Intra-Operative Neuropathology for the Non-Neuropathologist Cynthia T Welsh Editor Intra-Operative Neuropathology for the Non-Neuropathologist A Case-Based Approach Editor Cynthia T Welsh Department of Pathology and Laboratory Medicine Medical University of South Carolina Charleston, SC 29425, USA welshct@musc.edu ISBN 978-1-4419-1166-7 e-ISBN 978-1-4419-1167-4 DOI 10.1007/978-1-4419-1167-4 Springer New York Dordrecht Heidelberg London Library of Congress Control Number: 2011935368 © Springer Science+Business Media, LLC 2012 All rights reserved This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made The publisher makes no warranty, express or implied, with respect to the material contained herein Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com) Preface Doing neuropathology without all the information you can garner is like crossing some of the less busy city streets without looking first; you can get away with it for awhile, but sooner or later you are going to get hit by a bus Neuropathologists have extra years of training, but they are also familiar with some secrets that not everyone seems to know Neuropathology, much like bone pathology, is much better done in correlation with the radiologic features There is actually an entire chapter in this book devoted solely to a simplified scheme for differentiating different kinds of lesions based on radiologic features mainly in magnetic resonance imaging (MRI) The differential diagnosis in the central nervous system (CNS) revolves around age and location (information that can also be derived from the scans) Just because the neurosurgeon sends a specimen for intraoperative consultation does not mean a diagnosis is always necessary to decide what to next; they probably already have a plan, so relax If you are not sure of the diagnosis, tell them so If you can help them with decision making, fantastic! Sometimes you can abort the planned resection of what turns out to be a lymphoma or multiple sclerosis plaque Also, you almost never need a final diagnosis (just a preliminary), and sometimes the only answer they need is whether they are in the right area, so that ultimately a diagnosis can be derived The idea that started the process leading to this book was hatched one day because I wanted to make sure that all of our trainees were familiar with CNS touch preparations and smears This generally spread out to making this concept available through regional and national meetings by the way of presentations and seminars When the idea for a book was proposed, it seemed a natural extension This seems to be a popular theme among neuropathologists currently at courses and finally in book form, which I have been ecstatic to see Hopefully all of the attention will convince more pathologists, whether in formal training or in the continuing medical education phase, to try intraoperative neurocytology and convince them that correlation with the scans may make the whole process much easier Charleston, USA Cynthia T Welsh v Contents The Role of Clinical-Pathologic Correlation and Use of Cytologic Preparations in Intraoperative Neuropathology Consultation Cynthia T Welsh Neuroradiology as a Tool in Neuropathologic Diagnosis of Intracranial Masses Zoran Rumboldt 13 The Supratentorial Mass in an Adult Cynthia T Welsh 41 The Infratentorial Intra-axial Tumor Cynthia T Welsh 99 The Base of Skull (Including Pineal and Sella Turcica Regions) Lesion 127 Cynthia T Welsh The Spinal Neoplasm in an Adult 153 Cynthia T Welsh Index 163 vii Contributors Zoran Rumboldt, MD Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA rumbolz@musc.edu M Timothy Smith, MD Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, SC, USA smithti@musc.edu Cynthia T Welsh, MD Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, SC, USA welshct@musc.edu ix 156 Fig 6A.7 Histology – schwannoma – spindle nuclei, processes, loose areas which could be frozen artifact, and occasional large hyperchromatic nuclei C.T Welsh Fig 6A.8 Histology – metastatic tumor – papillary architecture covered with multiple layers of cells with hyperchromatic, irregular nuclei and some nucleoli Cautions papillary) of the myxopapillary ependymoma will not be present in schwannoma Peripheral nerve sheath tumors not smear well, unlike ependymomas The appearance on frozen sections will often be bland spindle cells (Fig 6A.7), but sometimes the biphasic nature will be apparent, and you may even have Verocay bodies Differential Diagnosis: Papillary/Mucinous Metastatic Neoplasms Tumors more often metastasize to vertebral column, dura, or leptomeninges than to the spinal cord itself Myxoid material and mucin can look very similar, especially on frozen sections The history of a systemic carcinoma should help bring it into the differential Looking at the morphology of the cells in the material will help sort out whether you are