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American Association of Neuropathologists, Inc.Abstracts of the 90th Annual Meeting
June 12Y15, 2014Portland, Oregon
PLATFORM SESSION 1: TUMORS 1 - PREDICTIVE
GLIOMA MARKERS
Friday 8-10 AM, June 13, 2014
Fashion Ballroom
1
Predicting the Likelihood of an IDH1 or IDH2 Mutation in Patients
Diagnosed with Infiltrative Gliomas
Craig Horbinski1, Zoya Voronovich2, Kenneth Clark2, Isaac Hands1,
Jonathan Mannas1, Meggen Walsh1, Marina Nikiforova2, Eric Durbin1,
Heidi Weiss1, Li Chen1. 1University of Kentucky; 2University of Pittsburgh
Background: Several variables are associated with isocitrate dehydrogen-
ase 1 or 2 (IDH1/2) mutation likelihood in gliomas, though no guidelines
yet exist for when testing is warranted, especially when an R132H IDH1
immunostain is negative.
Methods: A cohort of 89 patients was used to build IDH1/2 mutation prediction
models in WHO grade II-IV gliomas, and an external cohort of 100 patients was
used for validation. Logistic regression and backward model selection with Akaike
information criterion were used to develop prediction models. A third cohort from
The Cancer Genome Atlas (TCGA) was also used for additional validation.
Results: A multivariate model, incorporating patient age, glioblastoma (GBM)
diagnosis,andpriorhistoryofgradeIIor IIIglioma,wasdevelopedtopredict IDH1/
2 mutation probability. This model generated an area under the curve (AUC) of
0.934 (95%CI: 0.878, 0.978) in the external validation cohort and 0.941 (95%CI:
0.918, 0.962) in the TCGA cohort. When R132H IDH1 immunostain information
was added, AUC increased to 0.986 (95% CI: 0.967, 0.998). This model had an
AUC of 0.947 (95% CI: 0.891, 0.995) in predicting whether an R132H IDH1
immunonegative case harbored a less common IDH1 or IDH2mutation. Its ability
topredict IDH1/2mutation status ingrades II-IVgliomas from theCancerGenome
Atlas (94%)was superior to the84%accuracyof aboard-certifiedneuropathologist
who evaluated the same cohort. An interactive web-based application for
calculating the probability of an IDH1/2 mutation is now available using these
models (http://www.kcr.uky.edu/webapps/IDH/app.html).
Conclusions: We have integrated multiple variables to generate a
probability of an IDH1/2 mutation. The associated web-based application
can help triage diffuse gliomas that would benefit from mutation testing in
both clinical and research settings.
2
Glutamine Based PET Imaging Facilitates Enhanced Metabolic
Detection of Gliomas in Vivo
Sriram Venneti1, Mark Dunphy1, Hanwen Zhang1, Kenneth Pitter1, Carl
Campos1, Sean Carlin1, Serge Lyashchenko1, Karl Ploessl2, Daniel Rohle1,
Antonio Omuro1, Justin Cross1, Cameron Brennan1, Wolfgang Weber1, Eric
Holland3, Ingo Mellinghoff1, Hank Kung2, Jason Lewis1, Craig Thompson1.1Memorial Sloan-Kettering Cancer Center; 2University of Pennsylvania;3University of Washington
Glutamine is the most abundant plasma amino acid and many cancers show
altered glutamine metabolism to support their growth and proliferation. We
evaluated glutamine metabolism in gliomas using biochemical and in vivo PET
imaging approaches. Our results demonstrate that glutamine is a key TCA cycle
anaplerotic substrate in gliomas and that glutamine is metabolized to generate
2-HG in IDH1 mutant gliomas. To begin to understand glutamine metabolism
in vivo we used PET imaging with18F-labeled glutamine (18F-FGln), which
showed high uptake in gliomas but low background uptake in the surrounding
brain in RCAS-PDGF/PTEN null and IDH1 mutant glioma animal models.
This facilitated clear tumor delineation in contrast to that seen with 18F-FDG.
We did not observe 18F-FGln uptake in animals with neuroinflammation with a
disrupted BBB. Further, 18F-FGln uptake was specifically reduced on chemo/
radiation therapy corresponding with a histologic decrease in tumor volume.
Finally, 18F-FGln showed high avidity in a human glioma patient with low
uptake in the surrounding brain. These data suggest that 18F-FGln is specifically
taken up by gliomas, can be used to detect themetabolic state of gliomas in vivo
and may serve as a valuable tool in the clinical management of gliomas.
