Brain/meningeal tumor: Difference between revisions

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Also look into the patient's history for past cancers that may have metastasized to the brain.
Also look into the patient's history for past cancers that may have metastasized to the brain.


The location, younger vs older age, as well as the overall pattern provide the main differential diagnoses:
===Location and younger vs older age===
{|class=wikitable
{|class=wikitable
|+Main brain tumors<ref>From notes by Dr. Kurt Schaberg, in turn citing: {{cite book | last=Perry | first=Arie | last2=Brat | first2=Daniel J. | title=Practical Surgical Neuropathology | publisher=Churchill Livingstone | publication-place=Philadelphia, PA | date=2017-12-07 | isbn=978-0-323-44941-0 | page=}}</ref>
|+Main brain tumors<ref name=Kurt-BratDaniel2017>From [https://schaberg.faculty.ucdavis.edu/ notes by Dr. Kurt Schaberg], in turn citing: {{cite book | last=Perry | first=Arie | last2=Brat | first2=Daniel J. | title=Practical Surgical Neuropathology | publisher=Churchill Livingstone | publication-place=Philadelphia, PA | date=2017-12-07 | isbn=978-0-323-44941-0 | page=}}</ref>
! Location !! Child or young adult !! Older adult
! Location !! Child or young adult !! Older adult
|-
|-
Line 86: Line 88:
| Schwannoma, meningioma, epidermoid cyst, choroid plexus papilloma, endolymphatic sac tumor
| Schwannoma, meningioma, epidermoid cyst, choroid plexus papilloma, endolymphatic sac tumor
|}
|}
===Overall patterns===
;Parenchymal Infiltrate with hypercellularity<ref name=Kurt-BratDaniel2017/>
Hypercellular infiltrate but intact architecture:
*Diffuse gliomas
*Diffuse large B cell lymphoma of the CNS
*Angiocentric glioma
*Inflammatory/infectious processes
*Active demyelinating diseases
*Histiocytic disorders (e.g., Erdheim-Chester disease)
*Infarcts
*Metabolic/toxic diseases
*Reactive gliosis
;Solid mass<ref name=Kurt-BratDaniel2017/>
A sharply demarcated lesion:
*Metastases
*Ependymoma
*Subependymoma
*Subependymal giant cell astrocytoma (SEGA)
*Neurocytoma
*Pineal parenchymal tumor
*Embryonal neoplasm
*Choroid plexus tumor
*Hemangioblastoma
*Paraganglioma
*Pituitary adenomas
*Astroblastoma
*Chordoid glioma of the 3rd ventricle
;Solid and infiltrative process<ref name=Kurt-BratDaniel2017/>
Mostly solid, but with ill-defined margin towards adjacent brain tissue:
*Pilocytic astrocytoma
*Pilocytic xanthoastrocytoma
*Glioblastoma/gliosarcoma
*Ganglioglioma
*Dysembryoplastic neuroepithelial tumor
*Embryonal neoplasms (e.g., Medulloblastoma)
*Choroid plexus carcinoma
*Germ cell tumors
*Craniopharyngioma
*Diffuse large B-cell Lymphoma
*Sarcoma
*Histiocytic tumor
*Abscess/infection
;Destructive/necrotic process<ref name=Kurt-BratDaniel2017/>
Extensive necrosis and destruction of normal tissue:
*Infarcts
*Glioblastoma
*Radiation necrosis/treatment effect
*Infection
*Vasculitis
*Lymphoma
*Severe demyelinating disease
*Metabolic/toxic disease
;Vasculocentric<ref name=Kurt-BratDaniel2017/>
Centered around blood vessels:
*Diffuse large B-cell lymphoma
*Intravascular lymphoma
*Angiocentric glioma
*Ependymoma
*Vasculitis
*Demyelinating diseases
*Amyloid angiopathy
*Arteriosclerosis
*Vascular malformations
*Infection
*Sarcoidosis
*Thromboembolic disease
;Extra-axial mass<ref name=Kurt-BratDaniel2017/>
Outside brain or spine
*Meningioma
*Solitary fibrous tumor/hemangiopericytoma
*Hemangioblastoma
*Peripheral nerve sheath tumors
*Metastasis
*Melanocytoma/melanoma
*Paraganglioma
*Pituitary adenoma
*Sarcoidosis
*Infection
*Bone tumors
*Histiocytic tumors
*Leukemia/lymphoma
;Almost Normal Tissue<ref name=Kurt-BratDaniel2017/>
Only very subtle abnormalities:
*Nonrepresentative biopsy (they missed)
*Subtle diffuse glioma
*Cortical dysplasia and other malformations
*Mesial temporal sclerosis
*Intravascular lymphoma
*Encephalitis
*Cerebral malaria
*Microembolic disease
*Neurodegenerative diseases
*Metabolic/toxic disorders
*Reactive gliosis
*Cerebral edema
*Spongiotic/vacuolar changes
*Ischemic changes
;Meningeal or cerebrospinal fluid infiltrate<ref name=Kurt-BratDaniel2017/>
Subarachnoid space expansion:
*Meningeal carcinomatosis
*Meningeal gliomatosis
*Meningeal melanocytis/melanomatosis
*Diffuse leptomeningeal glioneuronal tumor
*Metastatic medulloblastoma
*Leukemia/lymphoma
*Histiocytic disorders
*Meningitis
*Sarcoidosis
*Infection
*Collagen vascular disease
<noinclude>
<noinclude>
{{Bottom}}
{{Bottom}}
</noinclude>
</noinclude>

