A 51-year-old man developed headaches and subsequently had a seizure. Imaging revealed an area of abnormal T2 hyperintensity in the left insular region. He underwent a biopsy, which was nondiagnostic. Four months later, repeat imaging demonstrated an interval expansion of abnormal T2 hyperintensity. A second biopsy was performed, confirming an anaplastic astrocytoma, IDH1 wild-type. He was treated with conventional chemo-RT followed by 7 cycles of adjuvant temozolomide. Imaging subsequently revealed a new area of abnormal enhancement in the medial left temporal lobe. He elected to initiate treatment with dose-intense temozolomide and concurrent TTFields therapy. NovoTAL mapping was performed utilizing the extent of the T2 hyperintense signal, rather than focusing solely on the small area of abnormal enhancement (Fig. ).
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.