Composite cerebral neuroblastoma and astrocytoma. A mixed central neuroepithelial tumor

Desmoplastic infantile ganglioglioma: Report of a case and review of the literature

Desmoplastic infantile ganglioglioma (DIG) is a rare supratentorial brain tumor occurring mostly before the age of 2 years. It has a good prognosis and total excision of the tumor is curative, necessitating no further treatment. An accurate pathologic diagnosis is crucial. Until now, <60 cases of this tumor type have been reported. Herein, we report a 3-month-old boy with intractable seizure who was found to have DIG after surgery.

Unusual malignant glioneuronal tumors of the cerebrum of adults: a clinicopathologic study of three cases

Malignant glioneuronal tumors of the brain are rare and poorly characterized. Herein, we report the clinicopathologic features of three examples with unusual morphologies including both glial and neuronal differentiation. Hematoxylin and eosin-stained slides were reviewed in all cases. Immunohistochemical stains were performed on formalin-fixed, paraffin-embedded sections. Transmission electron microscopy (EM) was performed on both formalin-fixed (n=1) and paraffin embedded tissue (n=2). The immunogold technique for localization of GFAP was also performed. Two patients were male and one was female, age 66, 84, and 34 years, respectively. Radiologic studies demonstrated hyperdensity on CT (n=3), multicentricity (n=2), and a cortical based solid component with a cystic extension into underlying white matter (n=2). At surgery, all three tumors were superficial and relatively circumscribed. Histologically, they were composed of large epithelioid cells (n=3), spindle cells (n=1), and poorly differentiated smaller cells with high nuclear/cytoplasmic ratios (n=1). Brisk mitotic activity and coagulative non-palisading necrosis were present in all cases. The tumors were immunopositive for GFAP (n=3), S-100 (n=3), synaptophysin (n=3), chromogranin (n=3), Neu-N (n=2), and neurofilament protein (n=2). Stains for EMA were negative. EM demonstrated convincing neurosecretory granules in one case, some in filament-containing cells immunogold labeled for GFAP. Two patients expired 3-5 weeks after surgery. True malignant neoplasms with glial and neuronal differentiation do occur in the central nervous system of adults and may pursue a highly aggressive course. The use of minimal diagnostic criteria, e.g., immunoreactivity for a single antigen like neurofilament protein, may not be sufficient and should be discouraged.

Desmoplastic infantile ganglioglioma with calcification

Desmoplastic infantile gangliogliomas (DIGs) are rare intracranial, cystic tumors, usually detected within the first 2 years of life. Histologically, these tumors are characterized by intense desmoplasia and a divergent astrocytic and neuronal differentiation. Less than 60 well-documented cases of this extremely rare tumor are reported in the literature. We present the case of a 10-month-old male child presenting with a large, cystic, intracranial lesion and having the characteristic histological features of a DIG. In addition, the lesion also showed focal areas of calcification within the tumor, not usually considered a feature of this entity. The present case extends the reported spectrum of this rare entity and describes the unusual occurrence of calcification within the lesion.

A case of undifferentiated glioma in a 70-year-old woman

The present case involved a 70-year-old woman who was diagnosed with a right cerebral hemorrhage. Excisional surgery of the hematoma was performed. Grossly, a whitish, solid tumor (1 x 1 x 0.8 cm in size) was recognized in the hematoma. Histologically, the tumor was composed of large, polygonal cells and small undifferentiated cells in a jumbled architectural arrangement with a cartilage component. The large, polygonal cell component was conspicuous and somewhat rhabdoid in appearance and appeared to be an astrocytic tumor showing glial differentiation. The small, undifferentiated cell component resembled tumor cells of a primitive neuroectodermal tumor (PNET). Clinical follow-up of the patient for 2 months after the first operation revealed recurrence with rapid growth. A second operation was performed, but the patient died 8 months after the first operation (2 months after the second). Immunohistochemically, the tumor cells suggesting glial differentiation were positive for glial fibrillary acidic protein (GFAP), S-100, neuron-specific enolase (NSE), and vimentin. PNET-like components in the primary tumor were positive for NSE, GFAP, and S-100, and weakly positive for vimentin and synaptophysin. Each tumor cell was negative for epithelial membrane antigen (EMA), keratin, desmin, actin, myoglobin, neurofilament (NF), and MIC2 protein. The recurrent tumor revealed predominantly PNET-like components; however, only a few tumor cells were positive for GFAP. This appearance suggested that this brain tumor might originate from a common multipotential stem cell. Considering its histopathological and immunohistochemical characteristics, the primary tumor was finally regarded as an undifferentiated glioma with dedifferentiation of the glial component in the recurrent tumor.

