Glioblastoma. Status post prior re-irradiation and Avastin therapy. Presenting with progressive abnormality of gait, generalized weakness, and incoordination over the past 2 days. Additional clinical history from electronic medical records: Underwent craniotomy with complete radiographic resection (7/22/14, Dr. Lesniak). She lacked EGFRv3 mutation. She received RT/TMZ and then TMZ. This was for a total of 6 cycles of TMZ. When there was progression of disease she enrolled in RTOG1205 for which she received re-RT, as well as additional bevacizumab. She had then been continuing bevacizumab off study under the care of Dr. Nicolau in Florida. More recently, she returned to Chicago and received a dose of bevacizumab on 05/18/2016 with Dr. Narula. The right temporal surgical cavity is not significantly changed nor the associated contrast enhancement along its posterior margin. However, T1 and T2 hypointense lesions along the anterior and superior surgical margins have increased in size and shows peripheral contrast enhancement and mild diffusion restriction. The anterior one measures up to 2.3 cm, on postcontrast sagittal T1, compared to 1.7 cm previously. The superior one measures up to 1.7 cm on same image compared to 1.2 cm previously. Dynamic susceptibility contrast-enhanced perfusion imaging shows no prominent CBV increase in the treatment bed or adjacent parenchyma. The confluent white-matter T2-hyperintensity surrounding the surgical cavity has slightly increased, with more extension along the right internal and external capsules. There is no acute infarct or acute intracranial hemorrhage. There is no midline shift or brain herniation. The lateral ventricles are slightly less enlarged than before. Nonspecific periventricular T2-hyperintensity and mild global brain volume loss are not significantly changed. Major intracranial vascular flow voids are preserved. There are findings of prior bilateral cataract surgery. The right parietal craniotomy flap and the small underlying extra-axial fluid collection are not significantly changed. There is an unchanged subcentimeter nonspecific enhancing lesion in the left parietal bone.
1.Enlarging lesions with peripheral contrast enhancement and mild diffusion restriction along the anterior and superior surgical margins are suggestive of tumor progression despite the discernible contrast enhancement or hyperperfusion, perhaps due to superimposed treatment effects.2.There is no acute infarct, acute hemorrhage, mass-effect or brain herniation.3. Unchanged subcentimeter nonspecific enhancing lesion in the left parietal bone.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report.