UPMC Pathology Resident Didactic Series March 31

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CNS NEOPLASMS
UPMC Pathology Resident Didactic SeriesMarch 31
April 7, 2009
Scott M. Kulich, MD, PhDVA Pittsburgh Healthcare
SystemAssistant ProfessorDivision of
NeuropathologyDepartment of PathologyUniversity
of Pittsburgh
Acknowledgements Marta Couce, MD, PhD Ronald
Hamilton, MD Geoff Murdoch, MD, PhD
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Outline

• Neuroradiology for pathologists
• Familial tumor syndromes
• CNS neoplasms
• Astrocytic neoplasms
• Diffuse astrocytomas -gt GBM
• Variants
• Pilocytic astrocytomas
• Pleomorphic xanthoastrocytoma
• Subependymal giant cell astrocytoma
• Oligodendrogliomas
• Oligoastrocytomas
• Other neuroepithelial
• Angiocentric glioma, chordoid glioma,
  astroblastoma
• Ependymomas

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Outline (CNS neoplasms cont.)

• Choroid plexus
• Neuronal - Neuroglial Tumors
• Ganglioglioma
• Central neurocytoma
• Paraganglioma
• Embryonal tumors
• Meningeal tumors

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Outline

• Neuroradiology for pathologists
• Familial tumor syndromes
• CNS neoplasms
• Astrocytic neoplasms
• Diffuse astrocytomas -gt GBM
• Variants
• Pilocytic astrocytomas
• Pleomorphic xanthoastrocytoma
• Subependymal giant cell astrocytoma
• Oligodendrogliomas
• Oligoastrocytomas
• Other neuroepithelial
• Angiocentric glioma, chordoid glioma,
  astroblastoma
• Ependymomas

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NEURORADIOLOGY FOR PATHOLOGISTS

• Question Who cares?

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NEURORADIOLOGY FOR PATHOLOGISTS

• Question Who cares?

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NEURORADIOLOGY FOR PATHOLOGISTS

• Question Who cares?

Neuroradiology Gross pathology
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NEURORADIOLOGY FOR PATHOLOGISTS
Neuroradiology for

• Two main imaging techniques
• Computerized tomography (CT)
• 3D X-rays
• White areas areas that absorb or attenuate
  the passage of x-ray beam (acute hematoma, bone,
  calcium hyperdense/ attenuating)
• Black areas areas that do not absorb or
  attenuate the passage of x-ray beam (fat, air,
  CSF, edema hypodense/ attenuating)

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Neuroradiology for
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NEURORADIOLOGY FOR PATHOLOGISTS

• Magnetic resonance imaging (MRI)
• Not ionizing radiation but magnetic field to
  excite protons which emit signal upon
  relaxation
• Image appearance dependent upon time interval
  between each excitation and time interval between
  each collection
• Two basic weights of images based upon TE and
  TR
• T1 Short TE and TR
• T1 is the onethat looks like a brain
• T2 Long TE and TR

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NEURORADIOLOGY FOR PATHOLOGISTS

• Magnetic resonance imaging (MRI)
• Not ionizing radiation but magnetic field to
  excite protons which emit signal upon
  relaxation
• Image appearance dependent upon time interval
  between each excitation and time interval between
  each collection
• Two basic weights of images based upon TE and
  TR
• T1 Short TE and TR
• T1 is the onethat looks like a brain
• T2 Long TE and TR

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NEURORADIOLOGY FOR PATHOLOGISTS

• Magnetic resonance imaging (MRI)
• Not ionizing radiation but magnetic field to
  excite protons which emit signal upon
  relaxation
• Image appearance dependent upon time interval
  between each excitation and time interval between
  each collection
• Two basic weights of images based upon TE and
  TR
• T1 Short TE and TR
• T1 is the onethat looks like a brain
• T2 Long TE and TR

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NEURORADIOLOGY FOR PATHOLOGISTS

• T1

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NEURORADIOLOGY FOR PATHOLOGISTS

• T2

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NEURORADIOLOGY FOR PATHOLOGISTS

• Important info to glean from neuroimaging
• Age
• Location, location, location
• Multicentricity
• Bilateral hemisphere involvement
• Architecture
• Contrast enhancement
• Interaction with surrounding tissue

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Location, location, location
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Location, location, location
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Location, location, location
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NEURORADIOLOGY FOR PATHOLOGISTS

• Multicentricity
• Neoplasms
• Metastatic disease
• Others (lymphoma, high-grade glioma,)
• Non-neoplastic
• Demyelinating disease
• Infectious
• Bilateral hemisphere involvement
• butterfly lesion
• Glioblastoma multiforme (GBM), lymphoma

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NEURORADIOLOGY FOR PATHOLOGISTS

• Multicentricity
• Neoplasms
• Metastatic disease
• Others (lymphoma, high-grade glioma,)
• Non-neoplastic
• Demyelinating disease
• Infectious
• Bilateral hemisphere involvement
• butterfly lesion
• Glioblastoma multiforme (GBM), lymphoma

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NEURORADIOLOGY FOR PATHOLOGISTSButterfly lesion
(GBM)
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NEURORADIOLOGY FOR PATHOLOGISTS

• Architecture
• CYSTIC LOW-GRADE
• JPA (juvenile pilocytic astrocytoma), PXA
  (pleomorphic xanthoastrocytoma), ganglion cell
  tumors,
• Others (hemangioblastoma, craniopharygioma,
  supratentorial ependymomas, extraventricular
  neurocytoma)
• Frequently associated with a mural nodule (JPA,
  PXA, hemangioblastoma, ganglion cell tumors,PGNT,
  extraventricular neurocytoma)
• Dural tail
• Meningioma

