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Case 18 History: A 56 year-old man presented with headache and a pineal mass.

Diagnostic Challenge Pathology for Neurosurgery & Neurology Residents Department of Pathology University of Oklahoma Health Sciences Center, Oklahoma City, OK, U.S.A. Case 18 History: A 56 year-old man presented with headache and a pineal mass.

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Case 18 History: A 56 year-old man presented with headache and a pineal mass.

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  1. Diagnostic ChallengePathology for Neurosurgery & Neurology ResidentsDepartment of PathologyUniversity of Oklahoma Health Sciences Center,Oklahoma City, OK, U.S.A. Case 18 History: A 56 year-old man presented with headache and a pineal mass. Contributor: Kar-Ming Fung, M.D., Ph.D., karming-fung@ouhsc.edu Last updataded: 1/9/2009

  2. MRI T1 post contrast MRI T2 A B

  3. Permanent Section C D

  4. Permanent Section Cytologic Preparation à E F

  5. Glial Fibrillary Acidic Protein (GFAP) Synaptophysin G H

  6. Neurofilament Proteins Ki67 I J

  7. What is your diagnosis?

  8. Diagnosis: Pineal parenchymal tumor of intermediate differentiation (WHO Grade II). • Discussion: • First, germinoma is the most common one and must be ruled out. The characteristic histologic features are large geminoma cells in a benign background of reactive lymphocytes. • Although the round nuclei and high cellularity suggest lymphocytes, the overall morphology and the presence of neuropils (arrow) does not. Besides, there is a complete ablsence of large geminoma cells. • There is a lack of necrosis or high grade pleomorphism. At the same time, there is a lack of pineocytomatous rossettes or morphological features that suggest neuronal differentiation. • There is a lack of necrosis or high grade pleomorphism. At the same time, there is a lack of pineocytomatous rossettes or morphological features that suggest neuronal differentiation.

  9. The overall histology is a high cellularity of cells with montonous round nuclei. There is no necrosis and no rossettes. There is a lack of mitosis or high grade pleomorphism. See the small islands of neuropils (arrow). The cells also appears monotonous in cytologic preparation. • The tumor cells are strongly and diffusely positive for synaptophysin and neurofilament protein. Immunohistochemistry for GFAP demonstrate only reactive astrocytes in the background. • There is a lack of mitosis and the Ki67 labeling is low. • The overall features is most consistent with a pineal parenchymal tumor of intermediate differentiation of WHO grade II. The MRI reveals a rather well demarcated, enhancing lesion. These features, together with the age of this patient, also support the diagnosis.

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