Fig. 1

The timeline of treatments and typical MR, pathological images at the different stages. Brain MR images with post-gadolinium T1 before biopsy (A), before craniotomy surgery (B) and after craniotomy surgery (C) displayed rapid progress and intracranial metastasis of tumor, also demonstrated total resection of all enhancing tumor after craniotomy surgery. H&E staining demonstrated the classical appearance of a glioblastoma (I). Post-gadolinium T1 and contrast MR perfusion images of 6 weeks after surgery displayed rapid relapse at left lateral ventricular wall (D). After receiving combination therapies of dose-dense TMZ plus TTFields plus pembrolizumab for 10 weeks (E) and 16 weeks (F), MR images of post-gadolinium T1 and contrast MR perfusion displayed PR of relapsed tumor according to RANO criteria. Stop use of pembrolizumab for 4 weeks, several new enhancing lesions located at brainstem and temporal horn of right lateral ventricle were visible (G). Stop use of temozolomide, combination therapy of TTFields and everolimus for 4 weeks, brain MR images with post-gadolinium T1 demonstrated significant decreased in size of new metastasizing lesions (H). A secondary malignant neoplasm occurred during combined therapeutic course, femur MR and pathological detection of biopsy tissue demonstrated a secondary osteosarcoma (J). C. TMZ = concomitant Temozolomide; A. TMZ = adjuvant Temozolomide; mu = mutated; wt = wild type; CR = complete response; PR = partial response; PD = progressive disease