practical imaging for the surgical pathologist...practical imaging for the surgical pathologist...
TRANSCRIPT
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Practical Imaging for the Surgical Pathologist
Gregory N. Fuller, MD, PhDProfessor and Chief Neuropathologist
M D Anderson Cancer CenterHouston, Texas
3rd Annual
SoutheasternPathology Conference
November 2018
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The Importance of Imaging Studies to the Pathologist Cannot be Stressed Enough!
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Rubin’s Pathology7th Edition
2015
The Importance of Imaging Studies to the Pathologist Cannot be Stressed Enough!
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The Importance of Imaging Studies to the Pathologist Cannot be Stressed Enough!
Rubin’s Pathology7th Edition
2015
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The Importance of Imaging Studies to the Pathologist Cannot be Stressed Enough!
Rubin’s Pathology7th Edition
2015
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The Importance of Imaging Studies to the Pathologist Cannot be Stressed Enough!
Rubin’s Pathology6th Edition
2011
Contemporary neuroimaging techniques provide the first look at the “gross pathology” of a CNS lesion and constitute a rich source of information that can be utilized by the pathologist to formulate a refined differential diagnosis prior to surgical biopsy and tissue examination.
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The Importance of Imaging Studies to the Pathologist Cannot be Stressed Enough!
Rubin’s Pathology7th Edition
2015
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Go to the Operating RoomPeter C. BurgerAm J Surg Path 1988
1988
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Go to the Operating RoomPeter C. BurgerAm J Surg Path 1988
“…the radiographs on display in the operating theater are as relevant to the work of the pathologist as they are to the neurosurgeon.”
1988
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Importance of Knowing what the
Pre-operative MR Imaging Studies
Show
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Importance of Pre-op Imaging
Biopsy (H&E)
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Pre-operative MR Imaging
Pre-op MRI: coronal T1 post-contrast Biopsy (H&E)
Importance of Pre-op Imaging
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Pre-op MRI: coronal T1 post-contrast Biopsy (H&E)
YIKES!Importance of Pre-op Imaging
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Pre-op MRI: coronal T1 post-contrast Biopsy (H&E)
The biopsy was NOT representative!
Importance of Pre-op Imaging
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Our patients are best served by a collegial Team Approach –
surgeon, oncologist, radiologist, pathologist
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To be able to talk to the other team
members, you must be able to speak their
language!
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Practical Neuroimaging
for the
Surgical Pathologist
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Information Gained from MRI
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Information Gained from MRI
Anatomic location of the lesion(s)
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Information Gained from MRI
Anatomic location of the lesion(s)
Nature of interface of lesion border with brain parenchyma (sharp margin vs. diffuse infiltration)
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Information Gained from MRI
Anatomic location of the lesion(s)
Nature of interface of lesion border with brain parenchyma (sharp margin vs. diffuse infiltration)
Presence or absence of contrast enhancement
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Information Gained from MRI
Anatomic location of the lesion(s)
Nature of interface of lesion border with brain parenchyma (sharp margin vs. diffuse infiltration)
Presence or absence of contrast enhancement
If contrast-enhancing, pattern of enhancement
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Patterns of Contrast Enhancement
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Patterns of Contrast Enhancement
Smooth ring
Ragged ring
C-shaped ring
Solid, uniform
Cyst w/ nodule
Dark ring*
*T2, T2-FLAIR, GRE, SWI
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Patterns of Contrast Enhancement
Smooth ring Abscess
Ragged ring GBM, Metastasis
C-shaped ring Demyelinating pseudotumor
Solid, uniform Meningioma, PCNSL
Cyst w/ nodule JPA, PXA, Ganglioglioma
Dark ring* Cavernoma, Abscess
*T2, T2-FLAIR, GRE, SWI
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Patterns of Contrast Enhancement
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Patterns of Contrast EnhancementAbscess Demyelinating
PseudotumorGBM
PCNSL CavernomaPXA
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Magnetic Resonance Imaging
• Axial• Coronal• Sagittal
3 Planes of Section
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Sagittal
CoronalAxial
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Histopathology
•Hematoxylin & Eosin
1 “Work horse” Stain
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MRI
•T1 without contrast (pre-contrast)
•T1 with contrast (post-contrast)
•T2
•T2-FLAIR (fluid attenuation inversion recovery)
4 “Work horse” Sequences
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Magnetic Resonance Imaging
2 Simple Principles• On T2-weighted images, water (H20) is
hyperintense (bright, white)
• White matter is rich in myelin; myelin is a fat; thus, normal white matter contains lesswater than gray matter; thus, white matter is darker (hypointense) compared to gray matter on T2-weighted images
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T2-weighted images
( H20 )
• Cerebrospinal fluid (CSF) is very bright (white, hyperintense)
• Gray matter, because it has more water, is brighter (hyperintense) compared to white matter
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If the CSF is Bright (White, Hyperintense), it’s a T2-weighted
Sequence
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• Cerebrospinal fluid (CSF) is dark (black, hypointense)
• Gray matter is darker (hypointense) compared to white matter on T1-weighted images
T1-weighted Images (T1WI)
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Compare Cortex with White Matter
If Cortex is Brighter than White Matter: T2
If Cortex is Darker than White Matter: T1
(in an area of normal brain away from the lesion)
So… is it a T1? or a T2?
