Neuroradiology for pathologists

UPMC Pathology Resident Didactic Series

March 31 & April 7, 2009

CNS NEOPLASMS

Scott M. Kulich, MD, PhDVA Pittsburgh Healthcare SystemAssistant ProfessorDivision of NeuropathologyDepartment of Pathology

University of Pittsburgh

Acknowledgements:Marta Couce, MD, PhDRonald 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 PATHOLOGISTSQuestion: 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 PATHOLOGISTSQuestion: Who cares?

Neuroradiology = Gross pathology

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

• Two main imaging techniques– 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

• 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

• T1

• T2

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

Location, location, location…

CHILDREN

Location, location, location…ADULTS

• Multicentricity– Neoplasms

• Metastatic disease• Others (lymphoma, high-grade glioma,…)

– Non-neoplastic• Demyelinating disease• Infectious

• Bilateral hemisphere involvement– “butterfly” lesion

• Glioblastoma multiforme (GBM), lymphoma

• 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)

• 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

• 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

• 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)

• 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 PATHOLOGISTSHeterogeneous enhancement (GBM)

NEURORADIOLOGY FOR PATHOLOGISTSHomogeneous enhancement (Meningioma)

• 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

• 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

• Specimen preparation– Intraoperative cytology

• Smear preparations

• Specimen preparation– Intraoperative cytology

• Smear preparations

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?

• Grade of lesion

Kulich

Any questions?

Neuroradiology for pathologists

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