Neuroradiology-Neuropathology
Conference
May, 2011
Michael Solle, MD
Tom Bouldin, MD

History
 31 y/o male with 9 days headaches and nausea,
and intermittent confusion.
ADC
rCBV
SWI

Pathology
▪ Sections show proliferation of atypical astrocytes. Mitotic figures
are identified. Microvascular proliferation is present. Foci of
necrosis are also present. Histologic changes are consistent with
glioblastoma.
▪ Glioblastoma, WHO grade IV

CNS tumor classification (NCI webpage):
▪ WHO grade I includes lesions with low proliferative potential,
a frequently discrete nature, and the possibility of cure
following surgical resection alone.
▪ WHO grade II includes lesions that are generally infiltrating
and low in mitotic activity but recur. Some tumor types tend
to progress to higher grades of malignancy.
▪ WHO grade III includes lesions with histologic evidence of
malignancy, generally in the form of mitotic activity, clearly
expressed infiltrative capabilities, and anaplasia.
 WHO grade IV includes lesions that are mitotically
active, necrosis-prone, and generally associated with
a rapid preoperative and postoperative evolution of
disease.

History
 Patient was initially diagnosed with a posterior
fossa mass presenting with headaches and vision
disturbances in 6/2007.

Pathology
 Juvenile Pilocytic Astrocytoms, WHO grade I.
 Sections of posterior fossa mass show moderately
cellular glial proliferation with modest atypia and
scattered Rosenthal fibers and eosinophilic
granular bodies. Focally, there are microcytic
changes within the cellular proliferation. No
mitoses or necrosis are identified.
▪ Tumor cells stain positively for GFAP and negatively for
synaptophysin.

History
 3 y-o male complaining of intermittent severe
headache, was noted to have some gait ataxia by
his mother.

Lumbar puncture
-Malignant cells present, consistent with
medulloblastoma.

Pathology
 Intraoperative:
▪ Small round cell tumor consistent with medulloblastoma.
 Final:
▪ Sections show a densely cellular neoplasm with small to medium sized
nuclei. Some cells show nucleoli. There are mitotic figures and
apoptosis. Also present are anaplastic features, including cell
wrapping.
 Immunohistochemical stains for synaptophysin, chromogranin, EMA, and
GFAP are performed. The tumor cells are diffusely positive for synaptophysin.
There are a few cells staining faintly for chromogranin. There are areas of
strong staining for GFAP. There is only slight, focal, nonspecific staining for
EMA. Controls immunostain appropriately. The immunohistochemical
findings are consistent with medulloblastoma.
▪ Areas of this tumor show marked atypia, worrisome for anaplastic
features. A stain for INI-1 was positive in tumor cells, ruling out ATRT.
Anaplastic medulloblastoma
Pathological Subtypes of Medulloblasoma
Medulloblastoma
“Classic” medulloblastoma
Desmoplastic/nodular medulloblastoma
Medulloblastoma with extensive nodularity
Large cell medulloblastoma and anaplastic
medulloblastoma
(large cell/anaplastic medulloblastoma)

History
 … consultation for evaluation of a suprasellar
mass… 41-year-old right-handed woman who has
noted the onset of headaches for several years
 … some confusion and memory loss
 … progressive loss of vision, particularly in the
periphery of her right eye since 8/2010.
Operative Findings:
 1) Normal pituitary gland
 2) diffusely infiltrative infundibular mass with
subchiasmatic compression
 3) gross total resection
 4) preservation of right superior hypophyseal artery
and perforators
 5) visualization of third ventricle, basilar artery,
posterior cerebral arteries, posterior communicating
arteries, anterior communicating arteries, A2 vessels,
A1 vessels, bilaterally.

Pathology
 Intraoperative:
▪ Granular cell tumor of the infundibulum
 Final:
▪ Sections show a patternless proliferation of large cells with oval
nuclei and large amounts of pink cytoplasm. Cytoplasm has a
fine granularity. Modest nuclear pleomorphism.
Sections stained with PAS-D, S-100, GFAP, synaptophysin, and
CD68. Tumor cells show PAS-positive granules in cytoplasm.
Tumor cells show positive immunostaining for S100 and GFAP.
Tumor cells do not stain for synaptophysin. Numerous CD68positive cells, consistent with macrophages, are scattered
throughout the tumor.
H&E
PAS
Granular Cell Tumor of the
Infundibulum
• Rare tumor arising in the sella turcica or suprasellar
space.
• Arises from pituicytes, which are specialized astrocytes
found in the posterior pituitary (neurohypophysis).
• Pituicytes give rise to granular cell tumors and
pituicytomas, which are phenotypic variants.

History
 68 y-o female with multiple past cancers
(lymphoma, breast, thyroid, melanoma)
presenting with recently diagnosed lung and brain
masses. Patient became acutely aphasic and was
taken to the ED out of concern for a possible
stroke.

Pathology; Autopsy; Gross Description:
 Large numbers of black, well circumscribed
tumors, consistent with metastases, in all lobes of
the cerebrum. Metastases are often, but not
always, located at the gray/white junctions. Tumors
vary from 2 mm to 2 cm in diameter.…. The deep
gray matter nuclei also contain metastases.

Pathology: Light Microscopy.
 There is considerable involvement of
leptomeninges by the metastatic melanoma.
Tumor cells show marked pleomorphism. Some of
neoplastic cells contain brown pigment.
▪ Immunohistochemical stains for S-100, Mart-1, and GFAP
done on sections from brain. Many neoplastic cells show
positive staining for S-100. Scattered neoplastic cells show
positive staining for MART-1. The positive staining of
some cells for S-100 and MART-1 and presence of brown
pigment are consistent with malignant melanoma.




40-60% of patients with melanoma have brain
metastasis.
Melanoma cells are closely related to CNS cells
due to their embryonic origin and neural crest
cells, and they share common antigens such as
MAG-1 and MAG-2.
After melanoma is detected in the brain, median
survival is 3 months.
Source: eMedicine, brain metastases article.
▪ http://emedicine.medscape.com/article/1157902-overview#a0199