Neuropathology tumours

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A brain stem astrocytoma. (WC)

The article covers tumours in neuropathology. Tumours are a large part of neuropathology. Cytopathology of CNS tumours is dealt with in the article CNS cytopathology.

There are separate articles for peripheral nerve sheath tumours and pituitary/peri-pituitary lesions.

Brain tumours - overview

Adult

Four most common types of brain tumours:[1]

  1. Metastatic brain tumours (barely edges out primary tumours)
  2. Glioblastoma (previously known as glioblastoma multiforme).
  3. Anaplastic astrocytoma.
  4. Meningioma.

Children

  1. Astrocytoma.
  2. Medulloblastoma.
  3. Ependymoma.

Location (most common)

Certain tumours like to hang-out at certain places:[2]

Filum terminale

  • Filum terminale = bottom end of the spinal cord - has a limited differential.

DDx:[3]

Cerebellopontine angle

  • Abbreviated CP angle.

DDx:[4]

Cystic tumours

DDx:[5]

Primary versus secondary

  • AKA (primary) brain tumour versus metastatic cancer.

Primary

Glial tumours:

  • Cytoplasmic processes - key feature.
    • Best seen at highest magnification - usu. ~1 micrometer.
    • Processes may branch.
  • Ill-defined border/blend with the surrounding brain.

Lymphoma:

  • Large (lymphoid) cells, ergo usu. not a difficult diagnosis.
    • ~2x size of resting lymphocyte, nucleoli.
  • Lesion predominantly perivascular.

Secondary

Carcinomas:

  • Well-demarcated border between brain and lesion - key feature.
  • No cytoplasmic processes.
  • Usu. have nuclear atypia of malignancy.
    • Nuclei often ~3-4x the size of a RBC.
  • +/-Glandular arrangement.
  • +/-Nucleoli.

Common neuropathology tumours in a table

Type Key feature(s) Imaging History Notes IHC Images
Normal tissue cells regularly spaced, no nuc. atypia small lesion? / deep lesion? variable missed lesion? nil
Normal. (WC)
Reactive astrocytes astrocytes with well-demarcated eosinophilic cytoplasm, regular spacing, no nuc. atypia small lesion? / deep lesion? variable missed lesion / close to a lesion; non-specific pathologic process - need more tissue nil
Reactive astrocytes. (WC)
Astrocytoma (grade II or worse) glial processes (esp. on smear), nuclear atypia (size var. ~3x, irreg. nuc. membrane, hyperchromasia), no Rosenthal fibres in the core of the lesion † often enhancing (suggests high grade), usu. supratentorial, usu. white matter usu. old, occ. young very common, esp. glioblastoma IDH-1+/-, GFAP+
Astrocytoma. (WC)
Metastasis sharp interface with brain, often glandular, +/-nucleoli, no glial processes often cerebellular, well-circumscribed usu. old often suspected to have metastatic disease TTF-1, CK7, CK20, BRST-2
Metastasis. (WC)
Meningioma whorls, psammomatous calcs, nuclear inclusions extra-axial + intradural old or young may be diagnosed on smear, DDx: schwannoma, choroid plexus EMA, PR, Ki-67
Meningioma. (WC)
Schwannoma cellular areas (Antoni A), paucicelluar areas (Antoni B), palisading of nuclei (Verocay bodies) extra-axial + intradural old or young need frozen section to Dx, DDx: meningioma S100
Schwannoma. (WC)

† Rosenthal fibres at the periphery of a lesion are a non-specific finding seen in chronic processes.

Brain metastasis

Main article: Brain metastasis

Infiltrative astrocytomas

Main article: Astrocytoma

Overview

  • Low-grade (diffuse) astrocytomas (Grade II).
  • Anaplastic astrocytomas (Grade III).
  • Glioblastoma (Grade IV).

Notes:

Microscopic

Features:[7][8]

  • Glial processes - key feature.
    • Thin stringy cytoplasmic processes - best seen at high power in less cellular areas.
  • No Rosenthal fibres within the tumour itself.

