USU - The Nation’s Medical School

USU – Learning to Care for Those in Harm’s Way

Common Adult Brain Tumors
James G. Smirniotopoulos, M.D. Radiology and Radiological Sciences Uniformed Services University of the Health Sciences Bethesda, MD jsmirnio@rad.usuhs.mil

Educational Objectives
• • • • • • Distinguish Intraaxial from Extraaxial Circumscribed vs. Diffuse Astrocytoma Grades of Diffuse Astrocytoma Natural Hx of Astrocytoma Limitations of Surgery for Diffuse Astro Primary CNS Lymphoma

Radiology - http://rad.medpix.net Radiology - http://rad.usuhs.mil Radiology - http://rad.usuhs.mil

Radiology - http://rad.usuhs.mil

USU – Learning to Care for Those in Harm’s Way

USU – Learning to Care for Those in Harm’s Way

Brain Neoplasia: Frequency*
Radiology - http://rad.usuhs.mil

Primary CNS Neoplasms
• Primary
– Intraaxial
• Astrocytoma (Glioma)
– Circumscribed – Diffuse

~ 1/3 are Metastatic CNS Tumors ~ 2/3 are Primary CNS Tumors

• Lymphoma • Neuronal

– Extraaxial
• Meningioma • Schwannoma • Pituitary

Levin VA et al. Cancer: Principles & Practice of Oncology. 1997: 2022 - 2082.

USU – Learning to Care for Those in Harm’s Way

USU – Learning to Care for Those in Harm’s Way

Lesion Location

WHO Classification of Tumors
Radiology - http://rad.usuhs.mil

Where is the lesion ? – Intraaxial – Extraaxial

Tumors of neuroepithelium

Astrocytomas
Oligodendrogliomas Mixed gliomas Ependymomas Glial tumors- uncertain origin Neuronal tumors & mixed neuronal glial tumors Embryonal tumors Lymphomas & hematopoietic tumors Metastases

Gliomas

http://rad.usuhs.USU – Learning to Care for Those in Harm’s Way Primary CNS Neoplasms • Primary – Intraaxial • Astrocytoma (Glioma) – Circumscribed – Diffuse Circumscribed Astrocytoma Radiology . Diencephalon – rare in BS or Cerebrum PILOCYTIC ASTROCYTOMA • Biphasic pattern PATHOLOGY • Majority have significant “cyst” – “Cyst and Mural Nodule” • part of lining does NOT enhance – dense pilocytic glia – Rosenthal fibers – loose microcystic areas – Nodule may be heterogeneous – Exceptional purely solid • No necrosis • Low grade • Abnormal capillaries – allow enhancement – fluid production • Nodule NOT hyperdense • Calcification in 5-25% .http://rad.mil Radiology .http://rad.mil Radiology • Cerebellum.mil • Lymphoma • Neuronal – Extraaxial • Meningioma • Schwannoma • Pituitary USU – Learning to Care for Those in Harm’s Way USU – Learning to Care for Those in Harm’s Way Pilocytic Astrocytoma Pilocytic Astrocytoma Radiology .usuhs.usuhs.

mil Diffuse Astrocytoma: Enlarged Hemisphere • • • • Normal Astrocyte Neoplastic Anaplastic GBM WHO Gr 2 Deletions: 17 p P53 22q NF2 Excess production of: PDGF Deletions: 13q RB 19q 10 Gr 3 Gr 4 GBM Deletions: 10 PTEN/MMAC1 9p P16.mil • Lymphoma • Neuronal – Extraaxial • Meningioma • Schwannoma • Pituitary USU – Learning to Care for Those in Harm’s Way USU – Learning to Care for Those in Harm’s Way Astrocyte Mutation Radiology .usuhs.http://rad.http://rad.USU – Learning to Care for Those in Harm’s Way Diffuse Astrocytoma Primary CNS Neoplasms • Primary – Intraaxial • Astrocytoma (Glioma) – Circumscribed – Diffuse Radiology .usuhs.usuhs.usuhs.mil Astrocytoma WHO Gr 2 • Increased brain volume – Cellularity of white matter WHO GR 4 WHO GR 3 WHO GR 2 Normal • NO Neovascularity – – – – Not allowed by WHO grading Intact normal vessels No enhancement No vasogenic edema • Homogeneous – Microcystic change .P14 Excess production of: EGFR VEGF Excess production of: CDK4 USU – Learning to Care for Those in Harm’s Way USU – Learning to Care for Those in Harm’s Way Diffuse Astrocytoma Radiology .http://rad.mil Radiology .P15.mil Radiology .http://rad.usuhs.http://rad.

