Female, 37 years old, history of GBM, presumably IDH wild type, MGMT unmethylated, prior to resection and TMT/RT; PD two cycles of IDO pathway immunotherapy, D56 on anti-angiogenic agent plus Avastin. Postop findings are again seen compatible with bilateral frontal craniotomy. A cystic space occupying the left frontal lobe has not significantly changed.A large area of signal abnormality and mass effect is again seen involving the entire right frontal lobe, corpus callosum, insula, basal ganglia, and thalamus. The core of the lesion demonstrates a scarlike area of intense enhancement with more feathery subtle enhancement elsewhere. The intensity of enhancement has decreased when compared to the prior examination. However, the overall size of the abnormal has progressed. In particular, tumor-like bulkiness expanding many of the frontal gyri has progressed in areas which previously appeared simply edematous.Mass effect is again seen in the right cerebral hemisphere including inferior displacement and partial effacement of the right lateral ventricle, and a midline shift to the left of at least 5 mm. The left lateral ventricle is not dilated.Progressive enhancement has also occurred within the left cerebellum. The prior single enhancing nodule has become larger, and there is now a new rim-enhancing nodule which projects into the fourth ventricle, and perhaps an additional new satellite nodule just lateral to the original lesion. The fourth ventricle is partially effaced and signal abnormality extends from these lesions into the midbrain.
Findings are again seen concerning for progressive disease. Although the intensity of enhancement of the right frontal lobe lesion has diminished, the overall size of the abnormality, and in particular the tumor-like bulkiness of many of the frontal gyri, have progressed. Furthermore, new and larger enhancing nodules are also demonstrated adjacent to the fourth ventricle.