USU - The Nations Medical School

USU Learning to Care for Those in Harms 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

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USU Learning to Care for Those in Harms 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.

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USU Learning to Care for Those in Harms 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

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Primary CNS Neoplasms

Primary
Intraaxial
Astrocytoma (Glioma)
Circumscribed Diffuse

Circumscribed Astrocytoma

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

Lymphoma Neuronal

Extraaxial
Meningioma Schwannoma Pituitary

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USU Learning to Care for Those in Harms Way

Pilocytic Astrocytoma

Pilocytic Astrocytoma

Radiology - http://rad.usuhs.mil

Radiology Cerebellum, 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%

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Diffuse Astrocytoma

Primary CNS Neoplasms

Primary
Intraaxial
Astrocytoma (Glioma)
Circumscribed Diffuse

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

Lymphoma Neuronal

Extraaxial
Meningioma Schwannoma Pituitary

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USU Learning to Care for Those in Harms Way

Astrocyte Mutation
Radiology - http://rad.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,P15.P14 Excess production of: EGFR VEGF

Excess production of: CDK4

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USU Learning to Care for Those in Harms Way

Diffuse Astrocytoma
Radiology - http://rad.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

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USU Learning to Care for Those in Harms Way

Gliomatosis Cerebri

White Matter Tracts

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

Radiology - http://rad.usuhs.mil

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USU Learning to Care for Those in Harms Way

Gliomatosis Cerebri

Gliomatosis Cerebri = Diffuse Astrocytoma

CHO Cr

Radiology - http://rad.usuhs.mil

NAA ?

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USU Learning to Care for Those in Harms Way

Brainstem Astrocytoma

Brainstem Astrocytoma

Radiology - http://rad.usuhs.mil

WHO Gr 2

Gr 3

Gr 4 GBM

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USU Learning to Care for Those in Harms Way

Diffuse Astrocytoma

Diffuse Astrocytoma

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

Radiology - http://rad.usuhs.mil

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USU Learning to Care for Those in Harms Way

Astrocytoma: Microcystic change

Primary CNS Neoplasms

Primary
Intraaxial
Astrocytoma (Glioma)
Circumscribed Diffuse

Radiology - http://rad.usuhs.mil

Lymphoma Neuronal

Extraaxial
Meningioma Schwannoma Pituitary

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USU Learning to Care for Those in Harms Way

Astrocytoma WHO Gr 4
Glioblastoma multiforme Aggressive hypervascular mass
Abnormal arteries and veins Glomeruloid capillaries Incr. rCBV, rCBF, short MTT Absent BBB

Glioblastoma Multiforme
Radiology - http://rad.usuhs.mil

Heterogeneous

Deceptive lesion

Necrosis, vascular rim with tumor Surrounding edema and tumor Looks focal but is diffusely infiltrating

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USU Learning to Care for Those in Harms Way

Glioblastoma Multiforme
Radiology - http://rad.usuhs.mil Radiology - http://rad.usuhs.mil

Diffuse Astrocytoma Spread

We all see the enhancing hypercellular and hypervascular RIM Microscopically, cells spread through the white matter Corona of vasogenic edema has tumor But, tumor may extend beyond area of T2 abnormality MRS, DTI, Anisotropy may help

T2

T1-Gd

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USU Learning to Care for Those in Harms Way

Pseudopalisading Necrosis

Radiology - http://rad.usuhs.mil USU Learning to Care for Those in Harms Way

Radiology - http://rad.usuhs.mil

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Pseudopalisading

GBM: 55-15% are Multifocal

Radiology - http://rad.usuhs.mil

Radiology - http://rad.usuhs.mil

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USU Learning to Care for Those in Harms Way

Terrorist Cells Infiltrate Brain

Radiology - http://rad.usuhs.mil Radiology - http://rad.usuhs.mil USU Learning to Care for Those in Harms Way Radiology - http://rad.usuhs.mil Radiology - http://rad.usuhs.mil

GBM on Surface

GBM

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USU Learning to Care for Those in Harms Way

Early Draining Veins

Radiology - http://rad.usuhs.mil

Glioblastoma Multiforme

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Glioblastoma Multiforme

New Tools for Grading and Staging

Radiology
Perfusion - rCBV Diffusion and DTI Spectroscopy PET/SPECT Monoclonal Ab.

Pathology
Labeling Index Chromosomes Histochemical Electron Microscopy

Radiology - http://rad.usuhs.mil

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USU Learning to Care for Those in Harms Way

MR Perfusion Imaging
Radiology - http://rad.usuhs.mil Radiology - http://rad.usuhs.mil Radiology - http://rad.usuhs.mil Radiology - http://rad.usuhs.mil

DTI and Tumor Imaging

T2
Courtesy of James Provenzale, Duke University

DTI

From: J. Burdette and Neeraj Chepuri, WFU

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USU Learning to Care for Those in Harms Way

DTI and Tumor Imaging

GBM Corpus Callosum

Radiology - http://rad.usuhs.mil

Schematic

DTI

From: J. Burdette and Neeraj Chepuri, WFU

USU Learning to Care for Those in Harms Way

USU Learning to Care for Those in Harms Way

Primary CNS Neoplasms

Primary
Intraaxial
Astrocytoma (Glioma)
Circumscribed Diffuse

Deep Periventricular Lesions

Radiology - http://rad.usuhs.mil

Lymphoma Neuronal

Extraaxial
Meningioma Schwannoma Pituitary

T2W

FLAIR
Courtesy V. Mathews, IA

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PCNSL: Immunocompetent

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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.usuhs.mil

Radiology - http://rad.usuhs.mil

Multifocal Rings are undulating and irregular Hypermetabolic (SPECT, Thallium)

T1-non

T2

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USU Learning to Care for Those in Harms 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 - http://rad.usuhs.mil Radiology - http://rad.usuhs.mil

Radiology - http://rad.usuhs.mil

USU Learning to Care for Those in Harms Way

USU Learning to Care for Those in Harms Way

Radiology - http://rad.usuhs.mil

USU Learning to Care for Those in Harms Way

USU Learning to Care for Those in Harms Way

Small Round Blue Cell Tumor

CT - Hyperdense
Radiology - http://rad.usuhs.mil

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

Perivascular Infiltrate

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USU Learning to Care for Those in Harms Way

MR - Hypointense
Radiology - http://rad.usuhs.mil

RIM PHOMA

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USU Learning to Care for Those in Harms Way

Rimphoma: Rimphoma: It HUGS the Ventricles

RIM PHOMA

Radiology - http://rad.usuhs.mil

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PCNSL: Nl vs. AIDS

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Lymphoma - Hypointense

Radiology - http://rad.usuhs.mil

Radiology - http://rad.usuhs.mil

T1-gad

T1-gad

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USU Learning to Care for Those in Harms Way

Lymphoma - Undulating
Radiology - http://rad.usuhs.mil USU Learning to Care for Those in Harms Way Radiology - http://rad.usuhs.mil

Lymphoma - Undulating

1 mon.

Relapse after Tx
2 mon. 3 mon.

Radiology - http://rad.usuhs.mil