Transcriptome profiling reveals PDZ binding kinase as a novel biomarker in peritumoral brain zone of glioblastoma.

PURPOSE: Peritumoural brain zone (PT) of glioblastoma (GBM) is the area where tumour recurrence is often observed. We aimed to identify differentially regulated genes between tumour core (TC) and PT to understand the underlying molecular characteristics of infiltrating tumour cells in PT. METHODS: 17 each histologically characterised TC and PT tissues of GBM along with eight control tissues were subjected to cDNA Microarray. PT tissues contained 25-30% infiltrating tumour cells. Data was analysed using R Bioconductor software. Shortlisted genes were validated using qRT-PCR. Expression of one selected candidate gene, PDZ Binding Kinase (PBK) was correlated with patient survival, tumour recurrence and functionally characterized in vitro using gene knock-down approach. RESULTS: Unsupervised hierarchical clustering showed that TC and PT have distinct gene expression profiles compared to controls. Further, comparing TC with PT, we observed a significant overlap in gene expression profile in both, despite PT having fewer infiltrating tumour cells. qRT-PCR for 13 selected genes validated the microarray data. Expression of PBK was higher in PT as compared to TC and recurrent when compared to newly diagnosed GBM tumours. PBK knock-down showed a significant reduction in cell proliferation, migration and invasion with increase in sensitivity to radiation and Temozolomide treatment. CONCLUSIONS: We show that several genes of TC are expressed even in PT contributing to the vulnerability of PT for tumour recurrence. PBK is identified as a novel gene up-regulated in PT of GBM with a strong role in conferring aggressiveness, including radio-chemoresistance, thus contributing to recurrence in GBM tumours.

Rare pathologies in the posterior third ventricular region in children: case series and review.

Tumors of the pineal region in children often belong to 2 categories, namely germ cell tumors and pineal parenchymal tumors. Very rare pathologies have previously been reported in this region. Most of these tumors may be similar radiologically, while their management differs. The present series reports 2 children with pineal region tumors, each one being a rare pathological entity by itself, namely an embryonal tumor with abundant neuropil and true rosettes (ETANTR) and a rosette-forming glioneuronal tumor (RGNT). Very few such cases in each pathology have been reported in the literature for the pediatric age group up to now. Our series consists of 2 children, both presenting with a raised intracranial pressure of short duration. Imaging revealed lesions in the pineal region with similar radiological features. Both ETANTR and RGNT demonstrated mild enhancement. The 2 patients underwent surgical decompression either by Poppen's approach (n = 1) or a supracerebellar infratentorial approach (n = 1). The patient with ETANTR was advised radiotherapy, while the child with RGNT was advised a regular follow-up. This series presents some rare pathologies which can occur in the posterior third ventricular region with similar radiological features. Management differs based on the histology of the case.

Delineating the Spectrum of Pituitary Adenoma Based on the WHO 2017 Classification.

BACKGROUND: The WHO 2017 classification of endocrine tumors incorporates lineage-specific transcription factors (TF) and hormone expression for the classification of pituitary adenoma (PA). There is paucity of reports describing the spectrum of PA based on this classification. OBJECTIVE: The aim of this study was to delineate the spectrum of PA based on WHO 2017 classification of endocrine tumors. MATERIALS AND METHODS: PA diagnosed in the year 2018 were studied. H and E and hormonal immunohistochemistry (IHC) for GH, PRL, ACTH, TSH, FSH, LH, CK, T-Pit and MIB-1 were performed and the results were analyzed. RESULTS: The cohort included 88 cases. M: F ratio was 2:1. Clinically, 22 (25%) were functional and 66 (75%) were non-functional adenomas. Amongst the clinically functional adenomas, GH secreting adenomas were the commonest (68%). Majority (83%) of non-functional adenomas were hormone positive with gonadotroph adenomas being the commonest (72.7%). Eleven (12.5%) PA were clinically and hormonally silent. Three of these showed intense nuclear T-Pit positivity, classifying them under silent corticotroph adenoma. Lineage of the remaining eight adenomas remained undetermined, since, IHC for Pit-1 and SF-1 was not performed. The aggressive adenomas identified by IHC included sparsely granulated somatotroph adenoma, Crooke cell adenoma, silent corticotroph adenoma, densely granulated lactotroph adenoma in men and constituted 17% of the PA. Four (4/88) cases were clinically invasive. CONCLUSION: A large majority of PA including aggressive adenomas can be identified by IHC. Addition of T-Pit helped to identify silent corticotroph adenoma. Pit -1 and SF-1 TF would help identify plurihormonal Pit-1 PA and null cell adenomas.

