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 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.