looking at something malignant and metastatic or the histologically benign myxopapillary ependymoma Papillary metastatic tumors are usually necrotic and mitotically active, unlike myxopapillary ependymomas They generally have fibrovascular cores surrounded by tumor cells (Fig 6A.8) as opposed to the pseudorosette Myxopapillary ependymoma may not be papillary and the myxoid background may require overstaining to make it show up very well References Myxopapillary Ependymoma Bradly DP, Reddy VB, Cochran E, Gattuso P Comparison of cytological features of myxopapillary ependymomas on crush preparations Diagn Cytopathol 2009;37(8):607–12 Takei H, Kosarac O, Powell SZ Cytomorphologic features of myxopapillary ependymoma: a review of 13 cases Acta Cytol 2009; 53(3):297–302 Layfield LJ Cytologic differential diagnosis of myxoid and mucinous neoplasms of the sacrum and parasacral soft tissues Diagn Cytopathol 2003;28(5):264–71 Kulesza P, Tihan T, Ali SZ Myxopapillary ependymoma: cytomorphologic characteristics and differential diagnosis Diagn Cytopathol 2002;26(4):247–50 Ortega L, Jiménez-Heffernan JA, Sanz E, Ortega P Squash cytology of intradural myxopapillary ependymoma Acta Cytol 2002;46(2):428–30 Bardales RH, Porter MC, Sawyer JR, Mrak RE, Stanley MW Metastatic myxopapillary ependymoma: report of a case with fine-needle aspiration findings Diagn Cytopathol 1994;10(1):47–53 The Spinal Neoplasm in an Adult 157 Case 6B: A 36-Year-Old Male with Leg Weakness and History of Neurofibromatosis (NF1) Cynthia T Welsh Clinical History • • • • • 36-year-old male Increasing difficulty walking History of NF1 Multiple previous spinal surgeries Exam: – Can’t stand without support – Sensory level above umbilicus – Increased reflexes lower extremities Fig 6B.2 Axial MRI T2 – CSF is brighter than the mass, the dark areas are spinal nerves Fig 6B.1 Axial MRI T1 postcontrast – small well-circumscribed homogeneously contrast enhancing mass posterior to spinal cord Fig 6B.3 Smear (DQ stain low magnification) – the tissue does not smear well; in the effort to squash/smear it, the nuclei have also been smeared 158 Fig 6B.4 Smear (H&E stain low magnification) – tissue fragments are not very cellular and not finely fibrillary/vacuolated Fig 6B.5 Frozen section (H&E stain low magnification) – biphasic architecture What Is Your Diagnosis? C.T Welsh Fig 6B.6 Frozen section (H&E stain low magnification) – palisading nuclei The Spinal Neoplasm in an Adult Figure Discussion Scans Small round well-circumscribed extra-axial (outside spinal cord) lesion, posterior to and compressing cord, which enhances (Figs 6B.1–6B.2) Pathology The smears show clumps of tissue that didn’t smear well and quite a bit of variation in nuclear size and shape Some larger cells in the background almost appear neuronal The tissue sections show a biphasic pattern with loose focally microcystic areas (Antoni B) and the higher magnification of a denser area (Antoni A) shows cells in palisades along relatively anuclear areas (Verocay bodies) (Figs 6B.3–6B.6) Diagnosis: Schwannoma Extra-axial intradural neoplasms of the spinal canal may be peripheral nerve sheath, meningeal, or metastatic Ependymomas and paragangliomas also can occur there Typically, benign peripheral nerve sheath tumors (BPNST), particularly schwannomas, are sporadic Multiple schwannomas suggest either NF2 or schwannomatosis Most spinal schwannomas are seen in adults Just as cerebellopontine angle schwannomas are usually on the vestibular division of cranial nerve eight, spinal schwannomas occur most often on sensory nerve roots, so they tend to be posterior to the cord, as in this case Schwannomas are often cystic, they enhance well, and the spinal ones may erode bone and/or have a dumbbell shape from crawling through the neural foramen This patient had NF1, so clinically was suspected to have a neurofibroma The diagnosis at intra-operative consultation is very often just “low grade (or benign) peripheral nerve sheath tumor,” or spindle cell lesion anyway, depending on the amount of differentiation seen Schwannomas have thick hyalinized vessel walls with hemosiderin usually scattered nearby as opposed to neurofibromas If Antoni A (cellular, compact) areas are present with oval to elongated nuclei, then it is a schwannoma If only the Antoni B loose areas with wavy nuclei are present, it may be either BPNST Schwannomas are among the benign/ low grade tumors (Table 6B.1) which commonly have scattered large, hyperchromatic irregular nuclei 159 Differential Diagnosis: Neurofibroma Neurofibromas in spinal roots often infiltrate into and expand the ganglion (Fig 6B.7) The appearance can be similar to a ganglioneuroma Neurofibromas are virtually inseparable from the loose Antoni B areas of schwannomas Keep in mind that sampling can be an intra-operative issue with the denser Antoni A areas not appearing