Neuro-Oncology

This 63-year-old patient with non-small cell lung cancer and solitary brain metastasis was treated with surgery followed by adjuvant fractionated stereotatic radiation therapy. Additional treatments included chemoradiotherapy to the lung primary tumor followed by immunotherapy. She developed symptomatic radiation necrosis 18 months after stereotatic radiation therapy. She was treated with steroids without relief and ultimately underwent surgery, which confirmed the diagnosis of radiation necrosis. (A) T1 post-contrast sequence with typical “cut green pepper” ring enhancement. (B) ADC is typically elevated in the area of radiation necrosis. (C) Perfusion MRI typically shows decreased relative cerebral blood volume in the area of radiation necrosis. (Contributed by Dr. Puyao Li.)

This 69-year-old woman presented with confusion and word-finding difficulties. Brain MRI was obtained and showed a dominant 2.5 cm enhancing lesion in the left temporo-occipital lobe (1A). Multiple other enhancing lesions were seen, including a 7 mm left frontal gyrus (1D). Chest CT showed no evidence of a primary tumor. After multidisciplinary discussion, resection of the left temporal lesion was recommended. She was taken for a left temporal craniotomy, and the tumor was removed en bloc. Pathology from the surgery showed metastatic adenocarcinoma, and immunohistochemistry was consistent with a lung primary origin. Postoperative MRI (1B) showed no evidence of residual disease. She was evaluated by thoracic medical oncology, neuro-oncology, and radiation oncology. Postoperative radiation therapy was recommended for the resection cavity, along with stereotactic radiosurgery to the residual lesions. The resection cavity was treated with 3D conformal radiation to 30 Gy in 10 fractions (1C), and stereotactic radiosurgery was delivered to the intact lesion, 18 Gy in 1 fraction (1E.) Following completion of radiation therapy, she was treated with carboplatin, pemetrexed, and pembrolizumab. She showed no evidence of further CNS disease over 1 year after presentation. (Contributed by Dr. Helen Shih.)

Progression of Axial T2 MRI findings in a 13-year-old male with a diffuse pediatric-type high-grade glioma, H3-wildtype and IDH-wildtype. (a, b) Obtained at time of diagnosis, MRI shows a diffuse, expansile T2 hyperintense signal that involved the corpus callosum and extended into the right cerebral hemisphere and cortical spinal tracts. (c, d) At the completion of radiation, MRI showed a slight increase in the T2/FLAIR hyperintensity in the subcortical white matter of the frontal lobes. (e, f) Two months after radiation, the tumor showed increased infiltration into the left cerebral hemisphere with midline shift to 11 mm. (g, h) After 8 months of this therapy, there was a significant decrease in enhancement along the corpus callosum, left peritrigonal white matter, and the centrum semiovale. (Contributed by Dr. Elizabeth Finch.)

Large right frontal mass with cystic and solid components. The lesion shows evidence of hemorrhage and areas of calcification (panel C). (A) Axial T1 post-contrast imaging. (B) Axial T2 flair image. (C) Sagital T1 flair image. (Contributed by Dr. Adriana Fonseca.)

MRI in a 72-year-old man with pituitary apoplexy demonstrates a sellar and suprasellar heterogeneous lesion with high T1-signal within the mass compatible with acute hemorrhage as well as evidence of laterosellar macroadenoma. (Source: Drissi Oudghiri M, Motaib I, Elamari S, Laidi S, Chadli A. Pituitary apoplexy in geriatric patients: a report of four cases. Cureus 2021;13[12]:e20318. Creative Commons Attribution License [CC-BY 4.0].)

MRI demonstrates enhancement of a sellar and suprasellar heterogeneous lesion in a 72-year-old man with pituitary apoplexy. (Source: Drissi Oudghiri M, Motaib I, Elamari S, Laidi S, Chadli A. Pituitary apoplexy in geriatric patients: a report of four cases. Cureus 2021;13[12]:e20318. Creative Commons Attribution License [CC-BY 4.0].)

