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UNI\,tsRSITATSMBDIZIN GOTTINCI]N
Deparlment of Neulomdiology

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Tel.055l 39 8475

Name: Stan, Sofi

Date of bidh: 18.10.2009
Patient no.: 13709208
Case number: 72152931
Station: 403 I -KIND

Findings shipmenl 10.11.2015 07:54:40

Report of findings

CMRT with contrast agenl lrom 09.11.2015

Anam esis: Difxse intrinsic Fontine elioma finitial diagnosis 1212014). biopsv 01/2015 (IN1
If ann a y e r + H e kl e I b e t g)
Radio-chemotherapy and radiotherapy from 2,1.02 uniil 07.04.2015,
Mainlenance therapy widl Temozolomide and Sorafenib starting on 22.05.15. In the prclirninar)
examination from 24.08.2015 suspicion oltumor progression. I&erapy: continued, due ta the supposition
of r he ps eudo-pro gre s sion

Methodology: CMRT with contrast agent (3 T): T1-3D before and after contrast agent with muliiplanar
reconstructions and subtraction, axial FLAIR, axial DWl and ADC, perfusion with subsequent bi11ing,
sagittal T2, coronary T2, transveme T2.

Diagnostic findings: There are several preliminary examinations available for comparison, since
26.01.2015, the latest from 24.08.2015.
At the time ofthe last preliminary examinaiion significant increase ofT2 h]?er-intense signal changes in
the pons, now inueasingly dght lateral continued up into the right cerebrum side, a more separate lesiol'l
within the cranial podion ofthe right thalamus, which leads to a delomation ofthe bottom ofthe right
Cella media (central part ofthe lateral ventricle), is also signiflcantly progressive. Shows increasing
reduction olthe pre-pontine cerebral fluid interspaces and ofthe fouth ventdcle. No pro$essive dilation
ofthe supratentorial cerebrospinal fluid interspaces. [n the diffusion weighting still predominantDWl
facilitadon of the tumor with sporadically disseminated Dwl limitations. Iregular inhomogeneous
enhancement after administering the contrast media, especially ofthe left pontine tumor part, with the
formation ofa lateral small necrotic cavity, bui nol relevant overall compa.red to the VU. Sharyiy defined
intense enhancement of the contrast agent of a smaller, somewhat cranial lesion determined by the main
findings, only minimally progressive compared to ihe VU (preliminary examination). Regarding the
perfusion, predominant nonnoperfusion up to hypoperlusion ofthe tumor.
Evaluation: In the 10-week course since the last examination from 24.08.2015, there appears a findines
plQglglgiq1 especially olthe tumor part presumably not put into the irradiation lpld !1_!!!IEqqljlg
spreadjns ofthe tumor is risht pontine alons the right cerebral crus. as well as a further manifestation in
the cranial portion ofthe riqht thalamus- Central necrosis in the left pontine tumor pad dd rather
radiogenic. The tumor parts receivirg KM arc only minimally progressive. Increasing the shift ofthe
infraientodal outer cerebrospinal fluid inierspaces, currently no evidence ofa cerebrospinal fluid
blockage.
Page 1/2

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UNI!'ERSITATSMDDIZIN GOTTINGEN

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Department of Neuroradiology

Tel.055l lg 8475

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Name: Stan, Sofia-Maria

Dare of birrh: 18.10.2009
Patient no.i 13709208
Case numbe| 72152931
Stalion: 40:l I -KTNf)
Findings shipment 10.11.2015 07:54:40

Rport of finditrgs

Ptge 2/2

Kroner loana, authofized interprcter an.l translatar for Geman and English, certifi)
lhe exactness ofthe translatianfiam Rotna ian into English.

1, the undersigned

Aulhorized inletpreler and

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UnNe6lbtsmedizin GiJringen, Pediorric tlemalolqy/Oncolog

tlospitnl for Children nnd YouIh Medicin.