Intramedullary metastasis in a case of vermian medulloblastoma.

Medulloblastoma is one of the commonest primary CNS malignancies in children. Leptomeningeal dissemination and distant metastasis have been associated with medulloblastoma, but intramedullary metastases are very rare. CSF cytology and contrast-enhanced MRI are the main modalities used to diagnose leptomeningeal dissemination. However, intramedullary metastases are best picked up with contrast-enhanced axial sequences on MR imaging. In this report, a patient with medulloblastoma who developed intramedullary metastasis is described. The role of imaging and CSF cytology in diagnosing the spread along the CSF pathways is reviewed. Allusions are made to the possible mechanism of intramedullary metastasis in these tumors.

Basic requirements to establish a neuromuscular laboratory.

Histopathological analysis of muscle biopsy is a prerequisite in the evaluation of neuromuscular disorders, particularly inflammatory myopathies, metabolic myopathies, congenital myopathies, muscular dystrophies and differentiating myopathies and neurogenic disorders with overlapping clinically features. It not only provides useful information that helps in the diagnosis but also treatment and management. Fundamental skills and basic knowledge regarding handling, processing and analyzing a muscle biopsy are required in any specialized or a general pathology lab supporting neuromuscular clinical services. Care during transport of the muscle biopsy, sample receipt in the laboratory and grossing is very important. Standard operating procedure should be followed for the preanalytical steps (freezing and cryomicrotomy), routine and special staining (enzyme and non enzymatic) and immunohistochemistry. A well organized neuromuscular laboratory with good quality management system is necessary for the practice of myopathology. This article gives an overview of establishing such a laboratory.

Hereditary neuropathies: Genetics and utility of nerve biopsy.

Peripheral neuropathy is one of the most common neurological conditions of the nervous system. Hereditary neuropathies (HNs) form an important group with varying degrees of severity, causing a significant disease burden. Accurate diagnosis is essential for management, counseling, and preventing unnecessary extended workups for acquired etiologies and inappropriate treatment. Several hereditary neuropathies have characteristic or diagnostic histologic findings; however, in the era of molecular diagnostics, the role of nerve biopsy in the diagnosis of hereditary neuropathy has reduced significantly. Nevertheless, in sporadic cases, cases without a clear family history, clinical mimics, cases with rare mutations, and genetic variants of unknown significance, a nerve biopsy can confirm the diagnosis, provide an unexpected diagnosis, or direct a targeted molecular testing. HN may be non-syndromic, affecting predominantly the peripheral nervous system or syndromic where it is a part of more widespread neurological or multisystem involvement. This review summarizes the microscopic pathological features in a nerve biopsy in some of the more commonly encountered inherited peripheral neuropathies highlighting their utility in selected cases.

Evaluation of markers of oxidative stress, antioxidant function and astrocytic proliferation in the striatum and frontal cortex of Parkinson's disease brains.

Dopaminergic neurons die in Parkinson's disease (PD) due to oxidative stress and mitochondrial dysfunction in the substantia nigra (SN). We evaluated if oxidative stress occurs in other brain regions like the caudate nucleus (CD), putamen (Put) and frontal cortex (FC) in human postmortem PD brains (n = 6). While protein oxidation was elevated only in CD (P < 0.05), lipid peroxidation was increased only in FC (P < 0.05) and protein nitration was unchanged in PD compared to controls. Interestingly, mitochondrial complex I (CI) activity was unaffected in PD compared to controls. There was a 3-5 fold increase in the total glutathione (GSH) levels in the three regions (P < 0.01 in FC and CD; P < 0.05 in Put) but activities of antioxidant enzymes catalase, superoxide dismutase, glutathione reductase and glutathione-s-tranferase were not increased. Total GSH levels were elevated in these areas because of decreased activity of gamma glutamyl transpeptidase (γ-GT) (P < 0.05) activity suggesting a decreased breakdown of GSH. There was an increase in expression of glial fibrillary acidic protein (GFAP) (P < 0.001 in FC; P < 0.05 in CD) and glutathione peroxidase (P < 0.05 in CD and Put) activity due to proliferation of astrocytes. We suggest that increased GSH and astrocytic proliferation protects non-SN brain regions from oxidative and mitochondrial damage in PD.

