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Intraaxial Masses:Intraaxial Masses:Approach to AstrocytomaApproach to Astrocytoma
James G. Smirniotopoulos, M.D.James G. Smirniotopoulos, M.D.Uniformed Services UniversityUniformed Services University
of the Health Sciencesof the Health SciencesBethesda, MDBethesda, MD
Visit us at: http://Visit us at: http://rad.usuhs.edurad.usuhs.edu
You are Here!*
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First StepsFirst Steps
Favor NeoplasmFavor Neoplasm–– PrimaryPrimary
SolitarySolitaryDeepDeepLarge lesions +/Large lesions +/-- vasogenic edemavasogenic edema
–– SecondarySecondaryMultipleMultipleSubcorticalSubcorticalSmall lesion Small lesion –– lots of vasogenic edemalots of vasogenic edema
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Primary vs. SecondaryPrimary vs. Secondary
Remember!45 – 55% of
metastasis present as a solitary lesion –
even on MR
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PRIMARY NEOPLASMSPRIMARY NEOPLASMSNeuroectodermalNeuroectodermal
NeuroectodermNeuroectoderm–– Embryologic Neural TubeEmbryologic Neural Tube–– ““NeuroepithelialNeuroepithelial””Broad CategoriesBroad Categories–– Glial Tumors (Gliomas)Glial Tumors (Gliomas)–– Embryonal/Immature (P.N.E.T.Embryonal/Immature (P.N.E.T.’’s)s)–– Neuronal (Neurocytoma)Neuronal (Neurocytoma)–– Mixed (Ganglioglioma)Mixed (Ganglioglioma)
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WHO 1 vs. WHO 4WHO 1 vs. WHO 4
Courtesy of Paul Sherman Courtesy of R.D. Zimmerman
Define the Problem:Define the Problem:
Some Low Grade EnhanceSome Low Grade EnhanceSome Low Grade Do Not Some Low Grade Do Not
Some Low Grade => GBMSome Low Grade => GBMSome Low Grade Do NotSome Low Grade Do Not
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GRADING SYSTEMSGRADING SYSTEMSModified from Modified from SemSem Rad Onc (1991); 1: 2Rad Onc (1991); 1: 2--99
KernohanKernohan BergerBerger WHO 1993WHO 1993--2007 2007 1 Pilocytic,SEGA
Benign (1) Astrocytoma2 Astrocytoma, PXA
Benign (2)Anaplastic 3 Anaplastic, PXA
Anaplastic (3)
Glioblastoma (4) Glioblastoma 4 Glioblastoma
WHO ClassificationWHO Classification
Defines Histologic SubtypesDefines Histologic SubtypesGrades Biologic PotentialGrades Biologic PotentialAllows International CooperationAllows International CooperationAscending scale of Aggression from 1Ascending scale of Aggression from 1--44
WHO CORRELATIONWHO CORRELATION
Low Grade Low Grade –– GradeGrade 11
–– LongLong--Term SurvivalTerm Survival
–– Stable Histology no progressionStable Histology no progression
Possible Surgical Cure
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Cellularity Cellularity ⇑⇑Mitoses Mitoses ⇑⇑Endothelial proliferation Endothelial proliferation ⇑⇑Metabolism Metabolism ⇑⇑
Blood volume Blood volume ⇑⇑Blood flow Blood flow ⇑⇑MTT MTT ⇓⇓
Choline/CreatineCholine/Creatine ⇑⇑MyoInositolMyoInositol ⇓⇓⇑⇑ Lip/Lac and Lip/Lac and ⇓⇓ NAANAA
Incr
easing
Agg
ress
ion
Perfusion Imaging:
CT, MR, Angio
MR Spectroscopy
PET FDG or Th SPECT
⇑⇑ DWI matching ⇓⇓ ADC
Lesion Aggression and GradingLesion Aggression and Grading
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AstrocytomaAstrocytoma
Astrocytoma
WHO 1Circumscribed
EnhancingFluid secreting
WHO 2-3Infiltrating
Water signalMild to Mod. MassNo enhancement
WHO 3-4Infiltratingand Focal
HeterogeneousMass effect
EnhancementNecrosis
MyoInositol ⇑Perfusion ⇓
PWI ⇑Cho/Cr ⇑FDG ⇑