usuhs.http://rad.mil NAA ? { USU – Learning to Care for Those in Harm’s Way USU – Learning to Care for Those in Harm’s Way Brainstem Astrocytoma Brainstem Astrocytoma Radiology .http://rad.http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way USU – Learning to Care for Those in Harm’s Way Gliomatosis Cerebri “Gliomatosis Cerebri” = Diffuse Astrocytoma CHO Cr Radiology .usuhs.mil Radiology .usuhs.mil Radiology .usuhs.USU – Learning to Care for Those in Harm’s Way USU – Learning to Care for Those in Harm’s Way Gliomatosis Cerebri White Matter Tracts Radiology .mil Radiology .usuhs.http://rad.mil WHO Gr 2 Gr 3 Gr 4 GBM .http://rad.http://rad.

usuhs.mil • Lymphoma • Neuronal – Extraaxial • Meningioma • Schwannoma • Pituitary USU – Learning to Care for Those in Harm’s Way USU – Learning to Care for Those in Harm’s Way Astrocytoma WHO Gr 4 • Glioblastoma multiforme • Aggressive hypervascular mass – – – – Abnormal arteries and veins “Glomeruloid” capillaries Incr.mil Radiology .usuhs.http://rad.http://rad.mil Radiology .mil • Heterogeneous • Deceptive lesion – Necrosis. rCBF. short MTT Absent BBB Glioblastoma Multiforme Radiology . vascular rim with tumor – Surrounding edema and tumor – Looks focal … but is diffusely infiltrating .usuhs.usuhs.usuhs.http://rad.http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way USU – Learning to Care for Those in Harm’s Way Astrocytoma: Microcystic change Primary CNS Neoplasms • Primary – Intraaxial • Astrocytoma (Glioma) – Circumscribed – Diffuse Radiology .mil Radiology . rCBV.http://rad.USU – Learning to Care for Those in Harm’s Way USU – Learning to Care for Those in Harm’s Way Diffuse Astrocytoma Diffuse Astrocytoma Radiology .http://rad.

tumor may extend beyond area of T2 abnormality • MRS.usuhs.mil Radiology .usuhs.http://rad.http://rad.usuhs.usuhs.usuhs.mil . Anisotropy may help T2 T1-Gd USU – Learning to Care for Those in Harm’s Way USU – Learning to Care for Those in Harm’s Way Pseudopalisading Necrosis Radiology .http://rad.http://rad.USU – Learning to Care for Those in Harm’s Way USU – Learning to Care for Those in Harm’s Way Glioblastoma Multiforme Radiology . cells spread through the white matter • Corona of vasogenic edema has tumor • But. DTI.usuhs.http://rad.http://rad.mil USU – Learning to Care for Those in Harm’s Way Pseudopalisading GBM: 55-15% are Multifocal Radiology .mil USU – Learning to Care for Those in Harm’s Way Radiology .mil Radiology .mil Diffuse Astrocytoma Spread • We all see the enhancing hypercellular and hypervascular RIM • Microscopically.

mil Radiology .http://rad.mil Glioblastoma Multiforme USU – Learning to Care for Those in Harm’s Way Glioblastoma Multiforme New Tools for Grading and Staging • Radiology – – – – – Perfusion . • Pathology – – – – Labeling Index Chromosomes Histochemical Electron Microscopy Radiology .usuhs.rCBV Diffusion and DTI Spectroscopy PET/SPECT Monoclonal Ab.usuhs.http://rad.mil USU – Learning to Care for Those in Harm’s Way Radiology .http://rad.usuhs.http://rad.http://rad.http://rad.usuhs.mil .USU – Learning to Care for Those in Harm’s Way USU – Learning to Care for Those in Harm’s Way Terrorist Cells Infiltrate Brain Radiology .usuhs.mil Radiology .usuhs.mil GBM on Surface GBM USU – Learning to Care for Those in Harm’s Way USU – Learning to Care for Those in Harm’s Way Early Draining Veins Radiology .

