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Case Study 2

Case Study 2. Harry Kellermier. Question 1.

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Case Study 2

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  1. Case Study 2 Harry Kellermier

  2. Question 1 The following smear is from an intraoperative consultation for an 81-year-old female who presents with progressive loss of vision in her left eye and a large mass in the temporal region of her scalp.  Imaging is not available.  Intraoperatively, the surgeon informs you that the tumor involves the dural aspect of the skull as well as the skin surface.  Describe the following smear taken during this procedure. Click here to view slide.

  3. Answer a.  Cellular lesion
b.  Pseudosyncytial pattern
c.  Whorl-like structures
d.  Cells show:
     i.  Pulled taffy cytoplasm
    ii.  Intranuclear pseudoinclusions
   iii.  Some show prominent nucleoli
e.  Mitoses are easily found

  4. Question 2 What would the intraoperative consultation be based on the previous smear? (A: Category such as Defer, Reactive, or Neoplastic; B: More specific diagnosis, C: additional information)

  5. Answer a.  A: Neoplastic
b.  B: Meningioma
c.  C: A high grade lesion cannot be excluded

  6. Question 3 Describe the microscopic findings on the permanent section from the intraoperative specimen. Click here to view slide.

  7. Answer a.  Hypercellular neoplasm composed of atypical cellsb.  Pseudosyncytial appearancec.  The tumor invades soft tissued.  Whorls and Whorl-like arease.  Vaguely fascicular architecturef.  Areas of sheetingg.  Cells with prominent nucleolih.  Greater than 20 mitoses per 10 high power fields 

  8. Question 4 What is the differential diagnosis based on the H&E slide?

  9. Answer • Spindle cell carcinoma • Anaplastic meningioma • Leiomyosarcoma • Melanoma • Atypical fibrous xanthoma/malignant fibrous histiocytoma • Hemangiopericytoma with atypical features • Solitary fibrous tumor with atypical features

  10. Question 5 What immunohistochemical stain would you order to narrow your differential diagnosis?

  11. Answer • EMA (Positive in meningioma) • Ki-67 (Assess proliferative ability of tumor) • S100 (Positive in melanoma) • SMA (Positive in leiomyosarcoma) • CD34 (Positive in solitary fibrous tumor and hemangiopericytoma) • BCL-2 (Positive in solitary fibrous tumor • Cytokeratins (Positive in carcinomas) • Vimentin (Positive in meningiomas and other tumors)

  12. Question 6 What is the proliferation index of this tumor? Click here to view slide.

  13. Answer 20-30%

  14. Question 7 The EMA and vimentin come back positive.  What is your diagnosis? Click here to view slide.

  15. Answer Anaplastic meningioma

  16. Question 8 What is the characteristic appearance of a meningioma on MRI?

  17. Answer • Enhancing • Dural tail

  18. Question 9 Name the subtypes of meningiomas

  19. Answer Anaplastic; Rhabdoid; Papillary; Atypical; Chordoid; Clear cell; Meningothelial; Fibrous; Transitional; Microcystic; Psammomatous; Angiomatous (Don't use the term angioblastic meningioma.  That's an old term for a hemangiopericytoma); Metaplastic; Secretory; Lymphoplasmacyte-rich

  20. Question 10 What WHO grade are most meningiomas?

  21. Answer WHO grade 1

  22. Question 11 What subtypes are considered WHO grade 2?

  23. Answer a.  Atypical b.  Chordoid c.  Clear cell

  24. Question 12 What histologic characteristics are needed to make a diagnosis of atypical meningioma?

  25. Answer a.  4 mitoses per 10 hpfb.  3 out of the following 5 criteria:       i.  hypercellularity      ii.  necrosis     iii.  macronucleoli      iv.  small cell change      v.  sheeting

  26. Question 13 What subtypes of meningioma are considered to beWHO grade 3?

  27. Answer a.  Anaplastic b.  Rhabdoid c.  Papillary

  28. Question 14 What histologic characteristic is needed to make adiagnosis of anaplastic meningioma?

  29. Answer 20 mitoses per 10 hpf

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