Supratentorial and cerebellar liponeurocytomas: report of four cases with review of literature.

Liponeurocytoma is not exclusive to the cerebellar or fourth ventricular location. Since its inclusion in the central nervous system tumor classification in 2000, six cases with similar radiological, histomorphological and immunohistochemical features have also been described in the lateral ventricles. In the present study, we report clinical, radiological and pathological findings of three supratentorial and one cerebellar liponeurocytoma from our records, evaluated with an extensive panel of immunohistochemistry, and review published cases in the literature. The immunohistochemical pattern of supratentorial and infratentorial liponeurocytomas are almost identical, which indicates that these tumors are homologous.

Clinical, neuroimaging and pathological features of 5-nitroimidazole-induced encephalo-neuropathy in two patients: Insights into possible pathogenesis.

We report two patients manifesting with involvement of central and peripheral nervous system with brain magnetic resonance imaging (MRI) changes and pathological features of neuropathy possibly due to harmful and chronic use of various nitroimidazole group of medications for recurrent diarrheal illness. Patient 1, a 21-year-old man with obsessive-compulsive disorder, impulsive behavior and harmful use of substance (tinidazole), had developed encephalopathy and biopsy-proven neuropathy with partial remission. The MRI of brain showed involvement of bilateral caudate, lentiform and dentate nuclei, and splenium, with contrast enhancement of the caudate and putaminal lesions and restricted diffusion of the splenial lesion. Patient 2 was a 50-year-old woman with irritable bowel syndrome and was on harmful use of tinidazole and metronidazole. She manifested with encephalopathy, ataxia, and neuropathy. Her MRI of brain revealed involvement of bilateral putamen, dentate nuclei and periventricular white matter with restricted diffusion. Sural nerve biopsy revealed evidence of vasculitic neuropathy. At follow-up, there was definite, though incomplete, recovery in both the patients. The MRI alterations improved completely in patient 2 and substantially in patient 1. Increasing awareness among the physicians may enable early recognition of potentially reversible neurotoxicity and avoid unwarranted prescription of such medications.

Glycogen storage disease type V (Mc Ardle's disease): a report on three cases.

McArdle's disease (myophosphorylase deficiency), an uncommon autosomal recessive metabolic disorder, is characterized clinically by exercise intolerance beginning in childhood, myalgia, cramps, exercise-induced rhabdomyolysis, "second wind" phenomenon, elevated Creatine Kinase (CK) levels at rest, and previous episodes of raised CK levels following exercise. Several mutations in the PYGM gene and geographic variations have been described. We report three biopsy confirmed cases of McArdle's disease.

Central nervous system high grade neuroepithelial tumor with BCOR immunopositivity: Is there a molecular heterogeneity?

Central nervous system high grade neuroepithelial tumor - BCOR altered is a newly defined entity which is characterised by internal tandem duplication (ITD) in exon 15 of BCOR. These tumors resemble high grade glioma histologically and exhibit BCOR immunopositivity. However, recently fusions of BCOR are also described in CNS lower grade gliomas, thus questioning the sensitivity and specificity of BCOR immunohistochemistry for identification of BCOR-ITD. We describe four cases of high grade neuroepithelial tumor with BCOR immunopositivity which were diagnosed over a period of one year at our institute. Amongst these, only one tumor revealed BCOR-ITD on sequencing. SATB2 immunopositivity which is a sensitive marker of BCOR-ITD, BCOR fusions and YWHAE fusions was noted in three out of four cases. Our study suggests that BCOR immunopositive CNS high grade tumors are molecularly heterogeneous and could harbour genetic alterations other than BCOR-ITD.

