|
Neuropathology
Wednesday, March 5, 2008 , 7:30 PM
Convention Center 103
|
Moderator:
|
GREGORY N. FULLER
M.D. Anderson Cancer Center
Houston, TX
|
|
Disclosure:
|
The speakers have indicated they have nothing to disclose.
|
Clinical histories are displayed below.
For the fastest viewing of virtual slides, click:
under each thumbnail image below. You must have Aperio ImageScope installed on your PC.
|
If you do not already have Aperio ImageScope, Windows users with administrator privileges may download and install a free version in order to view USCAP Virtual Slides. Click the icon on the right to get your free copy: | 
|
Or, click on slide thumbnail images to view each slide
in a Web-based slide viewer, which is somewhat slower.
If you have any difficulties viewing these slides, email or call George Clay at +1.724.449.1137.
for Text and References
Submitted by: Anthony T. Yachnis - University of Florida College of Medicine, Gainesville, FL
A previously well 35-year-old man presented with new onset tonic clonic seizures. Imaging revealed bilateral, contrast-enhancing masses that were thought to represent meningiomas. There was no family history of neurofibromatosis (types 1 or 2), and the past medical history was unremarkable. The patient underwent a craniotomy with complete excision of the larger, symptomatic, right-sided lesion together with a margin of uninvolved dura mater. No intra-operative frozen section was requested. The second (left) lesion was surgically removed at a later time.
Case 1 - Slide 1
|
Case 1 - Figure 1
T1-weighted MRI showing bilateral contrast-enhancing dural-based masses.
|
Case 1 - Figure 2
Low magnification H&E-stained section showing a cellular lesion attached to the dura mater (lower left).
|
Case 1 - Figure 3
Intermediate magnification H&E-stained section showing a mixed inflammatory infiltrate composed of mature lymphocytes (left), plasma cells (right), and histiocyte-like cells.
|
Case 1 - Figure 4
High magnification H&E-stained section showing a prominent plasma cell infiltrate (right) and atypical histiocyte-like cells with large nuclei and prominent nucleoli.
|
Case 1 - Figure 5
High magnification H&E-stained section showing atypical histiocyte-like cells with large nuclei and prominent nucleoli in a background of mature lymphocytes.
|
Case 1 - Figure 6
High magnification H&E-stained section showing an atypical histiocyte-like cell that contains several engulfed mononuclear cells.
|
Case 1 - Figure 7
Immunohistochemical reaction for S-100 (high magnification) showing strongly reactive histiocytes with engulfed mononuclear cells.
|
Case 1 - Figure 8
Immunohistochemical reaction for CD68 (high magnification) showing positive reactivity of histiocytic cells.
|
for Text and References
Submitted by: Thomas J. Cummings - Duke University, Durham, NC
An otherwise healthy 43-year-old man presented with a one-year history of persistent neck pain. There was no history of trauma. On physical examination, pain was elicited on lateral neck rotation, and his neck had limited range of motion. The remainder of the neurologic examination was unremarkable. MRI of the cervical spine showed a 1.8 x 1.7 cm intradural, extramedullary, heterogeneously-enhancing mass at the level of the foramen magnum. There was mass effect upon the cervical spinal cord and medulla, with lateral displacement of the spinal cord. The patient underwent a suboccipital craniectomy and C1 laminectomy. Intraoperatively, the tumor was described as "rock hard" and was removed in a piecemeal manner.
Case 2 - Slide 1
|
Case 2 - Figure 1
Sagittal T1-weighted, contrast-enhanced MRI of the cervical spine shows a lesion at the level of the foramen magnum.
|
Case 2 - Figure 2
Sagittal T2-weighted MRI of the cervical spine shows the foramen magnum lesion.
|
Case 2 - Figure 3
Axial T2-weighted image showing mass effect on the upper cervical spinal cord.
|
Case 2 - Figure 4
The lesion exhibited multiple lobules with a hypocellular chondromyxoid matrix and a granulomatous-like appearance rimmed by palisading spindled/round cells (H&E x 4).
|
Case 2 - Figure 5
Higher magnification showing the hypocellular lobules rimmed by spindled cells (H&E x 20).
|
Case 2 - Figure 6
Areas of the lesion were ossified and calcified and showed a deeply basophilic appearance (H&E x 10).
|
Case 2 - Figure 7
High magnification showing coarse fibrillar basophilic material within the nodules and surrounded by spindled cells (H&E x 40).
|
Case 2 - Figure 8
Alcian blue histochemical stain shows positive staining of the matrix within the lobules.
|
Case 2 - Figure 9
Adjacent to some of the lobules were proliferations of spindled cells with occasional whorl structures among numerous blood vessels (H&E x 40).
|
Case 2 - Figure 10
An epithelial membrane antigen immunohistochemical stain highlights the spindle
|
for Text and References
Submitted by: Suzanne Powell - The Methodist Hospital, Houston, TX
A 71-year-old man presented with a 4-week history of word finding difficulty. An initial screening head CT followed by an MRI scan revealed a large ring-enhancing mass of the left temporal lobe that abutted the dura. The patient was referred to a tertiary care hospital where craniotomy and surgical resection of the mass were performed.