Lac/Lip ⇑
LocationCyst w/ Nodule
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AstrocytomaAstrocytoma
Astrocytoma
WHO 1Circumscribed
EnhancingFluid secreting
WHO 2-3Infiltrating
Water signalMild to Mod. MassNo enhancement
WHO 3-4Infiltratingand Focal
HeterogeneousMass effect
EnhancementNecrosis
MyoInositol ⇑Perfusion ⇓
PWI ⇑Cho/Cr ⇑FDG ⇑
Lac/Lip ⇑
PilocyticSubependymal GC
33
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AstrocytomaAstrocytoma
Astrocytoma
WHO 1Circumscribed
EnhancingFluid secreting
WHO 2-3Infiltrating
Water signalMild to Mod. MassNo enhancement
WHO 3-4Infiltratingand Focal
HeterogeneousMass effect
EnhancementNecrosis
MyoInositol ⇑Perfusion ⇓
PWI ⇑Cho/Cr ⇑FDG ⇑
Lac/Lip ⇑
PilocyticSubependymal GC
““BenignBenign”” ASTROCYTOMAASTROCYTOMA
Two typesTwo types––Low grade Low grade ““benignbenign””
Diffuse in AdultsDiffuse in AdultsWHO Grade 2WHO Grade 2
––Low grade Low grade ““specialspecial””Circumscribed in ChildrenCircumscribed in ChildrenWHO Grade 1WHO Grade 1
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Major ConceptMajor Concept
GliomaAstrocyte
Circumscribed Diffuse
PushingMargin
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InfiltratingMargin
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Major ConceptMajor Concept
GliomaAstrocyte
Circumscribed DiffuseWHO 2 - Astrocytoma
WHO 3 – Anaplastic A.
WHO 4 - Glioblastoma
WHO 1Pilocytic
Subependymal Giant Cell
WHO 2-3Pleomorphic Xantho
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What can we What can we DxDx??
Circumscribed AstrocytomaCircumscribed Astrocytoma–– WHO WHO GrGr 1 Pilocytic Astrocytoma1 Pilocytic Astrocytoma–– WHO WHO GrGr 1 Subependymal Giant Cell 1 Subependymal Giant Cell AstroAstro..–– WHO 2,3 WHO 2,3 PleomorphicPleomorphic XanthoastrocytomaXanthoastrocytoma
Diffuse AstrocytomaDiffuse Astrocytoma–– WHO WHO GrGr 2 (2 (““AstrocytomaAstrocytoma””))–– WHO WHO GrGr 3 (3 (““Anaplastic AstrocytomaAnaplastic Astrocytoma””))–– WHO WHO GrGr 4 (4 (““Glioblastoma MultiformeGlioblastoma Multiforme”” -- GBM)GBM)
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Circumscribed AstrocytomaCircumscribed Astrocytoma
WHO Grade 1
Pilocytic
Astrocytoma
SEGA
Circumscribed Astrocytoma
44
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AstrocytomaAstrocytoma
Astrocytoma
WHO 1Circumscribed
EnhancingFluid secreting
WHO 2-3Infiltrating
Water signalMild to Mod. MassNo enhancement
WHO 3-4Infiltratingand Focal
HeterogeneousMass effect
EnhancementNecrosis
MyoInositol ⇑Perfusion ⇓
PWI ⇑Cho/Cr ⇑FDG ⇑
Lac/Lip ⇑
LocationCyst w/ Nodule
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WHO Gr1 WHO Gr1 -- Pilocytic AstrocytomaPilocytic Astrocytoma
Circumscribed Mass:
Fluid-secreting
Cyst w/Nodule
Pushing Margin
ASTROCYTOMA:ASTROCYTOMA:CircumscribedCircumscribed
““SpecialSpecial”” AstrocytomasAstrocytomasAstrocytoma of YoungAstrocytoma of YoungVarious LocationsVarious LocationsWell circumscribed (yet, no capsule)Well circumscribed (yet, no capsule)
Do NOT spread along WMDo NOT spread along WMDo NOT change grade (except PXA)Do NOT change grade (except PXA)
Constellation of findings correlates w/ HistologyConstellation of findings correlates w/ Histology
PILOCYTIC ASTROCYTOMAPILOCYTIC ASTROCYTOMA
Cystic Cerebellar Astrocytoma Cystic Cerebellar Astrocytoma Juvenile Pilocytic AstrocytomaJuvenile Pilocytic Astrocytoma
((““PAPA”” or or ““JPAJPA””))
