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Tumor of the Nervous System
Dr Wiwit Ade FW, M.Biomed, SpPA
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Normal Cells
The principal cells of the CNS : • Neurons : functional unit of nervous system.
(axon & dendrites) • Glia : derived from neuroectoderm
(macroglia: astrocytes, oligodendrocytes, ependyma) or from bone marrow (microglia),
• the cells that compose the meninges and blood vessels.
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Tumors of CNS
• Incidence : 10-17 per 100,00 person for intracranial tumor.
• 1/2 -3/4 : primary tumor, & the rest are metastatic.
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Primary Tumors of the Central Nervous System
–Glioma• Astrocytoma• Oligodendroglioma• Ependymoma
–Neuronal lineage–Meningioma–Nerve Sheath Tumors
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Primary brain tumors: Cell types
1. Neuron: Gangliocytoma, ganglioglioma medulloblastoma
2. Astrocyte: Astrocytoma, glioblastoma3. Oligodendrocyte: Oligodendroglioma4. Ependymal cell: Ependymoma5. Microglial cell: Tumors derived from
microglial cells 6. Meningeal cell: Meningiomas are derived
from arachnoidal cells and are usually dural-based.
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Primary Tumours of the CNSTumour Cells of origin Site Age Behavior
Oligodendroglioma oligodendrocyte hemisphere adulthood Low to highgrade
Astrocytoma Astrocyte HemisphereCerebellum
AdulthoodChildhood
Low to highgradeLow grade
Glioblastoma multiforme
Astrocyte Hemisphere Adulthood High grade
Ependymoma Ependyma IVth ventricleSpinal cord
AdulthoodChildhoos
High gradeLow grade
Meningioma Arachnoidal Meninges Adulthood Low grade
Medulloblastoma Neuroectoderm Cerebellum Childhood High grade
Haemangioblastoma
Unknown Cerebellum All ages Low grade
Lymphoma Lymphocyte Hemisphere Adulthood High grade
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Gliomas
• Diffusely infiltrating (not easily resected)• Histologic appearance (grade) correlates
with overall survival• May become more malignant (higher
grade) over time (especially astrocytomas which become glioblastomas)
• May spread via CSF• Rarely (never) metastasize
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GLIOMAS
• ASTROCYTOMAS
• OLIGODENDROGLIOMAS
• EPENDYMOMAS
• MIXED GLIOMAS
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• Spectrum : low grade – high grade• 2 major categories :
1. infiltrating2. non infiltrating : >> astrocytoma pylocitic
(grade I/IV).
ASTROCYTOMA
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ASTROCYTOMA
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ASTROCYTOMA
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Infiltrating Astrocytomas
• 80% of adult primary brain tumors.• Cerebral hemisphere.• Symptom : seizures, headache & focal
neurologic deficits.• Spectrum histophat diff : correlates with
clinical course & outcame.
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Spectrum of Infiltrating Astrocytomas
• Diffuse astrocytoma ( grade II/IV)
• Anaplastic astrocytoma ( grade III/IV)
• Glioblatoma ( grade IV/IV)
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Diffuse Astrocytoma
Macroscopic: • Poorly defined, gray, infiltrative tumor• Size : few cm- replace an entire hemisphere.• Cut surface : firm/ soft gelatinous, cystic degeneration. • Infiltrating beyond the outer margin : always present.
Microscopic examination :• Mild to moderate increase in glial cellularity, variable
nuclear pleomorphic, back ground a fibrillary app.• Transition between neop & normal tissue : indistinct.• Tumor cells can be seen infiltrating normal tissue.
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Diffuse Astrocytoma
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Anaplastic astrocytoma
• More densely cellular, greater nuclei pleomorphic, >> mitotic figure.
• Gemistocytic astrocytoma : astrocytoma with brightly eosinophilic cell body.
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AstrocytomaFeatures of Anaplasia
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Glioblastomas
• = glioblastoma multiforme• Variation in gross app.• Firm & white, soft & yellow (necrosis),
cystic deg, hemorrhage.• Microscopic = anaplastic, malignant tumor
cells, additional : 1. necrosis with pseudopalisading app. 2. vascular / endothelial prolif.