Case 3 - Slide 1
|
Case 3 - Figure 1
MRI coronal section showing ring-enhancing temporal lesion abutting dura
|
Case 3 - Figure 2
Cytologic touch imprint preparation showing hypercellularity and nuclear pleomorphism
|
Case 3 - Figure 3
medium power: glial component with vascular proliferation and necrosis
|
Case 3 - Figure 7
low power: GFAP negative tumor cells with occasional reactive astrocytes within and in adjacent gliotic brain tissue
|
Case 3 - Figure 8
low power: Synaptophysin positive neoplastic small cells
|
Case 3 - Figure 9
high power: marked nuclear pleomorphism in large apparently glial cells with mitoses
|
for Text and References
Submitted by: Bette K. Kleinschmidt-DeMasters - University of Colorado School of Medicine, Denver, CO
The patient is a 46-year-old man who presented with approximately 1-2 years of shaking in the right hand, which progressed to increasing clumsiness of the hand, with dropping things. This prompted a visit to a neurologist. Neuroimaging studies showed several non-contiguous, intracerebral, non-dural based abnormalities in the left frontal lobe, associated with cerebral edema. These were interpreted as likely to be metastatic carcinoma or infectious in etiology.
Case 4 - Slide 1
|
Case 4 - Figure 4
Medium power photomicrographs illustrating features of the lesion, 10X.
|
Case 4 - Figure 5
Medium power photomicrographs illustrating features of the lesion, 10X.
|
Case 4 - Figure 6
Reticulin stain at interface between lesion (right) and brain (left), 20X
|
Case 4 - Figure 7
Trichrome stain at interface between lesion (left) and brain (right), 20X. Note Rosenthal fiber (red).
|
for Text and References
Submitted by: Tarik Tihan - The University of California, San Francisco, CA
The patient is a 51-year-old right-handed female who recently underwent a fine needle aspiration/drainage of a thyroid cyst, after which she developed low-grade but persistent headaches. Due to the prolonged nature of her headaches she was readmitted to determine a possible cause. She had a history of thyroid cysts, cesarean section 16 years previously, and a history of iron deficiency anemia.
A CT imaging study showed a calcified mass in the left frontal lobe, consistent with neoplasm. MRI studies revealed a large, wedge-shaped, well-demarcated T2/FLAIR-hyperintense lesion measuring approximately 5.2 x 5.3 in transaxial dimension located in the left middle and inferior frontal lobe area extending from the cortical surface to the adjacent ventricle. The lesion also involved a portion of the left external/extreme capsule, the subinsular region, and the anterior limb of the left internal capsule. This lesion demonstrated areas of T2 hypointensity, which was attributed to possible calcification. The mass did not demonstrate significant enhancement except for a small focus located in the inferior aspect of the left gyrus rectus. The degree of mass effect for a lesion of the size imaged was minimal. Perfusion imaging demonstrated increased cerebral blood volume within the mass compared to adjacent normal brain, and this raised the possibility of oligodendroglioma.
The patient was admitted for elective resection and underwent a left frontotemporal craniotomy. During the course of language mapping, frequent brief and self-limited after-discharges were elicited from multiple sites. Spontaneous epileptiform discharges were also recorded adjacent to the mass. Post-operative MRI showed a near gross total resection of the T2-hyperintense lesion in the left frontotemporal lobe, with residual FLAIR hyperintensity in the medial and posterior resection cavity walls, as well as a thin area of reduced diffusion around the resection cavity.
Case 5 - Slide 1
|
Case 5 - Slide 2
|
Case 5 - Figure 1
a,b - Axial fluid attenuated inversion recovery (FLAIR) and T2-weighted images showing a hyperintense mass in the left frontal lobe with no significant mass effect or peritumoral edema.
|
Case 5 - Figure 2
a,b - Axial pre- and post-contrast T1-weighted images showing a mass that is slightly hypointense to gray matter with no appreciable enhancement.
|
Case 5 - Figure 3
a,b - Coronal T2-weighted and post-contrast T1-weighted images showing the extent of tumor in the left frontal lobe and a small focus of enhancement in the inferior aspect of the mass.
|
Case 5 - Figure 4
a,b - MR perfusion image and graphic representation of perfusion in two selected regions of tumor (1,3) and two regions of normal-appearing parenchyma in the contralateral hemisphere (2,4).
|
Case 5 - Figure 5
a,b,c - Postoperative axial pre-contrast T1, FLAIR, and post-contrast T1-weighted images showing no appreciable residual signal attributable to residual tumor.
|
Case 5 - Figure 6
a,b - Postoperative FLAIR and diffusion-weighted images showing a narrow rim of diffusion abnormality around the resection cavity.
|
Case 5 - Figure 7
Medium power H&E image of one tumor component showing a rather monotonous population of cells.
|
Case 5 - Figure 8
Higher power H&E image of the monotonous population showing "fried-egg" (perinuclear halo) cells and delicate vasculature.
|
Case 5 - Figure 9
Medium power H&E image of another area of the tumor showing a more pleomorphic population of cells and delicate hypervascularity.
|
Case 5 - Figure 10
Medium-high power H&E image of the second tumor pattern showing only rare cells with a "fried-egg" appearance and delicate vascular background.
|
Case 5 - Figure 11
High power H&E image of a third morphologic pattern within the tumor showing a population of pleomorphic cells that exhibit elongated and irregular nuclei with hyperchromasia.
|
Case 5 - Figure 12
High power H&E image of the third pattern highlighting the nuclear and chromatin structure of the cells.
|
|
|
|
|
Click to view with ImageScope
Click to view with a Web-Based Viewer
