Brain Pathology Case of the Month - March 2007

Contributed by Andrew R. Virata; Padmini V. Holla; M. Shahriar Salamat
Department of Pathology and Laboratory Medicine, University of Wisconsin, Madison.


A 65-year-old man was diagnosed with esophageal adenocarcinoma with metastases to liver and lungs in July of 2001. Due to metastatic disease, he was not deemed to be a candidate for surgical resection but was given radiation and chemotherapy. Seven months later he presented with an 8x5x3.5 cm frontal, transcalvarial metastatic lesion. Past medical history includes cholecystectomy, appendectomy, osteoarthritis, left hemipelvectomy following a motor vehicle accident in 1970, and smoking with intermittent alcohol abuse since the age of 15. His clinical course continued to deteriorate and he eventually expired in December of 2002. An autopsy revealed widespread metastatic adenocarcinoma to the lungs, liver and calvarium with superficial extension into the dorsal surface of the frontal lobes, bilaterally. An acute, severe bronchopneumonia was also found.


At brain cutting, in addition to metastatic neoplasm to the brain, a tan, firm, fusiform intradural mass, measuring 5 cm in length and 0.7 cm in diameter is found attached to the lumbosacral cord on the left (figure 1A). At least one nerve rootlet is attached to the mass. On cross section, the mass is well demarcated from the spinal cord, but a small portion of the tumor is confluent with the left ventral gray matter (Figure 1B). Grossly the appearance of the mass is different from that of the metastatic adenocarcinoma to the brain.

Tissue sections reveal a well-circumscribed subarachnoid mass adherent to ventrolateral surface of lumbosacral cord (Figure 2A). With hematoxylin and eosin (Figure 2B) the lesion is moderately cellular, consisting of spindle cells with scant cytoplasm and elongated oval nuclei arranged in interlacing bundles and fascicles with negligible fibrous stroma. The lesion surrounds spinal vessels (Figure 2A, single arrow head) and occasionally extends into the cord in the perivascular spaces (Figure 2A, double arrow head). There is no extension into the cord by way of ventral nerve rootlets. Bielschowsky silver and Luxol fast blue stained sections (Figures 2C & 2D) reveal an abundance of dense interlacing axonal clusters that are surrounded by thin myelin sheaths. A few scattered, swollen axons are also found (Figure 2C, arrow). Immunohistochemical labeling is negative for GFAP in the lesion. The spinal cord is also remarkable for pallor and loss of axons in the left fasciculus gracilis (Figure 2A, arrow).


International Society of Neuropathology