until later specimens Differential Diagnosis: Meningioma Meningiomas in the spinal canal have a more decidedly female predominance than even the intracranial ones, so are less likely to enter the differential in a young male NF1 does not increase his likelihood of having spinal meningiomas either Meningiomas not have the predilection for the posterior aspect of the cord that schwannomas Neither tumor will squash well, although the meningioma will usually have more cells adhere to the slide than a schwannoma Whirls of cells, psammoma bodies (Fig 6B.8), and intranuclear cytoplasmic pseudoinclusions may be seen The nuclei are more round to slightly oval than the spindled nuclei of schwannoma Differential Diagnosis: Myxopapillary Ependymoma The myxoid background and spindled cells of an ependymoma can be misinterpreted as schwannoma Myxopapillary ependymomas are most common in the filum/cauda equina, but schwannomas may also occur there, and ependymomas Table 6B.1 Scattered large irregular hyperchromatic nuclei Pilocytic astrocytoma Hemangioblastoma Meningioma Schwannoma Fig 6B.7 Histology – neurofibroma – loose tissue with clumps of collagen and small wavy pointed nuclei invading a ganglion with normal ganglion cells some of which have some satellite cells 160 C.T Welsh Fig 6B.8 Histology – meningioma – nondescript tissue with psammoma bodies Fig 6B.10 Histology – pilocytic astrocytoma – hyalinized vessels, long thin “hair-like” processes, and the occasional large dark nucleus Fig 6B.9 Histology – myxopapillary ependymoma – long thin processes, a hint of anuclear zones around vessels, and small round to oval nuclei Fig 6B.11 Smear – pilocytic astrocytoma – spindle nuclei and unipolar to bipolar appearing cytoplasm can occur at any level The patient profile is often young male The symptoms are usually back pain, as with schwannomas Ependymomas of any type generally smear well The perivascular arrays (pseudorosettes) of cells (Fig 6B.9) on either smear or frozen section give away the ependymal nature of this tumor Differential Diagnosis: Pilocytic Astrocytoma Running into one of the rare intraparenchymal schwannomas or not knowing about the extra-axial location of the specimen at which you are looking, may bring pilocytic astrocytoma into the differential Both are biphasic, have hyalinized vessels (Fig 6B.10), and may be cystic Pilocytic astrocytomas of the spinal cord are less common than intracranial ones, but not uncommon They are more often pediatric no matter what the location Knowing whether the tumor is in the cord (intra-axial/pilocytic) or outside the cord (extra-axial/ schwannoma) is the best place to start with the differential Pilocytic astrocytomas smear better than schwannomas Rosenthal fibers and/or granular bodies, if present, help you tell that it is a pilocytic Hair-like “piloid” bipolar cells may be seen (Fig 6B.11) The Spinal Neoplasm in an Adult 161 Differential Diagnosis: Ganglioneuroma/ Blastoma Neuroblastoma, ganglioneuroblastoma, and ganglioneuroma occur not just as adrenal masses but also as paraspinal masses which can involve the extradural dural space in addition Both the cells and the stroma have a range of differentiation which may produce a mature ganglioneuroma This can be confused with peripheral nerve sheath tumors Neurofibromas in spinal nerves may invade back up into the ganglia (as in Fig 6B.7), but those normal ganglion cells have normal satelliting cells around them The ganglion cells of a ganglioneuroma cluster, and tend toward multinucleation They often have cytoplasmic vacuoles and not have normal satellite cells The ganglioneuroma has a very schwannian stroma (Fig 6B.12), so if there are no ganglion cells in your intraoperative specimen, you might easily think it a schwannoma History and scan characteristics may help to narrow your differential “Spindle cell lesion” may be the most general and applicable frozen diagnosis, and should not alter surgery Fig 6B.13 Histology – hemangiopericytoma – cellular tumor with “staghorn” vessels Differential Diagnosis: Malignant Spindle Cell Tumors (Primary or Metastatic) Hemangiopericytoma (Fig 6B.13), like meningioma, may enter the differential on scans These tumors are less common than nerve sheath tumors and meningiomas The radiologist may see larger feeding vessels entering the tumor, but will most likely consider it probably a meningioma Hemangiopericytomas smear much better than schwannomas The cells on smears show distinct cytoplasmic borders and round to oval nuclei, not the elongate nuclei of schwannian tumors On Fig 6B.14 Histology – metastatic tumor – this core biopsy of bone shows tumor surrounding trabecula of bone sections, at low power, the first impression will be of the “staghorn” and slit-like vessels These tumors are cellular (the nuclei often overlap and are randomly oriented) Nuclei are round to oval without