A Case Report of High-dose Local Chemotherapy With Carmustine Wafers in a Large-size Glioblastoma Multiforme:

A patient, admitted to our center with chronic intense headaches, vomiting, and diplopia, underwent neurologic examination that revealed a right sixth nerve palsy and bilateral papilledema secondary to elevated intracranial pressure. CT and MRI scans revealed an expansive, well-demarcated mass in the right frontal region with displacement and compression of the midline and ventricular system. Subsequent imaging studies were consistent with high-grade glioblastoma multiforme (GBM). Macroscopically complete resection was carried out through right frontotemporal craniotomy and right frontal lobectomy. Surgical biopsy findings, confirmed by histopathology, were consistent with glioblastoma multiforme. Carmustine wafers (N = 24) were implanted, and a lumbar drain was inserted to protect the sutures and removed after 5 days. Two weeks after resection, a neurostimulator was placed in the epidural space for radiosensitizing tumor bed cells. Adjuvant radiotherapy (total 60 Gy) with spinal cord stimulation and concomitant temozolomide (75 mg/m(2) daily) was followed by 6 cycles of monthly temozolomide (150 mg/m(2), 5 d/mo). Over the course of treatment, the patient developed a wound infection that was successfully resolved, and displayed a left hemiparesis postsurgery that developed into a hand paresis over the subsequent weeks. The patient progressed favorably and remained disease-free more than 18 months postsurgery. After this period, a disseminated relapse occurred, and the patient died 2 months later. Local treatment with a high dose of BCNU wafers seemed to improve tumor control for more than 18 months postsurgery. Use of high-dose local chemotherapy with carmustine wafers in a Large tumor cavity may be safe and effective as part of a multimodal treatment strategy.