Revision as of 19:06, 13 April 2024

Author: Mikael Häggström [note 1]

Intraoperative consultation of brain tumor fragments

Preparation

If you are expecting a brain/meningeal tumor, look at any radiology to find out what is the suspected diagnosis or differential diagnoses. A connection to the dura raises the suspicion of a meningioma. Multiple tumors raises the suspicion of metastasis or lymphoma.

Grossing

File:Gross pathology of melanoma metastasis.jpg
Resected fragments of a brain tumor, and in this case the very dark appearance supports a diagnosis of metastatic pigment-forming melanoma.

Measure the size of the specimen in 3 dimensions.

File:Histopathology of meningioma.png
Histopathology of a typical WHO grade 1 meningioma, H&E stain. It is of the meningothelial histologic type, which is the most common meningioma type. It shows its typical findings:
- A woven architectural pattern
- Psammoma bodies (spheroid calcifications)
- Syncytial cells (having indistinct cell membranes) with eosinophilic (pink) cytoplasms
- Round uniform nuclei
- Whorls (concentric cell arrangements)[1]

Squash prep

Remove a drop-size sample, place it on a glass-slide, then gently smear it out with another glass slide, followed by applying a fixative solution and staining with H&E.

Evaluation

The most common primary brain tumors are:[2]

Also look into the patient's history for past cancers that may have metastasized to the brain.

The location, younger vs older age, as well as the overall pattern provide the main differential diagnoses:

Location and younger vs older age

Main brain tumors[4]
Location Child or young adult Older adult
Cerebral, supratentorial Ganglioglioma, dysembryoplastic neuroepithelial tumor (DNET), pleomorphic xanthoastrocytoma (PXA),

ependymoma, atypical teratoid/rhabdoid tumor (AT/RT), CNS embryonal neoplasms

Glioblastoma, infiltrating astrocytoma (grades II-III), oligodendroglioma, metastasis, lymphoma, infection
Cerebellar, infratentorial, fourth ventricle Pilocytic astrocytoma, medulloblastoma, ependymoma, choroid plexus papilloma, atypical teratoid/rhabdoid tumor (AT/RT) Metastasis, hemangioblastoma, choroid plexus papilloma, subependymoma
Brainstem Pilocytic astrocytoma, diffuse midline glioma Astrocytoma, glioblastoma, diffuse midline glioma, metastasis
Spinal cord (intramedullary) Ependymoma, pilocytic astrocytoma, diffuse midline glioma, myxopapillary ependymoma, drop metastasis Ependymoma, astrocytoma, diffuse midline glioma, myxopapillary ependymoma (filum terminale), paraganglioma (filum terminale)
Spinal cord (extramedullary) Meningioma, schwannoma, metastasis, melanocytoma, melanoma Schwannoma, meningioma, melanocytoma, melanoma, malignant peripheral nerve sheath tumor (MPNST)
Spinal cord (extradural) Bone tumor, meningioma, abscess, vascular malformation, Herniated disk, lymphoma, abscess, metastases,
Extra-axial, dural, leptomeningeal Leukemia/lymphoma, Ewing sarcoma, rhabdomyosarcoma, disseminated medulloblastoma, diffuse leptomeningeal glioneuronal tumor (DLGNT), Meningioma, solitary fibrous tumor, metastasis, lymphoma
Sellar/infundibular Pituitary adenoma, craniopharyngioma, Rathke cleft cyst, pituicytoma, Langerhans cell histiocytosis (LCH), germ cell tumors Pituitary adenoma, craniopharyngioma, Rathke cleft cyst, pituicytoma, meningioma,

metastasis, chordoma

Suprasellar, hypothalamic, optic pathway, third ventricle Germ cell tumors, craniopharyngioma, pituitary adenoma, optic glioma, Langerhans cell histiocytosis (LCH) Colloid cyst, craniopharyngioma, chordoid glioma
Pineal Germ cell tumors, pineocytoma, pineoblastoma, pineal cyst Pineocytoma, pineal cyst, pineal parenchymal tumors of intermediate differentiation (PPTID)
Thalamus Pituitary adenoma, diffuse midline glioma Diffuse midline glioma, glioblastoma, lymphoma
Lateral ventricle Central neurocytoma, subependymal giant cell astrocytoma (SEGA), choroid plexus papilloma/carcinoma,

meningioma

Central neurocytoma, subependymal giant cell astrocytoma (SEGA), choroid plexus papilloma/carcinoma, subependymoma, meningioma
Nerve root, paraspinal Neurofibroma, schwannoma, malignant peripheral nerve sheath tumor (MPNST) Neurofibroma, schwannoma, MPNST, lymphoma, meningioma
Cerebellopontine angle Schwannoma, Choroid plexus papilloma, atypical teratoid/rhabdoid tumor (AT/RT) Schwannoma, meningioma, epidermoid cyst, choroid plexus papilloma, endolymphatic sac tumor

