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Neuropathology
Tuesday, March 1, 2005 - 7:30 PM
Convention Center, Room 007 A-D
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Moderator:
Marc Rosenblum
Memorial Sloan Kettering Cancer Center
New York, NY
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Click on each slide thumbnail image for an enlarged view
Submitted by:
Richard A. Prayson
Cleveland Clinic Foundation
Cleveland, OH
A 72-year-old male with a history of olfactory neuroblastoma diagnosed five years earlier presented
with a three-month history of right parietal headaches, intermittent dizziness, and intermittent
right-sided blurred vision and diplopia. The patient had no complaints of memory problems, decreased
hearing, arm or leg numbness, or limb incoordination. Physical examination showed decreased vision in
the right eye and was otherwise unremarkable. A MRI study of the brain performed at another institution
showed evidence of an enhancing skull-based mass which appeared to be centered in the sphenoid sinus but
also involved the clivus, right cavernous sinus, and infratemporal fossa. The mass measured
approximately 6.7 cm in greatest extent. The patient underwent right frontotemporal craniotomy via a
skull-based approach and subtotal resection of the lesion.
Submitted by:
Bette K. Demasters
University of Colorado School of Medicine
Denver, CO
The patient was a 34 year-old male who first presented in 1989, at the age of 23 years, with seizures
and migraine headaches. He was treated by his primary care physician with phenytoin; however, no imaging
studies were acquired. About one year later, the patient developed a right visual field cut, prompting a
visit to an ophthalmologist who ordered a CT scan and discovered a left parietal tumor. The patient was
referred to a neurosurgeon. The left parietal tumor was resected on 02/03/90 and diagnosed as
glioblastoma multiforme. He received post-operative radiation therapy, but no chemotherapy.
He underwent yearly serial magnetic resonance imaging (MRI) studies for approximately four years,
which were negative for recurrence. He was then lost to follow-up, but apparently did well during this
time and was employed as a dishwasher.
In 10/2000, 10 years after resection, the patient developed headaches and numbness on the right side
of his body. He did not seek medical attention until he started having difficulty with speech, which
prompted a visit to a different neurosurgeon in 01/2001. An MRI scan revealed a recurrent enhancing mass
in the same region as his original tumor. The patient underwent a second resection on 02/02/2001; it was
unclear from the operative report whether this was a gross total or subtotal resection. High grade tumor
(with an entirely different appearance than his first tumor) was documented; the patient had no adjuvant
therapy.
In 07/2001, the patient experienced recurrent symptoms and MRI showed abnormalities in the site of the
resection bed. At the time of surgery he was found to have an abscess in the region of his previous
operation; the abscess was drained and the bone flap removed. Blood cultures grew out Staphylococcus
aureus and he was treated with six weeks of antibiotics. He had persistent expressive aphasia but did
well until a follow-up scan on 10/08/2001 showed regrowth of the tumor.
He was referred to our institution (the fourth hospital and fourth neurosurgeon involved in his
care). On admission, MRI scan showed a very large parieto-occipital tumor that had rapidly regrown
within the site of the operative bed, extended to the adjacent dura, and into the left lateral
ventricle. A separate nodule was seen in choroid plexus. A gross total resection was undertaken on
11/07/01, with placement of a GliaSite balloon into the resection cavity. The balloon was infused with
radioactive iodine, delivering 50 Gy to a depth of 1 cm. over 72 hours, after which the balloon was
removed.
Several months following resection, he developed a left cerebellopontine angle subarachnoid metastasis
for which he received Gamma knife therapy on 3/14/02. A subcutaneous mass along his occipital incision
appeared and was removed on 04/24/2002. Over the ensuing months, additional enhancing masses developed
along the ependymal surfaces of the ventricle, adjacent to the pons and cerebellar hemispheres, in the
left internal auditory canal, and along the spine, all consistent with cerebrospinal fluid dissemination
of his tumor. Several cycles of chemotherapy with ifosfamide and mesna proved ineffective and he
succumbed on 8/18/2002.
Submitted by:
Gregory N. Fuller
M.D. Anderson Cancer Center
Houston, TX
A 60-year-old man presented with a right upper lobe lung mass and bilateral mass lesions of the
lateral ventricles.
Submitted by:
Anthony T. Yachnis
University of Florida College of Medicine
Gainesville, FL
This 53 year old woman came to clinical attention after a two month history of progressively worsening
headaches. Two weeks before admission, the patient experienced intermittent speech problems (dysarthria)
and a gait disturbance. An acute syncopal episode precipitated an emergency room visit and subsequent
admission. Physical examination confirmed signs of cerebellar dysfunction (ataxia, dysdiadokinesia of
the left arm and past pointing of the left finger). Imaging studies revealed a 5 x 3 cm. midline
posterior fossa mass, which occupied most of the fourth ventricle and appeared to arise from the roof of
this structure. The mass was relatively well-circumscribed, showed heterogeneous contrast enhancement on
the T1-weighted MRI, and was associated with significant hydrocephalus. The patient subsequently
underwent a left ventriculostomy and a midline suboccipital craniotomy with gross total excision of the
neoplasm.
Submitted by:
Mark L. Cohen
Case Western Reserve University
Cleveland, OH
This 25-year-old male presented to his physician with a chief complaint of headaches and double
vision. He had a two-month history of occipital headaches of progressive severity and frequency. These
headaches began soon after a minor automobile accident and eventually became generalized. The patient
also complained of double vision on right gaze with left eyelid twitching. The patient had a long
history of left eye "swinging in and out" for which he wore corrective lenses since age 2. Family
history was notable for "multiple moles and skin lesions" in first-degree relatives. Physical exam
revealed bilateral papilledema, multiple moles and skin lesions, and bilateral sixth nerve palsies. A CT
scan of the head was performed and demonstrated a left frontal lobe mass. Removal of the lesion
accompanied by "left frontal lobectomy" was performed.
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