Ultrastructural characterization of oligodendroglial-like cells in central nervous system tumors

Cells with uniform, small-round nucleus and clear cytoplasm (oligodendroglial-like cell, OLC) are commonly observed in central nervous system (CNS) neoplasm of glial and neuronal lineage, such as oligodendroglioma, clear-cell ependymoma, and central neurocytoma. Immunohistochemistry does not always contribute to the characterization of OLC because of (1) loss of antigen expression; (2) lack of specific markers for oligodendrogliomas; and (3) occasional coexpression of neuronal and glial antigens. An ultrastructural analysis associated with an immunohistochemical study of 20 cases of CNS tumors largely constituted by OLCs has been performed. Neurocytomas (12 cases), medullocytomas (2 cases), cerebral neuroblastoma (1 case), and ganglioglioma (1 case) showed OLCs with ultrastructural features of neuronal differentiation (neuritic processes, dense-core granules, synaptic structures). Oligodendroglioma (3 cases) OLCs were characterized by mitochondrial-rich cytoplasm, and ependymoma (1 case) OLCs showed microrosettes and scattered cilia. The electron microscopic analysis can provide a more precise diagnosis of these OLC-containing tumors despite their uniform morphological appearance.

Glioneurocytoma: tumor with glial and neuronal differentiation

We report two cases of low-grade glioma in which multiple cellular components, including cells with dense-core granules consistent with "neurocytes," were identified on electron microscopic studies. The first patient was an apparently normal boy until the onset of seizures at age 10 months. Initially, the seizures improved with phenobarbital treatment, but good seizure control was never achieved. Computed tomographic scan at age 23 months showed a calcified, nonenhancing left parietal mass. This tumor was composed of sheets of cells with clear cytoplasm and round to oval nuclei. Mucinous intercellular material stained positively with periodic acid-Schiff, mucicarmine, and alcian blue stains. Foci of calcification were evident. The second patient was a 13-year-old boy with a left parasagittal parieto-occipital mass who presented with a 4-month history of seizures and declining school performance. The tumor was composed of sheets of astrocytes with dark, hyperchromatic, pleomorphic nuclei in a fibrillary and microcystic background. The tumor contained the pleomorphism seen in the adult variant of pilocytic astrocytoma, as well as the microcystic component seen in the juvenile variety. Ultrastructurally in both cases, there were occasional tumor cells having round to oval nuclei with moderate amounts of cytoplasm containing 150- to 250-nm-diameter dense-core granules. These cells were admixed with the majority of tumor cells, which in case 1 had the ultrastructural features of astrocytes and oligodendrocytes and in case 2 had features of protoplasmic or pilocytic astrocytes.(ABSTRACT TRUNCATED AT 250 WORDS)

Composite cerebral metastasis and oligodendroglioma: an exceptional form of mixed neoplasia

Our report describes the uncommon case of a 61 year old female patient who underwent a left parietooccipital craniotomy and extirpation of a malignant tumor. Histological examination revealed a metastatic carcinoma of mammary origin intimately intermingled with a calcified oligodendroglioma WHO II. The preexisting oligodendroglial part had been detected four years before, but since then had been misinterpreted as a glious scar resulting from a previous brain trauma. Three years before neurosurgical intervention, the patient had undergone a left side mastectomy. The histological finding at that time was a solid breast tumor WHO T1N0. The occurrence of cerebral mixed neoplasias and possible causal factors are discussed.

