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(Student’s copy)

Jabatan Patologi, Fakulti Perubatan, UKM


Perkara : Pathology Practical , Neuroscience Module, Tahun 2
Tempat : MPG
Tajuk : Gross and Histology of Tumours of the Nervous System
Tarikh : Khamis, 26 April 2018; 10.30 pagi – 12.30 tengahari
Disediakan oleh: Prof Madya Dr. Reena Rahayu Md Zin
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1. A 30-year-old male presented with headache. CT scan showed a
tumour in the left cerebral hemisphere. Biopsy of the brain tumour was
done. It was reported as oligodendroglioma. Select the statement that
best describe the biopsy finding.
A. Small round blue cell tumour with numerous mitotic figures
B. Spindle cell tumour with wavy nuclei and no mitotic figures
C. Spindle cell tumour with pallisading nuclei and no mitotic figures
D. Uniform round tumour cells forming rosettes (flower-petal arrangement)
E. Uniform round tumour cells with small nucleus and clear vacuolated
cytoplasm

2. A 45-year-old male presented with headache. CT scan showed a


t
umour in the right cerebral hemisphere. Tumour biopsy was done. It
was reported as astrocytoma Grade II. Select the statement that best
describe the biopsy finding.
A. Tumour giant cells with enlarged bizarre nuclei
B. Tumour cells show pleomorphism only
C. Tumour cells show pleomorphism and mitosis only
D. Tumour cells show pleomorphism, mitosis and blood vessel
proliferation
E. Tumour cells show pleomorphism, mitosis and geographic serpentine
necrosis

3. A 45-year-old woman, a known breast cancer patient, presented with


seizures at the neurology clinic. MRI scan showed multiple tumours in
the deep white matter and basal ganglia. Tumour biopsy was done. It
showed infiltration of brain tissue by malignant breast ducts. Select
the most likely diagnosis.
A. Oligodendroglioma
B. Schwannoma
C. Ependymoma
D. Metastatic carcinoma
E. Medulloblastoma

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4. A 6-year-old girl was found to be unsteady while walking. MRI scan
showed a tumour in the right cerebellar hemisphere. The tumour was
resected. Histologically, it was composed of densely packed
undifferentiated “small round blue cells” arranged in solid sheets.
Frequent mitoses and tumour necrosis were seen. Select the most
likely diagnosis.

A. Medulloblastoma
B. Pilocytic astrocytoma
C. Craniopharyngioma
D. Haemangioblastoma
E. Germinoma

5. A 9 year old boy complained of a 3-week history of headache


associated with visual loss and vomiting. MRI showed a mass
within the fourth ventricle. Biopsy of the mass was performed.
Histologic examination showed perivascular pseudo-rosettes and
ependymal rosettes. Mitotic figures were not seen. What is the
most likely diagnosis?

A. Ependymoma
B. Neurofibroma
C. Craniopharyngioma
D. Metastatic carcinoma
E. Schwannoma

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CASE 1: Glioblastoma

A 50 year-old man had severe headache for 2 months. He died at home


suddenly. Post mortem was done. Coronal section of brain showed a
right cerebral tumour 5cm. diameter. It was reported as „glioblastoma‟.
The tumour was resected and sent for histopathological examination
(Picture A).

1. Describe the histopathological features seen in Picture A.

Three criteria: nuclear atypia, mitoses, endothelial proliferation and/or necrosis


Necrosis in geographic or serpentine pattern,
occurs in areas of hypercellularity with malignant tumour cells
crowded along the edges of the necrotic regions, producing a histologic
pattern referred to as pseudopallisading

2. What is the WHO grade of this tumour?


WHO Grade IV

3. Explain the WHO grading system of astrocytomas


Grading is based on presence of the following four histological criteria:
Nuclear atypia (pleomorphism),
mitoses,
endothelial proliferation,
necrosis.
If only one of these criteria is found the tumor is a Grade II.
Two of the criteria make the tumor a Grade III
and if three or four of the criteria are found the tumor is a Grade IV or
Glioblastoma.

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CASE 2: Meningioma

A 49-year-old woman complained of difficulty in walking that became


progressively worse over a period of three months. On examination she
had weakness of her left lower limb. MRI scan showed a localized
tumour attached to the dura and indenting the right parietal cortex.The
tumour was resected and sent for histopathological examination

Picture B shows gross appearance of the tumour


Picture C shows histopathological features of the tumour

1. Describe the gross appearance of the tumour in Picture B.

- Meningioma attached to dura


- Haemorrhagic

2. Describe the histopathological features seen in Picture C.

- The tumor cells arrange in concentric whorls which resemble


normal arachnoid granulation
- Nuclei are round to oval, uniform, no mitosis
- Psammoma body (the red-purple round body) are calcified bodies

3. What are the sites of predilection for this neoplasm?

- Parasagittal and convexity region has the highest incidence,


- followed by sphenoid ridge,
- olfactory groove,
- suprasellar region,
- posterior fossa,
- spine,
- periorbital region,
- temporal fossa, and
- falx.

