Transcript Document

CNS NEOPLASMS
UPMC Pathology
Resident Didactic Series
March
31 & April 7, 2009
Scott M. Kulich, MD, PhD
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