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Case Study 35

Case Study 35. Henry Armah, M.D., M.Phil. Question 1. Clinical history: 72-year-old white male who presented with left lower extremity weakness. He was a non-smoker, occasionally used alcohol socially, and did not use illicit drugs. Describe the abnormal cranial MRI findings?. T1 + C. T1 + C.

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Case Study 35

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  1. Case Study 35 Henry Armah, M.D., M.Phil.

  2. Question 1 Clinical history: 72-year-old white male who presented with left lower extremity weakness. He was a non-smoker, occasionally used alcohol socially, and did not use illicit drugs. Describe the abnormal cranial MRI findings?

  3. T1 + C

  4. T1 + C

  5. T1 + C

  6. Answer Contrast enhancing lesion extending superiorly from the posterior limb of the right internal capsule/lateral thalamus, through the right cerebral peduncle/midbrain, to the right hemipons inferiorly.

  7. Question 2 What are your differential diagnoses based on the patients’ age and the radiological findings?

  8. Answer • High-grade glioma • Malignant lymphoma • Metastasis (from carcinoma, melanoma, etc) • Abscess • Inflammatory demyelinating lesion • Subacute infarct

  9. Question 3 The neurosurgeon performs a CT-guided stereotactic biopsy of the mass and requested an intraoperative consultation. Describe the microscopic findings on this smear slide? Click here to view slide.

  10. Answer Brain tissue infiltrated by pleomorphic granular cells.

  11. Question 4 What is your intraoperative diagnosis? (A: Category such as Defer, Reactive/Non-neoplastic, or Neoplastic; B: More specific diagnosis or statement)

  12. Answer • Neoplasm • Defer to permanent sections

  13. Question 5 The permanent section from the intraoperative specimen has returned from histology. Describe the microscopic findings on this H&E slide? Click here to view slide.

  14. Answer Fragments of brain tissue markedly infiltrated by a neoplastic proliferation of pleomorphic granular cells. There are focal areas of necrosis and florid endothelial proliferation.

  15. Question 6 What additional studies would you like to perform based on the findings of the permanent section?

  16. Answer GFAP, EGFR, p53, Ki-67 (MIB-1), CD68, S-100, Melan-A, HMB-45, Synaptophysin, Neurofilament, Pancytokeratin, CD45 (LCA), CD20 (L26), and CD3.

  17. Question 7 What do you see on this GFAP immunostain slide? Click here to view slide.

  18. Answer GFAP weakly to moderately stains the tumor cell processes.

  19. Question 8 What do you see on this EGFR immunostain slide? Click here to view slide.

  20. Answer EGFR is strongly and diffusely positive in tumor cells.

  21. Question 9 What do you see on this p53 immunostain slide? Click here to view slide.

  22. Answer p53 is negative in tumor cells.

  23. Question 10 What do you see on this Ki-67 (MIB-1) immunostain slide? Click here to view slide.

  24. Answer Ki-67 (MIB-1) is positive in the nuclei of up to 30% of tumor cells focally.

  25. Question 11 What do you see on this CD68 immunostain slide? Click here to view slide.

  26. Answer CD68 is positive in pleomorphic granular tumor cells.

  27. Question 12 What do you see on this S-100 immunostain slide? Click here to view slide.

  28. Answer S-100 is negative in tumor cells.

  29. Question 13 What do you see on this Melan-A immunostain slide? Click here to view slide.

  30. Answer Melan-A is negative in tumor cells.

  31. Question 14 What do you see on this HMB-45 immunostain slide? Click here to view slide.

  32. Answer HMB-45 is negative in tumor cells.

  33. Question 15 What do you see on this Synaptophysin immunostain slide? Click here to view slide.

  34. Answer Synaptophysin is focally and weakly positive in tumor cells, and highlights entrapped neuropil.

  35. Question 16 What do you see on this Neurofilament immunostain slide? Click here to view slide.

  36. Answer Neurofilament is negative in pleomorphic granular tumor cells, and highlights a few preserved axons between the infiltrating rows and sheets of pleomorphic granular tumor cells.

  37. Question 17 What do you see on this Pancytokeratin immunostain slide? Click here to view slide.

  38. Answer Pancytokeratin is negative in tumor cells.

  39. Question 18 What do you see on this CD45 (LCA) immunostain slide? Click here to view slide.

  40. Answer CD45 (LCA) highlights several lymphocytes and macrophages throughout the lesion.

  41. Question 19 What do you see on this CD3 immunostain slide? Click here to view slide.

  42. Answer CD3 highlights scattered T-lymphocytes throughout the lesion.

  43. Question 20 What do you see on this CD20 (L26) immunostain slide? Click here to view slide.

  44. Answer CD20 (L26) is positive in rare B-lymphocytes in the lesion.

  45. Question 21 What is your final diagnosis in this case?

  46. Answer Granular cell astrocytoma/glioblastoma

  47. Question 22 What is the corresponding WHO grade of this lesion?

  48. Answer WHO Grade 4.

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