Per EPIC, patient with multiple recurrent GBM status post resection (11/18/11), RT/TMZ (completed 12/11/12) and explored alternative therapies until there was tumor growth in 01/2013. He then started TMZ and received 6 cycles (completed 09/13). With additional tumor growth, he enrolled in a Phase II randomized ReACT Trial and received bevacizumab +/- rindopepimut. He received 4 cycles and there was radiographic progression (MRI 04/14/14). He shortly thereafter developed symptomatic intracranial hemorrhage,and would not allow him to move forward with potential therapy on the DCVax Trial at Cedars-Sinai for which he underwent a craniotomy (06/17/14) with preliminary pathology from the biopsy revealing exclusively necrosis. Final pathology revealed viable tumor, however. He then resumed treatment on the ReACT Trial but without the bevacizumab because of the hemorrhage. He then developed rapid clinical and radiographic progression (MRI 09/09/14). He then underwent a craniotomy with extensive tumor resection (09/22/14). Now on everolimus+Optune. Evaluate for growth. There are post-operative findings related to right sided craniotomy. There is interval increase in size of the heterogenously enhancing mass within the right sided resection bed measuring 9.1 x 5.9 x 6.6 cm (AP x TR x CC), previously 7.4 x 3.7 x 6.0 cm. There are increased areas of necrosis posteriorly. On perfusion imaging, there is elevated relative cerebral blood volume within the majority of the enhancing tissue. There is increased local mass effect with effacement of the right lateral ventricle and increased right to left midline shift measuring 1.4 cm, previously 0.9 cm. There is minimal enlargement of the left lateral ventricle, which may be entrapped. There is mild right uncal herniation. There are multiple foci of susceptibility effect and residual foci of T1 hyperintensity, compatible with old blood products. There is diffusion restriction at the posterior aspect of the tumor, which may indicate areas of hypercellular tumor. There is increased T2 hyperintensity throughout the right cerebral white matter and corpus callosum as well as the right thalamus. Increased T2 hyperintensity in the right cerebral peduncle and right medullary pyramid, likely represents direct tumor spread with superimposed Wallerian degeneration. The major cerebral flow voids are intact. There is unchanged minimal punctate non-specific enhancement within the left internal auditory canal.
Post-operative findings related to right-sided craniotomy with interval increase in size of the heterogenously enhancing mass, increased T2 hyperintense signal, local mass effect and increased right to left midline shift measuring 1.4 cm, compatible with continued tumor progression. Mild right uncal herniation. Minimal enlargement of the left lateral ventricle, which may be entrapped. 