Choroid Plexus Papilloma MRI

A 1 y o male with headache, signs of raised ICT. 

On Admission CT followed by MRI Brain with Contrast.

This CT and MRI study of Brain shows an intra ventricular ovoid solid frond like well defined lesion in right lateral ventricle.
Lesion is isodense on CT with faint specks of calcifications.
Restricted diffusion on Dw MRI Images.
Avid homogeneous enhancement on post contrast T1w MRI.
No adjacent parenchymal invasion.

Imaging diagnosis given was Choroid Plexus Papilloma, moderate communicating hydrocephalus due to over production of Csf.

HISTOPATHOLOGY REPORT

Specimen : Excisional biopsy, right lateral ventricle mass.

Gross appearance : Multiple irregular soft to friable soft pieces of dull gray tan tissue, together measuring ~ 44x4x29mm. The cut section thru the larger piece appears papillary.

Microscopy : Benign neoplasm of probable choroid plexus epithelia comprising predominantly complex and branching neoplastic papillae lined by single layer of low cuboidal epithelia - devoid of significant cellular pleomorphism nor increased mitosis. In few foci the epithelia show focal stratification and crowding. The sub epithelial cord substance of the papillae appears focally odematous with congested blood vessels and sparse lymphocytic infiltrates. There is no evidence of cytological anaplasia.

Histopathological diagnosis : Choroid Plexus Papilloma.

Choroid Plexus Papilloma (CPP)

Imaging findings:
Location wise most common i.e ~ 50% in  atrium of lateral ventricle, left> right, ~ 40%  fourth ventricle.
~ 10%  third ventricle (roof) and ~ 5%  multiple sites.
• Morphology: Well delineated, lobulated intra ventricular cauliflower like mass, frond like surface projection.
Benign, slowly growing tumor often larger at the time of presentation.
Solid density on CT and signal intensity on MRI.
Foci of calcification best seen on CT.
Intense homogenous enhancement on post contrast T1.
CSF seeding of lesions is known.

Clinical Presentation: 
Age: Lateral ventricular CPPs common in infants and children where as fourth ventricular CPPs common in adults.
Most common signs/symptoms are of raised ICT, Macrocrania, bulging fontanelle, vomiting, headache, ataxia.

DD: 
Imaging wise difficult to differentiate from Choroid plexus carcinoma (CPCA)
Heterogeneous enhancement, invasion of adjacent brain parenchyma goes in favor of CPCA.

Reference : DI Osborn.

Choroid plexus papilloma MRI

A 3 yo female child presents with vomiting.

MRI Brain

Findings:
Axial T1w image shows a lobulated, intra ventricular mass in the left lateral ventricle, isointense
to grey matter, left lateral ventricle slightly expanded compared to right. Intense homogenouse enhancement on post contrast T1, frond like surface projections. A single linear vascular flow void noted on Non contrast T1.

Radiological and histopathological diagnosis: Choroid plexus papilloma.

Choroid plexus papilloma

Syn: Choroid plexus papilloma (CPP)
An intraventricular, papillary neoplasm derived from choroid plexus epithelium.

Imaging wise a lobuated well circumscribed intra ventricular Cauliflower-like mass with frond like surface projections intensely and homogenously enhancing on post contrast is a diagnostic clue.
Most common locations, in ~ 50% cases atrium of lateral ventricle, left > right. , followed by fourth ventricle and third ventricle. Multiple masses are also known.
On CT density of mass is iso- or hyperattenuating in ~75% cases with an associated calcification in ~25%.
On MRI Iso intense to cortical grey matter on T1 and iso to hyper intense on T2 with an  associated linear vascular flow voids within the lesion.
Usually larger in size by the time of diagnosis, often associated with overproduction" hydrocephalus".

DD 
Choroid plexus carcinoma (CPCA) : Difficult to distinguish CPP from CPCA by imaging findings alone. Often associated with adjacent brain parenchymal invasion.

Clinical Presentation
Most common signs/symptoms: Macrocrania, bulging fontanelle, vomiting, headache, ataxia
Child in first two years of life with signs and symptoms of elevated ICP
Focal neurologic signs and symptoms suggests CPCA.

Prognosis
Benign, slowly growing. May seed CSF pathways (CPP & CPCA)

Treatment
Total surgical resection.

Reference : Diagnostic imaging Osborn.