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Whether or not a lesion exhibits contrast enhancement is assessed
only on T1-weighted sequences
(the contrast agent is gadolinium)
(compare T1-pre with T1-post)
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Whether or not a lesion exhibits contrast enhancement is assessed
only on T1-weighted sequences
T1-pre
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Whether or not a lesion exhibits contrast enhancement is assessed
only on T1-weighted sequences
T1-pre T1-post
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Whether or not a lesion exhibits contrast enhancement is assessed
only on T1-weighted sequences
T1-pre T1-post T2
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DO NOT CONFUSE T2 Brightness (Water: CSF, Edema) with Contrast
Enhancement !
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DO NOT CONFUSE T2 Brightness (Water: CSF, Edema) with Contrast
Enhancement !
T1
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DO NOT CONFUSE T2 Brightness (Water: CSF, Edema) with Contrast
Enhancement !
T1
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DO NOT CONFUSE T2 Brightness (Water: CSF, Edema) with Contrast
Enhancement !
T1
The CSF in the subarachnoid space is BRIGHT, and the CORTEX IS BRIGHTER than the white matter, so it’s a T2 sequence!
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T1 T2
DO NOT CONFUSE T2 Brightness (Water: CSF, Edema) with Contrast
Enhancement !
The CSF in the subarachnoid space is BRIGHT, and the CORTEX IS BRIGHTER than the white matter, so it’s a T2 sequence!
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T1 T2 T1-post
DO NOT CONFUSE T2 Brightness (Water: CSF, Edema) with Contrast
Enhancement !
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T1 without (pre) or with (post) contrast? Look for bright blood
vessels, choroid plexus
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T1 without (pre) or with (post) contrast? Look for bright blood
vessels, choroid plexus
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T1 pre T1 post
T1 without (pre) or with (post) contrast? Look for bright blood
vessels, choroid plexus
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• Normal H20 (CSF) signal is suppressed; thus the ventricles and subarachnoid spaces are dark (black, hypointense)
• But… the gray matter is still brighter (hyperintense) compared to the white matter, so it is a T2-based sequence, not a T1 T2-FLAIR
What is a T2-FLAIR Image?
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The Ventricles are Black:
Is it a T1? or a T2-FLAIR?
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The Ventricles are Black:
Is it a T1? or a T2-FLAIR?
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Compare Cortex with White Matter to Determine if the Scan
is a T1 or T2 weighted sequence!
The Ventricles are Black:
Is it a T1? or a T2-FLAIR?
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The Ventricles are Black:
Is it a T1? or a T2-FLAIR?
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T2-FLAIR T1-pre
The Ventricles are Black:
Is it a T1? or a T2-FLAIR?
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T2-FLAIR T1-preT2
The Ventricles are Black:
Is it a T1? or a T2-FLAIR?
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You see Abnormal Bright Signal!
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You see Abnormal Bright Signal! Is it contrast enhancement on a T1 post, or
is it edema on a T2 or T2-FLAIR ???
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You see Abnormal Bright Signal! Is it contrast enhancement on a T1 post, or
is it edema on a T2 or T2-FLAIR ???
