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AMENDED - Per Dr. J. Jacobsohn, add diagnosis rendered by Dr. Peter Berger, Johns Hopkins
Hospital, 01/13/04

Date Collected 12/10/03; Date Received 12/10/03; Date Reported 01/15/04

GROSS AND MICROSCOPIC DIAGNOSIS:

A - E.  Brain, right occipital lobe, excision:
MALIGNANT UNDIFFERENTIATED POLYGONAL CELL NEOPLASM.  See Comment.

Comment:  The mass in this patient's occipital lobe is clearly a malignant neoplasm though its site
of origin and derivation are unclear, in spite of the many diagnostic studies performed.  It is most
likely a matastic carcinoma or melanoma though it does not stain with epithelial or melanocytic
markers.  The brisk pilocytic astrocytic proliferation adjacent to the malignant cells suggest the
possibility of a pilocytic astrocytoma though the astrocytic proliferation is most likely reactive.  If it is
neoplastic the polygonal cells may represent a malignant transformation of the underlying low grade
glioma.  Such events are uncommon and the malignant cells do not stain with glial markers.  The
malignant cells do not stain with markers for germ cell tumors, a lymphoma, or a variety of
sarcomas.

[ADDENDUM REPORT]
Dr. Peter Berger at Johns Hopkins Hospital, Baltimore, Maryland, has reviewed this case and
rendered the following diagnosis (S03-67357)

Brain (J9949): MALIGNANT NEOPLASM, SEE COMMENT.
COMMENT:  The lesion is difficult to classify.  It has a mitotically active GFAP-negative epithelioid
component and a GFAP-positive spindle cell component with Rosenthal fibers and eosinophilic
granular bodies.  In areas, the latter tissue suggests gliosis but in others is rather cellular and
consistent with a neoplasm.  The large cells are often perivascular if not within the vessel wall, and
enmeshed in reticulin.  These cells are immunonegative for multiple antigens, i.e. HMB-45, EMA,
Factor VIII, AFP, HCG, Synaptophysin, and desmin.  If the FGAP-positive component is neoplasm,
which we believe it is, then the lesion is best viewed as primary.  The relation of the epithelioid cells
with the vessels raises the issue of gliosarcoma.

PREOPERATIVE DIAGNOSIS:
Right occipital lesion

OPERATIVE PROCEDURE AND FINDINGS
Right occipital lesion

INTRAOPERATIVE DIAGOSIS
SMA + TPB: Brain, right occipital lobe, excision - malignant polygonal cell neoplasm
Intraoperative Consult performed at: Neurologic and Orthopedic Institute of Chicago

GROSS DESCRIPTION:
A.  Specimen, submitted fresh, labeled with the patient's name and "brain tumor".  It consists of five
fragments of a soft tan mass, all measuring between 0.2 and 0.5 cm in diameter.  An intraoperative
smear preparation is made.  Submitted in total, labeled A1.

B.  Specimen, submitted fresh, labeled with the patient's name and "brain tumor".  It consists of two
fragments of a soft tan mass, measuring 1.2 x 0.4 x 0.2 cm and 0.5 x 0.3 x 0.2 cm.  An intraoperative
touch preparation is made.  Submitted in total, labeled B1.

C.  Specimen, submitted fresh, labeled with the patient's name and "brain tumor".  It consists of an
irregularly shaped portion of cerebral cortex, measuring 3.3 x 1.8 x 1.3 cm.  Representative sections
are submitted, labeled C1.  Multiple small fragments of a soft tan mass accompany the cortex with
aggregate dimensions of 1.5 x 1.5 x 0.3 cm.  Representative fragments are submitted labeled C2.

D.  Specimen, submitted in a container, labeled with the patient's name and "brain cyst fluid".  It
consists of 5 ccs of blood, clot, and fragments of soft tan tissue.  The fragments of clot and soft
tissue are submitted in total, labeled D1.

E.  Specimen, submitted in formalin, labeled with the patient's name and "brain tumor".  It consists of
multiple fragments of a firm, tan-yellow-red mass with aggregate dimensions of 2.0 x 2.0 x 1.0 cm.  
Representative fragments are submitted, labeled E1.

MICROSCOPIC DESCRIPTION
(12 H&E, 1 trichrome, 1 retic, 1 PAS, 1 PAS/D, 1 HMB45, 1 Melan A, 1 S100, 1 PLAP, 1 AFP, 1 HCG, 1
AE 1/3, 1 EMA, E vimentin, 1 GFAP, 1 HHF35, 1 desmin, 1 CD34, 1 factor 8, 1 synaptophysin, 1
CD45, 1 CD68, 9 negative controls)

Sections of all of the brain tumor specimens (A1-E1) show a malignant neoplasm composed of
sheets of pleomorphic, anaplastic polygonal cells with abundant granular eosinophilic cytoplasm.
Occassionally multi-nucleated giant cells are seen.  There are numerous mitoses and areas of
coagulative necrosis.  The tumor forms a generally well delineated border with the adjacent brain
parenchyma though individual cell infiltrate into the brain.  The adjacent brain parenchyma shows a
brisk pilocytic astrocytic proliferation with abundant Rosenthal fibers and eosinophilic granular
bodies.  There are scattered axonal spheroids, perivascular and parenchymal chronic inflammation,
focal old hemorrhage, and microcalcifications.  Focally, the tumor invades the leptomeninges.  
Trichrome and reticulin stains show few fibers among the neoplastic cells.

The tumor cells do not stain with PAS with or without diastase.

The tumor cells stain strongly with an antibody to vimentin and focally with an antibody to the S100
protein.

They do not stain with antibodies to HMB45, Melan A, placental alkaline phosphatase,
alpha-fetoprotein, human chorionic gonadotropin, cytokeratins, the epithelial membrane antigen, the
glial fibrillar acidic protein, smooth muscle actin, desmin, CD34, factor 8, synaptophysin, the
leukocyte common antigen, or CD68.

Antibodies to the glial fibrillary acidic protein, cytokeratins, the S100 protein, vimentin, and CD34
stain the pilocytic astrocytic proliferation.  
Surgical Pathology Report
To Our Friend Anna -
We just don't know how
else to help.
We can't make it go
away.................