Intra-arterial Bevacizumab for Posterior Fossa Hemangioblastoma

Abstract

Hemangioblastoma (HB) is a rare, highly vascularized, and benign central nervous system (CNS) tumor. This vascularity is due to a high degree of signaling by vascular endothelial growth factor (VEGF). Consequently, anti-VEGF agents, such as bevacizumab, have been postulated and shown in a few cases to be effective in treating these tumors when surgical therapy is not feasible. Additionally, selective intra-arterial (IA) administration of bevacizumab has shown promise in treating other cancers such as glioblastoma (GBM). Here, we present the case of a 60-year-old female with a symptomatic posterior fossa HB where embolization and surgery were not feasible due to tumor location. She underwent selective IA treatment with bevacizumab, which led to tumor stability and symptomatic improvement. Bevacizumab has been used intravenously (IV) as a treatment for HB, however, its efficacy has not been well-established. This case demonstrates the potential viability of selective bevacizumab in HB, as demonstrated by symptomatic improvement and decreased tumor size on MRI. Further research is needed to demonstrate the specific efficacy of IA bevacizumab for CNS HB when surgery or other treatment modalities are not viable options.

Keywords: bevacizumab; endovascular; hemangioblastoma; neurosurgery; posterior fossa tumor; selective chemotherapy; von hippel landau.

Figure 1. Post-contrast T1-weighted MRI reveals an irregular, mixed solid and cystic avidly enhancing mass centered in the foramen of Luschka that measured approximately 3.5 x 3.0 x 4.2 cm​

Figure 2. Comparative axial image obtained after intra-arterial bevacizumab therapy now demonstrates the tumor measuring 3.59 x 3.19 cm with a decreased thickness of the enhancing tumor surrounding the cystic portion

Figure 3. Comparative axial image obtained after intra-arterial bevacizumab therapy now demonstrates the tumor measuring 3.59 x 3.19 cm with a decreased thickness of the enhancing tumor surrounding the cystic portion

Figure 4. Baseline MRI prior to the new course of intra-arterial bevacizumab therapy reveals a similar appearance of the tumor now measuring 4.08 x 3.51 cm

Figure 5. Comparative axial image obtained after intra-arterial bevacizumab therapy now demonstrates the tumor measuring 3.44 x 3.16 cm

Figure 6. Cerebral angiography via a left vertebral artery injection

The frontal view reveals marked vascularity of the mass with some early shunting.