PILOCYTIC ASTROCYTOMAPILOCYTIC ASTROCYTOMA
Synonyms: Polar Spongioblastoma, Cystic Cerebellar Synonyms: Polar Spongioblastoma, Cystic Cerebellar AstrocytomaAstrocytomaCell of Origin: Astrocyte (biCell of Origin: Astrocyte (bi--polar, hairlike)polar, hairlike)Associations: in Associations: in ON w/ NFON w/ NF--11Incidence: 3Incidence: 3--6% of ALL Cranial, 32% of Child6% of ALL Cranial, 32% of ChildAge: Age: 55--15 (Zulch 315 (Zulch 3--7)7) Sex: Slight F (11/9)Sex: Slight F (11/9)Location: Cerebellum, Chiasm/Hypothal, OpticLocation: Cerebellum, Chiasm/Hypothal, OpticTreatment: Surgery, patienceTreatment: Surgery, patiencePrognosis: Prognosis: 77% at 5 yrs, 75% at 10 yrs, 75% at 15 yrs77% at 5 yrs, 75% at 10 yrs, 75% at 15 yrs
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Pilocytic AstrocytomaPilocytic Astrocytoma
Cyst and Mural NoduleCyst and Mural Nodule–– balanced morphologybalanced morphology
Wall may not enhanceWall may not enhanceCyst fluid has proteinCyst fluid has protein–– Not identical to CSFNot identical to CSF
Nodule low density on CTNodule low density on CT–– may calcify up to 25%may calcify up to 25%
No increase in vascularityNo increase in vascularityWHO Grade 1WHO Grade 1Peak at ~10 yrsPeak at ~10 yrs
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PILOCYTIC ASTROCYTOMAPILOCYTIC ASTROCYTOMARadiologyRadiology
Cerebellum, DiencephalonCerebellum, Diencephalon–– rare in BS or Cerebrumrare in BS or Cerebrum
Majority have significant Majority have significant ““cystcyst””–– ““Cyst and Mural NoduleCyst and Mural Nodule””
part of lining does NOT enhancepart of lining does NOT enhance
–– Nodule may be heterogeneousNodule may be heterogeneous–– Exceptional purely solidExceptional purely solid
Nodule has increased waterNodule has increased waterCalcification in 5Calcification in 5--25%25%
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Pilocytic AstrocytomaPilocytic Astrocytoma
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“Cyst” Nodule
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Pilocytic AstrocytomaPilocytic AstrocytomaCyst and Mural NoduleCyst and Mural Nodule
–– balanced morphologybalanced morphologyWall may not enhanceWall may not enhanceCyst fluid has proteinCyst fluid has protein–– Not identical to CSFNot identical to CSF
Nodule low density on CTNodule low density on CT–– may calcify up to 25%may calcify up to 25%
No increase in vascularityNo increase in vascularityWHO Grade 1WHO Grade 1Peak at ~10 yrsPeak at ~10 yrs
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““CystCyst”” with Nodulewith Nodule
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WHO Gr1 WHO Gr1 –– Pilocytic Pilocytic AstrocytomaAstrocytoma
Circumscribed Mass:
Cyst w/Nodule
Pushing Margin
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PATHOLOGYPATHOLOGYBiphasic patternBiphasic pattern–– dense pilocytic gliadense pilocytic glia–– Rosenthal fibersRosenthal fibers–– loose microcystic areasloose microcystic areasNo necrosisNo necrosisLow gradeLow gradeAbnormal capillariesAbnormal capillaries–– allow enhancementallow enhancement–– fluid productionfluid production
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Pilocytic AstrocytomaPilocytic Astrocytoma
Variant AppearanceVariant Appearance
Variant LocationVariant Location
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Pilocytic AstrocytomaPilocytic AstrocytomaA Cyst with mural nodule?
