case_images: PMC11059094_01
case_images: The illustrated pre- and post-operation MR images of this case during the five times of surgery (A). Treatment flowchart outlining the patient's therapeutic journey (B).
case_images: fimmu-15-1369972-g001.jpg
case_images: PMC11059094_01_fimmu-15-1369972-g001.jpg
case_images: f1
case_images: TMZ-induced hypermutation ( Figure 4C ,  Supplementary Table 1 ). The relatively favorable immune microenvironment observed in sample B has been validated by the sustained tumor remission following immunotherapy administration ( Figure 4D ).
case_images: Genomic evolution of the tumor cells during recurrences.
case_images: fimmu-15-1369972-g002.jpg
case_images: PMC11059094_01_fimmu-15-1369972-g002.jpg
case_images: f2
case_images: To investigate the alterations in the tumor microenvironment pre- and post-immunotherapy, we obtained the third, fourth, and fifth tumor samples from the patient, as well as the fifth intraoperative cerebrospinal fluid sample, and conducted whole exome sequencing on these samples ( Figure 2 ).
case_images: Somatic mutation signature in post-TMZ treatment tumors. Signature 11 that exhibits a strong transcriptional strand-bias for C>T substitutions was found in sample C, suggesting a mutational pattern associated with alkylating agents.
case_images: fimmu-15-1369972-g003.jpg
case_images: PMC11059094_01_fimmu-15-1369972-g003.jpg
case_images: f3
case_images: Concurrently, we performed RNA transcriptome sequencing on the third, fourth, and fifth tumor samples obtained from the patient ( Figure 3 ).
case_images: Immunologic analysis of post-operative tumors, including comparisons of immunophenoscore (A), CIBERSORT results (B), and enriched pathways (C) between different tumor samples. (D) Following the fourth operation, the patient received 4 cycles of immunotherapy. with partial response observed in the enhanced lesion in the right frontal-parietal lobe during follow-up.
case_images: fimmu-15-1369972-g004.jpg
case_images: PMC11059094_01_fimmu-15-1369972-g004.jpg
case_images: f4
case_images: To assess the immune microenvironment of the tumor samples, we conducted a quantification scoring system called immunophenoscore, which incorporates MHC molecules, immunomodulators, effector cells, and suppressor cells ( Figure 4A ). Following treatment, tumor cell death resulted in the release of a substantial amount of tumor antigens, leading to heightened immune response in sample B, as evidenced by a significant increase in the proportion of M1 macrophages ( Figure 4B ). TMZ-induced hypermutation ( Figure 4C ,  Supplementary Table 1 ). The relatively favorable immune microenvironment observed in sample B has been validated by the sustained tumor remission following immunotherapy administration ( Figure 4D ).