![Page 61: Practical Imaging for the Surgical Pathologist...Practical Imaging for the Surgical Pathologist Gregory N. Fuller, MD, PhD Professor and Chief Neuropathologist M D Anderson Cancer](https://reader030.vdocument.in/reader030/viewer/2022040802/5e3bc45336dab62598666edb/html5/thumbnails/61.jpg)
You see Abnormal Bright Signal! Is it contrast enhancement on a T1 post, or
is it edema on a T2 or T2-FLAIR ???
The cortex is hyperintense to white matter, thus it’s a T2 sequence
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You see Abnormal Bright Signal! Is it contrast enhancement on a T1 post, or
is it edema on a T2 or T2-FLAIR ???
The cortex is hyperintense to white matter, thus it’s a T2 sequence
The CSF is dark, thus it’s a T2-FLAIR
![Page 63: Practical Imaging for the Surgical Pathologist...Practical Imaging for the Surgical Pathologist Gregory N. Fuller, MD, PhD Professor and Chief Neuropathologist M D Anderson Cancer](https://reader030.vdocument.in/reader030/viewer/2022040802/5e3bc45336dab62598666edb/html5/thumbnails/63.jpg)
You see Abnormal Bright Signal! Is it contrast enhancement on a T1 post, or
is it edema on a T2 or T2-FLAIR ???
The cortex is hyperintense to white matter, thus it’s a T2 sequence
The CSF is dark, thus it’s a T2-FLAIR
It’s a T2-FLAIR, thus the bright signal is edema, not contrast enhancement!
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Superior Sensitivity of T2 & T2-FLAIR compared to T1-post
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T1-post
Do you see an obvious
lesion?
Superior Sensitivity of T2 & T2-FLAIR compared to T1-post
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T2-FLAIR
Superior Sensitivity of T2 & T2-FLAIR compared to T1-post
T1-post
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ADVANTAGE of T2-FLAIR over T2
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ADVANTAGE of T2-FLAIR over T2
T2
Do you see an obvious
lesion?
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ADVANTAGE of T2-FLAIR over T2
T2 T2-FLAIR
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For a Quick Look: T2-FLAIRand T1-Post Contrast
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For a Quick Look: T2-FLAIRand T1-Post Contrast
T2-FLAIR T1-POST
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3 “Advanced” MR Imaging Sequences Relevant to Pathologic Diagnosis
DWI: Diffusion-Weighted Imaging
T2-GRE (Gradient Echo; T2*, “T2 Star”)
SWI: Susceptibility-Weighted Imaging
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DWI: Diffusion-Weighted Imaging
“Restricted Diffusion” Bright on DWI - Dark on ADC map - Bright on T2-trace
• Acute Infarct (within 6 hrs. of stroke –7d)
• Pyogenic Abscess
• Epidermoid cyst
• Hypercellular tumors (PCNSL, PNET, etc)
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Restricted diffusion: Abscess
DWI
DWI: Diffusion-Weighted Imaging
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Restricted diffusion: Abscess
DWI ADC Map
DWI: Diffusion-Weighted Imaging
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T2-GRE (T2*): Gradient Echo
Useful for detecting:
• Blood products
• Iron
• Calcium all appear hypointense (dark, black)
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Cavernous Malformation
T2-GRE (T2*): Gradient Echo
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SWI: Susceptibility-Weighted
Useful for detecting:
• Blood products
• Iron
• Calcium
• Small Veins
all appear hypointense (dark, black)
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SWI: Susceptibility-Weighted
Useful for detecting:
• Blood products
• Iron
• Calcium
• Small Veins
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Shifting Gears
Differential Diagnosisbased on
Preoperative Imaging
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POP
QUIZ!
