British Journal of Neurosurgery, October 2014; 28(5): 697–698 © 2014 The Neurosurgical Foundation ISSN: 0268-8697 print / ISSN 1360-046X online DOI: 10.3109/02688697.2014.887659
NEUROSURGICAL IMAGE
Recurrent glioblastoma multiforme presents as a mirror image in the contralateral temporal lobe Benjamin R. Uy, Lee A. Tan & Richard W. Byrne Departments of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
A 44-year-old woman with history of left temporal glioblastoma multiforme (GBM) presented with a generalized seizure and altered mental status. She had undergone surgical resection for the left temporal GBM 17 months ago with concurrent external beam radiotherapy and a 12-month cycle of temozolomide. Magnetic resonance imaging of the brain revealed a new right temporal lobe mass, while the original left temporal surgical site showed no sign of tumour recurrence (Fig. 1). MR spectroscopy of the new right temporal lesion was consistent with recurrence of GBM.
About 10% of recurrent GBM can occur outside the site of original tumour despite the combination of surgical resection, chemotherapy and radiation treatment.1,2 The mechanism of GBM spread is thought to be due to tumour cell migration through integrin focal adhesions along the extracellular matrix proteins of white matter tracts and basement membranes lining blood vessels.3 With temozolomide and radiotherapy becoming the standard of care, an increased number of tumours are seen further from the resection cavity and field of radiation.4 It is suggested that the increased survival time as well as the sensitivity to radiotherapy may provide an opportunity for
Fig. 1. Magnetic resonance imaging (MRI) brain T1-weighted with contrast. A&B, pre-operative MRI showing the left temporal lesion; C&D, postoperative MRI at 15 months showing no recurrence of tumour; E&F, post-operative MRI at 17 months showing recurrent GBM in the contralateral size with no evidence of recurrent disease at the original tumour site.
Correspondence: Lee A. Tan, MD, Departments of Neurosurgery, Rush University Medical Center, 1725 W. Harrison St. Suite 855, Chicago, IL 60612, USA. Tel: ⫹ 312-942-6644. Fax: ⫹ 312-563-3358. E-mail: [email protected] Received for publication 17 November 2013; accepted 19 January 2014
697
698
B. R. Uy et al.
GBM cells to distantly migrate while recurrence at original tumour site is suppressed.5 It is important to distinguish GBM recurrence from radiation necrosis in patients who had received radiation treatment. MR spectroscopy and perfusion studies can be very useful in these situations: choline (Cho)to-creatinine (Cr) and Cho-to-N-acetyl-aspartic acid (NAA) ratios are increased in both GBM and radiation necrosis; while NAA-to-Cr ratio is decreased in GBM and increased in radiation necrosis.6 A frank discussion with patients and family as well as a multidisciplinary approach are needed to ensure optimal management of patients with recurrent GBMs. Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper.
References 1. Choucair AK, Levin VA , Gutin PH, et al. Development of multiple lesions during radiation therapy and chemotherapy in patients with gliomas. J Neurosurg 1986;65:654–8. 2. Wick W, Stupp R, Beule AC, et al. A novel tool to analyze MRI recurrence patterns in glioblastoma. Neuro Oncol 2008;10:1019–24. 3. Zhong J, Paul A , Kellie SJ, O’Neill GM. Mesenchymal migration as a therapeutic target in glioblastoma. J Oncol 2010;2010:1–17. 4. Brandes AA , Tosoni A , Franceschi E, et al. Recurrence pattern after temozolomide concomitant with and adjuvant to radiotherapy in newly diagnosed patients with glioblastoma: correlation With MGMT promoter methylation status. J Clin Oncol 2009; 27:1275–9. 5. Milano MT, Okunieff P, Donatello RS, et al. Patterns and timing of recurrence after temozolomide-based chemoradiation for glioblastoma. Int J Radiat Oncol Biol Phys 2010;78:1147–55. 6. Hou LC, Veeravagu A , Hsu AR, Tse VCK . Recurrent glioblastoma multiforme: a review of natural history and management options. Neurosurg Focus 2006;20: E5.
