Clinical Progress and Treatment

October 2016: Redo right frontal craniotomy with stereotactic volumetric resection of tumor using microsurgical technique

Recurrent high grade glioblastoma with regions of necrosis (estimated approximately 10% to 15% of tumor area)
Tissue sent for molecular testing (again)

Traditional chemotherapy with bevacizumab (Avastin, Genentech)
Single-agent bevacizumab (not preferred as he has minimal fluid attenuated recovery [FLAIR] changes and no bulky disease)
Immunotherapy: Nivolumab (Opdivo, Bistol-Myers Squibb) off label

December 2016: Began treatment with nivolumab
January 2017: Scans show what was likely mixed progression/response, and patient developed subtle focal seizures. Given one dose of bevacizumab to assist with swelling from immunotherapy. No longer interested in surgery. Continuing nivolumab.
March 2017: Recent scans show response to immunotherapy. Will continue on nivolumab with additional bevacizumab when needed. No seizures.
April 2017: Continued to do well clinically; however new scan showed pathologic enhancement in the right temporal and right frontal parietal regions. Perfusion MRI was performed, and the findings were suspicious for tumor progression. Increased FLAIR changes noted also. Bevacizumab 10 mg/kg given again.
May 2017: Follow-up brain MRI shows decrease in the extent of enhancement associated with a large multilobular lesion centered in the right frontal lobe glioblastoma treatment bed, and surrounding T2 hyperintensity unchanged. No evidence of neoplastic progression in the interval, but enhancing lesion remained suspicious for recurrent malignancy, particularly with the abnormal associated perfusion parameters seen on the most recent comparison MRI.
Patient is continuing with cycle 6 of nivolumab therapy.
Patient remains clinically stable. He continues to work and is ambulatory. He has mild short-term memory and concentration impairments.

Glioblastoma