Desmoplastic cerebral astrocytoma of infancy. Light microscopy, immunocytochemistry, and ultrastructure

The first detailed ultrastructural study of a superficial desmoplastic cerebral astrocytoma of infancy is reported. This is a neoplasm which mimics a mesenchymal tumor, originally described in 1984 under the name of "superficial cerebral astrocytoma attached to dura." This tumor, which is believed to have a good prognosis, was resected from the frontoparietal region of a 6.5-month-old girl, in whom it had presented as a large densely enhancing vascular and cystic mass. The ultrastructure of the tumor appeared to be distinctive, characterized by the absence of neuronal elements, and the presence of large amounts of redundant and sometimes extensively duplicated basal laminal material and collagen between nonpleomorphic and nonlipidized astrocytes, corresponding to the reticulin fibers seen by light microscopic analysis between the S-100 protein and glial fibrillary acidic protein (GFAP)-positive cells. The features of the tumor, its differential diagnosis, and its relationship to other pediatric supratentorial tumors are discussed.

A case of cerebral composite ganglioneuroblastoma: an immunohistochemical and ultrastructural study

An unusual cerebral tumor is reported in a 14-year-old boy. On light and electron microscopy, the constituent cells were very complex; the majority of the neoplastic cells were primitive neuroectodermal cells dispersed in myxomatous or fibrous stroma. Neoplastic neuronal cells and hypertrophic astrocytes were also observed in these areas. The neuronal cells showed a continuous spectrum of differentiation from very primitive to mature ganglion cells. Furthermore, the tumor contained a highly cellular discrete area consisting of neuroblasts and their precursor cells. From these findings, a diagnosis of composite ganglioneuroblastoma was made.

The pathological spectrum of desmoplastic infantile gangliogliomas

A rare supratentorial neuroepithelial tumour in a 10-month-old girl is described. It was characterized by its voluminous size, a predominant leptomeningeal growth pattern with intense desmoplasia and divergent differentiation along astrocytic, neuronal and Schwann cell lines. The differential diagnoses are discussed with special reference to the recently described clinicopathological entity of desmoplastic infantile ganglioglioma.

Primary cerebral neuroectodermal tumors: neuroblastoma, differentiated neuroblastoma, and composite neuroectodermal tumor

Seven cases of primary cerebral neuroectodermal tumors with predominant neuroblastic features were studied ultrastructurally and five were evaluated immunohistochemically. The fine structural features were indicative of neuroblastic differentiation by the presence of elongated cytoplasmic processes, electron-dense neurosecretory granules, and neurotubules. Five of the seven cases had the morphologic findings of classic cerebral neuroblastoma, and the sixth case, originally diagnosed as an oligodendroglioma, had the features of a differentiated neuroblastoma. Desmoplastic and/or stromal foci were intermingled with neuronal-ganglionic cells and neuroblasts in the seventh case. In addition to strong immunoreactivity for S-100 protein and glial fibrillary acidic protein in the desmoplastic areas, the spindle cells had fibroblastic and Schwannian features by electron microscopy in the latter case. The neuroblastic cells and fibrillary network were immunoreactive for neuron-specific enolase and neurofilament in the five study cases. It is concluded that cerebral neuroectodermal tumors may express an range of phenotypic features from the exclusive neuroblastic stage to a neuronal and stromogenic phase analogous to the classic neuroblastoma of the sympathetic nervous system.

Intraventricular neurocytoma: clinicopathological features of six cases

The clinical and pathological features of six patients with so-called "intraventricular oligodendroglioma" are reported. The tumor had no predilection for sex, and the patients' age at diagnosis ranged from 15 to 39 years. The lesions were located in the lateral and/or third ventricles. Total removal of the tumor was performed in three patients, and the remaining three underwent partial resection. Postoperative irradiation was given to five patients. A follow-up study revealed that five patients were free of recurrent tumor at 15 to 227 months after treatment, and one was alive with disease 25 months after surgery. Histologically, all tumors were composed of small uniform cells, with perinuclear halos and regular round nuclei. Tumor cells were sometimes arranged around nucleus-free fibrillary zones. Mitoses were infrequent. Ultrastructurally, neoplastic cells had round nuclei with dispersed heterochromatin and organelle-sparse cytoplasm containing occasional microtubules, 20 to 25 nm in diameter, and scattered dense-core vesicles, 100 to 200 nm in diameter. Cell processes containing dense-core and clear vesicles were frequently present. Thus, these neoplasms should be considered neuronal in origin, and should be classified as "intraventricular neurocytomas."

