case_images: PMC9168415_01
case_images: (October 2008): axial T2-weighted (a) and sagittal T1-weighted (b) images show a supratentorial peripherally located left frontotemporal lobulated fairly well-defined heterogeneous mass having cystic (thick arrows) and solid components with evidence of hemorrhage (thin arrows), and relatively little adjacent peritumoral parenchymal T2 hyperintensity (arrow heads). Axial (c) and coronal (d) postcontrast T1-weighted images reveal heterogeneous enhancement of the tumor with rim enhancement of the cystic components (arrows).
case_images: SNI-13-221-g001.jpg
case_images: PMC9168415_01_SNI-13-221-g001.jpg
case_images: F1
case_images: Initial magnetic resonance imaging (MRI) on T1-weighted series demonstrated a 5.5 cm x 3.9 cm x 4.8 cm left frontotemporal peripherally located mass with solid and cystic components with evidence for internal hemorrhage but relatively little surrounding parenchymal T2 hyperintensity [Figure 1].
case_images: (January 2009): (a) Axial T2-weighted and (b) coronal post-contrast T1-weighted images obtained after resection show complete excision of tumor with residual gliotic and postsurgical changes involving the left temporal lobe.
case_images: SNI-13-221-g002.jpg
case_images: PMC9168415_01_SNI-13-221-g002.jpg
case_images: F2
case_images: Indeed, the postoperative MRI demonstrated postsurgical gliotic changes with focal atrophy in the left temporal lobe with no evidence of residual tumor [Figure 2].
case_images: A set of light microscopy images from tissue samples taken in October 2008 at initial surgery demonstrating (a) perivascular rosettes of tumor cells with broad processes passing down to the outside of central small blood vessels, (b) hyalinization of the blood vessel wall, and (c) positive (brown) immunostaining for glial fibrillary acid protein.
case_images: SNI-13-221-g003.jpg
case_images: PMC9168415_01_SNI-13-221-g003.jpg
case_images: F3
case_images: Subsequent histological analysis deemed the tumor to be an astroblastoma, based on morphological criteria of the then current 4th edition of the World Health Organization (WHO) classification of tumors of the CNS, with typical features such as perivascular rosettes [Figure 3a], hyalinization of the vascular wall [Figure 3b], and positive immunostaining for glial fibrillary acid protein [Figure 3c].
case_images: (September 2016) - Hematoxylin and eosin stained section of recurrent tumor in 2016, with mitotic figure at the lower left.
case_images: SNI-13-221-g004.jpg
case_images: PMC9168415_01_SNI-13-221-g004.jpg
case_images: F4
case_images: This process of recurrence occurred again in September 2016 [Figure 4] and May 2018, with the patient being treated with re-do craniotomy followed by 4 cycles of procarbazine (75%), lomustine, and vincristine (PCV) with granulocyte-colony-stimulating factor (G-CSF) cover (lipegfilgrastim) due to hematotoxicity (July-December 2018).
case_images: (July 2020): axial (a) and coronal (b) postcontrast T1-weighted images showing recurrent nodular enhancing tumor (arrows) along the inferior aspect of the medial temporal lobe, also showing increased perfusion on the relative cerebral blood flow map (c) obtained from dynamic susceptibility contrast planar imaging.
case_images: SNI-13-221-g005.jpg
case_images: PMC9168415_01_SNI-13-221-g005.jpg
case_images: F5
case_images: In January 2020, she experienced a further relapse, this time managed only with surgery due to previous low tolerance to chemotherapy; as expected, the tumor progressed further in July 2020 [Figure 5]. Although the surveillance MRI of July 2021 [Figure 6] showed a small contrast enhancement in the medial aspect of the left temporal lobe, there was overall less tumor volume compared to the previous studies [Figure 5]; the nature of the enhancing lesion remains unclear as the most recent MRI (September 2021) showed minimal changes compared to the previous study of July.
case_images: (July 2021): axial (a) and coronal (b) postcontrast T1-weighted images showing overall regression of the previous tumor with a new small indeterminate nodular area of contrast enhancement (arrows).
case_images: SNI-13-221-g006.jpg
case_images: PMC9168415_01_SNI-13-221-g006.jpg
case_images: F6
case_images: Although the surveillance MRI of July 2021 [Figure 6] showed a small contrast enhancement in the medial aspect of the left temporal lobe, there was overall less tumor volume compared to the previous studies [Figure 5]; the nature of the enhancing lesion remains unclear as the most recent MRI (September 2021) showed minimal changes compared to the previous study of July.