11
The WHO 2000 Astrocytoma
Classification
James G. Smirniotopoulos, M.D.
Uniformed Services University
of the Health Scie...
22
GRADING SYSTEMS
Sem Rad Onc (1991); 1: 2-9
Kernohan Berger WHO 1993
1 Pilocytic,SEGA
Benign (1) Astrocytoma
2 Astrocyto...
33
“BENIGN” ASTROCYTOMA
• Two types:
– Low grade (“benign”)
Diffuse (Adults)
– Low grade “special”
Circumscribed (Children...
44
ASTROCYTOMA:
Circumscribed
• “Special” Astrocytomas
• Astrocytoma of Young
• Various Locations
• Well circumscribed (ye...
55
Radiology-http://rad.usuhs.mil
USU – Learning to Care for Those in Harm’s Way
NOT a true cyst - no lining, just gliosis...
66
Radiology-http://rad.usuhs.mil
USU – Learning to Care for Those in Harm’s Way
Pilocytic Astrocytoma
A Cyst with mural n...
77
WHO GRADE I
• Circumscribed Astrocytoma
– JPA (Pilocytic)
– SGCA (Subependymal Giant Cell)
• Ganglioglioma
• Meningioma...
88
Radiology-http://rad.usuhs.mil
USU – Learning to Care for Those in Harm’s Way
ASTROCYTOMAS
• “Ordinary” Astrocytoma
• D...
99
Diffuse High Grade AstrocytomaDiffuse High Grade Astrocytoma …… Cells and VesselsCells and Vessels KERNOHAN (KS) 1 2 3 ...
1010
Radiology-http://rad.usuhs.mil
USU – Learning to Care for Those in Harm’s Way
WHO 4WHO 3WHO 2
Astrocytoma
Anaplastic
...
1111
Radiology-http://rad.usuhs.mil
USU – Learning to Care for Those in Harm’s Way
Gr 2 Fibrillary Astrocytoma
T1-gadT1-no...
1212
Radiology-http://rad.usuhs.mil
USU – Learning to Care for Those in Harm’s Way
CHO
Cr
NAA ?
{
Gliomatosis Cerebri
Radi...
1313
MODES OF SPREAD
1. Natural passages
2. Along surfaces
3. Along white matter tracts
4. Across the meninges
SPREAD ALON...
1414
Radiology-http://rad.usuhs.mil
USU – Learning to Care for Those in Harm’s Way
Expanded Brain
Radiology-http://rad.usu...
1515
Radiology-http://rad.usuhs.mil
USU – Learning to Care for Those in Harm’s Way
Anaplastic Astrocytoma
Radiology-http:/...
1616
Radiology-http://rad.usuhs.mil
USU – Learning to Care for Those in Harm’s Way
Glioblastoma Multiforme
Radiology-http:...
1717
Radiology-http://rad.usuhs.mil
USU – Learning to Care for Those in Harm’s Way
Radiology-http://rad.usuhs.mil
USU – Le...
1818
Radiology-http://rad.usuhs.mil
USU – Learning to Care for Those in Harm’s Way
T1-gadT2
Glioblastoma Multiforme
Radiol...
1919
Radiology-http://rad.usuhs.mil
USU – Learning to Care for Those in Harm’s Way
Glioblastoma Multiforme
vs. Abscess (to...
2020
Radiology-http://rad.usuhs.mil
USU – Learning to Care for Those in Harm’s Way
Early Draining Veins
X-Ray Perfusion Im...
2121
Radiology-http://rad.usuhs.mil
USU – Learning to Care for Those in Harm’s Way
Glioblastoma Multiforme
Radiology-http:...
2222
Radiology-http://rad.usuhs.mil
USU – Learning to Care for Those in Harm’s Way
Radiology-http://rad.usuhs.mil
USU – Le...
2323
EUXAPIΣTΩ !
Mahalo !
Gracias! Obregado
Merci Beaucoup
Danke Shoen
Thank You!