Images:

Notes:

  • Glial vs. non-glial tumours:
    • Glial: "blends into brain"/gradual transition to non-tumour brain.
    • Non-glial: no glial processes.
  • Rosenthal fibres within the tumour... make it into a pilocytic astrocytoma.
    • Rosenthal fibres may be seen around a (very) slow growing tumour and represent a reactive process.
  • Inflammatory cells and macrophages should prompt consideration of an alternate diagnosis (e.g. cerebral infarct, multiple sclerosis) - esp. if this is a primary lesion.[9]

Grading

Nuclear pleomorphism present:

  • At least grade II (diffuse astrocytoma).

Mitotic figures present:

  • At least grade III (anaplastic astrocytoma).

Microvascular proliferation or necrosis with pseudopalisading tumour cells:

  • Grade IV (glioblastoma AKA glioblastoma multiforme).

Notes:

  • Pseudopalisading tumour cells = high tumour cell density adjacent to regions of necrosis; palisade = a fence of poles forming a defensive barrier or fortification.

Images:

Table of common gliomas - grading

Histomorphologic comparison of common gliomas:

Entity Rosenthal
fibres / EGBs		 Nuclear atypia Mitoses Necrosis or MVP Infiltrative Image
Pilocytic astrocytoma yes usu. no usu. no usu. no no [1]
Low-grade astrocytoma no yes no no yes image?
Anaplastic astrocytoma no yes yes no yes [2]
Glioblastoma no yes yes yes yes [3]

Notes:

  • MVP = microvascular proliferation.
  • EGBs = eosinophilic granular bodies.

IHC

  • GFAP - should stain cytoplasm of tumour cells and the perikaryon (nuclear membrane).
  • Ki-67 - usu. high >20% of cells.
  • p53 - often +ve.
  • IDH1 (isocitrate dehydrogenase 1).

Notes:

  • IDH1 and IDH2 mutations - better survival.[11]

Pilocytic astrocytoma

Main article: Pilocytic astrocytoma

Pleomorphic xanthoastrocytoma

  • Abbreviated PXA.

General

Features:

  • Classically in the temporal lobe in children and young adults.
  • Associated with seizures.
  • Moderately aggressive (WHO Grade II).[12]

Gross

  • Temporal lobe - classic.
  • Usually assoc. with the leptomeninges,[12] i.e. superficial.

Microscopic

Features:[13]

  • Marked nuclear atypia.
  • Eosinophilic granular bodies - very common.[12]
  • Inflammation (chronic).

Notes:

Images:

Stains

Image:

IHC

  • GFAP +ve.
  • CD68 +ve.

Dysembryoplastic neuroepithelial tumour

  • Abbreviated DNT.
Main article: Dysembryoplastic neuroepithelial tumour

Subependymal giant cell astrocytoma

  • Abbreviated SEGA.
Main article: Subependymal giant cell astrocytoma

Pilomyxoid astrocytoma

Main article: Pilomyxoid astrocytoma

Atypical teratoid/rhabdoid tumour

See also: Extrarenal malignant rhabdoid tumour.
  • Commonly abbreviated AT/RT.
  • May be written atypical teratoid rhabdoid tumour, i.e. without the forward slash, or atypical teratoid-rhabdoid tumour (AT-RT).
Main article: Atypical teratoid/rhabdoid tumour

Oligodendroglioma

Main article: Oligodendroglioma

Oligoastrocytoma

General

  • Mixed tumour.

Microscopic

Features:

  • Astrocytoma-like and oligodendroglioma-like:
    1. Oligodendroglioma-like cells = round nucleus, peri-nuclear clearing.
    2. Astrocytoma-like cells = non-ovoid/elongated nucleus.

DDx:

  • Anaplastic astrocytoma.
  • Oligodendroglioma. (???)

IHC

  • Oligodendroglioma-like cells: MAP-2 +ve (cytoplasm).
  • Astrocytoma-like cells: GFAP +ve (cytoplasm, nuclear membrane).

Others:

  • Ki-67 ~10%. (???)
  • p53 - focally +ve. (???)
  • IDH-1 +ve. (85%)

Meningioma

Main article: Meningioma

General

  • Very common.
  • May be part of a syndrome.