Not Always !!!
Neoplasm + thin rim of enhancing
gliosis
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Courtesy of Paul Sherman
Pilocytic AstrocytomaPilocytic Astrocytoma
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Atypical:
Dense Ca++, No Cyst, No Enhancement
Pilocytic AstrocytomaPilocytic Astrocytoma
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PILOCYTIC ASTROCYTOMA:PILOCYTIC ASTROCYTOMA:LocationsLocations
CEREBELLUMCEREBELLUM
Chiasm And Optic NerveChiasm And Optic Nerve
Hypothalmus/thalamusHypothalmus/thalamusCerebral HemisphereCerebral HemisphereSpinal Cord (Intramedullary)Spinal Cord (Intramedullary)
Diencephalon
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PILOCYTIC ASTROCYTOMAPILOCYTIC ASTROCYTOMA(Juvenile Pilocytic)(Juvenile Pilocytic)
Childhood, Young AdultsChildhood, Young AdultsBenign, no mitosis/necrosisBenign, no mitosis/necrosisCircumscribed Circumscribed -- EnhancingEnhancingCyst Formation, Mural NoduleCyst Formation, Mural NoduleCerebellum and DiencephalonCerebellum and Diencephalon(Optic tracts, Hypothalmus)(Optic tracts, Hypothalmus)
WHO GRADE 1 TumorsWHO GRADE 1 Tumors
Circumscribed AstrocytomaCircumscribed Astrocytoma–– JPA (Pilocytic)JPA (Pilocytic)–– SGCA (Subependymal Giant Cell)SGCA (Subependymal Giant Cell)
GangliogliomaGangliogliomaMeningiomaMeningioma
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Subependymal Giant Cell AstroSubependymal Giant Cell Astro
85-95% associated with Tuberous Sclerosis
88
ASTROCYTOMASASTROCYTOMAS
““SPECIALSPECIAL”” ASTROCYTOMASASTROCYTOMAS–– Circumscribed Growth:Circumscribed Growth:
PilocyticPilocyticSubependymal Giant CellSubependymal Giant CellPleomorphic XanthoPleomorphic Xantho--AstrocytomaAstrocytoma
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Circumscribed AstrocytomaCircumscribed Astrocytoma
WHO Grade 1 2 3 4
PXA PXA
Circumscribed Astrocytoma
PLEOMORPHIC PLEOMORPHIC XANTHOASTROCYTOMAXANTHOASTROCYTOMA
Rare Variant of AstrocytomaRare Variant of AstrocytomaArises from Arises from Subpial AstrocytesSubpial AstrocytesAffects Superficial Cerebral Cortex and Affects Superficial Cerebral Cortex and MeningesMeningesSkull erosion (scalloped excavation)Skull erosion (scalloped excavation)Temporal > Frontal > ParietalTemporal > Frontal > ParietalWHO Grade 2,3WHO Grade 2,350% progress over time50% progress over time
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Pleomorphic XanthoastrocytomaPleomorphic Xanthoastrocytoma
““OrdinaryOrdinary““ AstrocytomasAstrocytomas
Diffuse Infiltration of WM by:Diffuse Infiltration of WM by:–– Fibrillary AstrocytesFibrillary Astrocytes–– Protoplasmic AstrocytesProtoplasmic Astrocytes–– Gemistocytic AstrocytesGemistocytic Astrocytes
WHO 2,3,4 WHO 2,3,4 (NOT 1)(NOT 1)
KS & Mayo Grades 1KS & Mayo Grades 1--44
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AstrocytesAstrocytes GFAP StainGFAP Stain
99
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USU – Learning to Care for Those in Harm’s WayNormal appearing white matter Normal appearing white matter …… few cell bodiesfew cell bodies
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USU – Learning to Care for Those in Harm’s WayDiffuse Grade 2 Astrocytoma Diffuse Grade 2 Astrocytoma …… too many cells !too many cells !