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The WHO 2000 Astrocytoma Classification

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The WHO 2000 Astrocytoma Classification

  1. 1. 11 The WHO 2000 Astrocytoma Classification James G. Smirniotopoulos, M.D. Uniformed Services University of the Health Sciences Bethesda, MD Visit us at: http://rad.usuhs.mil Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Features of Glioma • Site of Origin • Character of lesion – Signal intensity (MR) – Attenuation (CT) – Blood-brain-barrier (Gd or I) – Chemistry (MRS) – Metabolism (Th 201, FDG-PET) – Vascularity (PWI) • Mode of Spread – DTI Traditional Tumor Grading • PATHOLOGIST – LOW GRADE – HIGH GRADE • RADIOLOGIST – NON-ENHANCING – ENHANCING • NEUROSURGEON – “SUCKABLE” – “NON-SUCKABLE” Kernohan-Sayre (AFIP) Grading System: • GRADE I- “BENIGN” or “Low-Grade” • GRADE II - “ “ • GRADE III - ANAPLASTIC – cellular atypia, etc. • GRADE IV- MALIGNANT – NECROSIS, Vascularity, Mitoses – GLIOBLASTOMA MULTIFORME • NOTE: Numerous modifications exist, most into three grades, e.g..: Low Grade (Benign), Anaplastic, and GBM (w/ NECROSIS). Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Pathologic – Radiologic Correlation T2 SI, DWI & ADCCellularity T1 and T2 SI, DTIInfiltration MRS, Th 201 and FDGLabeling Indices T1 and T2 SIHemorrhage Ring Lesion, MRS, DWI & ADC Necrosis Enhancement, PWI, and Permeability Imaging Endothelial proliferation and Vascularity RadiologyPathology ASTROCYTOMA Five Year Survival 0 20 40 60 80 100 Percent Survival Glioblastoma (IV) Anaplastic (III) Astrocytoma (I-II) Pilocytic
  2. 2. 22 GRADING SYSTEMS Sem Rad Onc (1991); 1: 2-9 Kernohan Berger WHO 1993 1 Pilocytic,SEGA Benign (1) Astrocytoma 2 Astrocytoma Benign (2) Anaplastic 3 Anaplastic Anaplastic (3) Glioblastoma (4) Glioblastoma 4 Glioblastoma Define the Problem: • Some Low Grade Enhance • Some Low Grade Do Not • Some Low Grade => GBM • Some Low Grade Do Not WHO Classification • Defines Histologic Subtypes • Grades Biologic Potential • Allows International Cooperation • Ascending scale of Aggression from 1-4 WHO CORRELATION • Low Grade – Long-Term Survival – Stable Histology no progression Possible Cure WHO Grading CNS Tumors GRADE 1 JPA SGCA GANG MENING GRADE 2 PXA HPC GRADE 3 PXA ANAPLASTIC HPC GRADE 4 GBM CNS NEOPLASM-GLIAL Prognostic Factors Location Age Histology
  3. 3. 33 “BENIGN” ASTROCYTOMA • Two types: – Low grade (“benign”) Diffuse (Adults) – Low grade “special” Circumscribed (Children) Normal appearing white matterNormal appearing white matter …… few cell bodiesfew cell bodies Diffuse Low Grade AstrocytomaDiffuse Low Grade Astrocytoma …… too many cells !too many cells ! Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way WHO Gr1 - Pilocytic Astrocytoma Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way WHO Gr1 - Pilocytic Astrocytoma Circumscribed Mass: Cyst w/Nodule Pushing Margin Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Circumscribed Astrocytoma WHO Grade 1 Pilocytic Astrocytoma SEGA Circumscribed Astrocytoma
  4. 4. 44 ASTROCYTOMA: Circumscribed • “Special” Astrocytomas • Astrocytoma of Young • Various Locations • Well circumscribed (yet, no capsule) • Do NOT spread along WM • Do NOT change grade (except PXA) • Constellation of findings correlates w/ Histology PILOCYTIC ASTROCYTOMA Cystic Cerebellar Astrocytoma Juvenile Pilocytic Astrocytoma (“PA” or “JPA”) PILOCYTIC ASTROCYTOMA • Synonyms: Polar Spongioblastoma, Cystic Cerebellar Astrocytoma • Cell of Origin: Astrocyte (bi-polar, hairlike) • Associations: in ON w/ NF-1 • Incidence: 3-6% of ALL Cranial, 32% of Child • Age: 5-15 (Zulch 3-7) Sex: Slight F (11/9) • Location: Cerebellum, Chiasm/Hypothal, Optic • Treatment: Surgery, patience • Prognosis: 77% at 5 yrs, 75% at 10 yrs, 75% at 15 yrs PILOCYTIC ASTROCYTOMA Radiology • Cerebellum, Diencephalon – rare in BS or Cerebrum • Majority have significant “cyst” – “Cyst and Mural Nodule” • part of lining does NOT enhance – Nodule may be heterogeneous – Exceptional purely solid • Nodule NOT hyperdense • Calcification in 5-25% Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way