MRI in a 72-year-old man with pituitary apoplexy demonstrates a sellar and suprasellar heterogeneous lesion with high T1-signal within the mass compatible with acute hemorrhage. The patient presented with sudden onset of left ptosis with a complete third nerve palsy evident on examination. He underwent endoscopic endonasal transsphenoidal resection of the pituitary adenoma. There were no postoperative complications, and he completely recovered 10 days postoperatively. Anatomopathological examination of the resected tumor showed a nonsecreting pituitary macroadenoma. (Source: Drissi Oudghiri M, Motaib I, Elamari S, Laidi S, Chadli A. Pituitary apoplexy in geriatric patients: a report of four cases. Cureus 2021;13[12]:e20318. Creative Commons Attribution License [CC-BY 4.0].)

CT in a 31-year-old man with pituitary apoplexy precipitated by systemic chemotherapy demonstrates expansion of the sella consistent with a prior slow-growing tumor. (Source: Hamrick FA, Findlay MC, Rennert RC, Budohoski KP, Couldwell WT. Pituitary apoplexy precipitated by systemic chemotherapy. Cureus 2022;14[3]:e23004. Creative Commons Attribution License [CC-BY 4.0].)

MRI from a 31-year-old man with pituitary apoplexy precipitated by systemic chemotherapy demonstrates expansion of the sella consistent with a prior slow-growing tumor. Enhancement of the sphenoid sinus mucosa is also seen (gray arrows), which has been linked to higher intrasellar pressures and more severe pituitary apoplexy. (Source: Hamrick FA, Findlay MC, Rennert RC, Budohoski KP, Couldwell WT. Pituitary apoplexy precipitated by systemic chemotherapy. Cureus 2022;14[3]:e23004. Creative Commons Attribution License [CC-BY 4.0].)

MRI in a 31-year-old man with pituitary apoplexy precipitated by systemic chemotherapy shows a 2.0×2.8×2.1 cm sellar and suprasellar mass with upward displacement of the optic chiasm (white arrow) and internal blood products. (Source: Hamrick FA, Findlay MC, Rennert RC, Budohoski KP, Couldwell WT. Pituitary apoplexy precipitated by systemic chemotherapy. Cureus 2022;14[3]:e23004. Creative Commons Attribution License [CC-BY 4.0].)

MRI in a 31-year-old man with pituitary apoplexy precipitated by systemic chemotherapy shows a 2.0×2.8×2.1 cm sellar and suprasellar mass with upward displacement of the optic chiasm (white arrow) and internal blood products. The pituitary stalk and gland are displaced to the left, best seen on this postcontrast image. There is heterogeneous enhancement of the sellar and suprasellar mass. (Source: Hamrick FA, Findlay MC, Rennert RC, Budohoski KP, Couldwell WT. Pituitary apoplexy precipitated by systemic chemotherapy. Cureus 2022;14[3]:e23004. Creative Commons Attribution License [CC-BY 4.0].)

A 31-year-old man with a recent diagnosis of seminomatous germ cell testicular cancer with metastases to the pelvis and retroperitoneum presented to the emergency department with several days of severe, progressive bifrontal headaches, nausea, and right-sided blurry vision 1 week after initiating chemotherapy (bleomycin, etoposide, and cisplatin). Neurologic examination was normal except for decreased right temporal visual acuity. MRI showed a 2.0×2.8×2.1 cm sellar and suprasellar mass with upward displacement of the optic chiasm (white arrow) and internal blood products. He underwent urgent transnasal transsphenoidal surgery. Pathological analysis showed a partially necrotic and hemorrhagic adenoma with rare growth hormone– and adrenocorticotropic hormone–positive tumor cells, with a low proliferation rate (Mib-1 less than 2%).. (Source: Hamrick FA, Findlay MC, Rennert RC, Budohoski KP, Couldwell WT. Pituitary apoplexy precipitated by systemic chemotherapy. Cureus 2022;14[3]:e23004. Creative Commons Attribution License [CC-BY 4.0].)

Pathologically confirmed IDH-mutant diffuse astrocytoma. Axial MRI with a 26 mm x 23 mm x 18 mm in the L frontal cortex that is T2 (left) and FLAIR (middle) bright. No evidence of enhancement on T1 post-contrast (right). (Contributed by Dr. Orwa Aboud.)

