Frontal SOL, Guess Histopathology

A known case of Left frontal lesion referred for further management.

MRI BRAIN WITH CONTRAST REPORT

Left frontal well defined mixed signal intensity lesion, major portion of lesion is cystic measures ~ 75x45mm with thin enhancing wall, an ~ 23x25mm eccentric avidly enhancing mural nodule within the lesion, marked perilesional vasogenic odema. Mass effect, mid line shift of ~ 15 mm to right, sub falcine herniation, mild mid brain compression.

Imaging wise diagnosis given was Neoplastic Primary Glioma, Metastasis.

Any other guess ? 
Ok.. here is ...

REPORT OF HISTOPATHOLOGICAL EXAMINATION

Specimen         : Excisional biopsy – Left frontal lobe SOL.
Gross Appearance    : The specimen consists of multiple, irregular, soft to friable pieces of dull grey – tan tissue; together measuring 4.0X3.3X2.0 cm. The cut section shows dull grey tan appearance. Representative sections are submitted for processing.  Codes : A and B.

Microscopy        : Sections A and B both show cellular meningothelial neoplasm. It comprise lobules and sheets of intermediate sized, round to oval cells having modestly hyperchromatic nuclei with round to oval configuration and having delicate - peripherally condensed chromatin and many cells having small nucleoli. Overall scattered cells show nucleoli - cytoplasmic invaginations. The cells have faint eosinophilic cytoplasm with indistinct margins. The interstitium shows prominent congested vasculature with scattered few lymphocytes. Overall the entire tumour shows 0 – 2 mitosis per 10 HPF. There is no evidence of frank cytological anaplasia nor of brain invasion.

Diagnosis  :  Meningioma; grade I of III.

Even surgeon was also surprised with histopathology report.

Retrospectively review of case shows enhancing dural thickening in left frontal region. Meningioma is known to be associated with meningeal cysts which varies in size and can be large enough as in this case giving appearance of a predominantly cystic lesion with mural nodule. 

Psammomatous Meningioma MRI

A known case of pineal region mass with significant mass effect and obstructive hydrocephalus.

Patient underwent Ventricular shunt for obstructive hydrocephalus with biopsy for a pineal region mass. 

This is a follow up MRI study Brain.

MRI shows an ovoid well demarcated mass in pineal region, low signal intensity on all pulse sequences including T2*GRE implies to dense calcification. On post contrast no enhancement in the substance of mass, a layer of enhancement on the surface of mass is along the dural coverings. Gliosis in left parietal region along the tract of ventricular shunt and right occipital region of attempted biopsy.

Histopathology report: 

Description of finding: The resected specimen consist of an irregular, firm, bosselated, tan-white nodule with an attached dura mater on one side. The specimen fixed in buffered 10% formaldehyde and decalcified. Paraffin-embedded sections stained with H n E stain. The tissue consisted primarily of densely packed hyalinized collagen bundles. Major portion virtually acellular, occasional small nests of uniform meningothelial cells. Few areas of whorllike arranged collagen fibers.

- 'Psammomatous' variety of Meningioma.

Dense calcified Meningioma

Syn: 'Involuted sclerotic' Meningioma, 'Psammomatous' Meningioma.

Involuted sclerotic meningioma is a distinct subtype of benign meningioma that lack the classic appearance and manifestation of typical meningothelial meningiomas.
A classic meningioma on CT is a relatively hyper attenuating, extra axial mass broad based to Dura with a smooth or lobulated outline that enhances homogeneously on post contrast study. Most common histopathological variety of typical meningioma is fibrous meningioma shows parallel and interlacing bundles of spindle-like cells embedded in a matrix of collagen and reticulin on Histopathology.
Whereas a sclerotic meningiomas demonstrate whorl formation around sclerotic vessels, with tumor cells demonstrating glial fibrillary acidic protein expression. In the sclerotic variety due to dense calcification these masses are iso dense to bony calvarium on CT, contrast enhanced studies are non contributory as enhancement if any is difficult to interpret in the back ground of dense calcification. On MRI, lesion is low signal intensity on all pulse sequences, poor or partial enhancement on post contrast. Dural tailing on post contrast and focal hyperostosis of adjacent bony calvarium of a typical meningioma are absent. Differential diagnosis for an extra axial calcified mass at the cerebral convexity without dural tailing or bone reaction should include osteoma.