Microscopic

Features (memory device WCN):

  • Whorled appearance - key feature.
  • Calcification, psammomatous.
  • Nuclear pseudoinclusions - focal nuclear clearing with a sharp interface to unremarkable chromatin.

Grading: see meningioma.

Peripheral nerve sheath tumours

Main article: Peripheral nerve sheath tumours

A classification:[15]

Schwannoma

Main article: Schwannoma

General

  • Tumour of tissue surrounding a nerve.
    • Axons adjacent to the tumour are normal... but may be compressed.

Microscopic

Features:[15]

  • Antoni A:
    • Cellular.
    • 'Fibrillary, polar, elongated'.
  • Antoni B:
    • Pauci-cellular.
    • Loose microcystic tissue.
  • Verocay bodies - paucinuclear area surrounded by palisaded nuclei.
  • In the GI tract: classically have a peripheral lymphoid cuff.[16]

Images:

Notes:

  • Several subtypes exist.

Neurofibroma

Main article: Peripheral nerve sheath tumours#Neurofibroma

General

Microscopic

Features:

Image:

Ganglioneuroma

Not to be confused with ganglioglioma.

General

Classification:

Gross

  • Solid.
  • White.
  • Firm.
  • Well-circumscribed.
  • May be nodular.

Images:

Microscopic

Features:

  • Ganglion cells - key feature.
    • Large cells with large nucleus.
      • Prominent nucleolus.
  • Disordered fibrinous-like material.
  • Eosinophilic granular bodies.[19]

Images:

See: adrenal ganglioneuroma, colonic ganglioneuroma.

IHC

Features:[20]

  • Spindle cells: S-100 +ve.
  • Ganglion cells: NSE, synaptophysin, NF.

Ependymoma

General

  • Called the forgotten glial tumour.

Epidemiology:[21]

  • Usual site:
    • Adults: usu. spinal cord.
    • Children: usu. posterior fossa.
  • May be assoc. with neurofibromatosis 2.

Comes in two main flavours:

  1. Ependymoma (not otherwise specified).
  2. Myxopapillary ependymoma.
    • Classically at filum terminale.

Other flavours:[22]

  • Papillary ependymoma.
  • Clear cell ependymoma.

Microscopic

Classic ependymoma

Features:

  • Cells have a "tadpole-like" morphology.
    • May also be described as ice cream cone-shaped.[23]
  • Rosettes = circular nuclear free zones/cells arranged in a pseudoglandular fashion; comes in two flavours in ependymoma:
    • Perivascular pseudorosettes = (tumour) cells arranged around a blood vessel; nuclei of cells distant from the blood vessel, i.e. rim of cytoplasm (from tumour cells) surround blood vessel (nucleus-free zone); more common than ependymal rosette... but less specific.
    • Ependymal rosette (AKA true ependymal rosette) = rosette has an empty space at the centre - key feature.
  • Nuclear features monotonous, i.e. "boring".[24]
    • There is little variation in size, shape and staining.

DDx (classic ependymoma):

Images

www:

  • Ependymoma - intermed. mag. (WC)

  • Ependymoma - low mag. (WC)

Myxopapillary ependymoma

Features:

  • Perivascular pseudorosettes:
    • Myxoid material surround blood vessels.
      • Myxoid material surrounded by tumour cells.

Images:

Grading

Easy:

  • Subependymoma = WHO grade I.
  • Myxopapillary ependymoma = WHO grade I.

Not-so-easy:

  • Classic ependymoma = WHO grade II.
  • Anaplastic ependymoma = WHO grade III.

Grade II vs. Grade III:

  • Cellular density.
  • Mitoses.
  • Necrosis.
  • Microvascular proliferation.

Notes:

  • Many tumours fall between grade II and grade III. These are called "indeterminate" by many.

IHC

  • Reticulin.
  • GFAP.
  • MIB1.

Subependymoma

Main article: Subependymoma

Choroid plexus papilloma

Main article: Choroid plexus papilloma

Choroid plexus carcinoma

Main article: Choroid plexus carcinoma

Chordoma

Main article: Chordoma

Hemangioblastoma

Main article: Hemangioblastoma

Medulloblastoma

Main article: Medulloblastoma

Primitive neuroectodermal tumour

  • AKA primitive neuroepithelial tumour. (???)

