case_images: PMC11780143_01
case_images: Cranial magnetic resonance imaging 20 months prior to surgery. (a) Axial T2WI: The red arrows highlighted a hyperintense mass in the left temporal lobe with an irregular shape. Mild edema was observed surrounding the lesion. (b) Axial postcontrast T1WI: The same lesion seen in image a showed slight enhancement after contrast administration, with areas of irregular contrast uptake, measuring approximately 18 x 15 x 24 mm. There was mild displacement of the midline structure.
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case_images: At that time, cranial magnetic resonance imaging (MRI) revealed a faintly hyperintense lesion measuring approximately 18 x 15 x 24 mm in the left temporal lobe (Figure 1).
case_images: Postoperative pathological and immunohistochemical staining images of anaplastic PXA. (a and b) Pleomorphic and xanthic astrocytic cells, local epithelioid cells, multinucleated giant cells, and microvascular proliferation were observed in the surrounding brain parenchyma and perivascular spaces. The mitotic index was significantly elevated (more than 5 mitoses per 10 HPFs). (c and d) Immunohistochemical staining revealed a markedly increased Ki-67 labeling index. HPFs, high-power fields.
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case_images: The postoperative pathology and immunohistochemistry confirmed a diagnosis of anaplastic PXA, WHO grade III, with calcification (Figure 2). The mitotic index was significantly elevated (more than 5 mitoses per 10 high-power fields), as shown in Figure 2a and 2b. Immunohistochemical staining revealed a markedly increased Ki-67 labeling index (Figure 2c and 2d), with specific findings as follows: Ki-67 (5%-12%), GFAP (+), Olig-2 (+), p53 (+), ATRX (+), IDH1 R132H (-), MTAP (loss of expression), p16 (focally +), CD34 (+), BRAF V600E (+), Syn (+), NeuN (scattered +).
case_images: Cranial magnetic resonance imaging 1 month after surgery. An irregular surgical cavity change was observed in the left temporal lobe, measuring 41 x 28 x 52 mm. (a) Axial T1WI: The surgical cavity showed hypointense signal. (b) Axial T2WI: The surgical cavity showed hyperintense signal in the surrounding tissue (indicated by red arrows), with mild displacement of adjacent structures. (c and d) Axial and coronal postcontrast T1 images: The edges of the surgical cavity showed marked ring-like enhancement with an irregular shape. (e and f) Diffusion-weighted imaging and apparent diffusion coefficient maps: The lesion exhibited hyperintense signal in diffusion-weighted imaging and reduced signal in apparent diffusion coefficient maps, respectively, indicating the restricted diffusion.
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case_images: One month postoperatively, the patient's MRI demonstrated irregular surgical cavity changes in the left temporal lobe following tumor resection (Figure 3). Postcontrast images displayed prominent ring-like enhancement at the resection margins, measuring 41 x 28 x 52 mm, indicating some tumor cells residues (Figure 3c and 3d). Diffusion-weighted imaging (DWI) revealed hyperintensity in both the resection site and surrounding margins (Figure 3e), with a corresponding reduced signal on apparent diffusion coefficient (ADC) maps (Figure 3f), indicating the restricted diffusion.
case_images: Dose distribution (a) and dose-volume histogram (b) of PBT. (a) The total dose of PBT was 60 Gy (RBE) in 15 fractions. The color wash indicated the dose distribution, with the highest dose regions centered on the GTV and the dose gradually decreasing outward. (b) The GTV received the highest dose coverage, followed by CTV and PTV. The left cochlea received a lower dose, as indicated by the steep drop-off in the dose-volume histogram curve, demonstrating dose sparing for critical structures. Red line: GTV; Pink line: CTV; Dark blue line: PTV; Light blue line: Left cochlea. Abbreviations: CTV, clinical target volume; GTV, gross tumor volume; and PTV, planning target volume.
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case_images: Figure 4 shows the dose distribution of PBT. Figure 4b demonstrates the dose-volume histogram of PBT.