Rapid Progressive Glioblastoma despite Radiation in a Patient with Myelodysplastic Syndrome

The rapidity of glioblastoma progression can be exacerbated by impaired systemic immune surveillance. We describe an elderly woman with advanced 5q- myelodysplastic syndrome (MDS) associated with trilineage dysfunction in hematopoiesis. She also developed multiple solid tumor malignancies including ER/PR-positive and HER2-negative breast cancer, probable lung cancer without histologic confirmation, and primary glioblastoma with a high proliferation index of 80%. Because of low platelet counts of 20,000-30,000/µL that required periodic transfusion and a reduced white cell count of 600-900/µL, she was deemed unsafe to take concomitant daily temozolomide during radiation and her glioblastoma was treated with a shortened course of radiotherapy alone. Her baseline absolute neutrophil count was 110-390/µL, and CD4⁺ and CD8⁺ lymphocyte counts were 235/µL and 113/µL, respectively. During the last week of radiation, the patient developed a nonfluent aphasia, increased fatigue, and aspiration pneumonia. A gadolinium-enhanced head MRI, obtained 2 days after completion of radiation and 39 days after biopsy, demonstrated near tripling of the size of the left frontal tumor with a significant amount of adjacent cerebral edema. This case raises the possibility that advanced MDS is a negative immunomodulatory condition that can accelerate glioblastoma progression.