In WHO CNS-5, all IDH-mutant infiltrating astrocytomas are considered a single entity (ie, astrocytoma, IDH-mutant) and are graded as CNS WHO Grade 2, 3, or 4 depending on both histologic and molecular features. (Reproduced from: Weller M, van den Bent M, Preusser M, et al. EANO guidelines on the diagnosis and treatment of diffuse gliomas of adulthood. Nat Rev Clin Oncol 2021;18(3):170-86.)

One of the most-used decision paradigms for selecting appropriate management for spinal metastatic disease is the NOMS framework, which takes into account neurologic, oncologic, mechanical, and systemic considerations to optimize treatment. (Contributed by Dr. Deric Park.)

This section from a 23-year-old woman shows a classic PXA with bizarre, multinucleated giant cells, lipidized cells, EGBs, and chronic inflammatory infiltrates more prominent on the left lower aspect of the image. (Hematoxylin and eosin, 10x) (Contributed by Dr. Elena Daoud.)

This section from a conventional pleomorphic xanthoastrocytoma in a 23-year-old woman shows the intense reticulin staining outlining individual cells that is classic for this tumor. (reticulin, 20x) (Contributed by Dr. Elena Daoud.)

MRI of a patient with H3K27M-mutant midline glioma. (2A) Brain MRI axial view, post gadolinium contrast with heterogenous enhancement in the left thalamus. (2B) Brain MRI T2 flair sequence with expansile hyperintensity in the left thalamus without surrounding edema. (2C) Brain MRI sagittal view post gadolinium contrast with heterogenous enhancement in the left thalamus. (Contributed by Dr. Jigisha Thakkar.)

MRI of a patient with H3K27M mutant midline glioma. (1A) Brain MRI axial view post gadolinium contrast with heterogenous enhancement in the pons. (1B) Brain MRI T2 flair sequence with expansile hyperintensity in the pons without surrounding edema. (1C) Brain MRI coronal view post gadolinium contrast with heterogenous enhancement in the pons. (Contributed by Dr. Jigisha Thakkar.)

Photomicrograph of tumor immunostained with biotinylated anti-Hu IgG showing staining of some nuclei of tumor cells (dark blue color). Counterstaining with hematoxylin produces the light blue color of the negative cell nuclei. (Contributed by Dr. Francesc Graus.)

Axial FLAIR MRI showing increased signal abnormalities in the medial aspect of temporal lobes (arrows). (Contributed by Dr. Francesc Graus.)

Coronal MRI of left frontal diffuse astrocytic glioma, IDH wildtype, with molecular features of glioblastoma CNS WHO grade 4 demonstrating on post-contrast sequences a minimally enhancing mass (A) with associated mass-like FLAIR but without marked edema (B). (Contributed by Dr. Jennie Taylor.)

Sagittal and axial images demonstrate two intradural extramedullary lesions in the thoracic (A, C) and lumbar region (B, D) consistent with metastatic spinal myxopapillary ependymoma. This patient presented at 11 years of age with a spinal mass in the lumbar region but has had multiple masses in the spinal canal and intracranial compartment from seeding of this malignant type of myxopapillary ependymoma. (Contributed by Dr. Diana Gomez-Hassan.)

The lesion of this 9-year-old girl who has had seizures for more than 3 years is cortically based and has a hyperintense signal on the T2-weighted MR image (left) with a multicystic component that was mistaken for the flow-voids of a cavernous angioma. On the T1-weighted image with gadolinium contrast (right), the lesion is isointense to surrounding brain with some serpentine contrast enhancement. (Contributed by Dr. Scott Mintzer.)

Because of progressive neurologic decline, this patient underwent for the third time. Hypointensity was increased on T1-weighted images, and sulcal and meningeal enhancement was evident. There was evidence of worsening of the abnormalities previously noted on FLAIR and diffusion-weighted imaging and a new area of restricted diffusion in the left thalamus. (Contributed by Dr. Jon Glass.)

Coronal T2/FLAIR-weighted MRI showing a mass-like hyperintensity in the left uncus containing a central cystic region, distinct margins, and lack of surrounding edema, consistent with a low-grade ganglioglioma. (Contributed by Dr. Sarah Lapointe.)