Infiltrating “Margin”
Diffuse Mass
Non-destructive Infiltration
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AstrocytomaAstrocytoma
Astrocytoma
WHO 1Circumscribed
EnhancingFluid secreting
WHO 2-3Infiltrating
Water signalHomogeneous
Mild Mass effectNo enhancement
No Necrosis
WHO 3-4Infiltratingand Focal
HeterogeneousMass effect
EnhancementNecrosis
MyoInositol ⇑Perfusion ⇓
PWI ⇑Cho/Cr ⇑FDG ⇑
Lac/Lip ⇑
PilocyticSubependymal GC
Daddy,Daddy,Where do GlioblastomasWhere do Glioblastomas
come from?come from?
Progressive Transformation from lower grade diffuse
astrocytoma
- OR -
Arise de novo
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Astrocyte MutationAstrocyte MutationNormal AstrocyteNormal AstrocyteNeoplasticNeoplasticAnaplasticAnaplasticGBMGBM
Deletions:17 p P5322q NF2
Excessproduction of:PDGF
Deletions:13q RB19q 10
Excessproduction of:CDK4
Deletions: 10 PTEN/MMAC19p P16,P15.P14
Excessproduction of:EGFRVEGF
WHO Gr 2 Gr 3 Gr 4 = GBMNormal
Genetically Heterogeneous
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Diffuse AstrocytomaDiffuse Astrocytoma
WHO GR 2
WHO GR 3
WHO GR 4
Normal
1010
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WHO 4WHO 3WHO 2
AstrocytomaAnaplastic
Astrocytoma
Glioblastoma
Multiforme
A spectrum of PathologyA spectrum of tumors
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Diffuse Astrocytoma Diffuse Astrocytoma …… too many cells !too many cells !
Mild cellular atypia
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Glioblastoma multiforme … too many cells, Atypia, Mitoses, Vessels, and Necrosis!
ASTROCYTOMAASTROCYTOMARadiologic GradingRadiologic Grading
TYPE 1 TYPE 1 -- WHO 2, KS Grade 1WHO 2, KS Grade 1--2, 2, ““BenignBenign””–– HomogeneousHomogeneous–– No Enhancement, No Vasogenic EdemaNo Enhancement, No Vasogenic Edema
TYPE 2 TYPE 2 –– WHO Grade 3, AnaplasticWHO Grade 3, Anaplastic–– Variable Enhancement, EdemaVariable Enhancement, Edema–– 50% enhance 50% enhance -- 50% don50% don’’tt
TYPE 3 TYPE 3 –– WHO Grade 4 GlioblastomaWHO Grade 4 Glioblastoma–– Heterogeneous (Necrosis, Blood)Heterogeneous (Necrosis, Blood)–– Ring Enhancement, EdemaRing Enhancement, Edema
““BENIGNBENIGN”” ASTROCYTOMA:ASTROCYTOMA:WHO 2, KS 1WHO 2, KS 1--2, Mayo 12, Mayo 1
YOUNGER PATIENTYOUNGER PATIENT–– CHILDHOODCHILDHOOD–– Young Adults (20Young Adults (20’’s s -- 4040’’s)s)
NL VESSELS (NO NEOVASCULARITY)NL VESSELS (NO NEOVASCULARITY)–– BBB INTACTBBB INTACT–– NO EDEMANO EDEMA–– NO ENHANCEMENTNO ENHANCEMENT–– NO TUMOR VESSELS NO TUMOR VESSELS
Benign Benign -- DiffuseDiffuse
HOMOGENEOUSHOMOGENEOUS–– NO NECROSISNO NECROSIS–– NO HEMORRHAGENO HEMORRHAGE–– INCREASED WATERINCREASED WATER
DARK and Poorly Demarcated on CTDARK and Poorly Demarcated on CTDark and Sharp on T1WDark and Sharp on T1WBRIGHT and Sharp on T2WBRIGHT and Sharp on T2W
–– MICROCYST >>> MACROCYSTMICROCYST >>> MACROCYST(macrocysts occur in JPA, etc.)(macrocysts occur in JPA, etc.)