Late onset glycogen storage disease type II with reducing body-like inclusions.

Skeletal muscle tissue from 3 patients with clinical diagnosis of limb girdle muscular dystrophy revealed a vacuolar myopathy with glycogen storage and lysosomal activity. A diagnosis of late onset GSD Type II was considered. An interesting finding was the presence of round to oval eosinophilic inclusions which reduced on menadione linked a-glycerophosphate dehydrogenase (MAG). There are only two reports in the literature describing similar inclusions in late onset GSD II. We report morphological findings of this rare disorder and compare the findings with earlier two reports.

Increased expression of Aquaporin-4 and its correlation with contrast enhancement and perilesional edema in brain tumors.

INTRODUCTION: Aquaporins and astrocytes are important in maintaining water hemostasis in brain. Upregulation of AQP-4 has been described in conditions associated with brain edema. AIMS: To study the expression of aquaporin-4 in brain tumors and its correlation with contrast enhancement and perilesional edema. MATERIAL AND METHODS: 30 cases of brain tumors, both benign and malignant were included in the study to look for expression of AQP-4. RESULTS: AQP-4 expression was increased in brain tumors compared to normal brain but distribution and intensity of expression depend upon the type of tumor. A trend toward increased AQP-4 expression in enhancing lesions with perilesional edema was noticed. CONCLUSION: AQP-4 expression was seen in tumor tissue and perilesional reactive astrocytes in primary brain tumors, however only perilesional astrocytes showed positivity in secondary brain tumors. AQP-4 could be playing a role in alteration of blood-brain barrier leading to contrast enhancement and perilesional edema. Increased knowledge of Aquaporins may open new targeted therapy for brain edema.

Clinicopathological Study of Extra-Axial Small Round Cell Tumors of the Cranium.

INTRODUCTION: The cranium is a host to a variety of neoplasms and includes small round cell tumors (SRCTs) as an important malignant subset. Although SRCTs are histomorphologically similar, they are histogenetically diverse comprising of malignancies of epithelial, hematolymphoid, neuroectodermal, and mesenchymal origin. OBJECTIVE: The study aimed to review the clinical and pathological profile of cranial SRCTs. MATERIALS AND METHODS: Study is a retrospective review (clinical, imaging, and histopathology) of cranial (extra-axial) SRCTs diagnosed on histology (period: 3.5 years). RESULTS: Study included 126 cases constituting 1.5% of all intracranial neoplasms and age ranging from 11 months to 82 years (mean: 34.3 years; M:F = 1.46:1). Peripheral primitive neuroectodermal tumors (pPNET-8.2%) was the commonest neoplasm followed by plasmacytoma (14.2%), poorly differentiated carcinomas (13.5%), lymphomas (9.5%), and sarcomas (8.7%). Rare tumors included glioma (undifferentiated) deposits, germ cell tumors, melanoma, neuroendocrine neoplasms, and embryonal tumor. Children constituted one-third of the total with PNETs, embryonal tumors, and round cell sarcomas being the common neoplasms. Elderly patients constituted 14% with plasmacytomas and epithelial neoplasms being common. Three percent of the tumors remained unclassified. Clinical symptomology was location dependent, headache being the commonest followed by visual symptoms. Radiopathological discordance was high (60%). CONCLUSION: SRCTs are unusual tumors with a wide spectrum of histogenesis, biology and clinical presentation. Their rarity in cranium, atypical localization, overlapping clinical, and imaging features pose significant difficulty for clinicians, radiologists, and pathologists. A combined algorithmic analysis of the clinical, radiological, and histolopathological findings, supplemented with immunohistochemistry can aid in specific diagnosis which is crucial for optimal management.

A Case of Ollier's Disease with P53 Mutation Positive and IDH1 (R132H) Negative Multicentric Gliomas.