  5. 5. 55 Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way NOT a true cyst - no lining, just gliosis Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way WHO Gr1 - Pilocytic Astrocytoma Circumscribed Mass: Cyst w/Nodule Pushing Margin PATHOLOGY • Biphasic pattern – dense pilocytic glia – Rosenthal fibers – loose microcystic areas • No necrosis • Low grade • Abnormal capillaries – allow enhancement – fluid production Grading Problems in Gliomas 51 Pilocytic (WHO Gr. 1) KERNOHAN MAYO-ST.ANNE 1 26% 1 2% 2 69% 2 55% 3 6% 3 35% 4 0% 4 8% By conventional “feature counting” most pilocytic astrocytomas were overgraded. Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Pilocytic Astrocytoma • Variant Appearance • Variant Location
  6. 6. 66 Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Pilocytic Astrocytoma A Cyst with mural nodule? Not Always !!! Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Courtesy of Paul Sherman Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way PILOCYTIC ASTROCYTOMA: Locations • CEREBELLUM • Chiasm And Optic Nerve • Hypothalmus/thalamus • Cerebral Hemisphere • Spinal Cord (Intramedullary) Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way PILOCYTIC ASTROCYTOMA (Juvenile Pilocytic) • Childhood, Young Adults • Benign, no mitosis/necrosis • Circumscribed - Enhancing • Cyst Formation, Mural Nodule • Cerebellum and Diencephalon (Optic tracts, Hypothalmus)
  7. 7. 77 WHO GRADE I • Circumscribed Astrocytoma – JPA (Pilocytic) – SGCA (Subependymal Giant Cell) • Ganglioglioma • Meningioma Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Subependymal Giant Cell Astro Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way ASTROCYTOMAS • “SPECIAL” ASTROCYTOMAS – Circumscribed Growth: • Pilocytic • Subependymal Giant Cell • Pleomorphic Xantho-Astrocytoma Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Circumscribed Astrocytoma WHO Grade 1 2 3 4 PXA PXA Circumscribed Astrocytoma PLEOMORPHIC XANTHOASTROCYTOMA • Rare Variant of Astrocytoma • Arises from Subpial Astrocytes • Affects Superficial Cerebral Cortex and Meninges • Skull erosion (scalloped excavation) • Temporal > Frontal > Parietal • WHO Grade 2,3 • 50% progress over time
  8. 8. 88 Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way ASTROCYTOMAS • “Ordinary” Astrocytoma • Diffuse Infiltration of WM by: – Fibrillary Astrocytes – Protoplasmic Astrocytes – Gemistocytic Astrocytes • WHO 2,3,4 (NOT 1) • KS & Mayo Grades 1-4 Daddy, Where do Glioblastomas come from? Normal appearing white matterNormal appearing white matter …… few cell bodiesfew cell bodies Diffuse AstrocytomaDiffuse Astrocytoma …… too many cells !too many cells ! KERNOHAN (KS) 1 2 3 4 ANAPLASIA 0 Min >1/2 Marked CELLULARITY Mild Mild Inc Marked MITOSIS 0 0 Plus Marked ENDOTHELIAL 0 Min Min Marked Proliferation NECROSIS Marked TRANSITION <== Broad Sharp ==> ZONE
  9. 9. 99 Diffuse High Grade AstrocytomaDiffuse High Grade Astrocytoma …… Cells and VesselsCells and Vessels KERNOHAN (KS) 1 2 3 4 ANAPLASIA 0 Min >1/2 Marked CELLULARITY Mild Mild Inc Marked MITOSIS 0 0 Plus Marked ENDOTHELIAL 0 Min Min Marked Proliferation NECROSIS Marked TRANSITION <== Broad Sharp ==> ZONE KERNOHAN (KS) 1 2 3 4 ANAPLASIA 0 Min >1/2 Marked CELLULARITY Mild Mild Inc Marked MITOSIS 0 0 Plus Marked ENDOTHELIAL 0 Min Min Marked Proliferation NECROSIS Marked TRANSITION <== Broad Sharp ==> ZONE ASTROCYTOMA: DIFFUSE (Fibrillary, protoplasmic, etc.) “Adult type” or “Hemispheric” Astrocytoma Diffusely infiltrate brain, along WM tracts Continuum, from low-grade to high-grade Genetic Alterations 17 => 9 => 10 Many Progress in Histology over time, changing from WHO Gr. 2 => Gr. 3 => Gr. 4 (GBM) Imaging tends to correlate with histology, especially at the ends of spectrum Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Astrocyte Mutation • Normal Astrocyte • Neoplastic • Anaplastic • GBM Deletions: 17 p P53 22q NF2 Excess production of: PDGF Deletions: 13q RB 19q 10 Excess production of: CDK4 Deletions: 10 PTEN/MMAC1 9p P16,P15.P14 Excess production of: EGFR VEGF WHO Gr 2 Gr 3 Gr 4 = GBMNormal GeneticallyHeterogeneous Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Diffuse Astrocytoma WHO GR 2 WHO GR 3 WHO GR 4 Normal