1111
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Gr 2 Fibrillary AstrocytomaGr 2 Fibrillary Astrocytoma
T2PD
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T1-gadT1-non
Gr 2 Fibrillary Astrocytoma Gr 2 Fibrillary Astrocytoma
T2
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T1-gadT2
Gliomatosis CerebriGliomatosis Cerebri
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Astrocytoma: Microcystic changeAstrocytoma: Microcystic change
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Gliomatosis Cerebri:Gliomatosis Cerebri:Diffuse Astrocytoma Diffuse Astrocytoma –– 2 lobes2 lobes R
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Spread along White Matter TractsSpread along White Matter Tracts
1212
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Gliomatosis CerebriGliomatosis Cerebri
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CHO
Cr
NAA ?{Gliomatosis CerebriGliomatosis Cerebri
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MRS for the Complete IdiotMRS for the Complete Idiot
4 3 2 1 ppm
Lactate
Lipid
NAA
CR
Cho
MI Glx
Hunter’s Angle
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MRS MRS –– Hypothetical NeoplasmHypothetical Neoplasm
4 3 2 1 ppm
Lactate
LipidNAA
CR
Cho
MI
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Diffuse AstrocytomaDiffuse Astrocytoma
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1313
SPREAD ALONG WM TRACTS:SPREAD ALONG WM TRACTS:
Corona RadiataCorona RadiataPedunclesPedunclesCorpus CallosumCorpus CallosumAnterior Anterior CommissureCommissureArcuate FibresArcuate Fibres
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Pontine AstrocytomaPontine Astrocytoma
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Pontine Astrocytoma: WHO 2Pontine Astrocytoma: WHO 2
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Six Weeks Later
WHO 2 => GBMWHO 2 => GBM
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Expanded BrainExpanded Brain
Tracking Along WM – Uncinate Fasciculus
Anaplastic AstrocytomaAnaplastic Astrocytoma
1414
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Grade 3: Anaplastic AstrocytomaGrade 3: Anaplastic Astrocytoma
Astrocytoma
WHO 1Circumscribed
EnhancingFluid secreting
WHO 2-3Infiltrating
Water signalHomogeneous
Mild Mass effectNo enhancement
No Necrosis
WHO 3-4Infiltratingand Focal
HeterogeneousMass effect
EnhancementNecrosis
MyoInositol ⇑Perfusion ⇓
PWI ⇑Cho/Cr ⇑FDG ⇑
Lac/Lip ⇑
PilocyticSubependymal GC
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Anaplastic Astrocytoma: Anaplastic Astrocytoma: Overall CharacteristicsOverall Characteristics
Grade III malignant gliomaGrade III malignant gliomaLess aggressive than GBM, malignant with Less aggressive than GBM, malignant with somewhat better prognosissomewhat better prognosisFrequency: highest in young adults (30 Frequency: highest in young adults (30 –– 40 40 years)years)Recurrence: often as a higherRecurrence: often as a higher--grade gliomagrade gliomaChallenge: difficult to remove completely with Challenge: difficult to remove completely with surgerysurgeryMedian survival: 3 Median survival: 3 –– 4 years4 years
Anaplastic Astrocytoma: Cells, Vessels, but no necrosisAnaplastic Astrocytoma: Cells, Vessels, but no necrosis
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Anaplastic AstrocytomaAnaplastic Astrocytoma
Enhancement – But no necrosis
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Anaplastic AstrocytomaAnaplastic AstrocytomaNo Enhancement – Abnl MRS R