Dtrector: Proi Dr Med Jutta Gatuer

Family
Stan
Str. Ion CreangaNr. 11

RO 725200 Faliiceni, Suceava

Depr.tf, .nt Prdirt.ic Hedrtolo$r/On.ology

Medical Directorr Prol Dr Med ChrislofKrmm
17099 Col1]igen Lcttcr post
Robert Koch SmRe40,17015 Gr0ngen Addrc$
0551/39-6201Telefon
0551/19-6231 r.xx

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Please lorward to the aitendins pediatrician

Statr, Sofia-Maria, born otr 18.10.2009

Str. Ion Creanga Nr, 11,725200 Falticeni, Suceava

Patietrt numben 13709208
Dear colleagues,

We are reporting about the above mentioned patient, who was in our inpatient treatment in the time period from
I5.02.2015 until I7.02.2015, ftom 23.02.2015-2'7.02.2015 and 02.03.2015 up until 07.03.2015.
Diagnosis:

DiffLrse intrinsic pontine glioma (ED 1212014)

Condition after extended biopsy 01/20l5,INl Hamover

Pathology: Glioblastoma multifolme

Current:

Planninglhe therapy according to the HIT-HGG-2007 protocol (planning CT)

Re-Staging: CMRT, spinal MRT add lumbar punctu(e
Beginning radjochemotherapy accoding to the HIT-HCG-2007 protocol
Port implantation on 24.02.2015

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Stan, Sofia-Maria, bom on 18.10.2009

End of November 2014, the molher noticed ior the flrst time a 1eft eye twisted inward, which is compatible with a
abducens nerve paresis, and a hanging corner ofthe mouth to the left, which is compatible with a peripheral facial nerve
palsy. Furthermore, the left eye's eyelid did not shut completely. The mother did not notice slmptoms pointing on a
increased intracranial pressue, such as headaches, fasting vomiting or sedation. The gait pattem $,as unchanged.
The fi$t prcsenlalion to a specialist in Neurologr took place in Romania, lvithin the framework ofthese symploms. The
specialist ran a therapy with glucocorticoids (Dexamethasone, Prednisolone) Ior a tolal of four weeks. Hereunder, there
has been a significant improvement in the neurological symptoms. End ofDecember, after finishing the medication it has
come to a new increase of lhe neurological deficits. Theleupon, a presentation to the University Hospital in Bucharest

occured. The imaging performed here (CMRT) showed a brain tumor in the area of the brainstem, consislenl wilh a
diltrse intrinsic pontine glioma. The presentation at the Irternational Institute for Neurosciences (INl) in Hanover was
carried out on the initiative of the mother. The extended biopsy of the mass was carried out there. ln the histological
exanination showed a Glioblastoma multilorme. The inpatient admission $'as caffied out for the planning and
commencement oflherapy lor dilfuse intrinsic pontine glioma in accoldance with HIT-HGG-2007. Cu entiy, thc clinical
condition remains Lmchanged. There is still pronounced peripheral facial nerve palsy left and an Abducens nerve paresis
left. There are no signs ofinf'ectioll upon admission. Bowel movement and urination are without pathological findings. No
medication was taken.
TI

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are no rele\

"nr

pre erisring cordil or..

Farnily anamnesis: Sophia-Maria is the first child ola mother born in 1985 and ola father born in 1978. Originally, the
family comes lrom Romania, but wants lo continue the treatment in Gemary. Ihe parents, as well as the 3 years old
daughter are healthy. Regardjrg the family anamnesis, it is known that the patemal aunt had a pancreatic tumor and that
lhe grandmother a bone tumor. The

limily

lives together.

Birth anamnesisr Natural conception. Caesarean section in the 38'h week olpregnancy, without compljcations. Neonalal
phase without complications. Curreni psychomotor development is age-appropdate.
Examination findings: The examination was made significantly difficult due to $eatly reduced cooperation of the
patient. The 5 4/12 years old patient is in a good geneml and nutritional condition. Pale skin color, nojaundice, no signs of
bleeding. The left abducens nerve paresis as well as leli peripheml faciai paresis. As a rough mean of orientation, other
brain nerve status without pathological findings. Confident gait palter[ in the inleraction with the mother, no indication of
alaxic movenent disorder
Cofl Clean, rh)'thmic heart sounds, no pathological head munnur. Lu,rgs: eupnoca. vesicular breathing noises on both
sides, no rhonchus, r'lo obshuction. Abdomen: physiological intestinal noises i[ a1l four quadrants, no pressure pain, soft,
no organomegaly. ENTr PIa;n pharynx ring, tonsils bland on both sides.