3
Simplified Grading System for WHO Grade II-III Gliomas based on 1p/
19q Status, IDH 1/2 Mutation Status, and Nestin Expression
Kimmo Hatanpaa1, Vamsidhara Vemireddy1, Tianshen Hu1, Jack Raisanen1,
Chan Foong1, Bruce Mickey1, Samuel Barnett1, Dwight Oliver1, Paul Yell1,
Edward Pan1, Dennis Burns1, Charles White1, Elizabeth Maher1, Robert
Bachoo1. 1UT Southwestern Medical Center
Infiltrating astrocytomas and oligoastrocytomas of low to anaplastic grade
(WHO grades II-III), in spite of being associated with a wide range of clinical
outcomes, are often difficult to subclassify and grade. Unlike oligodendroglio-
mas and anaplastic oligodendrogliomas, which can be identified by the
presence of 1p/19q LOH, and glioblastomas, which are diagnosed based on
objective features on routine hematoxylin and eosin sections, the WHO criteria
for the subclassification of grade II-III astrocytomas and oligoastrocytomas
(A+OA II-III) are not as clearly defined. The current criteria depend on features
such as nuclear roundness and significant mitotic activity, leaving much room
for subjective interpretation in individual cases.
We recently identified nestin, a protein expressed by stem cells, as a strong
prognostic marker in human A+OA II-III tumors (p=0.0004; n=50)
(Hatanpaa et al., J Neurooncol 117:183-9, 2014). Both nestin protein and
mRNA level correlated with total survival. In multivariate survival analysis,
nestin and IDH 1/2 mutation status remained highly significant, whereas
histological covariates failed to reach significance (WHO grade II vs. III,
presence of oligodendroglial component, MIB-1 index). All tumors were
negative for 1p/19q LOH by PCR and EGFR amplification by CISH.
Here, we show that by combining information on nestin positivity, evaluated
by immunohistochemistry, and IDH 1/2 mutation status, evaluated by
immunohistochemistry for the IDH1 R132H mutation and followed by IDH
1/2 sequencing of the cases that are negative, A+OA II-III tumors can be
divided into three groups with markedly different clinical outcomes
(pG0.0001): (1) nestin negative and IDH mutated (both favorable), (2)
nestin negative and IDHwt or nestin positive and IDH mutated (mixed
favorable/unfavorable), and (3) nestin positive and IDHwt (both unfavor-
able). The total survival was favorable and similar to 1p/19q codeleted
oligodendrogliomas for group #1, intermediate for group #2, and dismal and
similar to glioblastomas (median survival, 1.5 years) for group #3.
585J Neuropathol Exp Neurol � Volume 73, Number 6, June 2014
J Neuropathol Exp NeurolCopyright � 2014 by the American Association of Neuropathologists, Inc.
Vol. 73, No. 6June 2014
pp. 585Y638
Copyright © 2014 by the American Association of Neuropathologists, Inc. Unauthorized reproduction of this article is prohibited.
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4
Loss of CDKN2A/p16 is Associated with Shortened Overall Survival in
Grade II and III Gliomas
Gerald Reis1, Melike Pekmezci1, Helen Hansen1, Roxanne Marshall1, Terri
Rice1, Joanna Phillips1, John Wiencke1, Margaret Wrensch1, Kyle Walsh1,
Arie Perry1. 1University of California San Francisco
Background: Lower WHO grade (II and III) gliomas (LGG) vary widely in
clinical behavior and are classified as astrocytoma (A2), oligodendroglioma
(O2), and oligoastrocytoma (OA2) or anaplastic astrocytoma (A3),
oligodendroglioma (O3), and oligoastrocytoma (OA3). Anaplasia depends
greatly on mitotic activity with CDKN2A loss considered the most common
mechanism for cell cycle dysregulation. Thus, we investigated whether loss
of the CDKN2A gene or its product, p16, is associated with patient survival
across pathologically and genetically defined subtypes.
Methods: UCSF Adult Glioma Study cases (95 males and 70 females;
average age: 43.2 and 41.1 years, respectively) consisted of 57 O2, 34 A2, 29
OA2, 20 O3, 16 A3, 9 OA3. Molecular parameters included isocitrate
dehydrogenase (IDH1 or IDH2) (97%) and 1p19q status (88% of oligoden-
droglial tumors). CDKN2A deletion was assessed by FISH, while p16 and
MIB1 (Ki-67) labeling indices (LI) were determined immunohistochemically.