Ollier disease is a rare nonhereditary disorder characterized by multiple enchondromas (enchondromatosis). To report a rare case of Ollier disease with gliomas and its mutation analysis. We hereby report a young lady who presented with seizures. She had a past history of multiple bony swellings in the right foot (operated) and swelling over the anterior chest wall for the past 15 years. MRI brain revealed multiple expansile T2/FLAIR hyperintense lesions in right superior and middle frontal gyri, left basifrontal lobe, and left precuneus in the cortical-subcortical location suggestive of glioma. She underwent biopsy which revealed left basifrontal anaplastic astrocytoma, not otherwise specified, WHO grade III, IDH1 (R132H) negative, P53 mutation positive, and ATRX loss of expression. We hereby report a rare case of Ollier disease with multicentric intracranial glioma-IDH1 (R132H) negative, P53 mutation positive, and ATRX loss of expression.

Circle of Willis abnormalities and their clinical importance in ageing brains: A cadaveric anatomical and pathological study.

The circle of Willis (CW) located at the base of the brain forms an important collateral network to maintain adequate cerebral perfusion, especially in clinical situations requiring compensatory changes in blood flow. Morphopathological changes in the CW may relate to the severity of the symptoms of certain neurodegenerative and cerebrovascular disorders. The purpose of this study was to investigate the CW abnormalities and their clinical importance in ageing brains. The CW was examined macroscopically in 73 formalin-fixed samples to determine the degree of stenosis of each CW component, atherosclerosis of the CW, hypoplasia (threshold diameter < 1 mm), anatomical variations and aneurysms. Age-related neurodegenerative and cerebrovascular pathologies were screened using immunohistopathological techniques on specific neuroanatomical regions based on standard guidelines. The majority of the elderly brains -93 % (68/73) presented at least a single hypoplastic CW component at death. Anatomical variations were mostly identified in communicating arteries, followed by proximal posterior and anterior cerebral arteries. Arterial bifurcations were found to be the predominant sites for cerebral aneurysms. More than 90 % of the elderly brains presented CW atherosclerosis at death. CW abnormalities did not show any strong associations with neurodegenerative pathologies except for an "at risk" significant association observed between Braak's neurofibrillary tangle (NFT) stages 1-VI and CW atherosclerosis grades ≥ mild (p = 0.05). However, a significant association was observed between microscopic infarcts in deep white matter and hypoplasia in communicating arteries with Fisher's exact test (p < 0.05). Overall, CW abnormalities were predominant in the ageing brains, however their relationships to the occurrence and severity of the symptoms of neurodegenerative pathologies were found to be low.

Diagnostic Utility of CUSA Specimen in Histopathological Evaluation of Tumors of Central Nervous System.

INTRODUCTION: Cavitron Ultrasonic Surgical Aspirator (CUSA) is a technique used for the surgical treatment of tumors that aids the surgeon in highly selective tumor sampling with minimal injury to surrounding tissues. The utility of the tissue obtained from CUSA for histopathological diagnosis of central nervous system tumors is not as well-known as its surgical benefits. Even though a few studies have evaluated the diagnostic accuracy of CUSA specimen, these have dealt with very few cases. METHODOLOGY: In this study, we nil analysed 73 cases of CNS tumors (glial and non-glial) where CUSA specimen was available for histopathological examination and compared with findings on conventional samples as gold standard. RESULTS: Most frequent types of artefacts induced by CUSA included tissue breakdown resembling necrosis, empty spaces in tissues, and crush artefacts particularly in cellular tumors, that interfered with interpretation. CUSA samples were found optimal for diagnosis of non-glial tumors (45/73), (mainly mesenchymal), wherein the diagnostic utility was comparable to the conventional samples. Difficulties were encountered in glial neoplasms, medulloblastomas and meningiomas. In glial neoplasms (28/73), accurate grading was not possible (9/28, 32%) utilising CUSA samples alone as necrosis and mitosis were not represented. Similarly in meningiomas, mitosis and brain invasion, essential for grading, was not recognizable in CUSA samples. In medulloblastomas, extensive crush artefacts interfered with diagnosis and histological subtyping making it mandatory to examine conventional tissue samples and CUSA. Immunohistochemistry results were optimal with CUSA tissue, wherever performed. CONCLUSION: The greatest benefits of CUSA, is its ability to sample multiple areas enhancing the yield in heterogenous tumors like gliosarcomas and its utility in tumors at surgically inaccessible sites. As a policy, we recommend that it is beneficial that all surgically excised tissues including those from the CUSA bottle and suction be sent for histopathological analysis for optimising diagnostic accuracy.

