BRAIN NEOPLASMS ON YOUR

DINNER TABLE
Dr. Alfred Odhiambo

Fellow, Neuroradiology (MIR)

Lecturer : University of Nairobi

 Lets start with the French binge…

• Members of the International Society of Neuropathology,

International Academy of Pathology and the Press
Foundation for Brain Tumor Research met in Lyon France
for several bottles of wine.
• In one of their many lengthy discussions they argued on
whether they should spell neoplasms as tumour or tumor!
• On the last day they concorted a classification now referred
to as the latest WHO revision.
 The WHOs who’s who of brain tumors.

1. Neuroepithelial tumors; glioma.

2. Neuronal and mixed glial tumors; DIGG.
3. Pineal region tumors; pineoblastoma.
4. Embryonal tumors; medulloblastoma.
5. Meningeal tumors; meningioma.
6. Peripheral neuroblastic tumors; neuroblastoma.
7. Lymphoma and hemopoietic tumors; microglioma.
8. Germ cell tumors; germinoma.
9. Tumors of cranial and spinal nerves; neurofibroma.
10. Metasases; death b chocolate.
 The beauty….

• The count of items is equal to the number of

toes that I have.
• So the only task is to assign a tumor type to a
toe!
The attraction ends once you look closely..
The neuroepithelial tumors are a whole clan!
• Astrocytoma.
• Astroblastoma.
• Chordoid glioma.
• Ependymoma.
• PXA.
• GBM
• Gliosarcoma.
• Gliomatosis cerebri.
• CPP.
• Oligodendroglioma.
• etc
Trust the pathologist to add insult to
injury splitting hairs..
Sample their adjectives on meningiomas….
1. Fibrous (fibroblastic).
2. Transitional (mixed).
3. Psammomatous.
4. Angiomatous.
5. Secretory.
6. Lymphoplasmacyte – rich.
7. Chordoid.
8. Papillary.
9. Rhabdoid.
10. Clear cell.
11. Microcystic.
12. Anaplastic.
 Disappointed by the West we
naturally turn East…

• Academics may not be our first love.

• Food always is.
• Tag tumor to food and you have arrived!
 Driving home the brain-food axis.

 Love for food is near universal.

 For many food is the source of our existence.

For an equal number it is the reason for our

existence.
Imagine you are challenged with a pleasant dish blind-
folded the first taste is critical….
 The first distinction you will need to make is
whether the food is a fruit , a meat or a
vegetable.
 A neuro-radiologist goes through a similar
mental exercise.
 Your first task is to decide whether a lesion is
intra or extra axial.

Multiplanar MRI has this task not

only simpler but also enjoyable.
Where is your reward for the toil?
 The most common extra-axial mass is a meningioma readily
treatable and diagnosable lesion.
 On the other hand when you are confronted with a solitary
intra-axial mass in an adult brain the odds are nearly even
that the lesion is either a solitary metastasis or a primary
brain tumor.
When do you decide that a lesion
is intra-axial?
 It expands the cortex of the
brain.
 There is no expansion of the
subarachnoid space.
 The lesion spreads across
well defined boundaries.
The hypointense dura and pial
blood vessels are peripheral
to the mass.
 Is the separation always so
neat?
 Extraaxial lesions including aggressive meningioma and
dural metastases may invade the underlying brain.
 This unsual finding may occur with lymphoma, GBM and
parenchymal metastases.
Astrocytoma that never was.
 There is a price for
misinterpretation…

 If you err in you gustatory analysis all your ruminations

will be flawed.
 Do understand that one may run across a soy burger
that is difficult to label as an animal or vegetable
product.
 Is biopsy the solution?
 Not always especially for some oversized low priced
samosas from Burma.
 Here biopsy may come back as vegetable filling or rodent
hair clearly a case of sampling error.
 You know where I am headed when you remember brain
tumours of mixed grade.
Becoming the top dog

