A 45-year-old man presented with headaches and was found to have a right frontal GBM (MGMT promoter unmethylated, EGFR not amplified, 1p/19q codeletion status unknown) (Figure a), for which he had a gross total resection followed by radiation and daily TMZ and then metronomic TMZ with NovoTTF therapy. He remained neurologically intact with no radiographic evidence of recurrence for 22 months. A surveillance MRI revealed a small enhancing lesion in the left parietal lobe (Figure b), which was resected, and his fields were adjusted accordingly. The histology of the recurrent lesion showed multiple giant syncytial-type cells, and he has remained in good health over the subsequent nine months.
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. ).