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Anaplastic AstrocytomaAnaplastic Astrocytoma
1515
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Anaplastic AstrocytomaAnaplastic Astrocytoma( WHO 3 )( WHO 3 )
No Enhancement – Clear Mass Effect
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Increased Cellularity, +/Increased Cellularity, +/-- minimal minimal vascular changes, no necrosis , no vascular changes, no necrosis , no
hemorrhagehemorrhage
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AstrocytomaAstrocytoma
Astrocytoma
WHO 1Circumscribed
EnhancingFluid secreting
WHO 2-3Infiltrating
Water signalHomogeneous
Mild Mass effectNo enhancement
No Necrosis
WHO 3-4Infiltratingand Focal
HeterogeneousMass effect
EnhancementNecrosis
MyoInositol ⇑Perfusion ⇓
PWI ⇑Cho/Cr ⇑FDG ⇑
Lac/Lip ⇑
PilocyticSubependymal GC
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GlioblastomaGlioblastoma
““MALIGNANTMALIGNANT”” ASTROCYTOMA:ASTROCYTOMA:Older patientOlder patient–– 4040’’s and ups and up–– exceptions (PNET)exceptions (PNET)–– ~ 1/2 arise from previous low grade (2~ 1/2 arise from previous low grade (2--3)3)
Abnormal Vessels (neovascularity)Abnormal Vessels (neovascularity)-- BBB abnormalityBBB abnormality–– vasogenic edemavasogenic edema–– contrast enhancementcontrast enhancement–– irregular vessels, shunting, etc.irregular vessels, shunting, etc.
HETEROGENEOUSHETEROGENEOUS–– hemorrhage (old/new)hemorrhage (old/new)–– tumor necrosistumor necrosis–– tumor itselftumor itself
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Glioblastoma multiformeGlioblastoma multiforme
1616
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Glioblastoma multiformeGlioblastoma multiforme
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Glioblastoma MultiformeGlioblastoma Multiforme
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Glioblastoma Glioblastoma –– WHO Grade 4WHO Grade 4
A solitary, deep, irregular, heterogenous, ring-enhancing mass with vasogenic edema.
Low NAA – High Choline/Creatine
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T1-gad T2
Glioblastoma MultiformeGlioblastoma Multiforme
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(Gr 4) Glioblastoma: PWI(Gr 4) Glioblastoma: PWI--CBVCBV
Increased perfusionIncreased perfusion
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MR Perfusion ImagingMR Perfusion Imaging
Courtesy of James Provenzale, Duke UniversityCourtesy of James Provenzale, Duke University
****
1717
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CT PerfusionCT Perfusion
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Early Draining Veins mean Short MTT
XX--Ray Perfusion ImagingRay Perfusion Imaging
Hypervascularity means ⇑ rCBV and ⇑ rCBF
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GBM GBM –– Thicker on SurfaceThicker on Surface
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Two Different Two Different GBMGBM’’ss
GBMGBMCenter of Abnl Center of Abnl Density/IntensityDensity/Intensity–– variegated necrosisvariegated necrosis
ENHANCING RIM– hypercellular, fleshy neoplasm– greatest neovascularityCorona of Corona of AbnlAbnl SignalSignal–– ““edematousedematous”” white matterwhite matter–– areas of microscopic neoplastic areas of microscopic neoplastic
infiltrationinfiltration
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GBM GBM -- GlioblastomaGlioblastoma
1818
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Pseudopalisading NecrosisPseudopalisading Necrosis
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