An autopsy case of widespread brain dissemination of glioblastoma unnoticed by magnetic resonance imaging after treatment with bevacizumab

BACKGROUND: Although glioblastoma has been shown to be able to disseminate widely in the intracranially after treatment with bevacizumab without any significant radiological findings, reports on such cases with subsequent autopsy findings are lacking. CASE DESCRIPTION: A 36-year-old man presented with a general seizure and a mass of the right frontal lobe, which was diagnosed as diffuse astrocytoma (WHO Grade II). The patient underwent a total of four surgeries from 2005 to 2017. He showed tumor recurrence, progression, and malignant transformation to glioblastoma (GBM) (WHO Grade IV) despite repeated tumor resections, radiotherapy, and chemotherapies with temozolomide and carmustine wafers. Bevacizumab (10 mg/kg body weight) was started following the fourth surgery. After bevacizumab administration, the patient’s clinical condition improved to a Karnofsky performance status (KPS) score of 50–60, and he was stable for several months before finally deteriorating and passing away. Although sequential magnetic resonance imaging (MRI) showed shrinkage of the lesion and a reduction of edema, an autopsy showed widespread tumor invasion that was not revealed on MRI. Neoplastic foci were identified extensively in the cerebral cortex, basal ganglia, pituitary gland, cerebellum, and brainstem, imposing as gliomatosis cerebri. CONCLUSION: Imaging follow-up of malignant gliomas needs to be interpreted with caution as marked improvement in radiological response after bevacizumab treatment may not be indicating tumor regression. Despite the notable lack of evidence to increase overall survival in GBM patients with bevacizumab, the increase in progression-free survival and the observed relief of symptoms due to a decrease in edema should be considered relevant for patient management.