Neuropathology Flashcards
You are evaluating a 65-year-old woman with the onset of low-grade headache and occasional word finding difficulties. Imaging demonstrates a left-sided ring-enhancing mass. You complete a gross total resection and the final pathology is demonstrated below. What gene amplification is often seen in this tumor type?
A. VEGF upregulation
B. EGFR amplification
C. 10p/19Q co-deletion
D. SHH deletion
A. VEGF upregulation
B. EGFR amplification
C. 10p/19Q co-deletion
D. SHH deletion
The pathology slide demonstrates evidence of glioblastoma, notable for pseudopalisading necrosis. GBM often demonstrates amplification of EGFR, and this can also be a reason for tumor transition from anaplastic astrocytoma to GBM.
Further Reading: Psaaros. The Definitive Neurosurgical Board Review, page 126.
A 30-year-old man experiences a first time seizure after a night of drinking with friends. In the emergency department, a head CT is obtained which is suggestive of a right anterior temporal hypodensity. Subsequent MRI confirms a non-enhancing, T2 hyperintense mass. Surgical resection is performed and final pathology is below. What is the most common chromosomal abnormality in this tumor type?
A. Loss of 1P/19Q
B. EGFR amplification
C. Loss of sex chromosome
D. Loss of chromosome 22
A. Loss of 1P/19Q
B. EGFR amplification
C. Loss of sex chromosome
D. Loss of chromosome 22
The pathology slide demonstrates an anaplastic astrocytoma, a WHO grade III glioma. Genetic mutations include P53 mutations and loss of sex chromosome. They often demonstrate GFAP positivity and occasionally S-100 positivity.
Further Reading: Psaaros. The Definitive Neurosurgical Board Review, page 126.
You resect a tumor from a 53-year-old man. Final pathology slide is shown in Question 2. What is likely to be demonstrated on further staining of the pathologic tissue?
A. IDH wild-type
B. IDH mutant
C. Loss of chromosome 22
D. Loss of chromosome 10
A. IDH wild-type
B. IDH mutant
C. Loss of chromosome 22
D. Loss of chromosome 10
IDH mutations are becoming important for both glioma identification/characterization as well as prognostication. IDH mutations in primary GBM are very rare. IDH mutations are much more commonly found in WHO grade II-III lesions. If a GBM is found to have IDH mutations, it is likely that it transformed from a lower grade glial neoplasm.
Further Reading: Cohen et al. IDH1 and IDH2 Mutations in Glioma. 2013.
You see a patient with this MRI. What histologic findings would you expect if this was found to be a glial neoplasm?
A. Prominent Rosenthal fibers
B. Focal calcification
C. Prominent reticulin staining
D. “Fried-egg appearance”
A. Prominent Rosenthal fibers
B. Focal calcification
C. Prominent reticulin staining
D. “Fried-egg appearance”
This MRI is suggestive of a pilocytic astrocytoma, given the cystic component with an enhancing nodule. Histologically, these tumors demonstrate parallel arrangement of bipolar astrocytes with Rosenthal fibers and eosinophilic granular bodies.
Further Reading: Psaaros. The Definitive Neurosurgical Board Review, page 127.
A 21-year-old woman patient with the tumor demonstrated on this slide is most likely to present with what symptoms?
A. Focal neurologic deficit
B. Headache
C. Seizures
D. Nausea
A. Focal neurologic deficit
B. Headache
C. Seizures
D. Nausea
This pathology slide demonstrates eosinophilic granular bodies and a “storiform” pattern of cellu- lar organization. This is common in pleomorphic xanthoastrocytoma. Intense reticulin staining can also be observed. These tumors often develop in the temporal lobe, have cystic components and present with seizures.
Further Reading: Psaaros. The Definitive Neurosurgical Board Review, page 127.
A 30-year-old man patient with the tumor demonstrated on this slide likely has what other abnormalities?
A. Cortical malformations
B. Optic glioma
C. Retinoblastoma
D. Hypotelorism
A. Cortical malformations
B. Optic glioma
C. Retinoblastoma
D. Hypotelorism
This pathology slide demonstrates gemistocytic type cells with a large eosinophilic cytoplasm and a large eccentric nucleus seen in subependymal giant cell astrocytomas. These tumors are seen in tuberous sclerosis, where cortical tubers can also be seen.
Further Reading: Psaaros. The Definitive Neurosurgical Board Review, page 128.
The tumor seen in this pathology slide often exhibits what genetic abnormality?
A. Chromosome 17 loss
B. Chromosome 21 loss
C. Isochromosome 17q
D. 1p/19q co-deletion
A. Chromosome 17 loss
B. Chromosome 21 loss
C. Isochromosome 17q
D. 1p/19q co-deletion
This pathology slide demonstrates classic “friedegg” appearance of oligodendrogliomas. These tumors often demonstrate 1p/19q co-deletion, and this finding is helpful for both therapeutic and prognostic applications.
Further Reading: Psaaros. The Definitive Neurosurgical Board Review, page 128.
You resect a tumor in a 40-year-old man that was causing triventricular hydrocephalus. Final pathology is demonstrated below. What characteristic is classic for these tumors?
A. S-100 positivity
B. EMA positivity
C. Synaptophysin positivity
D. 1p/19q co-deletion
A. S-100 positivity
B. EMA positivity
C. Synaptophysin positivity
D. 1p/19q co-deletion
This pathology slide demonstrates classic periventricular pseudorosettes and uniform cells with variable nuclear : cytoplasmic ratio commonly seen in ependymoma. These tumors often present in the ventricle, and are found to be GFAP, PTAH and EMA positive.
Further Reading: Psaaros. The Definitive Neurosurgical Board Review, page 128.
You resect a tumor in a 60-year-old man that was causing triventricular hydrocephalus. Final pathology is demonstrated below. What characteristic is classic for these tumors?
A. Homogenous gadolinium enhancement on MRI
B. Cystic cavity with enhancing mural nodule on MRI
C. Multicentric calcification on CT scan
D. Lack of gadolinium enhancement on MRI
A. Homogenous gadolinium enhancement on MRI
B. Cystic cavity with enhancing mural nodule on MRI
C. Multicentric calcification on CT scan
D. Lack of gadolinium enhancement on MRI
This pathology slide demonstrates classic subependymoma, showing small groups of cells with scant cytoplasm in a fibrillary background (islands of blue in a sea of pink). These tumors are often slow growing and can be completely asymptomatic, but due to their location in the 4th ventricle in most adults, they can present with hydrocephalus. On MRI, they classically are an intraventricular lesion that does not demonstrate enhancement with gadolinium.
Further Reading: Bernstein, Berger. Neuro-Oncology - The Essentials, 3rd edition, 2015, intraventricular tumors.
You resect a tumor in a 5-year-old girl with persistent seizures and an abnormality of the temporal lobe on MRI. Final pathology is below. What tumor type did you resect?
A. Plemorphic xanthoastrocytoma
B. Low-grade glioma
C. Juvenile pilocytic astrocytoma
D. Ganglioglioma
A. Plemorphic xanthoastrocytoma
B. Low-grade glioma
C. Juvenile pilocytic astrocytoma
D. Ganglioglioma
This slide demonstrates ganglioglioma, which is often seen to have binucleate cells (ganglion cells) with eosinophilic granular bodies. It is often seen in children at 5-6 years of age and present often with intractable seizures.
Further Reading: Psaaros. The Definitive Neurosurgical Board Review, page 128.
You resect a tumor in a 30-year-old girl. Final pathology is below. This tumor type is often seen in what location?
A. Attached to septum pellucidum
B. 4th ventricle
C. Lateral ventricle
D. Temporal lobe
A. Attached to septum pellucidum
B. 4th ventricle
C. Lateral ventricle
D. Temporal lobe
This slide demonstrates a central neurocytoma, with homogenous cells with round nuclei on a fibrillary background. These tumors are found within the lateral ventricle attached to the septum pellucidum.
Further Reading: Psaaros. The Definitive Neurosurgical Board Review, page 129.
You biopsy a multifocal lesion in the brain of a 60-year-old woman. The final pathology slide is shown below. What is the primary method of initial treatment for this neoplasm?
A. Temozolamide/External beam radiotherapy
B. Steroids
C. PCV chemotherapy
D. Stereotactic radiosurgery
A. Temozolamide/External beam radiotherapy
B. Steroids
C. PCV chemotherapy
D. Stereotactic radiosurgery
This slide demonstrates a cellular proliferation around small vascular channels/arterioles. This is highly suggestive of CNS lymphoma, and initial treatment can be carried out with steroids.
The tumor depicted in the slide below originates from which cells?
A. Astrocytes
B. Ependymal cells
C. Schwann cells
D. Arachnoid cap cells
A. Astrocytes
B. Ependymal cells
C. Schwann cells
D. Arachnoid cap cells
This slide demonstrates a classic meningioma. These tumors develop from arachnoid cap cells.
Further Reading: Psaaros. The Definitive Neurosurgical Board Review, page 131.
What type of meningioma is depicted below?
A. Fibrous
B. Psammomatous
C. Transitional
D. Angiomatous
A. Fibrous
B. Psammomatous
C. Transitional
D. Angiomatous
This slide demonstrates a classic psammomatous meningioma. While multiple subtypes of meninigomas may demonstrate psammoma bodies, when there is a high concentration of these structures, the overall morphology is likely a psammomatous meningoma.
Further Reading: Psaaros. The Definitive Neurosurgical Board Review, page 131.
What is the most common genetic malformation in the tumor type depicted in the figure in Question 14?
A. 1p/19q co-deletion
B. Loss of chromosome 22
C. EGFR amplification
D. P53 mutation
A. 1p/19q co-deletion
B. Loss of chromosome 22
C. EGFR amplification
D. P53 mutation
The slide demonstrates a meningioma. The most common genetic malformation in meningioma is loss of chromosome 22.
Further Reading: Psaaros. The Definitive Neurosurgical Board Review, page 131.
Which type of meningioma is considered a WHO grade III lesion?
A. Angiomatous
B. Psammomatous
C. Rhabdoid
D. Chordoid
A. Angiomatous
B. Psammomatous
C. Rhabdoid
D. Chordoid
Papillary, rhabdoid and anaplastic meningiomas are considered WHO grade III. Atypical and chordoid meningomas are considered WHO grade II, and all others are considered WHO grade I.
Further Reading: Psaaros. The Definitive Neurosurgical Board Review, page 131.
Meningiomas tend to demonstrate what charac- teristic positivity?
A. Vimentin
B. GFAP
C. Synaptophysin
D. Neurofilament
A. Vimentin
B. GFAP
C. Synaptophysin
D. Neurofilament
Meningiomas often have vimentin, EMA and occasionally S-100 positivity.
Further Reading: Psaaros. The Definitive Neurosurgical Board Review, page 131.
A tumor with the histology demonstrated below is most likely to arise from what region?
A. Sellar/suprasellar
B. Cerebellum
C. Convexity
D. Pineal
The tumor type depicted is a pineoblastoma. It is a poorly differentiated cancer of embryonal origin that demonstrates sheets of blue cells forming classic Flexner-Wintersteiner rosettes, pictured here. These are rosettes formed around cellular extensions rather than a blood vessel.
Further Reading: Psaaros. The Definitive Neurosurgical Board Review.
You are evaluating a 52-year-old patient with large hands, coarse fascies, excessive sweating and muscle pain. Ultimately a tumor is resected and the pathology is below. 40% of these tumors exhibit mutations in what gene?
A. n-Myc
B. gsp
C. P53
D. SHH
A. n-Myc
B. gsp
C. P53
D. SHH
The patient has signs of acromegaly, suggestive of a GH-secreting pituitary adenoma. 40% of GH-secreting adenomas exhibit a mutation of gsp.
Further Reading: Psaaros. The Definitive Neurosurgical Board Review, page 131.
You are evaluating a patient who is found on imaging to have a large pituitary mass. Pituitary function testing returns normal. You are concerned given the size that pituitary failure will develop. What is the first peptide deficiency you should expect to see?
A. GH
B. FSH/LH
C. TSH
D. ACTH
A. GH
B. FSH/LH
C. TSH
D. ACTH
Large, non-functioning pituitary adenomas can cause pituitary failure due to compression of the gland. GH is often the first peptide to be noticeably diminished in this setting.
Further Reading: Psaaros. The Definitive Neurosur- gical Board Review, page 132.
You resect a mass that appears to be originating in the suprasellar region. Final pathology is demonstrated below. What is the diagnosis?
A. Rathke’s cleft cyst
B. Germinoma
C. Papillary cranyiopharyngioma
D. Pilocytic astrocytoma
A. Rathke’s cleft cyst
B. Germinoma
C. Papillary cranyiopharyngioma
D. Pilocytic astrocytoma
The histologic slide demonstrates a papillary craniopharyngioma, the subtype more commonly found in adults. Adamantinomatous subtypes exhibit cholesterol clefts and scattered calcification.
Further Reading: Psaaros. The Definitive Neurosurgical Board Review, page 132.
This mass is resected over the convexity, and the final pathology is demonstrated below. What markers distinguish it from a meningioma?
A. EMA positive
B. EMA negative
C. Vimentin positive
D. Vimentin negative
A. EMA positive
B. EMA negative
C. Vimentin positive
D. Vimentin negative
This slide demonstrates a hemangiopericytoma, with classic staghorn vessels. While both meningiomas and HPCs stain positive for vimentin, HPCs are EMA negative while meningiomas are EMA positive.
Further Reading: Psaaros. The Definitive Neurosurgical Board Review, page 132.
A 42-year-old woman has chronic headaches and undergoes surgery to resect a mass lesion. Final pathology is below. What is the diagnosis?
A. Colloid cyst
B. Mature teratoma
C. Pilocytic astrocytoma
D. Dermoid cyst
A. Colloid cyst
B. Mature teratoma
C. Pilocytic astrocytoma
D. Dermoid cyst
This slide demonstrates a colloid cyst. The patient presented with headaches and likely low grade hydrocephalus. These lesions present within the third ventricle at the level of the foramen of Monro. They can transiently obstruct CSF flow leading to hydrocephalus. Histologically, they demonstrate a fibrous capsule with an inner epithelial layer and proteinaceous material within the cyst itself.
Further Reading: Psaaros. The Definitive Neurosur- gical Board Review, page 132.
The mass demonstrated in the pathology slide below originates from what structure?
A. Adenohypophysis
B. Pars intermedia
C. Tuburculum sellae
D. Pituitary stalk*
A. Adenohypophysis
B. Pars intermedia
C. Tuburculum sellae
D. Pituitary stalk
This slide demonstrates a Rathke’s cleft cyst, as evident by the cleft as well as normal surrounding pituitary tissue. These masses arise from the pars intermedia of the pituitary gland.
Further Reading: Psaaros. The Definitive Neurosurgical Board Review, page 132.
A 22-year-old man has this tumor removed after presenting with headaches and nausea. Where is this tumor most likely to arise from?
A. Superior medullary velum
**
C. Choroid plexus
D. C1 nerve root
A. Superior medullary velum
B. Floor of the 4th ventricle
C. Choroid plexus
D. C1 nerve root
The slide demonstrates perivascular pseudorosettes, columnar cells surrounding blood vessels. This is a classic finding for ependymoma, which is thought to arise from the floor of the 4th ventricle. Often times these tumors present with nausea compared to subependymomas.
Further Reading: Psaaros. The Definitive Neurosurgical Board Review, page 128.
You would expect the lesion pictured in Question 25 to stain positive for all markers except?
A. GFAP
B. Vimentin
C. EMA
D. PTAH
A. GFAP
B. Vimentin
C. EMA
D. PTAH
This slide demonstrates an ependymoma, classic with perivascular pseudorosettes. Ependymomas often have a loss of chromosome 22 and exhibit GFAP, PTAH and EMA positivity.
Further Reading: Psaaros. The Definitive Neurosurgical Board Review, page 128.
You are evaluating a patient who has headaches and received an MRI. The MRI demonstrated a small lesion in the 4th ventricle that does not enhance. The patient is adamant about removing the mass. At surgery, you resect it and send it for pathology, which is demonstrated below. What is the diagnosis?
A. Subependymoma
B. Ependymoma
C. Colloid cyst
D. Schwannoma
A. Subependymoma
B. Ependymoma
C. Colloid cyst
D. Schwannoma
This patient had a subependymoma resected. These masses classically do not enhance on MRI, and pathology demonstrates “islands of blue in a sea of pink.”
Further Reading: Psaaros. The Definitive Neurosurgical Board Review, page 128.
If the tumor type below was found to secrete bioactive amines, what is the diagnosis?
A. Ganglioglioma
B. Pleomorphic xanthoastrocytoma
C. Paraganglioma
D. Hemangiopericytoma
A. Ganglioglioma
B. Pleomorphic xanthoastrocytoma
C. Paraganglioma
D. Hemangiopericytoma
The slide demonstrates a paraganglioma, with evidence of capillary networks and nests of chief cells. These lesions can secrete bioactive amines.
Further Reading: Psaaros. The Definitive Neurosurgical Board Review, page 129.
This MRI demonstrates evidence of what process?
A. Metastases
B. Alcoholic cerebellar degeneration
C. Turcot’s syndrome
D. Lhermitte-Duclos disease
A. Metastases
B. Alcoholic cerebellar degeneration
C. Turcot’s syndrome
D. Lhermitte-Duclos disease
This MRI demonstrates findings consistent with Lhermitte-Duclos disease, with evidence of hypertrophic cerebellar folia.
Further Reading: Psaaros. The Definitive Neurosurgical Board Review, page 129.
What gene mutation is often linked with patients exhibiting the findings as shown under Question 29?
A. P53
B. SHH
C. PTEN
D. H-ras
A. P53
B. SHH
C. PTEN
D. H-ras
This MRI demonstrates findings consistent with Lhermitte-Duclos disease, with evidence of hypertrophic cerebellar folia. This finding can be seen in patients with Cowden’s syndrome, often caused by a mutation in PTEN.
Further Reading: Psaaros. The Definitive Neurosurgical Board Review, page 129.
This lesion is resected from the 4th ventricle of a 45-year-old woman. What is the most likely diagnosis?
A. Ependymoma
B. Choroid plexus papilloma
C. Subependymoma
D. Vestibular schwannoma
A. Ependymoma
B. Choroid plexus papilloma
C. Subependymoma
D. Vestibular schwannoma
The slide demonstrates a choroid plexus papilloma, which often arises from the 4th ventricle in adults. They exhibit columnar epithelium in papillary extensions with an interior fibrovascular region.
Further Reading: Psaaros. The Definitive Neurosurgical Board Review, page 130.
The tumor demonstrated under Question 31 is associated with a syndrome caused by mutation in which gene?
A. P53
B. PTEN
C. SHH
D. H-ras
A. P53
B. PTEN
C. SHH
D. H-ras
The slide demonstrates a choroid plexus papilloma, which has been shown to be associated with Li-Fraumeni syndrome, a syndrome caused by germline mutations in P53. CPPs are vimentin, GFAP and S100 positive.
Further Reading: Psaaros. The Definitive Neurosurgical Board Review, page 130.
This tumor is resected from the CP angle of a 55-year-old man. What histologic finding is demonstrated by the black arrow?
A. Antoni A
B. Antoni B
C. Verocay body
D. Flexner-Wintersteiner rosette
A. Antoni A
B. Antoni B
C. Verocay body
D. Flexner-Wintersteiner rosette
This slide demonstrates a schwanomma with two distinct histologic areas. The black arrow is located within an area with prominent fascicles of spindle shaped cells, indicative of an Antoni-A area.
Further Reading: Psaaros. The Definitive Neurosurgical Board Review, page 130.
This tumor is resected from the CP angle of a 55-year-old man. What histologic finding is demonstrated in this slide?
A. Antoni A
B. Antoni B
C. Verocay body
D. Flexner-Wintersteiner rosette
A. Antoni A
B. Antoni B
C. Verocay body
D. Flexner-Wintersteiner rosette
This slide demonstrates a schwanomma and prominently displays a Verocay body, classically described as “sequential nuclear palisading.”
Further Reading: Psaaros. The Definitive Neurosurgical Board Review, page 130.
A neurofibroma is thought to arise from what structure?
A. Epineurium
B. Perineurium
C. Endoneurium
D. Schwann cell
A. Epineurium
B. Perineurium
C. Endoneurium
D. Schwann cell
Neurofibromas are distinct from schwannomas and are thought to arise from the endoneurium of peripheral nerves.
Further Reading: Psaaros. The Definitive Neurosurgical Board Review, page 130.
A patient with multiple cutaneous nodules has several painful masses resected. They are sent for pathology and are demonstrated below. What is the diagnosis?
A. Schwannoma
B. Paraganglioma
C. Meningioma
D. Neurofibroma
A. Schwannoma
B. Paraganglioma
C. Meningioma
D. Neurofibroma
This slide demonstrates a neurofibroma, characterized by spindle-cells in a wavy pattern with large amounts of collagen and a myxoid background. They are often seen in NF1.
Further Reading: Psaaros. The Definitive Neurosurgical Board Review, page 130.
The lesion depicted in Question 36 most likely stains positive for what marker?
A. S-100
B. CD20
C. Vimentin
D. EMA
A. S-100
B. CD20
C. Vimentin
D. EMA
This slide demonstrates a neurofibroma, characterized by spindle-cells in a wavy pattern with large amounts of collagen and a myxoid background. Classically they stain positive for S-100.
Further Reading: Psaaros. The Definitive Neurosurgical Board Review, page 130.
A 9-year-old girl presents with wrist drop and a tumor is discovered. The lesion is resected with negative margins and final pathology is demonstrated below. What is the most likely diagnosis?
A. Schwannoma
B. MPNST
C. Neuroblastoma
D. Synovial sarcoma
A. Schwannoma
B. MPNST
C. Neuroblastoma
D. Synovial sarcoma
This slide demonstrates an MPNST, with the “storiform cellular pattern, prominent mitoses in a fascicular pattern.” Necrosis can also be seen on histology of MPNSTs.
Further Reading: Psaaros. The Definitive Neurosurgical Board Review, page 131.
A 42-year-old man has two lesions removed from his cerebellum. Final pathology is below. Mutations on what chromosome are associated with this neoplasm?
A. 3
B. 7
C. 17
D. 22
A. 3
B. 7
C. 17
D. 22
This slide demonstrates a hemangioblastoma, with a dense network of vascular channels and lipid containing interstitial cells. These tumors are associated with von-Hippel Lindau syndrome, characterized by a mutation on chromosome 3.
Further Reading: Psaaros. The Definitive Neurosurgical Board Review, page 132.
This mass is removed from the CP angle in a 28-year-old woman. What is the most likely diagnosis?
A. Vestibular schwannoma
B. Ependymoma
C. Epidermoid cyst
D. Choroid plexus papilloma
A. Vestibular schwannoma
B. Ependymoma
C. Epidermoid cyst
D. Choroid plexus papilloma
This slide demonstrates an epidermoid cyst, characterized by stratified squamous epithelium and significant keratin within the center.
Further Reading: Psaaros. The Definitive Neurosurgical Board Review, page 132.