ID the CNS disease, Part 2

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ID the CNS disease, Part 2

• Faith

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Pt. 9 A
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9 B (arrow)
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10. A
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10. B
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10 C1, 2
NUMBER ONE
NUMBER TWO
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10 D
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11 Metastases to the Brain

• Common source of metastatic tumors to the brain.
• Clinical presentation
• CT/MRI
• Gross
• Micro
• Natl Hx

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• CNS tumors include several neoplasms of clinical
• importance in pediatric and adult populations
• Pediatric tumors are most common in the posterior
• Fossa.
• Medulloblastoma, brainstem astrocytoma,
  pilocytic
• astrocytoma, ependymoma
• Adult tumors are most common in the cerebral
• hemispheres or extra extra-axial compartments
• High grade astrocytomas (GBM, anaplastic
  astrocytoma), metastatic tumors, meningioma,
  schwannoma

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• Circumscribed astrocytomas and extra extra-axial
  tumors generally have benign histologic
  characteristics and are amenable to surgical cure
  if complete resection possible.
• Diffuse astrocytomas and other gliomas tend to
• infiltrate widely making complete resection
  impossible.
• Surgical excision followed by recurrence,
  often at higher grade, with dissemination in CSF
• Metastasis outside CNS rare.

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Answers
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Diagnoses, slide 1

• Oligodendroglioma (Gross pinkish white
  hemorrhagic calcifications Histo chicken wire
  vasculature with fried egg cells- central nuclei
  with clear cytoplasm)
• Ependymoma (A child 4th ventricle, B adult
  spinal cord C perivascular pseudorosettes)
• Glioblastoma multiforme (A butterfly glioma-
  crossing over corpus callosum B palisading
  necrosis, C glomeruloid vascular proliferation
  CT ring-enhancing lesion Diff dx GBM (or
  primary brain tumors to include medulloblastoma),
  brain abscess, brain metastasis)
• Pilocytic Astrocytoma (A well-circumscribed
  lesion B cystic space with mural nodule,
  well-circumscribed C top left- loose
  microcystic zone, bottom- dense piloid cells,
  i.e. spindle cells w/long cytoplasmic Hairlike
  extensions)
• Subfalcine herniation
• Transtentorial herniation (uncal or hippocampal
  herniation)
• 6B. 1 subfalcine (? ACA infarct) 2
  transtentorial (?PCA infarct, ipsilat. Fixed
  dilated pupil b/c of crushed 3rd nerve, ipsil.
  Hemiparesis from pushing midbrain ag.
  Contralateral tentorium) 3 tonsillar/cerebellar
  (crushes resp. ctrs in medulla B/f LP, check
  for papilledema, do CT or MRI to check for
  increased ICP)
• Lagniappe Tumor cell origins
• Primitive cell tumors- Medulloblastoma Gliomas-
  Astrocytomas, Oligodendrogliomas, ependymoma
  Meninges-meningioma CNs and Spinal nerves-
  Schwannoma, neurofibroma

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Diagnoses, slide 2

• 7. Medulloblastoma (Small round blue cell tumor
  in kids from primitive precursor cells hi
  mitoses, apoptosis, pleomorphism 60 survival _at_
  5y with surgRxs. A/B- filling 4th ventricle from
  cerebellum on top of slide B C Homer Wright
  rosettes (indicates neural differentiation Dont
  confuse these with the ependymomas perivascular
  pseudorosettes that surround blood vessels)
• 8. Meningioma adult women, extra-axial mass from
  arachnoid cap of leptomeninges A
  well-circumscribed mass attached to dura, B
  swirls/spindles and whorls C psammoma bodies
  (concentric calcifications)
• Natural hx
• Slow growth over long period
• May entrap bvs and nerves, i.e. cranial/spinal
  nerves, blood vessels
• May infiltrate veins and bone, i.e. dural venous
  sinuses and overlying bone with secondary bone
  thickening (hyperostosis)
• Progesterone receptors may be present (assoc.
  with women)
• Allelic losses on chromosome 22
• Multiple meningiomas are characteristic of
  neurofibromatosis type 2

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• 9. Neurofibroma. A unencapsulated, diffuse
  fusiform expansion of nerve, shiny jelly cut
  surface B comma-shaped schwann cell nuclei on
  loose myxoid background with embedded parent
  nerve axons Other slow growth, affects PNS and
  terminal nerve branches in skin, many
  Neurofibromatosis type 1, can turn malignant
• 10. Schwannoma. A at cerebellopontine angle, B
  at spinal nerve root, C 1 loose Antoni B zone,
  2 dense Antoni A zone D Verocay bodies
  (palisading nuclei dont mix up with GBMs
  palisading tumor cells around central necrosis)
  Other curable with resection b/c
  well-circumscribed can cause hearing loss (8th
  n. affected) if many Neurofibromatosis Type 2
  (like lots of Meningiomas)
• 11. Lung carcinoma, breast carcinoma, malignant
  melanoma, GI tract carcinomas, renal cell
  carcinoma (Memory in the chest- lung? breast
  over the breast- skin, pigmented lower in
  abdomen GI tract deeper and in back- kidney)
• Clinical presentation Multiple (but sometimes
  single) CNS masses Gray-white junction of
  cerebral hemispheres favored site, but may occur
  anywhere Diffuse spread in subarachnoid space
  aka Carcinomatous meningitis Dural
  infiltration usu. By Breast and prostate
  carcinoma

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• CT/MRI Multiple (or single) heterogeneous masses
  with contrast enhancement and surrounding edema
• Gross Circumscribed tumors with necrosis,
  hemorrhage
• Microscopic Histology matches primary neoplasm
• Natural history Influenced by number and
  location of metastases, sensitivity of primary
  tumor to therapy.
• Median survival of patients with multiple brain
  metastases treated with radiation 3-6 month
• 12. Astrocytoma Grade II hypercellularity with
  pleomorphism. NO mitoses (/ Grade3),
  neovascularization, necrosis or hemorrhage (
  Grade 4)