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NEURORADIOLOGY FOR PATHOLOGISTSJPA
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NEURORADIOLOGY FOR PATHOLOGISTS

• Architecture
• CYSTIC LOW-GRADE
• JPA (juvenile pilocytic astrocytoma), PXA
  (pleomorphic xanthoastrocytoma), ganglion cell
  tumors,
• Others (hemangioblastoma, craniopharygioma,
  supratentorial ependymomas, extraventricular
  neurocytoma)
• Frequently associated with a mural nodule (JPA,
  PXA, hemangioblastoma, ganglion cell tumors,PGNT,
  extraventricular neurocytoma)
• Dural tail
• Meningioma

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NEURORADIOLOGY FOR PATHOLOGISTSMeningioma
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NEURORADIOLOGY FOR PATHOLOGISTS

• Contrast enhancement
• Breached blood-brain barrier
• Seen with neoplasms but can be seen with other
  conditions (e.g. infectious, demyelinating, )
• Pattern of enhancement often helpful
• Homogeneous versus non-homogeneous
• Lymphoma, hemangiopericytoma, meningioma
• GBM, mets, abscesses
• Patchy versus circumferential ( i.e. ring
  enhancement)

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NEURORADIOLOGY FOR PATHOLOGISTS

• Contrast enhancement
• Breached blood-brain barrier
• Seen with neoplasms but can be seen with other
  conditions (e.g. infectious, demyelinating, )
• Pattern of enhancement often helpful
• Homogeneous versus non-homogeneous
• Lymphoma, hemangiopericytoma, meningioma
• GBM, mets, abscesses
• Patchy versus circumferential ( i.e. ring
  enhancement)

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NEURORADIOLOGY FOR PATHOLOGISTS
Heterogeneous enhancement (GBM)
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NEURORADIOLOGY FOR PATHOLOGISTS
Homogeneous enhancement (Meningioma)
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NEURORADIOLOGY FOR PATHOLOGISTS

• Interaction with surrounding tissue
• Edema
• Activity of lesion
• Malignant neoplasms
• Inflammatory lesions
• Skull
• Erosion Long-standing low-grade lesions
• Dysembryoplastic neuroepithelial tumor (DNET),
  PXA, ganglion cell tumors,oligodendrogliomas,epide
  rmoid cysts
• Hyperostosis
• Meningiomas

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NEURORADIOLOGY FOR PATHOLOGISTS

• Interaction with surrounding tissue
• Edema
• Activity of lesion
• Malignant neoplasms
• Inflammatory lesions
• Skull
• Erosion Long-standing low-grade lesions
• Dysembryoplastic neuroepithelial tumor (DNET),
  PXA, ganglion cell tumors,oligodendrogliomas,epide
  rmoid cysts
• Hyperostosis
• Meningiomas

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NEURORADIOLOGY FOR PATHOLOGISTS

• Interaction with surrounding tissue
• Edema
• Activity of lesion
• Malignant neoplasms
• Inflammatory lesions
• Skull
• Erosion Long-standing low-grade lesions
• Dysembryoplastic neuroepithelial tumor (DNET),
  PXA, ganglion cell tumors,oligodendrogliomas,epide
  rmoid cysts
• Hyperostosis
• Meningiomas

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Approach to intraoperative consults

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Approach to intraoperative consults

• Review of imaging and history
• Questions for surgeon
• What do you NEED to know?
• Can you get more tissue if necessary?
• Specimen preparation
• Intraoperative cytology vs frozen sections
• touch and smear preparations

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Approach to intraoperative consults

• Review of imaging and history
• Questions for surgeon
• What do you NEED to know?
• Can you get more tissue if necessary?
• Specimen preparation
• Intraoperative cytology vs frozen sections
• touch and smear preparations

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Approach to intraoperative consults

• Review of imaging and history
• Questions for surgeon
• What do you NEED to know?
• Can you get more tissue if necessary?
• Specimen preparation
• Intraoperative cytology vs frozen sections
• touch and smear preparations

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Approach to intraoperative consults

• Specimen preparation
• Intraoperative cytology
• Smear preparations

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Approach to intraoperative consults

• Specimen preparation
• Intraoperative cytology
• Smear preparations

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A Wiley approach to intraoperative consults
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A Wiley approach to intraoperative consults
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A wiley approach to intraoperative consults

• Abnormal versus normal
• Reactive versus neoplastic
• Primary versus metastatic
• Grade of lesion
• Does diagnosis correlate with clinical and
  imaging data?

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A wiley approach to intraoperative consults

• Abnormal versus normal
• Reactive versus neoplastic
• Primary versus metastatic
• Grade of lesion
• Does diagnosis correlate with clinical and
  imaging data?

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A wiley approach to intraoperative consults

• Abnormal versus normal
• Reactive versus neoplastic
• Primary versus metastatic
• Grade of lesion
• Does diagnosis correlate with clinical and
  imaging data?

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A wiley approach to intraoperative consults

• Abnormal versus normal
• Reactive versus neoplastic
• Primary versus metastatic
• Grade of lesion
• Does diagnosis correlate with clinical and
  imaging data?

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A wiley approach to intraoperative consults

• Abnormal versus normal
• Reactive versus neoplastic
• Primary versus metastatic
• Grade of lesion
• Does diagnosis correlate with clinical and
  imaging data?

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Any questions?