General

  • Abbreviated PNET.
  • Should not be confused with peripheral primitive neuroectodermal tumour (abbreviated pPNET[25]), AKA Ewing sarcoma.

Microscopic

Features:

DDx:

Images:

Embryonal tumour with abundant neuropil and true rosettes

  • Abbreviated ETANTR.
Main article: Embryonal tumour with abundant neuropil and true rosettes

CNS lymphoma

Classification:

  • Primary CNS lymphoma.
  • Non-primary CNS lymphoma - see lymphoma article.

General - primary CNS

  • Classically periventicular distribution.
  • Usually large B cell; can be considered a type of diffuse large B cell lymphoma (DLBCL).
    • Prognosis of CNS (DLBCL) lymphomas worse than nodal (non-CNS) DLBCL.[27]

Microscopic

Features:

  • Large cell lymphoma.
    • Size = 2x diameter normal lymphocyte.
    • Nucleolus - common.
  • Perivascular clustering.

Images

www:

  • CNS lymphoma - low mag. (WC)

  • CNS lymphoma - intermed. mag. (WC)

  • CNS lymphoma - high mag. (WC)

  • CNS lymphoma - very high mag. (WC)

IHC

Can be subclassified in GCB (germinal centre B-cell-like) and non-GCB by CD10, Bcl-6, MUM1/IRF-4, and Bcl-2.[27]

Common pattern:

  • CD20 +ve - key stain.
  • CD3 -ve.
  • Ki-67 ~40%.
  • Bcl-6 +ve.
  • Bcl-1 -ve.

Neurocytoma

General

  • Rare.

Microscopic

Features:[28]

  • Pineocytomatous/neurocytic rosette = irregular rosette with a large meshwork of fibers (neuropil) at the centre.[29]
    • Similar to Homer-Wright rosette.
  • Perinuclear clearing.
  • Well-defined cell borders.

DDx:

Images:

IHC

  • Synaptophysin +ve.
    • Most glial tumour -ve.[30]

Central neurocytoma

  • Abbreviated CNC.

General

  • Rare - less than 1% of brain tumours.[31]
  • Benign.
  • First described in 1982.[31]

Gross/radiology

  • Intraventricular.[32]
    • Characteristically attached to the septum pellucidum.[33]

Microscopic

Features:[34]

  • Perivascular pseudorosette = circular/flower-like arrangement of cells with blood vessel at the centre.[29]
  • Islands of neuropil.
  • Polygonal cells with a perinuclear halo.

DDx:

DDx of perivascular pseudorosette:

Images

  • Central neurocytoma - intermed. mag. (WC)

  • Central neurocytoma - oligodendrogllioma-like area - high mag. (WC)

  • Central neurocytoma - pseudorosettes - high mag. (WC)

  • Central neurocytoma - pseudorossettes - very high mag. (WC)

www:

IHC

  • MIB1 - high may predict re-occurance.[35]

Ganglioglioma

Not to be confused with ganglioneuroma.

General

  • Rare.
  • Usu. temporal lobe.
  • Recognized as a cause of epilepsy.[36]

Microscopic

Features:

  • Atypical neurons.
  • Atypical glia.

Images:

Lhermitte-Duclos disease

  • Abbreviated LDD.
  • AKA dysplastic cerebellar gangliocytoma.[37]
  • AKA dysplastic gangliocytoma of the cerebellum.
Main article: Lhermitte-Duclos disease

Ganglioneuroblastoma

Main article: Neuroblastoma

General

  • Uncommon.
  • Part of the neuroblastic tumours group which includes:[18]

Microscopic

Features:

  • Ganglion-like cells with a prominent nucleolus.
  • Small undifferentiated cells with scant cytoplasm.

Images:

IHC

  • NSE +ve -- small cells.