much cytoplasm Metastatic sarcomas often end up in lung or bone, occasionally even skull or vertebral column Depending on the type of tumor, they may destroy bone or permeate through marrow spaces (Fig 6B.14) Cautions Fig 6B.12 Histology – ganglioneuroma – within the schwannian background are ganglion cells which have no satellite cells • Verocay-like structures can be seen in leiomyomas • Sampling of only the loose Antoni B areas of a schwannoma may make you think it is a neurofibroma 162 References Schwannoma Azarpira N, Torabineghad S, Sepidbakht S, Rakei M, Bagheri MH Cytologic findings in pigmented melanotic schwannoma: a case report Acta Cytol 2009;53(1):113–5 Li S, Ai SZ, Owens C, Kulesza P Intrapancreatic schwannoma diagnosed by endoscopic ultrasound-guided fine-needle aspiration cytology Diagn Cytopathol 2009;37(2):132–5 Klijanienko J, Caillaud JM, Lagacé R Cytohistologic correlations in schwannomas (neurilemmomas), including “ancient,” cellular, and epithelioid variants Diagn Cytopathol 2006;34(8): 517–22 Akhtar I, Flowers R, Siddiqi A, Heard K, Baliga M Fine needle aspiration biopsy of vertebral and paravertebral lesions: retrospective study of 124 cases Acta Cytol 2006;50(4):364–71 Domanski HA, Akerman M, Engellau J, Gustafson P, Mertens F, Rydholm A Fine-needle aspiration of neurilemoma (schwannoma) A clinicocytopathologic study of 116 patients Diagn Cytopathol 2006;34(6):403–12 C.T Welsh Wu JM, Sheth S, Ali SZ Cytopathologic analysis of paraspinal masses: a study of 59 cases with clinicoradiologic correlation Diagn Cytopathol 2005;33(3):157–61 Oliai BR, Sheth S, Burroughs FH, Ali SZ “Parapharyngeal space” tumors: a cytopathological study of 24 cases on fine-needle aspiration Diagn Cytopathol 2005;32(1):11–5 Laforga JB Cellular schwannoma: report of a case diagnosed intraoperatively with the aid of cytologic imprints Diagn Cytopathol 2003;29(2):95–100 Gupta RK, Cheung YK, Al Ansari AG, Naran S, Lallu S, Fauck R Diagn Cytopathol Diagnostic value of image-guided needle aspiration cytology in the assessment of vertebral and intervertebral lesions 2002;27(4):191–6 10 Klijanienko J, Caillaud JM, Lagacé R, Vielh P Cytohistologic correlations of 24 malignant peripheral nerve sheath tumor (MPNST) in 17 patients: the Institut Curie experience Diagn Cytopathol 2002;27(2):103–8 11 Kanahara T, Hirokawa M, Shimizu M, Terayama K, Nakamura E, Hino Y, Mikawa Y, Manabe T Solitary fibrous tumor of the spinal cord Report of a case with scrape cytology Acta Cytol 1999;43(3): 425–8 Index A ADC See Apparent diffusion coefficient Adult See also Supratentorial mass, adult cerebral tumor, headache and ataxia cysts, mural nodules, 118 sporadic tumors, 118 headaches and visual changes, 121 nested cells, 146 pineoblastoma, 146 plasmacytoma, 134 spinal neoplasm (see Spinal neoplasm, adult) Antoni A areas, 159 schwannoma, 159 tissue, 159 Antoni B BPNST, 159 neurofibromas, schwannoma areas, 159 tissue, 159 Apparent diffusion coefficient (ADC), 15, 16 Arm/leg weakness gliosarcoma, 82 pathology, 82 primary/metastatic sarcoma, 82 scans, 82 Astrocytoma and ependymoma, incidental frontal lesion fibrillary, 47 gemistocytic and pilocytic, 46–47 low-grade, 44 low-grade diffuse, 46–47 SEGA, 46 Ataxia and headache, 116–120 medulloblastoma, 107 ATRT See Atypical teratoid-rhabdoid tumor Atypical teratoid-rhabdoid tumor (ATRT) anaplastic medulloblastoma, 107 cytoplasm eccentricity, 109 dense cytoplasmic bodies, 109 tumor, 108–109 B Back pain See Spinal neoplasm, adult Base of skull headache dizziness and double vision, 132–135 medulloblastoma, 146, 147 nausea and vomiting, 148–152 normal pineal/pineal cyst, 146 pineoblastoma, 146 scans and pathology, 146 metastasis, 31 nasal congestion and forehead pain cautions, 143 clinical history, 140 olfactory neuroblastoma, 142 paranasal sinuses/nasopharynx, 142–143 pathology, 142 pituitary adenoma, 142 plasma cell dyscrasia, 142 scans, 142 swallowing difficulties, 136–139 visual disturbance and headaches clinical history, 127 germ cell tumors, 130 meningioma, 129–130 metastatic tumor, 130 normal anterior pituitary, 129 pathology, 129 pituicytoma, 130 pituitary adenoma, 129 plasma cell dyscrasia, 130 scans, 129 Benign peripheral nerve sheath tumors (BPNST) Antoni B, 159 sporadic, 159 Binucleate cells pituitary adenomas, 129 pituitary tumors, 134 plasma cell lesions, 130 Biphasic headache, nausea and vomiting tissue nature, 102 tumors, 102 C.T Welsh (ed.), Intra-Operative Neuropathology for the Non-Neuropathologist: A Case-Based Approach, DOI 10.1007/978-1-4419-1167-4, © Springer Science+Business Media, LLC 2012 163 164 Biphasic (Cont.) leg weakness and NF1 architecture, 158 hyalinized vessels, cystic, 160 pattern, 159 Blurry vision, 89–93 BPNST See Benign peripheral nerve sheath tumors C Calcifications cavernous sinus hemangioma, 32 chondrosarcoma, 34 choroid plexus papilloma, 30 craniopharyngioma, 