Overall patterns

Parenchymal Infiltrate with hypercellularity[4]

Hypercellular infiltrate but intact architecture:

  • Diffuse gliomas
  • Diffuse large B cell lymphoma of the CNS
  • Angiocentric glioma
  • Inflammatory/infectious processes
  • Active demyelinating diseases
  • Histiocytic disorders (e.g., Erdheim-Chester disease)
  • Infarcts
  • Metabolic/toxic diseases
  • Reactive gliosis
Solid mass[4]

A sharply demarcated lesion:

  • Metastases
  • Ependymoma
  • Subependymoma
  • Subependymal giant cell astrocytoma (SEGA)
  • Neurocytoma
  • Pineal parenchymal tumor
  • Embryonal neoplasm
  • Choroid plexus tumor
  • Hemangioblastoma
  • Paraganglioma
  • Pituitary adenomas
  • Astroblastoma
  • Chordoid glioma of the 3rd ventricle
Solid and infiltrative process[4]

Mostly solid, but with ill-defined margin towards adjacent brain tissue:

  • Pilocytic astrocytoma
  • Pilocytic xanthoastrocytoma
  • Glioblastoma/gliosarcoma
  • Ganglioglioma
  • Dysembryoplastic neuroepithelial tumor
  • Embryonal neoplasms (e.g., Medulloblastoma)
  • Choroid plexus carcinoma
  • Germ cell tumors
  • Craniopharyngioma
  • Diffuse large B-cell Lymphoma
  • Sarcoma
  • Histiocytic tumor
  • Abscess/infection
Destructive/necrotic process[4]

Extensive necrosis and destruction of normal tissue:

  • Infarcts
  • Glioblastoma
  • Radiation necrosis/treatment effect
  • Infection
  • Vasculitis
  • Lymphoma
  • Severe demyelinating disease
  • Metabolic/toxic disease
Vasculocentric[4]

Centered around blood vessels:

  • Diffuse large B-cell lymphoma
  • Intravascular lymphoma
  • Angiocentric glioma
  • Ependymoma
  • Vasculitis
  • Demyelinating diseases
  • Amyloid angiopathy
  • Arteriosclerosis
  • Vascular malformations
  • Infection
  • Sarcoidosis
  • Thromboembolic disease
Extra-axial mass[4]

Outside brain or spine

  • Meningioma
  • Solitary fibrous tumor/hemangiopericytoma
  • Hemangioblastoma
  • Peripheral nerve sheath tumors
  • Metastasis
  • Melanocytoma/melanoma
  • Paraganglioma
  • Pituitary adenoma
  • Sarcoidosis
  • Infection
  • Bone tumors
  • Histiocytic tumors
  • Leukemia/lymphoma
Almost Normal Tissue[4]

Only very subtle abnormalities:

  • Nonrepresentative biopsy (they missed)
  • Subtle diffuse glioma
  • Cortical dysplasia and other malformations
  • Mesial temporal sclerosis
  • Intravascular lymphoma
  • Encephalitis
  • Cerebral malaria
  • Microembolic disease
  • Neurodegenerative diseases
  • Metabolic/toxic disorders
  • Reactive gliosis
  • Cerebral edema
  • Spongiotic/vacuolar changes
  • Ischemic changes
Meningeal or cerebrospinal fluid infiltrate[4]

Subarachnoid space expansion:

  • Meningeal carcinomatosis
  • Meningeal gliomatosis
  • Meningeal melanocytis/melanomatosis
  • Diffuse leptomeningeal glioneuronal tumor
  • Metastatic medulloblastoma
  • Leukemia/lymphoma
  • Histiocytic disorders
  • Meningitis
  • Sarcoidosis
  • Infection
  • Collagen vascular disease

Notes

  1. ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.

Main page

References

  1. ↑ Image by Mikael Häggström, MD. Reference for typical findings: Chunyu Cai, M.D., Ph.D.. Meningioma. Pathology Outlines. Last author update: 10 November 2021}}
  2. ↑ Park, Bong Jin; Kim, Han Kyu; Sade, Burak; Lee, Joung H. (2009). "Epidemiology". Meningiomas: Diagnosis, Treatment, and Outcome . Springer. p. 11. ISBN 978-1-84882-910-7. 
  3. ↑ 3.0 3.1 3.2 . Brain Tumors - Classifications, Symptoms, Diagnosis and Treatments (in en). www.aans.org.
  4. ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 From notes by Dr. Kurt Schaberg, in turn citing: Perry, Arie; Brat, Daniel J. (2017-12-07). Practical Surgical Neuropathology . Philadelphia, PA: Churchill Livingstone. ISBN 978-0-323-44941-0. 

Image sources


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