39-year-old male with a right frontal lesion that was resected in 2010 (grade II oligodendroglioma positive for 1p/19q co-deletions with increased proliferative activity (MIB-1 of 8.2%). Developed progression on chemotherapy and repeat biopsy in January 2014 showed histologic progression to grade 3. There are changes related to previous right frontal craniotomy. Just deep to the surgical cavity in the anterior aspect of the right cranial fossa, there is remarkable progression of T2 hyperintensity which now involves most of the right frontal lobe white matter (reaching up to the precentral sulcus posteriorly and inferiorly to involve the right subinsular white matter). This is associated with mass effect resulting in mild anterior midline shaft as well as compression of the right lateral ventricle and right frontal sulci. There is abnormal T2 signal is associated with heterogeneous, nodular contrast enhancement that is most pronounced in the anterior-medial aspect of the new abnormality. The contrast-enhancing tissue is relatively T2 hypointense and mildly diffusion restricted. There are foci of susceptibility effect within the infiltrative signal abnormality which probably represent foci of intratumoral hemorrhage. On dynamic susceptibility contrast imaging, the abnormal tissue shows a heterogeneous elevation in relative cerebral blood volume (corrected for leakage) which is most pronounced also in the anterior-medial aspect of the abnormality where contrast enhancement is most pronounced. 2-D multivoxel MR spectroscopy with an intermediate echo time (144 ms) shows a generalized elevation of the choline peak as well as depression of N-acetylaspartate peak compared to the contralateral normal-appearing white matter. In some areas of the lesion, choline is markedly elevated reaching 2 to 2.5 times that seen in normal contralateral tissue. Some areas are also associated with the presence of lactate and lipid.Mild, confluent T2 hyperintensity in the left frontal periventricular white matter is separate from the tumor and has not changed since the previous examination and therefore may reflect effects of previous treatment. The remainder of the brain is normal. Besides the above described mass effect caused by the right frontal mass, the CSF-containing spaces are normal in size.
Compared to the July 2015 examination, there has been remarkable progression of infiltrative, heterogeneously contrast enhancing tissue in the right frontal lobe. This tissue is associated with significantly elevated choline on spectroscopy, as well as elevated rCBV. Findings are highly suspicious for progressive disease.