 You must go the full hog beyond the axial

localization test so that you also appreciate
qualities such as the shape (margination)
consistency (solid) and whether there is
calcium or hemorrhage.
 Then is the after taste or contrast
enhancement which is vital in predicting
vascularity as well as integrity of the BBB.
 Astrocytic tumours
 If one took all patients with a single mass in supratentorial
compartment the odds would be nearly even that the lesion is
an astrocytoma or a metastasis.
 Varieties remind us of forms or steak from sirloin to T-Bone
and are similarly graded.
 Grade 2

 Can occur anywhere but one third is seen in the frontal lobes
while another one-third is in the temporal lobes.
 The last third is in the posterior fossa.
 Extent of the lesion goes beyond signal abnormality at imaging.
New avenues with diffusion tensor imaging.
Low grade astrocytoma.
  Also called anaplastic
Grade 3 astrocytoma .
 Occur most commonly in the
4th and 5th decades.
 Usually evolve from lower
grade astrocytomy .
 Borders are ill defined with
prolific vasogenic oedema.
When all astrocytoma are
considered, anaplasia occurs
in 75% to 80% with ultimate
transformation to GBM in
50% of cases.
 Anaplastic
astrocytoma

 T2WI; heterogenous.
Hyperintense. Oedema with
finger like projections along
white matter tracts
 The lethal GBM
 Depicted as a meat GBM would be
represented by liver and onions.
 Just the thought turns your stomach.
 Can occur anywhere in the brain but with
marginal occipital sparing.
 Characterized at imaging by necrosis.
 Histologic grade roughly parallels
patients advancing age.
GBM

• CECT: nodular rim

enhancement
• Marked oedema
Butterfly
GBM

 T1WI T1Gd T2WI

 Heterogenous mass crosses corpus
callosum splenium. Peripheral
enhancement. Oedema on T2.
 Could it get worse?
 Yes in the gliosarcoma a GBM/mesenchymal tumour.
 Given the choice the cannibal would give it a pass.
 Constitute 2% of GBMS
…Gliomatosis
Cerebri

 T1WI: Mass effect lt thalamus

 Thickened gyri n T1Gd: no
enhancement
BSG
 Juvenile pilocystic astrocytomas
 Can be likened to a blowpop with a bubble gum centre
surrounded by candy.
 Imaging shows a predominantly cystic lesion with an
enhancing mural nodule.
 Seen in children pilocytic astrocytomas are usually well
outlined from normal brain.
 Favored sites of JPA
 60% are seen in the posterior fossa.
 The typical cerebellar astrocytoma
in the pediatric age group is cystic in
60-80% of cases.
 When seen in the optic chiasm third
ventricle region they will be
associated with neurofibromatosis.
 Chiasmatic hypothalamic
astrocytomas may present with the
diencephalic syndrome characterized
by weight loss, motor hyperactivity
and euphoria.
 Talk of tots sucking on blow pops
with a sugar buzz.
 PILOCYTIC ASTRO.

 CECT T1Gd T2WI

 19YM. Pilocytic astro right basal ganglia

JPA image gallery.
 “Sticky buns”
 Ependymomas are like sticky buns getting stuck to everything
they touch and are very hard to clean.
 Therefore recurrence after surgery is common.
 Origin in 4th ventricle may result with a presentation as a
cerebellopontine angle.
 Can occur anywhere in the neural axis.
Ependymomas; image gallery.
 Ribeye Steak
 Oligodendrogliomas are the ribeye steak of glial tumours.
 They may have calcification (bones) soft tissue (meat) and
low density areas (fat).
 Hemorrhage occurs in 20% as does cyst formation.
 At MRI heterogeneity of signal is the watchword.
Oligodendroglioma at CT and MR.
 Cooked eggs

 Meningioma can be likened to cooked eggs.

