60 Gy in 30 fractions with concurrent TMZ followed by adjuvant TMZ and TTF.
Near completion of pLDR (fraction 24) and 8 weeks post-surgery, he was admitted for worsening symptoms of gait dysfunction, nausea and vomiting, and dysphagia. MRI revealed increased enhancement around the resection cavity with increased mass effect and left ventricular trapping ( Figure 3A ). FTB maps revealed predominantly treatment effect within the contrast enhancement surrounding the resection cavity with 64.6% non-tumor, 19.1% tumor admixture, and 16.4% tumor ( Figures 3B, D ). Radiation was withheld and redo-craniotomy was performed in the absence of FTB-guidance. Five tissue specimens revealed necrotic tissue and sparse reactive brain tissue, consistent with treatment effect. Neurologically, the patient improved in memory and speech with residual comprehensive aphasia and right visual field defect. Bevacizumab was subsequently started at 10 mg/kg every 2 weeks.
The patient continued adjuvant treatment with bevacizumab, TMZ, and TTF. Of note, compliance with TTF averaged 75-90% of "ON" time throughout the treatment period. At one week post-surgery, brain MRI demonstrated retraction of the resection cavity and decreased peripheral enhancement along the surgical margins ( Figure 3C ). At 29 weeks post-redo surgery, the patient was transitioned to hospice, experienced respiratory failure caused by aspiration from worsening dysphagia and expired.