Neuroradiology-Neuropathology Conference

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• Neuroradiology-Neuropathology Conference
• May, 2011
• Michael Solle, MD
• Tom Bouldin, MD

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Case 1

• History
• 31 y/o male with 9 days headaches and nausea, and
  intermittent confusion.

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Case 1
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Case 1
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Case 1
ADC
rCBV SWI
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Case 1

• Pathology
• Sections show proliferation of atypical
  astrocytes. Mitotic figures are identified.
  Microvascular proliferation is present. Foci of
  necrosis are also present. Histologic changes are
  consistent with glioblastoma.
• Glioblastoma, WHO grade IV

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Glioblastoma (WHO grade IV)

• CNS tumor classification (NCI webpage)
• WHO grade I includes lesions with low
  proliferative potential, a frequently discrete
  nature, and the possibility of cure following
  surgical resection alone.
• WHO grade II includes lesions that are generally
  infiltrating and low in mitotic activity but
  recur. Some tumor types tend to progress to
  higher grades of malignancy.
• WHO grade III includes lesions with histologic
  evidence of malignancy, generally in the form of
  mitotic activity, clearly expressed infiltrative
  capabilities, and anaplasia.
• WHO grade IV includes lesions that are
  mitotically active, necrosis-prone, and generally
  associated with a rapid preoperative and
  postoperative evolution of disease.

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Case 2

• History
• Patient was initially diagnosed with a posterior
  fossa mass presenting with headaches and vision
  disturbances in 6/2007.

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Case 2
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Case 2

• Pathology
• Juvenile Pilocytic Astrocytoms, WHO grade I.
• Sections of posterior fossa mass show moderately
  cellular glial proliferation with modest atypia
  and scattered Rosenthal fibers and eosinophilic
  granular bodies. Focally, there are microcytic
  changes within the cellular proliferation. No
  mitoses or necrosis are identified.
• Tumor cells stain positively for GFAP and
  negatively for synaptophysin.

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Case 3

• History
• 3 y-o male complaining of intermittent severe
  headache, was noted to have some gait ataxia by
  his mother.

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Case 3
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Case 3
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Case 3
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Case 3

• Lumbar puncture-Malignant cells present,
  consistent with medulloblastoma.

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Case 3

• Pathology
• Intraoperative
• Small round cell tumor consistent with
  medulloblastoma.
• Final
• Sections show a densely cellular neoplasm with
  small to medium sized nuclei. Some cells show
  nucleoli. There are mitotic figures and
  apoptosis. Also present are anaplastic features,
  including cell wrapping.
• Immunohistochemical stains for synaptophysin,
  chromogranin, EMA, and GFAP are performed. The
  tumor cells are diffusely positive for
  synaptophysin. There are a few cells staining
  faintly for chromogranin. There are areas of
  strong staining for GFAP. There is only slight,
  focal, nonspecific staining for EMA. Controls
  immunostain appropriately. The immunohistochemical
  findings are consistent with medulloblastoma.
• Areas of this tumor show marked atypia, worrisome
  for anaplastic features. A stain for INI-1 was
  positive in tumor cells, ruling out ATRT.

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Pathological Subtypes of Medulloblasoma
Medulloblastoma Classic medulloblastoma Desmopla
stic/nodular medulloblastoma Medulloblastoma with
extensive nodularity Large cell medulloblastoma
and anaplastic medulloblastoma(large
cell/anaplastic medulloblastoma)
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Case 4

• History
• consultation for evaluation of a suprasellar
  mass 41-year-old right-handed woman who has
  noted the onset of headaches for several years
• some confusion and memory loss
• progressive loss of vision, particularly in the
  periphery of her right eye since 8/2010.

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 Case 4
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Case 4
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Case 4
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Case 4
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 Case 4

• Operative Findings
• 1) Normal pituitary gland
• 2) diffusely infiltrative infundibular mass with
  subchiasmatic compression
• 3) gross total resection
• 4) preservation of right superior hypophyseal
  artery and perforators
• 5) visualization of third ventricle, basilar
  artery, posterior cerebral arteries, posterior
  communicating arteries, anterior communicating
  arteries, A2 vessels, A1 vessels, bilaterally.

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 Case 4

• Pathology
• Intraoperative
• Granular cell tumor of the infundibulum
• Final
• Sections show a patternless proliferation of
  large cells with oval nuclei and large amounts of
  pink cytoplasm. Cytoplasm has a fine granularity.
  Modest nuclear pleomorphism.Sections stained
  with PAS-D, S-100, GFAP, synaptophysin, and CD68.
  Tumor cells show PAS-positive granules in
  cytoplasm. Tumor cells show positive
  immunostaining for S100 and GFAP. Tumor cells do
  not stain for synaptophysin. Numerous
  CD68-positive cells, consistent with macrophages,
  are scattered throughout the tumor.

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Granular Cell Tumor of the Infundibulum

• Rare tumor arising in the sella turcica or
  suprasellar space.
• Arises from pituicytes, which are specialized
  astrocytes found in the posterior pituitary
  (neurohypophysis).
• Pituicytes give rise to granular cell tumors and
  pituicytomas, which are phenotypic variants.

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Case 5

• History
• 68 y-o female with multiple past cancers
  (lymphoma, breast, thyroid, melanoma) presenting
  with recently diagnosed lung and brain masses.
  Patient became acutely aphasic and was taken to
  the ED out of concern for a possible stroke.

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Case 5
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Case 5
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Case 5
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Case 5

• Pathology Autopsy Gross Description
• Large numbers of black, well circumscribed
  tumors, consistent with metastases, in all lobes
  of the cerebrum. Metastases are often, but not
  always, located at the gray/white junctions.
  Tumors vary from 2 mm to 2 cm in diameter.. The
  deep gray matter nuclei also contain metastases.

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Case 5

• Pathology Light Microscopy.
• There is considerable involvement of
  leptomeninges by the metastatic melanoma. Tumor
  cells show marked pleomorphism. Some of
  neoplastic cells contain brown pigment.
• Immunohistochemical stains for S-100, Mart-1, and
  GFAP done on sections from brain. Many neoplastic
  cells show positive staining for S-100. Scattered
  neoplastic cells show positive staining for
  MART-1. The positive staining of some cells for
  S-100 and MART-1 and presence of brown pigment
  are consistent with malignant melanoma.

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Melanoma brain metastases

• 40-60 of patients with melanoma have brain
  metastasis.
• Melanoma cells are closely related to CNS cells
  due to their embryonic origin and neural crest
  cells, and they share common antigens such as
  MAG-1 and MAG-2.
• After melanoma is detected in the brain, median
  survival is 3 months. 
• Source eMedicine, brain metastases article.
• http//emedicine.medscape.com/article/1157902-over
  viewa0199