1. NYU Medical Grand Rounds Clinical Vignette Rachel Shur PGY-2 October 16, 2012 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. 56 woman who presented with 2 weeks of right foot numbness and weakness Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. The patient was in her usual state of good health until approximately 1 month prior to presentation when she started experiencing intermittent headaches with associated nausea and vomiting. Headaches became more frequent, occurring almost daily, worse in the morning 2 weeks prior to presentation, pt noted right foot numbness and weakness. Presented to NYU after she had difficulty driving with her right foot. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

4. Additional History Past Medical History: Gastroesophageal reflux disease Past Surgical History: none Social History: Lived with husband and 2 children, worked as real estate agent No smoking or drug use, drank 2 glasses of wine per week Family History : No family history of cancer or heart disease Allergies: No Known Drug Allergies Medications: Omeprazole 20mg daily U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. Physical Examination General: anxious, well appearing, no acute distress Vital Signs: T: 97.8ºF BP:133/86 HR: 87 RR:14 and O2 sat: 99% on room air Right foot: decreased sensation to light touch and pin prick on anterior and posterior aspect up to ankle, 4/5 strength on flexion and extension Remainder of Physical Exam was normal U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

6. Laboratory Findings CBC: Hemoglobin 11.8 gm/dL / Hematocrit 34.2% Remainder of CBC was within normal limits Basic Metabolic panel: within normal limits Hepatic panel: within normal limits U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. Other Studies CT and MRI brain revealed frontal lobe masses with edema and mass effect, but no herniation U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. The working diagnosis at this time was Gliobastoma Multiforme (GBM) Working Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. Hospital Day 3: –Pt underwent resection of the right sided lesion (pathology was consistent with glioblastoma multiforme) Hospital Day 10: –Pt developed deep vein thrombosis and was started on Lovenox/Coumadin Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Hospital Course

10. Pre and post contrast MRI obtained 1 week post craniotomy revealed post-operative changes +/- residual tumor Pt was discharged on Hospital Day 15 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Hospital Course

11. Within one month of surgery, she started focal external beam radiation therapy with concurrent temozolomide chemotherapy for a six week course (6480 cGy). Post radiation MRI revealed increased surrounding edema. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Disease Course

12. The patient completed 6 cycles of adjuvant temozolomide prior to having progression of disease. She then had once cycle of BCNU chemotherapy complicated by anemia requiring transfusion. She was offered participation in a clinical trial with bevacizumab, after an IVC filter was placed and coumadin was discontinued. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Disease Course

13. She had a dramatic response to bevacizumab therapy, maintained for 6 cycles. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Disease Course

14. A new lesion was detected, but additional treatment had to be interrupted in order to place a ventriculoperintoneal shunt for communicating hydrocephalus. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Disease Course

15. The patient had further treatment delays for shunt related complications and intractable seizures. She was treated with enzyme- inducing antiepileptic drugs (EIAEDs). She developed clinical and radiographic progression of disease. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Disease Course

16. Since her tumor over-expressed epidermal growth factor receptor (EGFR) and intact phosphate and tensin homolog gene (PTEN), she was treated with erlotinib despite being on EIAEDs. There was no response to erlotinib and she died several months later of progressive disease (~18 months from initial hospital admission). U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Disease Course

17. Gliobastoma multiforme Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS