Benign Brain Tumors

Henry Ford Hospital

Paul Mazaris PGY III

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 Types of CNS tumors
• Tumors of neuroepithelial tissue
• Tumors of cranial and spinal nerves
• Tumors of the meninges
• Hematopoietic neoplasms
• Germ cell tumors
• Cysts and tumor-like lesions
• Tumors of the cellar region
• Local extensions from regional tumors
• Unclassified tumors

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 Neuroepithelial tumors
• Astrocytic tumors
• Oligodendroglial tumors
• Ependymal tumors
• Mixed gliomas
• Choroid plexus tumors
• Neuornal and mixed neuronal-glial tumors
• Pineal tumors
• Embryonal tumors
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1. Neuroepithelial tumors
• Astrocytic tumors
– Astrocytoma (WHO grade II)
– Anaplastic astrocytoma (WHO grade III)
– Glioblastoma multiforme (WHO grade IV)
– Pilocytic astrocytoma (WHO grade I)
– Subependymal giant cell astrocytoma (WHO grade I)
– Pleomorphic xanthoastrocytoma (WHO grade I)
• Oligodendroglial tumors
– Oligodendroglioma (WHO grade II)
• Ependymal cell tumors
– Ependymoma (WHO grade II)
– Subependymoma (WHO grade I)
– Anaplastic ependymoma (WHO grade III)
• Mixed gliomas
– Mixed oligoastrocytoma (WHO grade II)
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• Tumors of the choroid plexus
• Neuronal and mixed neuronal-glial tumors
• Pineal Parenchyma Tumors
• Tumors with neuroblastic or glioblastic elements (embryonal tumors)

2. Tumors of the Sellar Region

3. Germ Cell Tumors

4. Tumors of the Meninges

– Variants
– Atypical meningioma
– Anaplastic (malignant) meningioma
5. Tumors of Cranial and Spinal Nerves
– Schwannoma (neurinoma, neurilemoma)
– Neurofibroma
– Peripheral nerve sheath tumors 5
6. Local Extensions from Regional Tumors
– Paraganglioma (chemodectoma)
– Chordoma

7. Cysts and Tumor-like Lesions

8. Mesenchymal, non-meningothelial tumors

– Lipoma
– Hemangioblastoma

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Pilocytic Astrocytoma

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 Pilocytic Astrocytoma
• Location
– Optic gliomas and hypothalamic gliomas
– Cerebral hemisphere
– Brainstem gliomas
– Cerebellum
• Radiographic apperance
– Well circumscribed
– Enhance with contrast
– Cystic component
– Most often periventricular
• Pathology
– Rosenthal fibers

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 Pilocytic astrocytoma:
Optic & hypothalamic region

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Pilocytic Astrocytoma:
Third ventricular region

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Pilocytic Astrocytoma:
Cerebral hemisphere

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 Pilocytic Astrocytoma:
Cerebellum & brainstem

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Pilocytic Astrocytoma

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 Pilocytic Astrocytoma
• CT
– Hypodense to
isodense
– Enhances with
contrast
• MRI
– T1- Hypo/isointense
– T2- Hyperintense
with enhancement of
solid tumors and
mural nodules.

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Pilocytic Astrocytoma

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Pilocytic Astrocytoma

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Pilocytic Astrocytoma

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Meningiomas

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 Meningiomas
• Key features
– Incidence: 15-20% of primary intracranial tumors
– Slow growing
– Usually cured if completely removed
– Common locations
• Parasagittal
• Convexity
– Hyperostosis of adjacent bone
– Calcification
– Hormonal receptors
– Rarely metastasize
– Arachnoid cap cells (NOT DURA)
– Monosomy 22

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 Meningiomas
• Locations
– Cranial (90%)
• Parasagittal 21%
• Convexity 15%
• Tuberculum sellae 13%
• Sphenoid ridge 12%
• Olfactory groove 10%
• Falx 8%
• Lateral ventricle 4%
• Tentorial 3.5%
• Middle fossa 3%
– Spinal (9%)
– Ectopic (1%)
– Multiple meningiomas (9% of cases)
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 Meningiomas:
Paraagittal and falx

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Meningiomas:
Convexity

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Meningiomas:
Sphenoid wing

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 Meningioma classification
Classification system:
1. Meningothelimatous (Syncytial)
2. Fibrous (fibroblastic)
3. Transitional
Variants may be associated with any of the above 3
subtypes:
– Microcytic -Psammomatous
– Myxomatous -Xanthomatous
– Lipomatous -Granular
– Secretory -Chondroblastic
– Osteoblastic -Melanotic

4. Angioblastic
5. Atypical meningioma
6. Malignant meningioma
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 Meningiomas
• CT
– Homogenous, densely enhancing mass
– Dural tail
– Non-contrast Hounsfield numbers of 60-70
– Cerebral edema
• MRI
– T1
• Isointense 60-65%
• Hypointense 35-40% (compared to grey matter)
– T2
• Isointense 50%
• Hyperintense 35-40%
• Hypointense 10-15% (compared to grey matter)
– Homogenous enhancement with contrast
– MRA/MRV

• Angio
– Characteristically have external carotid artery
feeders.
– Provides information about blood supply and
patency of the adjacent sinuses.
– Sunburst pattern on angiography- prominent
late arterial vascular blush.
– Mother-in-law sign: Tumor blush.

