A 65-year-old man initially presented with word processing difficulties. MRI of the brain revealed a heterogeneously enhancing left temporo-occipital mass. He underwent an awake craniotomy with subtotal resection. Pathology was consistent with GBM, IDH1 wild-type, MGMT unmethylated. He was treated with conventional chemo-RT. His postradiation MRI showed disease progression and bevacizumab was initiated, resulting in a radiographic improvement. After 5 months of treatment, his MRI demonstrated progression of the nonenhancing tumor and the patient declined clinically. At progression, he was started on dexamethasone, temozolomide, and TTFields. NovoTAL mapping was performed targeting the new nonenhancing FLAIR abnormality (Fig. ).
A 39-year-old woman who presented after a new-onset seizure was found to have a left parietal GBM (genetics not available) (Figure a). She underwent subtotal resection followed by radiotherapy with daily temozolomide (TMZ), and then NovoTTF Therapy with metronomic TMZ. After 3 months, her MRI showed progression near her initial resection site, and temozolomide was replaced by bevacizumab (BEV), with NovoTTF Therapy continuing. Nine months later, she had local recurrence in addition to bifrontal enhancing lesions (Figure b), and her TTFields were adjusted. Over the next five months, her multifocal tumor burden increased, and death was preceded by a right insular recurrence.