Cox proportional hazards modeled overall survival, stratifying by histology and
adjusting for sex, age, grade, and molecular subtype. 66 events (deaths) were
observed with median follow-up time of 6.4 years.
Results: Reduced p16 LI was associated with decreased overall survival
across all grades (P=0.05) and adjusted for age, histology, and IDH status
(P=0.02). CDKN2A deletion was strongly associated with worse survival in
astrocytomas (P=0.002; HR=4.4; 95% CI=1.73-11.0) but not oligodendro-
gliomas or oligoastrocytomas (P=0.60 and 0.96, respectively). IDH mutation
and CDKN2A deletion were inversely associated across all subtypes
(p=0.03). CDKN2A FISH and p16 IHC results were only weakly associated
(P=0.10), while no clear associations between CDKN2A and MIB1 (P=0.21)
or p16 and MIB1 (P=0.21) were found.
Conclusions: Loss of p16 expression is associated with shortened survival
in all LGG, whereas CDKN2A deletions decrease survival in astrocytomas,
most being IDH wild type. CDKN2A/p16 studies may provide further
clinical aid in LGG sub-stratification beyond IDH and 1p19q studies.
5
Biopsy Site has Important Prognostic Implications in Gliomas
Rocio Guevara de Bonis1, Marta Brell1, Javier Ibanez1, Carmen Vidal1,
Francisca Nebot1, Marta Couce2. 1Hospital Universitari Son Espases, Palma,
Spain; 2University Hospitals Case Medical Center
Predictive biomarkers are part of the diagnostic tests battery in gliomas. Some
patients, in spite of bearing predictors of poor behavior will have longer
survivals; whereas others, with good prognostic markers, will have shorter life
expectancies. Recently, the generally accepted good predictive value of O6-
methylguanine-DNA methyltransferase promoter methylation (MGMTpm),
was questioned. In addition, one study reported that only those patients with
wild type isocitrate dehydrogenase 1 (IDH1wt) would benefit from that
prediction. Biochemical and molecular characterization of distant regions of
gliomas could be key to understand these different clinical responses.
44 patients undergoing gross total resection of gliomas were consented for the
study (11 low-grade gliomas (LG), and 33 high-grade gliomas (HG)) and
followed from 36 to 85 months. Central and peripheral tumoral regions were
examined. IDH1mutation (IDH1mut) (by immunohistochemistry and sequenc-
ing analysis), IDH1 mRNA expression and MGMTpm were evaluated.
1) IDH1 mutation was present in 72.7 % LG and 18.2 % HG, and showed no
regional differences. 2) IDH1 mutation was associated with longer survival,
particularly in HG (pG0.05). 3) HG, had significantly higher expression of
IDH1mRNA as compared with LG (pG0.05). 4) A positive correlation
between IDH1 mutation and MGMTpm was identified (pG0.01). 5) MGMT
was more frequently methylated in central regions in both types of gliomas
(29.4% HG and 42.9 % LG were methylated in central and not in peripheral
regions). 6) Chemotherapy was beneficial for those patients with concom-
itant MGMTpm, and IDH1mut.
We conclude that the combination of IDH1mut and MGMTpm predict the
best possible outcome for these patients. MGMTpm alone does not increase
the survival in IDH1wt gliomas in our study. In addition, we found that
biopsies from central regions in gliomas are more informative in order to
accurately characterize the MGMTpm in these tumors.
6
Is hTERT Immunohistochemistry Predictive of 1p/19q Co-deletion in
Grade II-III Diffuse Gliomas?
Christina Appin1, Daniel Brat1. 1Emory University School of Medicine
Background: One mechanism for maintaining telomere length in diffuse
gliomas is by activating somatic mutation of the human telomerase reverse
transcriptase (hTERT) promoter. hTERT promoter mutations are associated
with increased gene expression and are frequently present in IDH-mutated,
1p/19q co-deleted and in IDH-wildtype diffuse gliomas, but rarely in those
that are IDH-mutated, 1p/19q intact. We investigated whether the
immunohistochemical (IHC) expression of hTERT was predictive of 1p/19q
co-deletion among IDH-mutated diffuse gliomas.
Methods: IHC for hTERT and IDH1mutant protein (R132H) was performed on
43 grade II-III diffuse gliomas. Fluorescence in situ hybridization (FISH) was
performed to assess 1p and 19q status.Diffuse gliomas immunostained for hTERT
included 20 IDH1-mutated, 1p/19q co-deleted tumors; 15 IDH1-mutated, 1p/19q
intact tumors and 8 IDH1-wildtype, 1p/19q intact tumors. Statistical analysis of
correlations between alterations was performed using Chi-square analysis.