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Circumscribed Intraventricular Mass Lesion
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• Choroid plexus papilloma• Atypical choroid plexus papilloma• Choroid plexus carcinoma• Choroid plexus meningioma• Choroid plexus xanthogranuloma• Ependymoma• Subependymoma• Subependymal giant cell astrocytoma• Central neurocytoma• Solitary metastasis to the choroid
plexus (especially renal cell carcinoma)
Circumscribed Intraventricular Mass Lesion
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Circumscribed Cyst with
Enhancing Nodule in the Cerebellum
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• Pilocytic astrocytoma• Hemangioblastoma• Cystic metastasis
Circumscribed Cyst with
Enhancing Nodule in the Cerebellum
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Circumscribed Cyst with
Enhancing Nodule in the Cerebellum
in a 5yo Child
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Circumscribed Cyst with
Enhancing Nodule in the Cerebellum
in a 5yo Child
• Pilocytic astrocytoma
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Circumscribed Cyst with
Enhancing Nodule in the Cerebellum
in a 56yo Man
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Circumscribed Cyst with
Enhancing Nodule in the Cerebellum
in a 56yo Man
• Hemangioblastoma• Cystic metastasis
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Circumscribed Intraventricular Mass Lesion in the Lateral Ventricle Atrium (choroid plexus: glomus choroideum)
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Circumscribed Intraventricular Mass Lesion in the Lateral Ventricle Atrium (choroid plexus: glomus choroideum)
Choroid plexus meningioma MORE LIKELY
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Circumscribed Intraventricular Mass Lesion in the Lateral Ventricle Atrium (choroid plexus: glomus choroideum)
Choroid plexus meningioma MORE LIKELY
Central neurocytoma LESS LIKELY
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Sellar / Suprasellar Mass
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Sellar / Suprasellar Mass• Pituitary adenoma• Pituitary adenoma• Pituitary adenoma• Pituitary adenoma• Pituitary adenoma• Pituitary adenoma• Pituitary adenoma
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• Craniopharyngioma• Granular cell tumor• Pituicytoma• Spindle cell
oncocytoma• Etc.
Sellar / Suprasellar Mass
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Diffuse Lesion
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• Diffuse glioma
Diffuse Lesion
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T1 T2-FLAIRT2 T1-Post
T1 - hypointenseT2 and T2-FLAIR – hyperintense – extends into cortical gray up to pial surface when invasion is presentT1-post - no enhancement
Diffuse Glioma – ImagingGrades II & III
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Not Just Histologic - Radiologic Too!
“Blurring” of the Gray-White Junction
Rubin’s Pathology, 6th Ed, 2011
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T2-Hyperintense Diffuse Lesion: “Blurring of the Gray-White Junction” Secondary to Diffuse Glioma Infiltration of the Cortex
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Ring Enhancing (Rim Enhancing) Mass
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Smooth ring
Ring Enhancing (Rim Enhancing) Mass
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• Abscess
Smooth ring
Ring Enhancing (Rim Enhancing) Mass
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• Abscess• Glioblastoma• Metastasis
Smooth ring
Ring Enhancing (Rim Enhancing) Mass
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Pineal Region Mass
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• Germinoma
Pineal Region Mass
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• Germinoma• PPT
Pineal Region Mass
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• Germinoma• PPT• Meningioma
Pineal Region Mass
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• Germinoma• PPT• Meningioma• CPP
Pineal Region Mass
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• Germinoma• PPT• Meningioma• CPP• Ependymoma
Pineal Region Mass
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• Germinoma• PPT• Meningioma• CPP• Ependymoma• PTPR
Pineal Region Mass
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• Germinoma• PPT• Meningioma• CPP• Ependymoma• PTPR• Metastasis
Pineal Region Mass
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Diffuse Enlargement of the
Pons
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Diffuse Enlargement of the
Pons• DIPG
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Diffuse Enlargement of the
Pons• DIPG
(diffuse intrinsic pontine glioma)
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Multiple Lesions
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• Metastasis
Multiple Lesions
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• Metastasis• Multiple
abscesses
Multiple Lesions
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• Metastasis• Multiple
abscesses
Multiple Lesions
• Tumor Predisposition Syndrome (multiple primary tumors)
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• Multiple vascular malformations
Multiple Lesions
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• Multiple vascular malformations
• Multiple parasites (eg, cysticercosis)
Multiple Lesions
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• Multiple vascular malformations
• Multiple parasites (eg, cysticercosis)
Multiple Lesions
• Multicentric glioma
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Ring Enhancing Mass
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Ring Enhancing Mass
Ragged ring
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Ring Enhancing Mass
Ragged ring
• Glioblastoma• Metastasis
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Ring Enhancing Mass
Ragged ring
• Glioblastoma• Metastasis
• Abscess
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Uniformly Enhancing Periventricular Masses
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PCNSL
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PCNSL(primary CNS large B-cell lymphoma)
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Dura-Based Mass
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•Meningioma•Meningioma•Meningioma•Meningioma•Meningioma•Meningioma•Meningioma•Meningioma•Meningioma•Meningioma•Meningioma•Meningioma•Meningioma•Meningioma•Meningioma
Dura-Based Mass
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•SFT/HPC Family Tumor
•Plasmacytoma
•Granulocytic Sarcoma (Chloroma)
•Dural Marginal Zone (MALT-like) B-cell lymphoma
•Solitary metastasis
•Calcifying pseudotumor (fibro-osseous lesion)
• Inflammatory pseudotumor
• Idiopathic hypertrophic pachymeningitis
•Sarcoidosis
•Rosai-Dorfman Disease
•Castleman Disease
•Meningioma•Meningioma•Meningioma•Meningioma•Meningioma•Meningioma•Meningioma•Meningioma•Meningioma•Meningioma•Meningioma•Meningioma•Meningioma•Meningioma•Meningioma
Dura-Based Mass
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The Pathologist as a Physician
Putting it all together…
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Case StudyPutting it all together…
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HistoryA 30-year old woman presented with complaint of headache.
