• 50 year old man presented with complaints of headache and behavioural change of 3 months duration in July 2011.
• Associated with gait disturbances of 1 month duration

• Pre-operative MRI (02.08.2011) showed a large complex solid cystic enhancing intraaxial mass lesion in the right temporo-parietal and frontal region

He underwent radical excision by right temporo-parietal craniotomy and excision on 05.08.2011

• Post operative MRI on 18.08.2011 shows good exicision of the mass

• High grade glial tumour with oligodendroglial component

• Significant large confluent areas of necrosis

• GBM with oligodendroglial component (GBM-O) versus anaplastic oligodendroglioma were proposed as differentials. Former was favoured

• Plan : Adjuvant concurrent chemoradiation.
• He concluded focal conformal radiotherapy (59.4Gy/33#) along with Cap Temozolomide (75mg/sq. metre) on 02.11.2011.
• Tolerated the treatment well.

• Patient clinically well without any deficits

MRI scan 28.11.2011

MRI scan 28.11.2011

Patient was planned for 6 adjuvant monthly cycles of Cap Temozolomide

Follow up MRI scan was done after 6 cycles of adjuvant Temozolomide (completed in April 2012)

T1 post contrast images Patient asymptomatic

MRI scan 30.5.2012

MRI scan 30.5.2012

• He was kept on observation and was asymptomatic for over 9 months.
• He developed neurological symptoms (headache and gait disturbance) in February 2013.

T1 post contrast images

• What is the likely diagnosis?
• Is it tumour progression?

MR Spectroscopy revealed a tall lipid/lactate peak No significant choline peak identified

MR Spectroscopy revealed a tall lipid/lactate peak No significant choline peak identified

• Would steroids help?
• What is the quantum of benefit expected in steroid administration?
• Is complete clinical resolution expected to reflect on radiology as well?

T1 Post Contrast axial cuts MRI scan done 2 months later, on 15.4.2013

• Such changes have been described in early post RT+TMZ (typically within 3 months)
• These changes may however be seen even after several months on follow up (9 months in the presented case)
• The patient showed complete neurological recovery over several months with intermittent steroids and significant radiological resolution on MRI scans

• Defined as the increase in the size of contrast-enhancing lesions; immediately after radiotherapy. Temozolomide accentuates the effect.
• Caused by vasodilation and disruption of blood brain barrier.
• Incidence of 25-40%

• Leukoencephalopathy syndrome
• True radio-necrosis
• Large vessel occlusion (Moya-Moya syndrome)
• Telengectasias
• White matter abnormalities

• Close observation alone, if no or mild symptoms
• Steroids in tapering doses if symptomatic
• Recently anti-VEGF (Bevacizumab) has been tried with good success in refractory or steroid dependence.*

• While a majority of patients will show these treatment related effects within few (1-3 months) after completing RT/RT+TMZ, these changes can be seen even several months after definitive treatment.
• Most patients show either no or mild symptoms but occasionally patients can be symptomatic too, especially if lesions are in eloquent area.
• To continue Temozolomide/observation even if apparent increase is seen on radiology.
• MR Spectroscopy and MR perfusion can aid considerably for confirmation and differentiating from true tumour progression (accuracy reported between 80-90%). Amino acid PET may help too.
• Cortex is invariably spared in these situations and any cortical involvement on MRI should raise a suspicion of true tumour progression.