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4. What is the presumed cell of origin of common nervous system

tumours?

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4. State the effects and complications of brain tumour (in general) as a
space-occupying-lesion (SOL).

1.Increased intracranial pressure due to

Brain tumors act upon the adjacent brain causing:


•2. Compression.
The effects of compression depend on the location of the tumor (specific localizing
signs).
Tumour may cause loss of motor functions (e.g. paralysis), loss of sensory functions
(e.g., loss of sensation), or it may stimulate certain parts of the brain and cause epileptic
fits, or abnormal sensory stimuli.

•3.Destruction.
Invasive tumours may destroy or stimulate nerve cells and produce the same symptoms
as those tumors that are compressing the brain.

•4. Infarction and hemorrhage.


The tumour may invade blood vessels or compress blood vessels and thus cause
ischemic necrosis. Necrotic tumors tend to bleed.

5.Cerebral edema.
- It is typical response to all intracranial pathologic processes. Brain edema involves the
peritumoral brain tissue but also parts of the brain at a distance from the tumor.

6. Obstruction of cerebrospinal fluid flow.


- leads to formation of hydrocephalus.

7. Changes in the cerebrospinal fluid composition. –


- The CSF pressure is typically increased, and the CSF contains increased amounts of
protein. Tumour cells may occasionally be seen, most often in tumours like
medulloblastoma and lymphoma.

8.Headaches:
The most common site for headache in brain tumour is bifrontal.

amount of midline shift as demonstrated by MRI scan.


headache is the result of
traction on intracranial pressure-sensitive structures, including large blood vessels, the
dura, and certain cranial nerves.

indicative of increased intracranial pressure,

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CASE 3: Schwannoma

A 35-year-old woman complained of progressive hearing loss in her right


ear. MRI showed a tumour at the right cerebellopontine angle. Surgical
resection of the tumour was done. Specimen was sent for histopathological
examination (Picture D).

1. Describe the histopathological features seen in Picture D.

- Microscopic appearance: A spindle cell lesion.

densely packed spindle-shaped cells with frequent nuclear pallisading.


s areas with spindle or oval cells with
indistinct cytoplasm in a loose vacuolated background.

body).

2. How is this neoplasm related to neurofibromatosis?

- Sporadic schwannomas are associated with mutations in NF2 gene.

3. Discuss the location (topography) of central nervous system neoplasms.

Most brain tumors found in adult (two-thirds or 70%) are supratentorial.

craniopharyngioma, pituitary adenoma, schwannoma, metastases to brain.

m cell tumour, peripheral


neuroectodermal tumour (supratentorial PNET), ependymoma.

Infratentorial tumors (posterior fossa), i.e., tumors of the cerebellum and the brain stem
located underneath the tentorium cerebelli. Most brain tumors in children ( two-thirds or
70%) are found in this location.

Children: Medulloblastoma, pilocytic astrocytoma


Adult: Haemangioblastoma

Spinal cord tumors

Adult: Neurofibroma, schwannoma, ependymoma, metastatic carcinoma

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CASE 4: Medulloblastoma

A 4-year-old boy was noted by his mother to fall down frequently. On


examination in the hospital he had left lower limb weakness and
nystagmus. MRI scan showed a tumour in the right cerebellar hemisphere.
The radiological diagnosis was medulloblastoma. The tumour was
resected. Specimen was sent for histopathological examination (Picture E).

Describe the histopathological features of medulloblastoma seen in Picture


E.

- Small round blue cells with Rosette formation.


- densely packed undifferentiated (anaplastic) “small blue cells” arranged into solid
sheets. Frequent mitoses and necrosis.

CASE 5: Pilocytic astrocytoma

A 9-year-old girl presented with ataxia and tremors. On examination there


was hypotonia of both lower limbs. The MRI scan showed a midline cystic
cerebellar lesion with a solid mural nodule.

The radiological diagnosis was pilocytic astrocytoma. Parents refused


consent for surgery. She died. Post mortem was performed.

Picture F shows the gross appearance of the cerebellar tumour.


Picture G shows the histopathological appearance of the tumour.

1. Describe the gross appearance of the cerebellar tumour in Picture F

- Cystic and well circumscribed tumour

2. Describe the histopathologic appearance of the tumour in Picture G.

- Histologically composed of elongated bipolar astrocytes with


thin cytoplasmic processes,
- often shown Rosenthal fibres (eosinophilic deposits of intermediate filament, GFAP),
- microcystic spaces.

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PICTURE A

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PICTURE B

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PICTURE C

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PICTURE D

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PICTURE E

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Picture F

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PICTURE G

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