Contributed by Manoj Gopal Madakshira, MD1, Kirti Gupta, MD1, Apinderpreet Singh, MS, MCh2, Pravin Salunke, MS, MCh2
Departments of 1Histopathology and 2Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
A 65-year-old gentleman, chronic smoker without any known co-morbidity presented with sudden onset right hemiplegia associated with headache and vomiting. He soon developed altered sensorium. However, there was no history of preceding trauma or hypertension. Contrast enhanced CT scan showed a left parietal hematoma with mass effect (Figs. 1A, 1B). In view of the expanding hematoma and deteriorating clinical condition, craniotomy was done to remove the hematoma and decompress the brain. A fleshy soft tissue with hematoma was excised. Postoperatively, his sensorium improved but the paresis persisted. Postoperative scans showed evacuation of the clot along with excision of lesion (Fig. 1C). A week later, he died and a whole-body scan could not be performed.
Microscopic examination revealed multiple tissue fragments admixed with extensive hemorrhage. No normal brain parenchyma was identified. Embedded within the haemorrhagic material were fragments composed of small clusters of atypical cells composed of uninucleate and multinucleated cells (Figs. 1D, 1E). These cells were large with irregular nuclear contours, clumped chromatin pattern, conspicuous nucleoli and moderate amount of amphophilic cytoplasm. Many of the cells showed eosinophilic hyaline globules (Fig. 1F). Mitosis was readily identified (Fig. 1G). On immunohistochemistry, the atypical cells demonstrated cytoplasmic immunopositivity for pan-cytokeratin, while the multinucleated cells showed cytoplasmic positivity for beta human chorionic gonadotrophin (β-HCG) (Figs. 1H, 1I). What is your diagnosis?