MR imaging studies showed a non-enhancing multicystic left frontal lobe lesion.
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History
Open biopsy was performed at the local community hospital.
The H&E slides were outsourced to a reference lab, where a diagnosis of “low-grade diffuse astrocytoma” was rendered, with recommendation that additional molecular signature studies be performed (testing not available at the reference laboratory).
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History
Subsequent immunohistochemical and FISH testing at 3 different reference and university laboratories showed:Ki67 index: <1%1p/19q intact (negative for codeletion)
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History
The last university lab recommended that additional molecular testing for diffuse glioma-associated biomarkers be performed by chromosome microarray.
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History
Based on the outsourced report data from the 3 reference laboratories, the final community hospital diagnosis was:
Diffuse Astrocytoma, NOS (IDH status was never determined, despite the use of 3 outside laboratories)
WHO Grade II
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History
SRS (stereotactic radiosurgery) was administered to the residual portion of the lesion
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History
SRS (stereotactic radiosurgery) was administered to the residual portion of the lesion
The patient received 3 cycles of temozolomide (Temodar)
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History
SRS (stereotactic radiosurgery) was administered to the residual portion of the lesion
The patient received 3 cycles of temozolomide (Temodar)
Temodar treatment was subsequently discontinued secondary to side effects
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History
Surveillance MR imaging showed no effect of the SRS or 3 cycles of chemotherapy on the residual lesion; the patient was told there were no further treatment options.
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History
Patient self-referred to MDACC for a second opinion on treatment options.
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History
As part of standard MDACC procedure, the referring institution biopsy slides, all reference lab reports, and
the preoperative MR imaging studies were obtained for review.
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History
As part of standard MDACC procedure, the referring institution biopsy slides, all reference lab reports, and
the preoperative MR imaging studies were obtained for review.
This represented the first time in the patient’s clinical
evaluation that a single physician, the Pathologist, had assembled and reviewed all of the relevant clinical information (including, critically, the preoperative MR imaging studies).
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Food for Thought
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Food for Thought
Two things evolving over the last two decades have transformed surgical pathology and the surgical pathologist.
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Food for Thought
Two things evolving over the last two decades have transformed surgical pathology and the surgical pathologist.
• The Advent of Genomic Pathology
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Food for Thought
Two things evolving over the last two decades have transformed surgical pathology and the surgical pathologist.
• The Advent of Genomic Pathology
• The Electronic Medical Record
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Food for Thought
For the first time in the history of our Specialty
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Food for Thought
For the first time in the history of our Specialty the Pathologist is the FIRST MEMBER of the Clinical Team
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Food for Thought
For the first time in the history of our Specialty the Pathologist is the FIRST MEMBER of the Clinical Team to have all of the Critical Information needed to render an Integrated Diagnosis
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Food for Thought
For the first time in the history of our Specialty the Pathologist is the FIRST MEMBER of the Clinical Team to have all of the Critical Information needed to render an Integrated Diagnosis upon which everything is based.
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Team Approach to Patient Care - the
Standard of
Excellence
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Weekly Multidisciplinary MDACC Neuropathology Case Conference
25-30 attendees, including neuroradiologists, neurosurgeons, neuro-oncologists
2018