33 ependymoma, 28 ganglioglioma, 23 oligodendrogliomas, 18 pineal, 37, 38 Central nervous system (CNS) PNETs, 107 RCC, 118 Cerebellopontine angle (CPA) differential diagnosis, 123 spindle cell lesions, 125 Chicken-wire capillary pattern, 52 Chondrosarcoma, 34, 36 Chordoid glioma, 11 Chordoma chondroid variant, 138 diagnosis, 137–138 eosinophilic cells, myxoid matrix, 155 mucinous carcinomas, 138–139 sacrum, 155 Choroid plexus carcinoma (CPC), 12 Choroid plexus papilloma (CPP), 30, 32, 96 Colloid cyst, 11 Computerized tomography (CT) abscess, 20 axial nonenhanced brain basal ganglia, 17 centrum semiovale, 14 imaging, 21 lateral ventricles, 16 subacute infarction, 19 terminology, 13 Confusion, 76–79 Craniopharyngioma nonenhanced axial CT image, 35 papillary, 97 sagittal postcontrast T1WI, 35 Cytologic preparations, intraoperative neuropathology abnormal astrocyte cytoplasm, 6, air drying, 5, blood vessel smear, 4, cerebellum and medulloblastoma, 11 cortex, neuronal organization, 10 deep gray matter, 9, 10 Diff-Quik stains, 5–6 embolic material, meningioma, 7, frozen section astrocyte processes, hemangioblastoma., 4, tearing and folding, ice crystal artifact, 2, location-based tumor differential diagnosis, 11–12 macrophages, Index microcalcifications, 7, mitoses, nuclei, frozen, psammoma bodies, questions, RBCs, 5, reactive astrocyte, smearing astrocytes, cerebellum, 10 cytoplasm, 5, fragile nuclei, tissue, 4, sponge artifact, 11 squash preparation, staining cytopreparations, technique, touch preparation, 5, tumor nuclei, D Decline, motor skills, 94 Diffusion-weighted images (DWIs), 15 Dizziness cautions, 135 clinical history, 132 germ cell tumors, 134–135 and left arm/leg weakness, 80–82 meningioma, 134, 135 pathology, 132–134 plasmacytoma, 134 scans, 132, 134 Double vision cautions, 135 clinical history, 132 germ cell tumors, 134–135 meningioma, 134, 135 pathology, 132–134 plasmacytoma, 134 scans, 132, 134 Dysembryoplastic neuroepithelial tumor (DNET), 11 E Enhancing left trigeminal nerve, 34 lesion, left cerebral hemisphere, 20, 21 mass heterogeneous, 40 homogenous, 31 intracranial and extracranial components, 37 lower cervical spine, 38 pineal region, 31 right basal ganglia, 21 nodule, spinal cord, 40 vs nonenhancing, pituitary gland, 35 Ependymoma headache, irritability and vertigo neuronal rosettes, 108, 109 tissue freezing, 108 headache, nausea/vomiting and vertigo perivascular pseudorosettes, 114 pituitary adenoma, 113 rosettes, nonvascular central opening, 113 operation, Index Epidermoid cyst, 12 Esthesioneuroblastoma cell neoplasms, 146 cribriform plate, 142 neuronal/neuroblastic rosettes, 146 Extra-axial headaches and visual changes, 123 sella/skull base/pineal masses cavernous sinus hemangioma, 32, 34 chondrosarcoma, 34, 36 chordoma, 34, 36 craniopharyngioma, 33, 35 germ cell tumor, 37, 38 olfactory neuroblastoma, 34, 37 parasellar meningioma, 32, 33 parasellar schwannoma, 33, 34 pineoblastoma, 34, 37 pituitary adenoma, 30, 33 plasmacytoma/multiple myeloma, 34, 35 supra/infratentorial masses choroid plexus papilloma, 30, 32 meningioma, 16, 29, 31 metastasis, 30, 31 schwannoma, 30, 32 systemic lymphoma, 30, 31 F FLAIR See Fluid-attenuated inversion recovery Flow-voids arterio-venous malformation (AVM), 18, 20 intratumoral vasculature, 30 Fluid-attenuated inversion recovery (FLAIR) lateral ventricles, 24 lobulated slightly heterogeneous mass, GBM, 18 midbrain, 25 postcontrast axial, 32 right temporal well-defined lesion, 25 white and gray matter, 16 G Ganglioglioma, 23, 25, 86 GBM See Glioblastoma Germ cell tumor CNS, 150 ependymoma, 151 germinoma, 150 monotonous cells, 130 pineal area, 134 pineoblastoma, 150 Glioblastoma (GBM) FLAIR images, 63 shaggier wall, enhancement, 62 variants, 61 Gliosarcoma, 82, 125 H Haloes cautions, 57 neurocytomas, 54–55 perinuclear, 56 Headache blue cell tumors, 147 cautions, 135, 147, 152 clinical history, 132, 144, 148 165 confusion and personality change, 76–79 ependymoma, 151 germ cell neoplasm, 147 tumors, 134, 150 irritability and vertigo, 105–109 medulloblastoma, 146–147 meningioma, 134 metastases, 134 metastatic tumors, 150–151 nausea blurry vision, 89–93 vomiting, 99–104 normal pineal/pineal cyst, 146 pathology, 134, 145, 146, 150 pineoblastoma, 146 pituitary, 150, 151 plasmacytoma, 134 scans, 134, 144, 146, 148, 150 and visual changes, 121–125 Hemangioblastoma blood vessels, frozen section, headache and ataxia cyst, mural nodule, 118 scattered large irregular hyperchromatic nuclei, 118 VHL syndrome, 118 Hemangiopericytoma, 11 Hemiparesis dense abscesses, 74–75 cautions, 75 glioblastoma, 74 infarct, 73–74 MS, 74 PML, 74 scans and pathology, 71–73 female, 58–65 Hoff cells pituitary adenoma, 130 scattered binucleate, 142 eccentric nuclei, 134 perinuclear golgi clearings, 134 Hyperdense medulloblastoma, 28 meningioma, 29 parasellar meningioma, 32 