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Meningioma

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Meningioma

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Meningioma

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 Meningioma
• Histology
– Basophilic psammoma bodies & whorls
• Immunochemistry
– +Vimentin
– +EMA
• Treatment
– Surgery
• Preoperative embolization
• Symptomatic vs asymptomatic
– XRT
• Malignant
• Recurrent
• Vascular
• Non-resectable

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Choroid plexus papilloma

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 Choroid plexus papilloma
• Key features
– Intraventricular lesion
– < 1% of brain tumors
– Peak age is <10 years
• One of the most frequent brain tumors before 2 years.
– 50% are located in the lateral ventricle (left atrium in
children)
– 40% are located in the fourth ventricle (in adults)
– 10% are located in the third ventricle
– Rarely located in the CPA cistern

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 Choroid plexus papilloma
• Features
– Well circumscribed, vascular & enhancing
– Benign
– 25% have calcifications
– Increased CSF protein & xanthrochromia are seen in
approximately 60% of cases.
– Persistent hydrocephalus
• Presentation
– Increased ICP from hydrocephalus
• HA, N/V, craniomegaly
• Hemiparesis
• CN deficits

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Choroid plexus papilloma

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 Choroid plexus papilloma
• CT
– Isodense to hyperdense
with prominent
enhancement.
• MRI
– Lobulated masses
– T1: Isointense
– T2: Isointense to slightly
hyperintense with
enhancement
• Angiography
– Prominent choroidal
feeders

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Choroid plexus papilloma

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Choroid plexus papilloma

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Choroid plexus papilloma

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 Choroid plexus papilloma
• Histology
– Cauliflower papillary
shaped appearance
with cubodial and
columnar cells.
– No nuclear atypia
– Rare mitosis
– No mucin

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 Choroid plexus papilloma
• Immunochemistry
– Transthyretin
– Vimentin
– Keratin
– S100
• May rarely invade the
underlying brain even
with benign pathologic
findings.
• May seed the CSF
• Treatment
– Surgical resection
– No role for chemotherapy
or radiation in benign
lesions.

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Craniopharyngioma

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 Craniopharyngioma
• Key fratures
– Account for 2-5% of primary brain tumors
– No sex predominance
– Bimodal age distribution. Peak age 5-10 years with a
second peak between age 55-65.
– 70% are suprasellar and intracellar
– Arise form the anterior superior margin of the pitutary
– Contain both solid and cystic components
• “Machine oil” fluid
– Do not undergo malignant transformation
– Calcifications

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 Craniopharyngioma
• Features
– Symptoms
– Benign- Intimate
adherence to the
infundibular stalk and
hypothalamus predisposes
to a number of
endocrinologic &
neurobehavioral problems.
– Endocrinopathies in
children
• Short stature
• Delayed puberty

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 Craniopharyngioma
• Pathology
– Adamantinomatous pattern
• Cholesterol clefts
• Calcifications
• Squamous cells
– Papillary pattern
• Sheets of squamous epithelium
• Keratin pearls

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Craniopharyngioma

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Craniopharyngioma

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Craniopharyngioma

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Craniopharyngioma

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Craniopharyngioma

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Craniopharyngioma

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 Craniopharyngioma
• Preoperative evaluation
– A complete endocrinologic evaluation is
performed before therapy.
– Adequate thyroid replacement
– Pre- and intraoperative replacement of
corticosteroids is mandatory and should be
carried out radidly.
– A neuor-ophthalmologic evaluation is
obtained to follow the patient’s postoperative
and postradiation visual status.
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 Craniopharyngioma
• Surgery
– Tumor size
– Degree of tumor adherence to the chiasm and great
vessels
– Subtotal resection
• Biopsy and radiation
• Stereotactic radiosurgery
• Recurrent craniopharyngioma
– “Total” removal
– Higher morbidity & lower probability of cure
• Predominantly cystic craniophayrngioma

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Central neurocytoma

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 Central neurocytoma
• Features
– Rare lesions
– Affects young adults
• Males > females
– Benign
• Malignant variation & behavior
– Slow growing
– Calcified
– Location
• Septum pellucidum
• Lateral ventricle
• Third ventricle

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 Central neurocytoma
• Variants:
– Extraventricular neurocytomas
– Central liponeurocytoma
• Pathology
– Similar to oligodendrogliomas
– Contain dense core vesicles
• Immunochemistry
– Synaptophysin
– Neuron-specific enolase
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Central neurocytoma

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Central neurocytoma

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Central neurocytoma

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Central neurocytoma

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Central neurocytoma

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Central neurocytoma

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 Central neurocytoma
• Treatment
– Surgery
– Stereotactic radiosurgery
– Chemotherapy
• Etoposide
• Cisplatin
• Cyclophosphamide

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