 There are postoperative findings related to prior right parietal craniotomies. There has been significant progression of enhancing tissue within the right frontal lobe. For example, the dominant anterior enhancing lesion now measures 41 x 59 mm, previously 17 x 19 mm. The more posterior and superior lesion currently measures 19 x 20 mm, previously 8 x 7 mm. The enhancement does however have a somewhat abnormal appearance with the superior portions respecting the gyral morphology, and the inferior margin showing a very ill-defined speckled pattern of enhancement. The more anterior dominant enhancing lesion now infiltrates inferiorly into the genu and body of the corpus callosum. There has also been a significant increase in the surrounding T2 hyperintensity that now crosses to the left side of the corpus callosum. There is a significant increase in mass effect with new 6 mm leftward midline shift and subfalcine herniation. The mass effect is however slightly less than expected given the size of the enhancing lesion. These enhancing masses demonstrate markedly elevated relative cerebral blood volume, at least along their periphery.
Significant progression of right frontal enhancement is seen with corresponding increase in mass effect and new leftward subfalcine herniation. Particularly given the elevated rCBV, these findings are concerning for progressive tumor.However, considering the rapidity of progression compared with the previous slow progression of tumor from 2013, and considering the recent administration of an immune modulating drug and somewhat atypical imaging appearance of the lesion, a component of superimposed inflammation may also be contributing to this appearance. 