Results: IHC expression of hTERT was detected in 15 of 20 (75%) IDH1-
mutated, 1p/19q co-deleted gliomas; 6 of 8 (75%) IDH1-wildtype gliomas;
and 6 of 15 (40%) IDH1-mutated, 1p/19q intact gliomas. Among the IDH1-
mutated gliomas, we found a significant correlation between hTERT
expression and 1p/19q co-deletion (p = 0.0364). However, IHC expression
of hTERT was only 75% sensitive and 60% specific for 1p/19q co-deletion
within IDH1-mutated gliomas. The positive predictive value of hTERT IHC
for 1p/19q co-deletion was 71% and the negative predictive value was 64%.
Conclusions: hTERT IHC expression was noted in 75% of IDH1-mutated,
1p/19q co-deleted tumors and 75% of IDH1 wildtype, 1p/19q intact tumors.
However, the frequency of hTERT IHC expression in IDH1-mutated, 1p/19q
intact gliomas (40%) suggests that this test is not highly specific or predictive
for 1p/19q co-deletion.
7
TERT Promoter Mutation is Associated with Older Age at Diagnosis,
Independent of Glioma Grade, Histology and IDH1/2 Status
Melike Pekmezci1, Gerald Reis1, Helen Hansen1, Terri Rice1, Shichun
Zheng1, John Wiencke1, Arie Perry1, Margaret Wrensch1, Kyle Walsh1.1University of California San Francisco
Background: Young age at diagnosis is a favorable prognostic factor and
impacts clinical management of patients with infiltrating glioma. The literature
suggests that grade II tumors and oligodendroglial tumors are diagnosed at
younger ages than anaplastic and astrocytic tumors, respectively. With the
exception of isocitrate dehydrogenase (IDH) mutations, molecular features
driving these age differences remain largely unknown.Heritable variation in the
telomerase reverse transcriptase (TERT) gene is associated with later age at
diagnosis in glioma patients. We sought to evaluate whether somatic TERT
mutations are also associated with later age at diagnosis in glioma patients,
within strata of grade, histology and IDH1/2 status.
Methods: Adults (age Q18 years) with histopathologically confirmed infiltrat-
ing glioma were selected from the UCSF Adult Glioma Study (n=351). The
TERT promoter region was analyzed by Sanger sequencing and tumors were
classified as TERT-wild type and TERT-mutated. Associations between TERT
status and age at diagnosis were assessed by t-tests.
Results: TERT promoter mutation was associated with an approximately 8
year older age at diagnosis across all glioma grades (gradeIV p=0.0003,
Abstracts J Neuropathol Exp Neurol � Volume 73, Number 6, June 2014
� 2014 American Association of Neuropathologists, Inc.586
Copyright © 2014 by the American Association of Neuropathologists, Inc. Unauthorized reproduction of this article is prohibited.
Page 3
GradeIII p=0.014, GradeII p=0.0001) and histologies (Glioblastoma
p=0.0003, Astrocytoma p=0.007, Oligodedroglioma p=0.16, Mixed
p=0.005). Among patients with IDH wild-type grade II-III gliomas, TERT
promoter mutation was associated with a 10 year older age at diagnosis
(p=0.0065). Among patients with IDH-mutated grade II-III gliomas, TERT
promoter mutation was associated with a 7 year older age at diagnosis
(p=0.0002). Overall, patients with IDH mutation who lack TERT promoter
mutation have the youngest age at diagnosis (Average=36.5). This group
consists primarily of astrocytic neoplasms.
Conclusions: Somatic mutations in IDH are associated with younger age at
diagnosis, while somatic mutations in TERT promoter are associated with
older age at diagnosis. Among patients with IDH mutated tumors, those with
TERT mutation (primarily oligodendroglioma) are diagnosed at later ages
than those without TERT mutation (primarily astrocytoma).
8
Efficacy of Mono and Dual PI3K and MAPK Inhibition in Glioblastoma
and Triple-Negative Breast Cancer Brain Metastasis Models
Robert McNeill1, Amanda Van Swearingen1, Ryan Bash1, Salma Azam1,
Demitra Canoutas1, Brian Constance1, Ralf Schmid1, Carey Anders1, C.
