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UPMC Pathology Resident Didactic Series
March 31 & April 7, 2009
CNS NEOPLASMS
Scott M. Kulich, MD, PhDVA Pittsburgh Healthcare SystemAssistant ProfessorDivision of NeuropathologyDepartment of Pathology
University of Pittsburgh
Acknowledgements:Marta Couce, MD, PhDRonald Hamilton, MD
Geoff Murdoch, MD, PhD
Outline• Neuroradiology for pathologists• Familial tumor syndromes • CNS neoplasms
– Astrocytic neoplasms• Diffuse astrocytomas -> GBM
– Variants
• Pilocytic astrocytomas• Pleomorphic xanthoastrocytoma• Subependymal giant cell astrocytoma
– Oligodendrogliomas• Oligoastrocytomas
– Other neuroepithelial • Angiocentric glioma, chordoid glioma, astroblastoma
– Ependymomas
Outline (CNS neoplasms cont.)• Choroid plexus
• Neuronal - Neuroglial Tumors– Ganglioglioma
– Central neurocytoma
– Paraganglioma
• Embryonal tumors
• Meningeal tumors
Outline• Neuroradiology for pathologists• Familial tumor syndromes • CNS neoplasms
– Astrocytic neoplasms• Diffuse astrocytomas -> GBM
– Variants
• Pilocytic astrocytomas• Pleomorphic xanthoastrocytoma• Subependymal giant cell astrocytoma
– Oligodendrogliomas• Oligoastrocytomas
– Other neuroepithelial • Angiocentric glioma, chordoid glioma, astroblastoma
– Ependymomas
NEURORADIOLOGY FOR PATHOLOGISTSQuestion: Who cares?
Answer: You will when your favorite neurosurgeon hands you a piece of tissue the size of a grain of salt and tells you he needs you to tell him if he can go ahead and stick Gliadel chemotherapeutic wafers in the patient’s brain
NEURORADIOLOGY FOR PATHOLOGISTSQuestion: Who cares?
Neuroradiology = Gross pathology
Answer: You will when your favorite neurosurgeon hands you a piece of tissue the size of a grain of salt and tells you he needs you to tell him if he can go ahead and stick Gliadel chemotherapeutic wafers in the patient’s brain
NEURORADIOLOGY FOR PATHOLOGISTS
• 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)
Neuroradiology for
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 one…that looks like a brain
– T2 :Long TE and TR
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 one…that looks like a brain
– T2 :Long TE and TR
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 one…that looks like a brain
– T2 :Long TE and TR
NEURORADIOLOGY FOR PATHOLOGISTS
• Important info to glean from neuroimaging– Age– Location, location, location– Multicentricity– Bilateral hemisphere involvement– Architecture– Contrast enhancement– Interaction with surrounding tissue
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
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
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
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
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)
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)
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,epidermoid cysts
• Hyperostosis– Meningiomas
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,epidermoid cysts
• Hyperostosis– Meningiomas
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,epidermoid cysts
• Hyperostosis– Meningiomas
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
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
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
Approach to intraoperative consults
• Specimen preparation– Intraoperative cytology
• Smear preparations
Approach to intraoperative consults
• Specimen preparation– Intraoperative cytology
• Smear preparations
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?
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?
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?
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?
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?