IA .mil • Lymphoma • Neuronal – Extraaxial • Meningioma • Schwannoma • Pituitary T2W FLAIR Courtesy V.mil Radiology . Burdette and Neeraj Chepuri.usuhs.mil Radiology .usuhs. Burdette and Neeraj Chepuri.http://rad.mil DTI and Tumor Imaging * * T2 Courtesy of James Provenzale.usuhs.usuhs. Mathews. Duke University DTI From: J.USU – Learning to Care for Those in Harm’s Way USU – Learning to Care for Those in Harm’s Way MR Perfusion Imaging Radiology . WFU USU – Learning to Care for Those in Harm’s Way USU – Learning to Care for Those in Harm’s Way Primary CNS Neoplasms • Primary – Intraaxial • Astrocytoma (Glioma) – Circumscribed – Diffuse Deep Periventricular Lesions Radiology .mil Radiology .usuhs.http://rad.mil Schematic DTI From: J.http://rad. WFU USU – Learning to Care for Those in Harm’s Way USU – Learning to Care for Those in Harm’s Way DTI and Tumor Imaging GBM Corpus Callosum Radiology .http://rad.http://rad.usuhs.http://rad.

mil USU – Learning to Care for Those in Harm’s Way USU – Learning to Care for Those in Harm’s Way Radiology .mil .http://rad.usuhs.http://rad.http://rad.http://rad.usuhs.usuhs.mil Radiology . Thallium) T1-non T2 USU – Learning to Care for Those in Harm’s Way USU – Learning to Care for Those in Harm’s Way PCNSL Micro Pathology • • • • • • DENSELY CELLULAR Perivascular infiltration Increased RETICULIN fibers HIGH N/C (nuclear/cytoplasm) Small Round Blue Cell Tumor High attenuation/low signal intensity Radiology .usuhs.mil • Multifocal • Rings are undulating and irregular • Hypermetabolic (SPECT.http://rad.mil Radiology .usuhs.usuhs.USU – Learning to Care for Those in Harm’s Way PCNSL: Immunocompetent USU – Learning to Care for Those in Harm’s Way CNS Lymphoma • Usually Parenchymal and paracentral • Small Round Blue-cell Tumor – HUGS the Ventricles – CT => Fluffy high density lesions – MR => Gray matter (or lower) Signal Radiology .http://rad.mil Radiology .

mil .mil Perivascular Infiltrate USU – Learning to Care for Those in Harm’s Way USU – Learning to Care for Those in Harm’s Way MR .usuhs.mil Radiology .http://rad.http://rad.http://rad.USU – Learning to Care for Those in Harm’s Way USU – Learning to Care for Those in Harm’s Way Small Round Blue Cell Tumor CT .http://rad.http://rad.mil Radiology .usuhs.mil Radiology .Hypointense Radiology .http://rad.usuhs.usuhs.usuhs.mil RIM PHOMA USU – Learning to Care for Those in Harm’s Way USU – Learning to Care for Those in Harm’s Way Rimphoma: Rimphoma: It HUGS the Ventricles RIM PHOMA Radiology .Hyperdense Radiology .usuhs.

http://rad. Relapse after Tx 2 mon.mil Lymphoma . AIDS USU – Learning to Care for Those in Harm’s Way Lymphoma .usuhs. 3 mon.usuhs.usuhs.usuhs.USU – Learning to Care for Those in Harm’s Way PCNSL: Nl vs.Undulating 1 mon.mil USU – Learning to Care for Those in Harm’s Way Radiology .http://rad. Radiology .http://rad.mil Radiology .http://rad.Undulating Radiology .Hypointense Radiology .mil T1-gad T1-gad USU – Learning to Care for Those in Harm’s Way USU – Learning to Care for Those in Harm’s Way Lymphoma .mil .usuhs.http://rad.

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