 The common mixed and syncytial types are very similar to
eggs cooked easy what with a central hypodensity and a
trailing dural based edge which would represent the whites
of the egg at the periphery.
 Fibrous meningioma on the other hand are wholly ovoid
like a hard boiled egg.
 There are exceptions

• Eggs are not always benign

• So too are meningiomas.
 The gender gap
 Whether intracranial or intraspinal meningioma more
commonly affect middle aged women.
 Its high frequency translates to wider age groups and men
becoming victims of cross fire.
Cribriform plate meningioma
 Jelly Beans
 Think of jelly beans when you consider nerve sheath
tumours.
 They come in many colours and flavours so do varieties of
schwannomas and neurofibromas arising from many of the
cranial and peripheral nerves.
 The conglomerate
 One occassionally gets a sticky conglomerate of
multiple moist jelly beans. This is akin to the
plexiform neurofibroma.
 In the end jelly beans are sweet and neurogenic
tumors are benign.
epidermoids
pineal
 Embryonal tumours
 There has been a recent impetus to rename medulloblastomas and
similar cell line tumours as primitive neuroectodermal tumors (PNET).
 The food equivalent then is a peanut in any case there is no cell line
called the “medullo cell”.
 The high nuclear cytoplasmic ratio is responsible for the blue
appearance at histology and underscores the solid “peanut” nature.
Further spread the subarachnoid space makes the peanut butter sugar
analogy relevant.
 Cause for indigestion
 20% of medulloblastomas are seen in adults and they tend
to be eccentric in location.
 The less common desmoplastic medulloblastoma may arise
in extraaxial location.
 It is an exotic fish fit for serving the unsuspecting surgical
resident leading to gastric discomfort.
 Hemangioblastomas
 This is the most common primary intraparenchymal cerebellar mass
in adults.
 This benign lesion is highly curable with surgery.
 The stereotypical imaging appearance is that of a mass with a solid
mural nodule which is highly vascular.
 Think of red strawberry in cream.
 Lymphomas
 May be thought of rotten apples of the smorgasbord
while rotten apple juice coats the ventricles.
 Tend to be located in deep gray matter nuclei.
 Coating of the ventricles is seen in 38% .
 Meatballs
 When you think of metastases think of meatballs.
 How else would you imagine round masses near gray-white
matter cerebral junction which enhance with contrast.
 Yes a single meat ball provokes a lot of thought just as a sing
metastases.
Image gallery
 Dural metastases
 Look like peanut butter spreading out along the bread
coating it in an ominous film.
 The culprits are breast, bronchus, black melanoma and big
prostates.
 Atypical lesions
 Virtually all metastases evoke some vasogenic oedema.
 Sometimes however like a smashed meatball that rolled off
the table onto the floor metastases may be ill defined and
infiltrate with incredible brain swelling.
 Epileptogenic tumours
 Commonly located in the periphery of temporal lobes they
arise from subpial astrocytes.
 May show a base in meninges in upto 70% of cases.
 Because of predilection for temporal lobes they cause
seizures in most cases.
 Homogeneous contrast enhancement is common.
 The shopping list
 DNETS
 PXA
 GG
 O.D.
 Abbreviations confusing but exciting.
 Like word salads they fill you up and really taste the same.
Miniskirt menu for tumors associated with epilepsy.
 Intraventricular tumors.

• Reminds me of a shipping expedition.

Intraventricular tumors.
(types of fish)
 Chordoid glioma

 Described in 1998 they are

tumours of the anterior 3rd
ventricle and hypothalamus.
 Are assigned WHO grade II.
 The lesion is slow growing
solid, well circumscribed and
avidly enhancing.
 Look like little olives sitting
at the third ventricle except
for lack of pigmentation.
 Looking into the future.
• Pretreatment evaluation in the coming decade may include a
look into the genetic code for the tumor.
• 30% of astrocytomas express in deficiency TP53, a tumor
suppressor gene on chromosome 17p which encodes for the
p53 protein.
• Oligodendrogliomas show allelic loss on 1p and 19q.
• RB gene is important for cell cycle arrest and is modulated
by genes at many other sites.
 Importance of the letter and number salad.
• As molecular imaging takes off imaging will
target these hot genes, drugs or viruses
directed at the defective genes.
• Adenoviruses that can replicate in cells
deficient in TP53 have been developed. They
selectively kill tumor cells.
• Interferon with anti-angiogenic shown to
suppress certain tumors.
• Retoviruses encoding for VEGF have been
implanted and suppress angiogenesis in rats.
As go rats so will man the larger rodent
version
 T1 FFT2 DIR VBM MTR

Image showing abnormalities with novel MRI contrasts in the left frontal lobe that
were not detected on conventional MRI
Imaging is your partner not
nightmare.