A 48-year-old man was referred to our clinic for evaluation of a new dural-based lesion 6 years after excision, skin flap repair, and bone graft placement for a skull-base esthesioneuroblastoma followed by adjuvant radiation. His posttreatment course was complicated by externalization of the bone flap requiring a second skull-base bone flap resection. After 5 years of no radiographic evidence of residual disease, a routine follow-up magnetic resonance imaging (MRI) scan at 6 years revealed an enhancing dural lesion over the right frontal lobes [].\nThe patient underwent a right frontotemporal craniotomy for resection of the enhancing dura and tumor, which was found to be partially invading the brain parenchyma. Pathological analysis indicated the lesion was consistent with recurrent metastatic esthesioneuroblastoma. The patient received adjuvant stereotactic radiosurgery. His follow-up MRIs approximately every 6 months remained negative until additional dural-based lesions along the frontal sinus, right temporal lobe, and right sphenoid wing were observed at 3 years []. Follow-up imaging 5 months later revealed progressive interval growth of the dural-based lesions. Treatment with cisplatin and etoposide was stopped after one cycle because of intractable nausea and vomiting. Approximately 1 year later, the patient restarted treatment with sunitinib, but the tumor showed clear progression 12 months later and the drug was discontinued. The patient succumbed to the disease 6 months later, 11 years after his initial diagnosis.
A 32-year-old left-handed female patient was referred to our department with an MR scan showing a right fronto-opercular diffuse low-grade glioma and performed as a diagnostic work-up for headache (). Left-handedness was confirmed with Edinburgh’s inventory. She had no preoperative language disorders.\nAfter navigation-guided identification of the tumour boundaries, an “awake” resection was performed and intraoperative identification of Broca’s area (tag 5) with “speech arrest” and inferior fronto-occipital fascicle (IFOF) with transient fonemic paraphasia was reached (tag 8) , and . Resection was then stopped.\nHistology provided evidence for isocitrate dehydrogenase 1(IDH1)-mutated, ATP-Dependent Helicase (ATRX)-wild diffuse low-grade astrocytoma. Postoperative MR showed a subtotal removal with residual disease where IFOF was intraoperatively identified (). No adjuvant therapy was then proposed, and the patient is currently fully working. If evidence of residual disease progression is observed, a new surgery will be proposed, delaying eventual adjuvant therapy as much as possible.\nThis may be considered an example case of the “multi-staged” approach to dealing with diffuse low-grade gliomas, making it possible to get control of the disease as much as possible, postponing chemotherapy or radiotherapy as far as possible and reserving them for when surgery can no longer be performed.