PCNSBCL, 19 pineoblastoma, 34 systemic lymphoma, 30 Hypodense infarcts, 18 lesion, 19 vasogenic edema, 19, 21 I Ice crystal artifact freezing, frozen sections, 5, Immunocompromise lymphoma, 68 PCNSL, 47–48, 78 PML, 74 166 Infarct and abscesses, 74 acute, 17, 25 description, 25 gemistocytic astrocytes, 73 necrosis, brain lesions, 73 subacute, 19, 73 Infiltrative edema, 16, 18, 23 high-grade glioma, 69 melanomas, 70 oligodendrogliomas, 54, 91 pleomorphic cells, 77 primary lymphomas, 79 Infratentorial choroid plexus papilloma, 30, 32 intra-axial masses, 26–29 intra-axial tumor, headache (see Infratentorial intra-axial tumor) meningioma, 16, 29, 31 metastasis, 30, 31 midline mass, 28 schwannoma, 30, 32 systemic lymphoma, 30, 31 Infratentorial intra-axial tumor headache and ataxia cautions, 120 clinical history, 116 cyst, mural nodule differential, 118 hemangioblastoma, 118 meningioma, 118–119 metastatic clear cell carcinoma, 118 normal cerebellum, 118, 119 pilocytic astrocytoma, 119 RBCs and cells, multiple cytoplasmic vacuoles, 117, 118 vascular malformation, 119, 120 vessels, 117, 118 vessels and small round nuclei, 117, 118 headache, irritability and vertigo axial diffusion, 105 axial MRI T1 precontrast and postcontrast, 105 cautions, 109 clinical history, 105 ependymoma, 108 frozen section, small cells cords, 106 H&E stain low magnification, 106 medulloblastoma, 107 normal cerebellum, 107–108 pleomorphic cells, little cytoplasm, 106 PNET, 109 round blue cell, 109 smear, 108, 109 teratoid/rhabdoid tumor, 109 headache, nausea and vomiting axial T2 FLAIR MRI, 100, 102 axial T1 MRI postcontrast and T2 MRI, 99, 102 cautions, 104 clinical history, 99 ependymoma, 103–104 fibrillary astrocytoma, 103 frozen section-enlarged, hyperchromatic nuclei, 101, 102 frozen section-rosenthal fibers, microcysts, 101, 102 medulloblastoma, 104 pilocytic astrocytoma, 102 piloid gliosis, 102–103 smear, 100, 102 vascular malformation, 103 Index headache, nausea/vomiting and vertigo axial MRI T2 FLAIR-midline cerebellar lesion, 111, 113 cautions, 115 choroid plexus papilloma, 115 clinical history, 111 ependymoma, 113 glioma, 114 heterogeneous enhancement, 111, 113 medulloblastoma, 113, 114 neurocytoma, 115 perivascular areas, nuclei and cells rings, 107 smear, 111–113 subependymoma, 111 headaches and visual changes calcification and small round, oval nuclei, 122, 123 cautions, 125 cells tight whirls, central mineralization, 122, 123 clinical history, 121 cyst, schwannoma, 124 elongate nuclei, pink globular cytoplasm, 122, 123 gliosarcoma, 125 hemangiopericytoma, 124, 125 lesion smears, 121, 123 meningioma, 123–124 schwannoma, 124 Intra-axial See also Infratentorial intra-axial tumor gliosarcoma, 82 infratentorial masses ependymoma, 28, 29 hemangioblastoma, 28, 30 medulloblastoma, 21, 28, 29 metastasis, 19, 29 PA, 22, 26, 28 subependymoma, 28, 30 supratentorial masses abscess, 17, 20, 22, 25, 27 central neurocytoma, 23, 26 DNET, 23, 25 ganglioglioma, 23, 25 high-grade glioma, 23, 24 infarct, 17, 19, 25 low-grade astrocytoma, 22, 23 metastasis, 14, 19, 25, 27 oligodendroglioma, 22, 23 PCNSBCL, 19, 21, 23, 25, 26 PML, 26, 28 tumefactive demyelinating lesion, 18, 21, 26, 27 Intracranial masses CT, 13, 14 density/signal intensity adenocarcinoma metastasis, 18, 19 infarcts, 18, 19 melanoma metastases, 18, 19 PCNSBCL, 18, 19 diffusion medulloblastoma, 21 MR imaging, 20 PA, 21, 22 edema, 16–18 enhancement patterns eccentric “target”, 20 homogenous, 20, 21 incomplete ring, 20, 21 smooth peripheral, 20 extra-axial Index sella/skull base/pineal masses, 30, 32–37 supra/infratentorial masses, 29–30 flow-voids, 18, 20 imaging features, 15, 16 intra-axial infratentorial, 26–29 supratentorial, 22–26 MRI, 13, 15, 16 perfusion decreased, 21, 22 elevated, multicentric GBM, 21, 22 shape, 17, 18 spinal masses, 37–40 Intranuclear cytoplasmic pseudoinclusions, 61, 123, 130, 134, 135, 159 Intravenous contrast agents CT and MRI, 13 intracranial masses, 20 T1w sequences, 15 Intraventricular lesion, child, 96 tumor, 89–91 tumors ependymomas, 96 papillary, 97 Irritability, headache and vertigo, 105–109 Isodense basal ganglia, 38 lesions, 13 L Leg pain See Spinal neoplasm, adult M Magnetic resonance imaging (MRI) FLAIR, 22, 23, 25, 26 higher contrast resolution, 13 terminology DWIs, 15 normal brain, 15 pulse sequences, 13 T1w and T2w, 13, 15 Malignant spindle cell tumors hemangiopericytoma, 161 metastatic, 161 Medulloblastoma neoplastic rosette types, 107 small cell neoplasms, 107 Meningioma embolic material, vessel, headaches and visual changes chordoma, 123 pituitary adenoma, 123, 124 rhabdoid tumor, 123 secretory meningioma, 123 thyroid metastasis, 123, 124 nondescript tissue, psammoma bodies, 159, 160 psammoma bodies, 7, Metastatic multiple lesions, scans, 70 tumor, 11, 12, 68 Microcysts “floating” neurons, 87 headache, nausea and vomiting 167 biphasic