Copyright of British Journal of Neurosurgery is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
NEUROSURGICAL IMAGE
Recurrent glioblastoma multiforme presents as a mirror image in the contralateral temporal lobe Benjamin R. Uy, Lee A. Tan & Richard W. Byrne Departments of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
A 44-year-old woman with history of left temporal glioblastoma multiforme (GBM) presented with a generalized seizure and altered mental status. She had undergone surgical resection for the left temporal GBM 17 months ago with concurrent external beam radiotherapy and a 12-month cycle of temozolomide. Magnetic resonance imaging of the brain revealed a new right temporal lobe mass, while the original left temporal surgical site showed no sign of tumour recurrence (Fig. 1). MR spectroscopy of the new right temporal lesion was consistent with recurrence of GBM.
About 10% of recurrent GBM can occur outside the site of original tumour despite the combination of surgical resection, chemotherapy and radiation treatment.1,2 The mechanism of GBM spread is thought to be due to tumour cell migration through integrin focal adhesions along the extracellular matrix proteins of white matter tracts and basement membranes lining blood vessels.3 With temozolomide and radiotherapy becoming the standard of care, an increased number of tumours are seen further from the resection cavity and field of radiation.4 It is suggested that the increased survival time as well as the sensitivity to radiotherapy may provide an opportunity for
Fig. 1. Magnetic resonance imaging (MRI) brain T1-weighted with contrast. A&B, pre-operative MRI showing the left temporal lesion; C&D, postoperative MRI at 15 months showing no recurrence of tumour; E&F, post-operative MRI at 17 months showing recurrent GBM in the contralateral size with no evidence of recurrent disease at the original tumour site.
Correspondence: Lee A. Tan, MD, Departments of Neurosurgery, Rush University Medical Center, 1725 W. Harrison St. Suite 855, Chicago, IL 60612, USA. Tel: ⫹ 312-942-6644. Fax: ⫹ 312-563-3358. E-mail: [email protected] Received for publication 17 November 2013; accepted 19 January 2014
697
698
B. R. Uy et al.
GBM cells to distantly migrate while recurrence at original tumour site is suppressed.5 It is important to distinguish GBM recurrence from radiation necrosis in patients who had received radiation treatment. MR spectroscopy and perfusion studies can be very useful in these situations: choline (Cho)to-creatinine (Cr) and Cho-to-N-acetyl-aspartic acid (NAA) ratios are increased in both GBM and radiation necrosis; while NAA-to-Cr ratio is decreased in GBM and increased in radiation necrosis.6 A frank discussion with patients and family as well as a multidisciplinary approach are needed to ensure optimal management of patients with recurrent GBMs. Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper.
References 1. Choucair AK, Levin VA , Gutin PH, et al. Development of multiple lesions during radiation therapy and chemotherapy in patients with gliomas. J Neurosurg 1986;65:654–8. 2. Wick W, Stupp R, Beule AC, et al. A novel tool to analyze MRI recurrence patterns in glioblastoma. Neuro Oncol 2008;10:1019–24. 3. Zhong J, Paul A , Kellie SJ, O’Neill GM. Mesenchymal migration as a therapeutic target in glioblastoma. J Oncol 2010;2010:1–17. 4. Brandes AA , Tosoni A , Franceschi E, et al. Recurrence pattern after temozolomide concomitant with and adjuvant to radiotherapy in newly diagnosed patients with glioblastoma: correlation With MGMT promoter methylation status. J Clin Oncol 2009; 27:1275–9. 5. Milano MT, Okunieff P, Donatello RS, et al. Patterns and timing of recurrence after temozolomide-based chemoradiation for glioblastoma. Int J Radiat Oncol Biol Phys 2010;78:1147–55. 6. Hou LC, Veeravagu A , Hsu AR, Tse VCK . Recurrent glioblastoma multiforme: a review of natural history and management options. Neurosurg Focus 2006;20: E5.
Copyright of British Journal of Neurosurgery is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