  10. 10. 1010 Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way WHO 4WHO 3WHO 2 Astrocytoma Anaplastic Astrocytoma Glioblastoma Multiforme A spectrum of tumors Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Dr. Eastwood: The Good The Bad The Ugly Diffuse Astrocytoma ‘Astrocytoma’ Anaplastic Astrocytoma Glioblastoma Multiforme ASTROCYTOMA Radiologic Grading • TYPE 1 - WHO 2, KS Grade 1-2, “Benign” – Homogeneous – No Enhancement, No Vasogenic Edema • TYPE 2 – WHO Grade 3, Anaplastic – Variable Enhancement, Edema – 50% enhance - 50% don’t • TYPE 3 – WHO Grade 4 Glioblastoma – Heterogeneous (Necrosis, Blood) – Ring Enhancement, Edema “BENIGN” ASTROCYTOMA: WHO 2, KS 1-2, Mayo 1 • YOUNGER PATIENT – CHILDHOOD – Young Adults (20’s - 40’s) • NL VESSELS (NO NEOVASCULARITY) – BBB INTACT – NO EDEMA – NO ENHANCEMENT – NO TUMOR VESSELS Benign - Diffuse • HOMOGENEOUS – NO NECROSIS – NO HEMORRHAGE – INCREASED WATER • DARK and Poorly Demarcated on CT • Dark and Sharp on T1W • BRIGHT and Sharp on T2W – MICROCYST >>> MACROCYST (macrocysts occur in JPA, etc.) Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Gr 2 Fibrillary Astrocytoma T2PD
  11. 11. 1111 Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Gr 2 Fibrillary Astrocytoma T1-gadT1-non Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Gr 2 Astrocytoma: PWI Reduced perfusionReduced perfusion ADCADC PWIPWI--CBVCBV Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way T1-gadT2 Gliomatosis Cerebri Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Gliomatosis Cerebri: Diffuse Astrocytoma – 2 lobes Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Spread along White Matter Tracts Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Gliomatosis Cerebri
  12. 12. 1212 Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way CHO Cr NAA ? { Gliomatosis Cerebri Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Thickened Genu Enlarged Fornix Blurring of Gray Matter Infiltration of peduncle Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Astrocytoma: Microcystic change Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Astrocytoma Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way
  13. 13. 1313 MODES OF SPREAD 1. Natural passages 2. Along surfaces 3. Along white matter tracts 4. Across the meninges SPREAD ALONG TRACTS: • Corona Radiata • Peduncles • Corpus Callosum • Anterior Commisure • Arcuate Fibres Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Astrocytes Track Along WM Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Pontine Astrocytoma Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Pontine Astrocytoma: WHO 2 Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Six Weeks Later WHO 2 … GBM
  14. 14. 1414 Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Expanded Brain Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Expanded Brain Anaplastic Astrocytoma Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Anaplastic Astrocytoma: Overall Characteristics • Grade III malignant glioma • Less aggressive than GBM, malignant with somewhat better prognosis • Frequency: highest in young adults (30 – 40 years) • Recurrence: often as a higher-grade glioma • Challenge: difficult to remove completely with surgery • Median survival: 3 – 4 years Anaplastic AstrocytomaAnaplastic Astrocytoma Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Anaplastic Astrocytoma
  15. 15. 1515 Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Anaplastic Astrocytoma Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Anaplastic Astrocytoma ( WHO 3 ) Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Increased Cellularity, +/- minimal vascular changes, no necrosis , no hemorrhage Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way GBM - Glioblastoma “MALIGNANT” ASTROCYTOMA: • Older patient – 40’s and up – exceptions (PNET) – ~ 1/2 arise from previous low grade (2-3) • Abnormal Vessels (neovascularity) - BBB abnormality – vasogenic edema – contrast enhancement – irregular vessels, shunting, etc. • HETEROGENEOUS – hemorrhage (old/new) – tumor necrosis – tumor itself Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Astrocytoma Gr4: Necrosis ! Angiogenesis
  16. 16. 1616 Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Glioblastoma Multiforme Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Glioblastoma Multiforme vascularity necrosis Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way T1-gadT2 Glioblastoma Multiforme Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way (Gr 4) Glioblastoma: PWI-CBV Increased perfusionIncreased perfusion Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Glioblastoma – WHO Grade 4 A solitary, deep, irregular, heterogenous, ring- enhancing mass with vasogenic edema. Low NAA – High Choline/Creatine GBM • Center of Abnl Density/Intensity – variegated necrosis • ENHANCING RIM – hypercellular, fleshy neoplasm – greatest neovascularity • Corona of Abnl Density/Intensity – “edematous” white matter – areas of microscopic neoplastic infiltration
