Presentation
Seizure and visual field loss.
Patient Data
In the left occipital and parietal lobe a heterogeneous mass with calcification and enhancing and cystic components is present with surrounding edema.
Prominent senescent basal ganglia calcification is noted incidentally.
A heterogeneous mass in the left parieto-occipital region with prominent hemosiderin staining and calcium (better seen on CT) has enhancing components as well as cystic components. Intrinsic T1 signal hyperintensity is in keeping with subacute blood.
The rCBV map is impossible to interpret given the amount of T2* effect from hemosiderin and calcification. Similarly, ADC values are difficult to interpret especially as the solid enhancing component is stretched into septae rather than nodular and coated in hemosiderin.
Conclusion
This is an unusual-appearing mass, most likely representing a tumor rather than a very large unusual cavernous malformation; the amount of enhancing tissue is excessive. It most likely represents a primary brain tumor and although a glioblastoma could have this appearance the prominence of calcification, blood and lack of convincing infiltrating component raises the possibility of alternative diagnoses e.g. supratentorial ependymoma, pilocytic astrocytoma, parenchymal neurocytoma etc...
Case Discussion
The patient went on to have a resection.
Histology
The sections show brain parenchyma with necrosis, calcification, cholesterol deposition and inflammation associated with a gliofibrillary neoplasm. The neoplastic cells have round-to-oval nuclei, speckled chromatin and granular eosinophilic cytoplasm. There is abundant pigmentation. Perivascular pseudo-rosettes are present. Some tumor cells have pleomorphic nuclei. There is necrosis present. The mitotic count is 1 per 10 HPF.
Immunohistochemistry
The tumor cells are GFAP positive. They show perinuclear dot-like staining with EMA.
Final diagnosis
Supratentorial ependymoma (WHO Grade 3).
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