Primary differentiated neuroblastoma of the orbit

A 49-year-old woman had a 12-year history of a localized left orbital tumor that required five subtotal excisions, orbital radiotherapy, and finally an exenteration. The last procedure was performed after visual function had deteriorated and in order to prevent spread of the tumor into a surrounding compartment. The biopsy specimens from the first four surgeries showed a stroma-free spindle cell tumor with benign cytologic features and no mitotic activity, which exhibited palisading of nuclei, imbrication of delicate cytoplasmic processes (neuropil), true perivascular rosettes with cytoplasmic processes oriented perpendicular to vessel walls, and Wright rosettes. The biopsy after radiotherapy and the exenteration specimen contained more polyhedral (gemistocytoid) tumor cells with abundant eosinophilic cytoplasm and tapering cell processes; nuclear pleomorphism without mitotic activity was also seen. Electron microscopy showed the presence of neurosecretory dense-core granules in the perikaryon region of the tumor cells and in the myriad interweaving cytoplasmic processes (neurites); neither Nissl substance nor synapses were identified. Immunohistochemical staining for neuron-specific enolase was positive, but glial fibrillary acidic protein stained negative. This previously undescribed orbital tumor is interpreted as a primary differentiated neuroblastoma without evidence of ganglion cell differentiation that exhibited locally aggressive behavior. The distinctions between neuroblastic and neuroendocrine tumors are discussed.

Maturation of cerebellar neuroblastoma into ganglioneuroma with melanosis. A histologic, immunocytochemical, and ultrastructural study

A ganglioneuroma with areas of melanosis was resected from the cerebellum of a 6.5-year-old girl. At 2.5 years of age, she was diagnosed to have cerebellar neuroblastoma, which was incompletely resected and then radiated. Histologic, ultrastructural, and immunocytochemical studies undertaken on tissue from both stages of the tumor demonstrated a neuroblastic origin and differentiation into a predominantly neuronal tumor with limited astroglial participation. In addition, widespread deposition of basal lamina material, perineuronal distribution of S-100 protein-bearing cells and melanosis were found. The various features and unusual biology of the tumor are discussed in the light of a review of the literature.

The correlation of neoplastic vulnerability with central neuroepithelial cytogeny and glioma differentiation

The vulnerability of neuroepithelial cells in the central nervous system (CNS) to neoplastic transformation results from the interaction of several factors: the existence of a reserve population of stem cells, the capability of differentiated cells to reenter the kinetic cycle, the number of replicating cells at risk at a particular time, the length of time during which a particular cell population remains in the cycle, the state of differentiation and the further differentiation potential of that population, and the steps of differentiation that are achieved in successive cell generations. This concept explains many aspects of CNS tumor incidence and the relationship of central neuroepithelial embryonal tumors to tumors of adult cell type. The incidence of different types of central neuroepithelial tumors can be correlated with the width of the window of neoplastic vulnerability. Examples illustrating the existence of only a narrow window include such rare tumors as medulloepitheliomas, cerebral neuroblastomas, gangliogliomas and ependymoblastomas. By contrast, cerebellar medulloblastomas, astrocytomas, mixed astrocytomas and oligodendrogliomas, and glioblastomas exemplify instances in which a relatively wider window of vulnerability exists in the light of cellular neuro-ontogeny and of the capacity of glial cells for postnatal replication. The relationship that may occasionally be established between the development of a glioma and the production of cellular gliosis such as may follow brain injury or accompany multiple sclerosis can also be viewed in the light of that concept. Increasing awareness is needed concerning the development of postradiation gliomas, in particular after the apparently successful treatment of acute lymphocytic leukemia.