Case Study - University of Pittsburgh

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Case Study 35
Henry Armah, M.D., M.Phil.
Question 1
Clinical history: 72-year-old white male who presented
with left lower extremity weakness. He was a non-smoker,
occasionally used alcohol socially, and did not use illicit
drugs. Describe the abnormal cranial MRI findings?
T1 + C
T1 + C
T1 + C
Answer
Contrast enhancing lesion extending superiorly from the
posterior limb of the right internal capsule/lateral
thalamus, through the right cerebral peduncle/midbrain, to
the right hemipons inferiorly.
Question 2
What are your differential diagnoses based on the
patients’ age and the radiological findings?
Answer
1. High-grade glioma
2. Malignant lymphoma
3. Metastasis (from carcinoma, melanoma, etc)
4. Abscess
5. Inflammatory demyelinating lesion
6. Subacute infarct
Question 3
The neurosurgeon performs a CT-guided stereotactic
biopsy of the mass and requested an intraoperative
consultation. Describe the microscopic findings on this
smear slide?
Click here to view slide.
Answer
Brain tissue infiltrated by pleomorphic granular cells.
Question 4
What is your intraoperative diagnosis? (A: Category such
as Defer, Reactive/Non-neoplastic, or Neoplastic; B: More
specific diagnosis or statement)
Answer
1. Neoplasm
2. Defer to permanent sections
Question 5
The permanent section from the intraoperative specimen
has returned from histology. Describe the microscopic
findings on this H&E slide?
Click here to view slide.
Answer
Fragments of brain tissue markedly infiltrated by a
neoplastic proliferation of pleomorphic granular cells.
There are focal areas of necrosis and florid endothelial
proliferation.
Question 6
What additional studies would you like to perform based
on the findings of the permanent section?
Answer
GFAP, EGFR, p53, Ki-67 (MIB-1), CD68, S-100, Melan-A,
HMB-45, Synaptophysin, Neurofilament, Pancytokeratin,
CD45 (LCA), CD20 (L26), and CD3.
Question 7
What do you see on this GFAP immunostain slide?
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Answer
GFAP weakly to moderately stains the tumor cell
processes.
Question 8
What do you see on this EGFR immunostain slide?
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Answer
EGFR is strongly and diffusely positive in tumor cells.
Question 9
What do you see on this p53 immunostain slide?
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Answer
p53 is negative in tumor cells.
Question 10
What do you see on this Ki-67 (MIB-1) immunostain
slide?
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Answer
Ki-67 (MIB-1) is positive in the nuclei of up to 30% of
tumor cells focally.
Question 11
What do you see on this CD68 immunostain slide?
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Answer
CD68 is positive in pleomorphic granular tumor cells.
Question 12
What do you see on this S-100 immunostain slide?
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Answer
S-100 is negative in tumor cells.
Question 13
What do you see on this Melan-A immunostain slide?
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Answer
Melan-A is negative in tumor cells.
Question 14
What do you see on this HMB-45 immunostain slide?
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Answer
HMB-45 is negative in tumor cells.
Question 15
What do you see on this Synaptophysin immunostain
slide?
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Answer
Synaptophysin is focally and weakly positive in tumor
cells, and highlights entrapped neuropil.
Question 16
What do you see on this Neurofilament immunostain
slide?
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Answer
Neurofilament is negative in pleomorphic granular tumor
cells, and highlights a few preserved axons between the
infiltrating rows and sheets of pleomorphic granular tumor
cells.
Question 17
What do you see on this Pancytokeratin immunostain
slide?
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Answer
Pancytokeratin is negative in tumor cells.
Question 18
What do you see on this CD45 (LCA) immunostain slide?
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Answer
CD45 (LCA) highlights several lymphocytes and
macrophages throughout the lesion.
Question 19
What do you see on this CD3 immunostain slide?
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Answer
CD3 highlights scattered T-lymphocytes throughout the
lesion.
Question 20
What do you see on this CD20 (L26) immunostain slide?
Click here to view slide.
Answer
CD20 (L26) is positive in rare B-lymphocytes in the lesion.
Question 21
What is your final diagnosis in this case?
Answer
Granular cell astrocytoma/glioblastoma
Question 22
What is the corresponding WHO grade of this lesion?
Answer
WHO Grade 4.

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