UNC Neuro RadPath Conference

1. UNCNeuroRadPath Conference Yueh Z. Lee, MD/PhD October 26, 2011

2. Case #1 • 46 y/o female with history of NSCLC, who presents with confusion. History of paraspinal mass in right back/chest region, for which she received chemoradiation. • Pt transferred due to a mass found on head CT. • Operative Findings: • Large frontal mass that had clearly invaded the dura. Osseous invasion was also noted with hyperostotic effects.

3. Imaging Findings • CT • Large enhancing hyperdense mass, edema • Central necrosis • MRI • Heterogenous mass with central necrosis • DDX - large solitary metastatic lesion, meningioma, hemangiopericytoma

4. Pre - CT Post- CT

5. Pre –T1 T2 Post T1 rCBV

7. CD99 IHC

8. Ewing sarcoma / peripheral PNET (p-PNET) • Ewing sarcoma and peripheral PNET (p-PNET) are round cell sarcomas that show varying degrees of neuroectodermal differentiation and have characteristic molecular genetic abnormalities. • Ewing sarcoma/p-PNET rarely involves the CNS. • The molecular genetic abnormalities are chromosomal translocations involving a fusion of the EWS gene with a member of the Ets family of transcription factors, which leads to the expression of their chimeric fusion oncoproteins. • These characteristic translocations are not found in central PNET. The common molecular abnormalities in c-PNET include isochromosome17q and myc gene amplifications in patients with medulloblastoma or less commonly, supratentorial PNET. (Kazmi et al. DiagnMolPathol 2007;16:108–111) • It is important to distinguish peripheral and central PNETs, since they are biologically different entities. • Kazmiet al. DiagnMolPathol2007;16:108–111

9. Case #2 54 y/o female with intermittent bilateral facial numbness. Workup demonstrated sellar/clival lesion. Prior attempt at trans-sphenoidal biopsy resulted in significant intra-op bleeding.

10. Imaging Findings • CT • Destructive soft tissue mass extending from sphenoid sinus with clival and sellar floor destruction • MR • Heterogenous enhancing lesion in the clivus extending into the sphenoid sinuses. The lesion abuts the pituitary gland with associated osseous destruction.

11. Non-con CT

12. T2 Post-T1 Post-T1

13. ACTH production adenoma as shown in immunohistochemistry stain

14. Case #3 56 y/o male presents with dysarthria and LUE weakness, right facial droop. His exam stabilized, and he was discharged with close follow-up. Approximately 1 week later, he was readmitted with worsening symptoms.

15. Case #3 • Initial MRI • Randomly distributed lesions throughout the subcortical and deep white matter as above, with cystic centers and peripheral enhancement concerning for hematogenousspread of infection or metastases. • “Final” MRI • Multifocal randomly distributed lesions throughout the subcortical and deep white matter • Concerning for Balo’s concentric sclerosis

16. Initial MRI FLAIR Post T1

17. Subsequent MRI T2 FLAIR Post –T1 Post –T1

20. Tumefactive Demyelinating Disease • Tumefactive MS — presentation of MS lesion as a large mass lesion that mimics a neoplasm clinically and radiologically. • Neurologic abnormaliites depends on size and location of lesion and may be subacute or chronic. • The tumefactive MS lesion is typically supratentorial and often presents with hemiparesis, hemisensory loss, visual field defects, decreased consciousness, or seizures. • Imaging features include size of the lesion >2 cm, mass effect, edema, ring enhancement, peripheral restriction on diffusion-weighted imaging (DWI), and venular enhancement. • Most patients with tumefactive MS go on to develop typical relapsing-remitting MS. Monophasic cases occur but are uncommon. • The pathogenesis of tumefactive MS is unknown. It has been suggested that tumefactive MS falls within the spectrum of MS rather than being an intermediate entity between MS and ADEM or a distinct variant of MS. • Wu and Lucchinetti. SeminImmunopathol (2009) 31:439–453

21. Case #4 40 y/o male with a chroniicleft facial paresis, recently Multiple prior MRIs were negative. Subsequent recent MR demonstrated a geniculate ganglion mass.

22. Imaging Findings • MR • Enhancing lesion seen at the level of the left geniculate ganglion. Contiguous spread of enhancement to the lateral wall of the ipsilateral cavernous sinus and dura of the middle cranial fossa. • DDx • lymphoma, or perineural spread of neoplasm, 1ry tumor

23. Post –T1 T2 Post –T1

24. Imaging Findings • Temporal Bone CT • Lesion centered at left geniculate ganglion with stippled calcifications. • Most likely DDx • Geniculate ganglion hemangioma

25. Non-con CT

28. Hemangioma of the Geniculate Ganglion (GG) • Incidence was 0.7% in a series of1,430 intratemporal bone vascular tumors. • Historically termed “hemangioma,” but now thought to represent a venous malformation rather than a true neoplasm. • Speculated to arise from the rich vascular network surrounding the GG. This vascular network receives its blood supply from the petrosal artery, which is a branch of the middle meningeal artery. • Geniculate ganglion hemangiomaspresent with facial nerve dysfunction at an early stage. • Because of the relative disparity between the facial nerve dysfunction and the small size of the hemangioma, it is suggested that some of the nerve dysfunction may be due to vascular steal and nerve ischemia. • . • Semaan et al. OtolNeurotol 31:665Y670, 2010