nature, tissue, 102 biphasic tumors, 102 frozen section, rosenthal fibers, 101, 102 pilocytic astrocytoma, 119 histology, 46 smears, 52 tumors, 52 MRI See Magnetic resonance imaging Myxoid leg and back pain change and perivascular pseudorosettes, 154, 155 matrix, 155 stroma, 155 lesions, 138 stroma, 138 tumor, 138 Myxopapillary ependymoma leg and back pain “cauda equina” syndrome, 155 hyalinized vessels, nuclei congregate, 155 myxoid stroma, 155 leg weakness and NF1 filum/cauda equina, 159 perivascular arrays, cells, 160 sagittal T2WI, 38 N Nasal congestion cautions, 143 clinical history, 140 olfactory neuroblastoma, 142 paranasal sinuses/nasopharynx, 142–143 pathology, 142 pituitary adenoma, 142 plasma cell dyscrasia, 142 scans, 142 Nausea cautions, 152 clinical history, 148 ependymoma, 151 germ cell tumor, 150 headache blurry vision, 89–93 vomiting, 99–104 metastatic tumors, 150–151 pathology, 150 pineoblastoma/medulloblastoma, 150 pituitary, 150 scans, 150 Neurocytoma central, 23, 26, 91 haloes, 91 neuronal rosette, 91 nuclei, 91 Neurofibroma occurrence, 155 spinal nerves, 161 spinal roots, 159 Neurofibromatosis, Neurofibromatosis (NF1), 157–161 Neuronal rosettes ependymoma, 108 normal internal granular cell layer, 107, 108 smear-PNET, 109 168 Nonenhancing abnormality, 13 vs enhancing, hypointense well-delineated mass, 22 patterns, 20 rounded areas, 37 O Olfactory neuroblastoma (ONB) description, 34 esthesioneuroblastoma, 142 T1WI, sagittal plane, 37 Oligodendroglioma axial nonenhanced CT image, 23 cell distribution, brain, 52 clear cell ependymomas, 56 description, 22, 54 haloes, 45 high-grade, 57 histology, 46 microcalcifications, 52 microcystic, 52 nuclei, 50 reactive astrocytes, 53 smear, 45, 46 ONB See Olfactory neuroblastoma P PA See Pilocytic astrocytoma Papillary/mucinous metastatic neoplasms, 156 Paraganglioma, 12, 18, 159 Pediatric astrocytoma, 39 ependymomas, 96 germ cell neoplasm, 147 headache, nausea/vomiting and vertigo age group, 114 cellular tumors, posterior fossa, 113 Peripheral nerve sheath tumor frozen sections, bland spindle cells, 156 schwannomas and neurofibromas, 155–156 Perivascular cuffing, 78 Perivascular pseudorosettes cellular tumors, pediatric, 113 diagnosis, 113 leg and back pain ependymal, 155 and lobular architecture, 155–156 and myxoid change, 154 nuclei, ependymomas, 114 tissue, 113 Personality change, 76–79 Physaliphorous, 138 Pilocytic astrocytoma (PA) biphasic hyalinized vessels and cystic, 160 tumors, 102 cyst, mural nodule, 102 increased diffusion, 22 oligodendroglial-like cells, 55, 56 rosenthal fibers, 102 scattered large irregular hyperchromatic nuclei, 102 smear, 160 Index Pineal calcifications, 37, 38 gland, 37 pineoblastoma, 34, 37 Pineal cyst, 11 Pineal parenchymal tumor, 11 Pineoblastoma axial nonenhanced CT image, 37 craniospinal dissemination, 146 described, 34 differential diagnosis, 150 histology, 150, 151 midsagittal T1WI, 37 neuronal/neuroblastic rosettes, 146 nuclei, 146 small cell neoplasms, 146 smear, 108 Pituitary adenoma nasal congestion and forehead pain, 140–141 psammoma bodies, 8, reticulin, touch preparation, visual disturbance and headaches binucleate cells, 128, 129 frozen section diagnosis, 129 meningioma, 130 plasmacytoid morphology, 130 Plasmacytoma bone algorithm and window, 35 bone lesions, 134 clivus/skull base, 134 langerhans cell lesions, 134 sella, 132 Pleomorphic xanthoastrocytoma (PXA), 44, 63 Primary CNS lymphoma (PCNSL) B-cell, 78 cerebral blood volume (CBV), 21 differential diagnosis, 47–48, 55 histology, 63 homogenous contrast enhancement, 21 immunocompromise, 78 Primitive neuroectodermal tumors (PNETs), 109 Pseudopalisading high-grade glial lesions, 64 necrosis, 61 Pseudopapillary, 64, 69 R Renal cell carcinoma (RCC) “clear cell”, 118 patients, VHL syndrome, 118 Rosettes, 147, 151 S Schwannoma Antoni B areas, 159 cerebellopontine angle, 159 description, 30 differential diagnosis, 124 FLAIR images, 32 leg weakness and NF1 scattered large irregular hyperchromatic nuclei, 159 spinal, 159 Index multiple, 159 parasellar, 33, 34 spinal, 37, 38 vessels, 155 Seizures female cautions, 57 DNETs, 55 ependymoma, 56 extraventricular neurocytoma, 54–55 glioblastoma, 57 gliosis, 53 low-grade diffuse astrocytoma, 54 normal white matter, 53–54 oligodendroglioma, 52 pathology, 52 PCNSL, 55 pilocytic astrocytomas, 55–56 scans, 52 small cell anaplastic, 56 male cautions, 88 DNET, 87 ganglioglioma, 86 neurons, tumor, 86–87 pathology, 85, 86 scans, 86 SEGA, 87–88 and unilateral weakness cautions, 70 clinical history, 66 high-grade glioma, 69 lymphoma, 68–69 malignant dural tumors, 69 metastatic tumor, 68 primary bone tumors vs skull base, 70 scans and pathology, 68 Sella extra-axial, 30, 32–37 suprasellar extension, 33 Skull base See Base of skull Spinal masses astrocytoma, 39, 40 ependymoma, 39, 40 hemangioblastoma, 39, 40 meningioma, 39 