Lesions of the sella turcica

Main article: Pituitary gland

Lesions of the sella turcica, the pituitary gland environs, is a topic for it self. The differential diagnosis for lesions in this area includes:

See also

References

  1. ↑ http://neurosurgery.mgh.harvard.edu/abta/primer.htm
  2. ↑ URL: http://www.msdlatinamerica.com/ebooks/DiagnosticNeuropathologySmears/files/4ce563fb7e8e48fc9ed8b42e296a7747.gif and http://www.msdlatinamerica.com/ebooks/DiagnosticNeuropathologySmears/sid117213.html. Accessed on: 2 November 2010.
  3. ↑ JLK. 31 May 2010.
  4. ↑ R. Kiehl. 8 November 2010.
  5. ↑ URL: http://path.upmc.edu/cases/case320/dx.html. Accessed on: 14 January 2012.
  6. ↑ URL: http://www.pathologyoutlines.com/Cnstumor.html#cystsgeneral. Accessed on: 14 January 2012.
  7. ↑ Rong Y, Durden DL, Van Meir EG, Brat DJ (June 2006). "'Pseudopalisading' necrosis in glioblastoma: a familiar morphologic feature that links vascular pathology, hypoxia, and angiogenesis". J. Neuropathol. Exp. Neurol. 65 (6): 529–39. PMID 16783163.
  8. ↑ http://dictionary.reference.com/browse/palisading
  9. ↑ URL: http://path.upmc.edu/cases/case79/dx.html. Accessed on: 2 January 2012.
  10. ↑ Yan H, Parsons DW, Jin G, et al. (February 2009). "IDH1 and IDH2 mutations in gliomas". N. Engl. J. Med. 360 (8): 765–73. doi:10.1056/NEJMoa0808710. PMC 2820383. PMID 19228619. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2820383/.
  11. ↑ Houillier C, Wang X, Kaloshi G, et al. (October 2010). "IDH1 or IDH2 mutations predict longer survival and response to temozolomide in low-grade gliomas". Neurology 75 (17): 1560–6. doi:10.1212/WNL.0b013e3181f96282. PMID 20975057.
  12. ↑ 12.0 12.1 12.2 Fouladi, M.; Jenkins, J.; Burger, P.; Langston, J.; Merchant, T.; Heideman, R.; Thompson, S.; Sanford, A. et al. (Jul 2001). "Pleomorphic xanthoastrocytoma: favorable outcome after complete surgical resection.". Neuro Oncol 3 (3): 184-92. PMID 11465399.
  13. ↑ Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson; Aster, Jon (2009). Robbins and Cotran pathologic basis of disease (8th ed.). Elsevier Saunders. pp. 1333. ISBN 978-1416031215.
  14. ↑ 14.0 14.1 Dias-Santagata, D.; Lam, Q.; Vernovsky, K.; Vena, N.; Lennerz, JK.; Borger, DR.; Batchelor, TT.; Ligon, KL. et al. (2011). "BRAF V600E mutations are common in pleomorphic xanthoastrocytoma: diagnostic and therapeutic implications.". PLoS One 6 (3): e17948. doi:10.1371/journal.pone.0017948. PMID 21479234.
  15. ↑ 15.0 15.1 15.2 Wippold FJ, Lubner M, Perrin RJ, Lämmle M, Perry A (October 2007). "Neuropathology for the neuroradiologist: Antoni A and Antoni B tissue patterns". AJNR Am J Neuroradiol 28 (9): 1633–8. doi:10.3174/ajnr.A0682. PMID 17893219. http://www.ajnr.org/cgi/reprint/28/9/1633.
  16. ↑ Levy AD, Quiles AM, Miettinen M, Sobin LH (March 2005). "Gastrointestinal schwannomas: CT features with clinicopathologic correlation". AJR Am J Roentgenol 184 (3): 797–802. PMID 15728600. http://www.ajronline.org/cgi/content/full/184/3/797.
  17. ↑ URL: http://medical-dictionary.thefreedictionary.com/ganglioma. Accessed on: 8 November 2010.
