The patient underwent stereotactic craniotomy and excision of both right frontal lesions. Histopathology, however, was inconclusive.
Histopathology: brain tissue: features of reaction to remote hemorrhage; no evidence of tumour seen. Further immunohistochemistry and special stains will be performed and a supplementary report issued.
SUPPLEMENTARY REPORT:
CD34 immunostaining highlights the intense vascularity of the lesion. No solid CD34 +ve tissue is seen. The features remain those of reactive vascular proliferation and resolving remote hemorrhage. Possible etiologies include embolus from atrial myxoma causing hemorrhagic infarction which is now resolving or the very remote possibility of a small metastasis of melanoma which has either undergone regression or has been destroyed by the local hemorrhage.
There were concerns that these lesions may represent malignant metastases, or an embolic phenomenon relating to this patient’s recently excised atrial myxoma. After further discussions between the neurosurgeons and the patient, two months later, in the hope of a definitive diagnosis, the patient underwent further surgery (stereotactic craniotomy and excision of right occipito-parietal metastasis).
Histopathology:
MICROSCOPIC DESCRIPTION:
1. The sections show fragments of cerebral cortex and white matter. The lumen of a superficial small caliber muscular artery is distended by myxomatous material containing stellate shaped myxoma cells. A poorly circumscribed collection of myxomatous material also containing myxoma cells is noted in cortex adjacent to this vessel. Myxoma cells are arranged singly, in cords and in peri-vascular pseudorosettes and have moderately pleomorphic round and oval hyperchromatic nuclei and delicate processes. No mitotic figures or areas of necrosis are identified. Adjacent brain tissue shows collections of haemosiderin filled macrophages consistent with previous haemorrhage and reactive proliferation of small capillaries. There is also moderate reactive astrocytic gliosis. The features are of embolic/metastatic myxoma consistent with an origin from atrial myxoma.
2. The sections show multiple fragments of cerebral cortex and white matter. These show foci of recent hemorrhage and reactive gliosis No evidence of tumor is seen.
3&4. The sections show fragments of fibrous tissue and an ectatic small caliber muscular artery in specimen 4. Specimen 3 contains a small nidus of small caliber vascular channels. These are lined by unremarkable endothelium. No evidence of tumor is seen in either specimen.
DIAGNOSIS:
1. Right occipital lesion: Embolic/metastatic myxoma arising from atrial myxoma.
2. Right occipital lesion: Cerebral cortex and white matter with non-specific reactive changes; no evidence of tumor seen.
3. Deep: Fibrous tissue containing a nidus of small caliber vascular channels; no evidence of tumor seen.
4. Abnormal artery: Ectatic small caliber muscular artery. No evidence of tumor seen.
Six months later, the patient re-presented with partial seizures of the right eye, and right lower limb.