myxopapillary ependymoma, 39 schwannoma, 37, 38 Spinal neoplasm, adult leg and back pain cautions, 156 chordoma, 155 clinical history, 153 myxoid change and perivascular pseudorosettes, 154, 155 myxopapillary ependymoma, 155 papillary/mucinous metastatic, 156 peripheral nerve sheath tumor, 155–156 sagittal MRI T1 precontrast and postcontrast, 155 smear-cells, 154, 155 leg weakness and NF1 axial MRI T2–CSF, 157, 159 axial MRI T1 postcontrast, 157, 159 cautions, 161 clinical history, 157 frozen section, biphasic architecture, 158, 159 169 frozen section, palisading nuclei, 158, 159 ganglioneuroma/blastoma, 161 malignant spindle cell tumors, 161 meningioma, 159 myxopapillary ependymoma, 159–160 neurofibroma, 159 pilocytic astrocytoma, 160 schwannoma, 159 smear, 160 Spine leg weakness and NF1 axial MRI T2–CSF, 157, 159 axial MRI T1 postcontrast, 157, 159 canal, 159 neurofibromas, nerves and roots, 159 schwannomas, 159 sagittal MRI pre and postcontrast scans, lumbar lesion, 155 Stromal cells frozen/cytologic preparation, 116, 118 hemangioblastoma, 118 normal cerebellum, 118 tumor characteristics, 118 Subependymal giant cell astrocytoma (SEGA), 11 Subependymoma, 12 Supratentorial intra-axial masses, 22–26 Supratentorial mass, adult dense hemiparesis and kidney transplant abscess, 74–75 cautions, 75 clinical history, 71 glioblastoma, 74 infarct, 73–74 MS, 74 pathology, 71–73 PML, 74 scans, 73 developmental regression cautions, 98 choroid plexus papilloma, 96 clinical history, 94 ELST, 96–97 papillary craniopharyngioma, 97 papillary ependymoma, 96 papillary meningioma, 97 papillary metastatic tumor, 97 scans and pathology, 94, 96 dizziness and left arm/leg weakness gliosarcoma, 82 primary/metastatic sarcoma, 82 scans and pathology, 80, 82 headache, confusion and personality change cautions, 79 glioma, 78, 79 metastases, 78 non-neoplastic lymphoid proliferations, 79 pathology, 76–78 primary CNS B-cell lymphoma, 78 scans, 76, 78 incidental frontal lesion gliosis, 44–45 low-grade astrocytoma, 44 oligodendroglioma, 45–46 pathology, 44 PCNSL, 47–48 primary low-grade glial tumor, 46–47 scans, 41–42, 44 170 Supratentorial mass, adult (Cont.) nausea, headache and blurry vision cautions, 93 ependymoma, 92 metastatic small cell carcinoma, 92 neurocytoma, 91 oligodendroglioma, 91 pathology, 89–91 scans, 89, 91 subependymoma, 92 new-onset seizures female, 49–57 male, 84–88 seizure and hemiparesis, female abscess, 62 cautions, 65 clinical history, 58 high-grade glioma, 61 high-grade oligodendroglioma, 62 infarcts, 64–65 metastasis, 63–64 primary lesions, 63 scans and pathology, 58–61 seizure and unilateral weakness, male cautions, 70 clinical history, 66 high-grade glioma, 69 lymphoma, 68–69 malignant dural tumors, 69–70 metastatic tumor, 68 primary bone tumors vs skull base, 70 scans and pathology, 68 Swallowing difficulties cautions, 139 chondrosarcoma, 138 chordoid meningioma, 139 chordoma, 138 clinical history, 136 metastatic carcinoma, 138–139 myxopapillary ependymoma, 138 pathology, 137, 138 scans, 136, 138 T T1-weighted (T1w) cavernous sinus hemangioma, 34 edema, 16 intravenous contrast agents, 15 meningioma, 31 midsagittal nonenhanced, 30 parasellar meningioma, 33 pituitary adenoma, 33 systemic lymphoma, 31 T2-weighted (T2w) chordoma, 36 flow-voids, 18, 20, 30 Index irregular and heterogeneous right cerebellar mass, 19 lateral ventricles, 27 lower thoracic spine, 38 midline infratentorial mass, 28 schwannoma, 32 white and gray matter, 15 V Verocay leg weakness and NF1 tissue, 157–161 verocay-like structures, 161 schwannoma, 124 Vertigo and headache, irritability, 105–109 and headache, nausea/vomiting, 111–115 Visual changes, 121–125 Visual disturbance cautions, 131 germ cell tumors, 130 meningioma, 129–130 metastatic tumor, 130 normal anterior pituitary, 129 pituicytoma, 130, 131 pituitary adenoma, 129 plasma cell dyscrasia, 130 scans and pathology, 129 Vomiting cautions, 152 clinical history, 148 ependymoma, 151 germ cell tumor, 150 headache and nausea, 99–104 metastatic tumors, 150–151 pathology, 150 pineoblastoma/medulloblastoma, 150 pituitary, 150 scans, 150 von Hippel–Lindau (VHL) syndrome child, 119 hemangioblastomas, 118 W Well-circumscribed ependymomas, 113 extra-axial lesion, 159 vs infiltrative, metastases, 68 neurocytoma, 91 Y Young adult, 113, 155 .. .Intra-Operative Neuropathology for the Non-Neuropathologist Cynthia T Welsh Editor Intra-Operative Neuropathology for the Non-Neuropathologist A Case-Based Approach... residents fix the smeared slides while they cut the frozen sections, and then run them all through the H&E stain together (saving time and effort) We intentionally use DiffQuik stains for possible... components The lesion extends from the nasal cavity and nasopharynx to the frontal lobe, with the epicenter and waist at the level of the cribriform plate The intracranial portion of the tumor