  17. 17. 1717 Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way GBM - Glioblastoma Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Pseudopalisading Necrosis Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Ring Lesion and Infiltration GLIOBLASTOMA MULTIFORME (Surrounding Zone of Infiltration) • GBM arose from a preexisting low grade – surrounding lower grade neoplasm – may also transform over time • GBM arose de novo – sends cells to invade the brain
  18. 18. 1818 Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way T1-gadT2 Glioblastoma Multiforme Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Courtesy of R.D. Zimmerman, NY Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way GBM - Multifocal Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Multifocal GBM Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way DWI of Glioblastoma (Gr 4) Park et al., Neuroradiology 2000;42:716-721 DWIDWIT1T1--gadgad Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Ring Enhancing Mass •Round •Smooth •Thin wall •Undulating •Irregular •Thick wall Benign Malignant
  19. 19. 1919 Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Glioblastoma Multiforme vs. Abscess (toxo) Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way DWI: Necrosis vs. PUS GBM Abscess Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way meningealcallosal Glioblastomas: Growth/Spread Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way T1-gadT1-gad Glioblastoma: Ependymal spread Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way GBM – Thicker on Surface
  20. 20. 2020 Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Early Draining Veins X-Ray Perfusion Imaging Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way MR Perfusion Imaging Courtesy of James Provenzale, Duke UniversityCourtesy of James Provenzale, Duke University **** Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way GBM with increased rCBV Courtesy Mauricio Castillo, Chapel Hill Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way New Tools for Grading and Staging • Radiology – Perfusion Imaging rCBV and rCBF – Diffusion Imaging, ADC and DTI – Spectroscopy – PET/SPECT – Monoclonal Ab. • Pathology – Labeling Index – Chromosome Analysis – Histochemical – Electron Microscopy Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way DTI Loss of Anisotropy DTI and Tumor Imaging T2 From: J. Burdette and Neeraj Chepuri, WFU Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Astrocytes Track Along WM Anisotropy: Diffusion (ADC) is different in different directions
  21. 21. 2121 Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Glioblastoma Multiforme Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Glioblastoma Multiforme Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Two Port Radiotherapy • Bad News – Can’t define full extent of tumor by any current test • Good News – 90% of tumor recurrence within 2cm of enhancing rim Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way 6/15 7/22 Courtesy of R.D. Zimmerman, NY Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way
  22. 22. 2222 Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way 5 weeks later Define the Problem: • Some Low Grade Enhance • Some Low Grade Do Not • Some Low Grade => GBM • Some Low Grade Do Not Define the Problem: Answers • Some Low Grade Enhance * • Some Low Grade Do Not • Some Low Grade => GBM • Some Low Grade Do Not * * These are the Circumscribed Astrocytomas The others are the Diffuse Astrocytomas Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way WHO Astrocytoma Summary Astrocytoma Anaplastic Astrocytoma Glioblastoma Multiforme WHO Grade 1 2 3 4 PXA PXA Pilocytic Astrocytoma SEGA Circumscribed Astrocytoma Diffuse Astrocytoma A spectrum of tumors Radiology-http://rad.usuhs.mil USU – Learning to Care for Those in Harm’s Way WHO 4WHO 3WHO 2 Astrocytoma Anaplastic Astrocytoma Glioblastoma Multiforme A spectrum of tumors
  23. 23. 2323 EUXAPIΣTΩ ! Mahalo ! Gracias! Obregado Merci Beaucoup Danke Shoen Thank You!

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