A 41-year-old man presented after a week of intermittent headaches and was found to have a left frontal enhancing mass (Figure a). A gross total resection was performed and the pathology showed GBM with primitive neuroectodermal tumor (PNET) component (MGMT promoter unmethylated, EGFR not amplified, 1p/19q co-deletion negative). Surgery was followed by radiotherapy and daily TMZ and then NovoTTF therapy/metronomic TMZ. Six months later, a distal lesion were noted (Figure b), and he underwent further resection with adjustment of his fields. In order to address the PNET component if his tumor, and because a combination of ifosfamide, carboplatin, etoposide (ICE) has been shown to be effective against this tumor type [], his chemotherapy was changed to bevacizumab with ICE (ifosfamide, carboplatin, etoposide) × six cycles. He continued on bevacizumab with NovoTTF therapy for over a year until he developed leptomeningeal disease and passed away in July 2013.
A 49-year-old man developed left arm weakness. Imaging revealed a ring-enhancing nodule in the posterior right frontal lobe. He underwent a gross total resection with pathology confirming a GBM, MGMT unmethylated. He was treated with conventional chemo-RT, followed by 1 cycle of maintenance temozolomide. The patient experienced disease progression and was started on bevacizumab, with continuation of temozolomide. After completing 6 cycles of temozolomide, he had a further progression and underwent a repeat tumor resection, with placement of Gliadel wafers. Following the surgery, he received bevacizumab in combination with dose-intense (daily) temozolomide for 2 months. Subsequently, the patient developed new symptoms of worsening left-sided weakness. Imaging performed at that time demonstrated three areas of abnormal enhancement, including the resection cavity with Gliadel wafers, an enhancing area in the medial right frontal lobe suggestive of a subdural collection, and a new enhancing mass in the deep right hemisphere (Fig. ). NovoTAL mapping was performed utilizing measurements of the deep tumor, and TTFields therapy was initiated.