Absence of age-related changes in nigral dopaminergic neurons of Asian Indians: relevance to lower incidence of Parkinson's disease.

Age-related loss of melanized nigral neurons reported in the British Caucasians is not observed in Asian Indian, American and French adults. In the Americans, loss of dopaminergic phenotype occurs from midlife, without frank neurodegeneration. Here, we investigated whether nigral dopaminergic neurons in Asian Indians are lost with age or undergo morphological or biochemical dysfunction. Using unbiased stereology we estimated volume, number of melanized, borderline/non-melanized (n=34, 28 gestational weeks to 80 years) and tyrosine hydroxylase (TH)-Nurr1 co-labeled neurons (n=32, 28 gestational weeks to 80 years) in substantia nigra pars compacta. We quantified Nurr1 and TH proteins by immunoblotting (n=18, 28 gestational weeks to 69 years) and apoptotic neurons by terminal deoxynucleotidyl transferase mediated dUTP nick end labeling (TUNEL) staining. Nuclear and soma size was estimated by morphometry. There was no age-related decline in volume, neuronal density, neuronal numbers and TH-Nurr1 co-labeled neurons. TH and Nurr1 protein expression remained stable. Lack of TUNEL-TH co-labeled cells confirmed absence of neuronal apoptosis. The neuronal size remained unaltered. Our findings of preserved nigral dopaminergic neurons suggest no age-related loss of nigral function in Asian Indians, unlike the Americans. This may explain the lower incidence of Parkinson's disease in Asian Indians.

Cerebellar Liponeurocytoma: A Rare Fatty Tumor and its Literature Review.

Cerebellar liponeurocytoma is a rare oncological entity, and the knowledge about the treatment and outcome of these rare tumors is still evolving. Very few cases have been described in literature. We report a middle-aged male who presented with raised intracranial pressure features and gait ataxia. His imaging features revealed classical features of liponeurocytoma in cerebellar vermis, with abundant fat component evident in both computed tomography and magnetic resonance imaging. He underwent resection of the lesion and has been asymptomatic for 4 years. This report describes the classical radiological and immunohistochemical features of this rare entity with favorable outcome and reviews the existing literature.

L1CAM Immunopositivity in Anaplastic Supratentorial Ependymomas: Correlation With Clinical and Histological Parameters.

Supratentorial ependymomas (ST EPNs) are molecularly characterized, of which the RELA fusion positive tumors are the most common and aggressive subgroup. Moreover, histologically, anaplastic ST EPN (ST-AE) often mimic other central nervous system primary high-grade tumors resulting in a diagnostic dilemma. We aimed to study a cohort of ST-AE; evaluate the expression of two RELA fusion-associated markers-L1CAM and p65 (NF-κB); and correlate their expression with clinical and histological parameters. Cases of ST-AE diagnosed in our department from January 2011 to June 2016 (n = 72) were reviewed. A battery of immunohistochemical markers was employed. A total of 65 confirmed ST-AE were included in the study. Age ranged from 9 months to 60 years. There was a slight predominance in the pediatric population (57%). Male-to-female ratio was 1:1.16. Histomorphological features were varied and mimicked other high-grade tumors in several cases. L1CAM immunopositive tumors constituted 26% of cases and were predominantly seen in young children, in the frontoparietal location, and exhibited clear cell morphology with calcification. A consistent pattern of L1CAM immunopositivity was noted in paired primary and recurrent tumor samples. Our study portrays the varied clinical and histomorphological spectrum of ST-AE. The study emphasizes the association of L1CAM immunopositivity with a wide spectrum of histological parameters, literature on which is scant till date. Since ST EPN-RELA are tumors with aggressive behavior, such a correlation would be clinically relevant, particularly when there is limited access to molecular testing.