211

.1

Stan, Sofia-Ma a, born on 18.10.2009

Bady \|eight 20.5 kg, Height: t i t_t cn, KOF: 0

SA

i,

36.2.C

Iteart ruLe: i AA/mi , Dloott pressure:

108/5 5

nn ltg, Teneeruturc

Laboratory findings durinq admission:

Blood count: Leukoc)'tes: 7100/d, Hb 12.4 g/dl, Thrombocltes 32?,000 /d, Ery.throcyres indices within smndards. rn
rhe
differenlial blood count 42% Segrnented,4% Monoc}1es, 54% Lymphoc),tes.

clinical chemistrv: srandard values lor sodium, poiassium. carcium, magnesium, plrosphorus, creatinine, glucose, biiirubin.
.^S'1. ALT and LDH.
Lxnibar puncture: ln the cerebral spinal fluid no cells ofa neoplasia were detecied.
NIRT head and spinal: The external MRT recordings are not available for compnison. siill, codtirmarion
ofa T2
hlperintensive mass, partially limited to diffusion, in thc brainstem. Particulaily in the left cerebellopontile

\hich accumulatcd contrasl media, can be slowly derennined

angle, rumor parts

left

On the caudal tumor malgir

in thc inlerior cerebellar peduncle- the accumulation otcontrastmedia is very pronoxnced
and il is conflgured circutarly, possibly residuxn ofthe biopsy defact (ipsilateral, relromastoidal
osteoplasric rrepanarion) or

central necrosis. Regular behavior ofsignal, diffusion and contrast media in tle supratentorial brain parcnchyma. postoperalive
changes left nuchal and left retromastoidal at condition after biopsy. Regular behavior ofthe signai
and contrasr media within
rhe mveloma. No evidence olrclevant forarninal or spinal stenosis. Evaluation: Confimraiion
ofa inrrinsic pondne glioma.

Therapy and coursel

The cunent inpatient admission ofSofia-Maria was caffied out for the completion of
therapy for the diffuse inlrinsic ponrine glioma.

tle diagnosis and conmencement ofthe

The imaglng ol the head and the spinal a-xis showed a pronounced mass in the area ofthe brainstem, compatible with
int nsic poniine giioma. In the spinal axis rhcre was no indication ofa spinal metaslasis.

diffuse

In collaboration with the Radiotherapy colleagues, a planning crwas canied oul conceming the upcoming radiofierapy. on
24.02 2015, the radiation therapy began under anesthesia. The complication-free implantarion ofpod-carheter system was
canicd out inihe same hospital stay.
The radiochemotherapy was well tolerared, without complications.
On the 07.03.20i5 we $ere able to discharge Sofia-Mada in good general condirion in your outpatienr follow-up.

Medicrtion upon disclarge: Dronabinol3 x I mg

Pancetamo1250 mg if necessarymax. every 6-8 h

Lactulose2x5ml
Laxans

x 5 drops if necessary

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Stan, Sofla-Maria, bom on 18.10.2009

Temozolomid 60 mg 1x evenings
Ondansetron (Zoftan) 4 mg per os before Temozolomid
Procedure: Inpatient readmission 4031 for continuation ofradiation therapy on 09.03.2015
at 07.45 o,clock.
Please do not hesitate to contact us for queries_

Be$ regards,
Illegib le hatlcl signafi.tre
Prof. Dr. Med. ChristofKramm

Director ofthe Dept. ped. HematoLogy/Oncol

I I legi b le hald s ignature

Ingrid Kiihnle
Senior physician ofthe Hospital

I I I e gib le h and

ignat ur e

F. V6lker

Assistant physician

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414

I, lhe unclefiigned Kron",Ioono,

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