CNS NEOPLASMS

UPMC Pathology Resident Didactic Series March 31 & April 7, 2009 VA Pittsburgh Healthcare System Assistant Professor Division of Neuropathology Department of Pathology University of Pittsburgh Acknowledgements: Marta Couce, MD, PhD Ronald 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 PATHOLOGISTS Question: Who cares?

NEURORADIOLOGY FOR PATHOLOGISTS Question: 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 PATHOLOGISTS Question: 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 = Gross pathology

•

NEURORADIOLOGY FOR PATHOLOGISTS

Two main imaging techniques – Neuroradiology for 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

• T1

NEURORADIOLOGY FOR PATHOLOGISTS

• T2

NEURORADIOLOGY FOR PATHOLOGISTS

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

Location, location, location…

Location, location, location…

CHILDREN

ADULTS

Location, location, location…

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: Butterfly lesion (GBM)

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: JPA

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: 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

Heterogeneous enhancement (GBM)

NEURORADIOLOGY FOR PATHOLOGISTS

Homogeneous enhancement (Meningioma)

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

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

A “Wiley” approach to intraoperative consults

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?

Any questions?

Kulich