  18. ↑ 18.0 18.1 Shimada H, Ambros IM, Dehner LP, Hata J, Joshi VV, Roald B (July 1999). "Terminology and morphologic criteria of neuroblastic tumors: recommendations by the International Neuroblastoma Pathology Committee". Cancer 86 (2): 349–63. PMID 10421272.
  19. ↑ R. Kiehl. 8 November 2010.
  20. ↑ Iacobuzio-Donahue, Christine A.; Montgomery, Elizabeth A. (2005). Gastrointestinal and Liver Pathology: A Volume in the Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 217. ISBN 978-0443066573.
  21. ↑ Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson; Aster, Jon (2009). Robbins and Cotran pathologic basis of disease (8th ed.). Elsevier Saunders. pp. 1334. ISBN 978-1416031215.
  22. ↑ URL: http://emedicine.medscape.com/article/1744030-overview. Accessed on: 17 January 2012.
  23. ↑ http://www.pathology.vcu.edu/WirSelfInst/tumor-2.html
  24. ↑ MUN. 6 Oct 2009.
  25. ↑ PST. 14 February 2011.
  26. ↑ Buccoliero AM, Castiglione F, Degl'Innocenti DR, et al. (February 2010). "Embryonal tumor with abundant neuropil and true rosettes: morphological, immunohistochemical, ultrastructural and molecular study of a case showing features of medulloepithelioma and areas of mesenchymal and epithelial differentiation". Neuropathology 30 (1): 84–91. doi:10.1111/j.1440-1789.2009.01040.x. PMID 19563506.
  27. ↑ 27.0 27.1 Raoux D, Duband S, Forest F, et al. (June 2010). "Primary central nervous system lymphoma: Immunohistochemical profile and prognostic significance". Neuropathology 30 (3): 232–40. doi:10.1111/j.1440-1789.2009.01074.x. PMID 19925562.
  28. ↑ URL: http://moon.ouhsc.edu/kfung/jty1/Composites/FNA0IE14-Neurocytoma-Micro.htm. Accessed on: 12 October 2011.
  29. ↑ 29.0 29.1 Wippold FJ, Perry A (March 2006). "Neuropathology for the neuroradiologist: rosettes and pseudorosettes". AJNR Am J Neuroradiol 27 (3): 488–92. PMID 16551982.
  30. ↑ URL: http://path.upmc.edu/cases/case383/dx.html. Accessed on: 15 January 2012.
  31. ↑ 31.0 31.1 Chuang, MT.; Lin, WC.; Tsai, HY.; Liu, GC.; Hu, SW.; Chiang, IC.. "3-T proton magnetic resonance spectroscopy of central neurocytoma: 3 case reports and review of the literature.". J Comput Assist Tomogr 29 (5): 683-8. PMID 16163043.
  32. ↑ URL: http://moon.ouhsc.edu/kfung/jty1/Com/Com307-1-Diss.htm. Accessed on: 12 January 2012.
  33. ↑ Kerkeni, A.; Ben Lakhdher, Z.; Rkhami, M.; Sebai, R.; Belguith, L.; Khaldi, M.; Ben Hamouda, M. (Oct 2010). "[Central neurocytoma: Study of 32 cases and review of the literature].". Neurochirurgie 56 (5): 408-14. doi:10.1016/j.neuchi.2010.07.001. PMID 20692674.
  34. ↑ URL: http://moon.ouhsc.edu/kfung/jty1/Com/Com307-1-Diss.htm. Accessed on: 27 May 2011.
  35. ↑ Schmidt, MH.; Gottfried, ON.; von Koch, CS.; Chang, SM.; McDermott, MW. (Feb 2004). "Central neurocytoma: a review.". J Neurooncol 66 (3): 377-84. PMID 15015671.
  36. ↑ Im, SH.; Chung, CK.; Cho, BK.; Lee, SK. (Mar 2002). "Supratentorial ganglioglioma and epilepsy: postoperative seizure outcome.". J Neurooncol 57 (1): 59-66. PMID 12125968.
  37. ↑ Yağci-Küpeli, B.; Oguz, KK.; Bilen, MA.; Yalçin, B.; Akalan, N.; Büyükpamukçu, M. (Mar 2010). "An unusual cause of posterior fossa mass: Lhermitte-Duclos disease.". J Neurol Sci 290 (1-2): 138-41. doi:10.1016/j.jns.2009.12.010. PMID 20060133.

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