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Glioblastoma Multiforme
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Glioblastoma Multiforme
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Pylocitic Astrocytoma• Relative benign behavior• Grow very slowly th/ by resection• Symptomatic recurrence : incomplete resection
cystic enlargement, rather than growth of the solid areas.
• Children & young adults• Located in :
- >> the cerebellum.- floor & wall of Ventricle III- optic nerve- cerebral hemisphere
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Pilocytic Astrocytoma
Morphology :
• >> cyctic• Solid, well demarcated, << infiltrative
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Microscopic: • Tumor is composed of bipolar cells with
long, thin “hair like” processes dense fibrillary meshworks.
• Rosenthal fibers• Eosinophilic granular bodies.• Biphasic areas : loose microcystic pattern &
fibrillary areas.• Necrosis & mitosis : uncommon.
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Pilocytic Astrocytoma
Rosenthal fibers Eosinophilic granular bodies
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OLIGODENDROGLIOMA
• 5-10% glioma• 4-5 decadce• Symptom : >> seizures• Location : >> cerebral hemisphere ( white
matter)• WHO grade II/IV
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Morphology of Oligodendroglioma• Well-circumscribed, gelatinous, gray masses, >>
cyst, focal haemorrhage, & calcification.• Microscopic :
- sheet of regular cells with spherical nuclei containing finely granular chromatin (=normal oligodendricytes) surrounded by clear halo cytoplasm.- typically contain a delicate network anastomosing capillaries (thin walled capillaries).
- calcification : > 90% tumors (foci to massive)- mitotic activity : <<
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Anaplastic Oligodendroglioma• WHO grade III/IV• Increased cell density, nuclear anaplasia,
mitotic activity >>, necrosis.
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OLIGODENDROGLIOMA
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EPENDYMOMA• Arise next to the ependyma line ventricular system.• Behave as WHO grade II/IV• Anaplastic ependymoma : WHO grade II/IV.Macroscopic :• In ventricle IV : solid/ papillary mass ascending from the
floor of the ventricle.• Well demarcated.Microscopic:• Composed of cells with regular, round to oval nuclei &
abundant granular cromathin.• Gland like round/ elongated app ( perivascular rossetes) ,
tumor cells are surrounded vessels.
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EPENDYMOMA
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NON-GLIAL TUMORS
• Medulloblastoma: Malignant cerebellar tumor of childhood
• Meningioma: Benign, superficial, well-circumscribed tumor derived from arachnoidal cells
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MEDULLOBLASTOMA• Origin : neuroectodermal• Poorly differentiated• >> children , 20% of the brain tumor in children• Location : midline of the cerebellum (children)
lateral of the cerebellum (adult) • Rapid growth occlude the flow CSF hidrocephalus.• Macros : well circumscribed, gray.• Micros :
- extremly cellular, with sheet anaplastic cells- individual tumor cells: small, scant cytop, hypercromatic nuclei.- >> mitosis- Homer Wright rossette/ neurosecretory granules.
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Medulloblastoma
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Medulloblastoma
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MENINGIOMA• Benign tumor of adult• Location : attached to dura• Arise from the meningothelial cells of arachnoid.• Low risk of recurrence.• WHO grade I/IV• Macros :
- rounded masses, well defined dural bases that comprise underlying brain.- encapsulated, thin fibrous tissue.- growth : polypoid, plaque.
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Histological pattern
• Sincytial (“meningothelial”) : whorled clusters of cells without visible cells membrane
• Fibroblastic : elongated cells and abundant collagen deposition between them.
• Transtitional :share features between sincytial and fibroblastic type.
• Psammomatous : with psammoma bodies ( calcification of the syncitial nest of meningothelial cells)
• Secretory : PAS (+) intracytoplasmic droplets & intracellular lumen (electron microscopy)
• Microcystic : with a loose, spongy app.
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MENINGIOMA
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Sincytial (“meningothelial”)
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Fibroblastic
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Secondary Involvement of the Central Nervous System
• Metastatic Tumor –Melanoma–Renal cell–Lung
• Contiguous involvement (pituitary adenoma and craniopharyngioma)
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METASTATIC MELANOMA
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