Brain Pathology Case of the Month - April 2010

Contributed by 1Brian H Le, MD and 2Matthew Sandusky, MD
1Department of Pathology, Reading Hospital and Medical Center, West Reading, PA
2Department of Diagnostic Imaging, Brown University, Providence, RI


CLINICAL HISTORY

An 81 year-old male with a clinical history of hypertension and hyperlipidemia presented with weakness, confusion, aphasia, and short-term amnesia. Five months prior to presentation he had sustained a stroke involving the left middle cerebral artery. Current imaging by CT scan reveals worsening edema in the vascular territorial distribution of the left middle cerebral artery accompanied an ovoid, mass-like lesion in the left temporal-parietal region. Follow-up MRI revealed, in the anterior aspect of the left temporal lobe and extending into the insula and basal ganglia, a 5.0 x 4.6 x 3.2 cm mass with serpiginous border enhancement. Foci devoid of enhancement were also observed, suggestive of necrosis. The patient subsequently underwent a craniotomy with attempt at gross total resection, yielding an approximate 20 mL aggregate of tissue.

MICROSCOPIC PATHOLOGY

Histologic examination of the tumor shows biphasic histology. The less dominant morphologic pattern consists of a hypercellular proliferation of pleomorphic cells, with occasional giant cells, present within a gliofibrillary background (figure 1). Foci of microvascular proliferation are observed (figure 2). Cellular elements within this component show reactivity for glial fibrillary acidic protein (GFAP), vimentin, and S-100 protein.

The second, more prominent component is composed of cells with large nuclei, present within a background of extensive necrosis (figure 3). High power magnification is notable for nuclear molding and an elevated mitotic index (figures 4 and 5). Cellular constituents comprising this component show faint immunoreactivity for S-100 and neurofilament, but more prominent reactivity for synaptophysin (figure 6), and neuron-specific enolase (NSE) (figure 7).

FINAL DIAGNOSIS


International Society of Neuropathology