Miller1. 1University of North Carolina Chapel Hill
Glioblastoma (GBM) and triple-negative breast cancer brain metastases
(BCBM) are biologically aggressive with limited therapeutic options. The
MAPK and PI3K arms of receptor tyrosine kinase (RTK) signaling are
attractive therapeutic targets because they are mutationally activated in both
diseases. We defined the in vitro and in vivo efficacy of brain penetrant pan-
PI3K (BKM120) and MEK1/2 (AZD6244) inhibitors in GBM and BCBM
models. GBM was modeled using G1/S-defective murine (TRP) and human
(NHA-RAS-AKT) astrocytes with genetically activated PI3K and MAPK
signaling. BCBM was modeled using SUM149, an established, basal-like,
BRCA1-mutant human cell line. BKM and AZD inhibited in vitro growth of
both TRP and NHA-RAS-AKT astrocytes by 995 and È75% at 1-100 KM.
BKM inhibited downstream PI3K signaling (decreased p-Akt and p-S6),
while AZD6244 inhibited MAPK signaling (decreased p-Erk). Compensa-
tory activation of the non-targeted pathway was evident in TRP astrocytes
treated with either drug alone. Dual inhibition was required to ablate
compensatory signaling and was synergistic at È4-110 KM in vitro. Daily
treatment of established (10 d) orthotopic TRP GBM allografts in syngeneic
mice with BKM (30 mpk), AZD (37 mpk), or both (25 and 18 mpk) did not
delay growth by bioluminescence imaging nor provide a significant survival
benefit (96, 108, and 84% of untreated animals). In contrast, while BKM and
AZD mono-therapy inhibited SUM149 cell growth similar to GBM
astrocytes, drug synergism was evident at È0.08-10 KM and the same
treatment regimens delayed growth of established (20 d) intracranial SUM149
xenografts and prolonged median survival (116, 160, and 9178% of untreated
animals). Thus, despite similar in vitro efficacy in both model systems, dual
BKM and AZD therapy was less synergistic and efficacious in the GBM vs.
BCBM models tested here. These results suggest that GBM and BCBM may
have unique, intrinsic resistance mechanisms to PI3K and MAPK inhibitors.
PLATFORM SESSION 2: NEURODEGENERATIVE
1 - AD, CTE, PRIONS
Friday 8-10 AM, June 13, 2014
Culture Ballroom
9
Pyroglutamylated Amyloid-A correlates with Hyperphosphorylated Tau
and Severity of Alzheimer’s Disease
Johannes Attems1, Lauren Walker2, Radmila Santic3, Ajeet Rijal Upadhaya4,
Sean Colloby1, Dietmar Thal4, Alan Thomas1, Achim Schneeberger3, Markus
Mandler3. 1Institute for Ageing and Health, Newcastle University; 2Newcastle
University; 3Affiris AG; 4Laboratory of Neuropathology, University of Ulm
Pyroglutamylated amyloid-A has been suggested to play a major role in
Alzheimer’s disease pathogenesis as amyloid-A oligomers containing
pyroglutamylated amyloid-A might initiate tau dependent cytotoxicity. We
aimed to further elucidate the associations between pyroglutamylated
amyloid-A, amyloid-A and hyperphosphorylated tau in human brain tissue.
We examined 41 post mortem brains (mean age 79.6 years, SE: T1.5) ofboth Alzheimer’s disease (n=18) and controls. Adjacent sections from each
frontal and entorhinal cortex, were stained with pyroglutamylated amyloid-
A, hyperphosphorylated tau and amyloid-A specific antibodies. We used
image analysis to quantitatively assess loads for pyroglutamylated amyloid-
A, hyperphosphorylated tau and non-pyroglutamylated amyloid-A. All loads
were significantly higher in Alzheimer’s disease as compared to controls
(pe0.01). However, regression analysis using amyloid-A loads as independ-
ent variables revealed that only frontal pyroglutamylated amyloid-A load
independently predicted the presence of Alzheimer’s disease (p=0.01). In
frontal and entorhinal cortices pyroglutamylated amyloid-A load independ-
ently predicted hyperphosphorylated tau load (PG0.001), while non-
pyroglutamylated amyloid-A failed to do so. All loads correlated with neuro-
fibrillary tangle Braak stages and Thal amyloid-A phases (PG0.01). However,
partial correlation analysis revealed respective correlations in the frontal cortex
only for pyroglutamylated amyloid-A load while in the entorhinal cortex
respective correlations were seen for both hyperphosphorylated tau and non-
pyroglutamylated amyloid-A loads. Mini Mental State Examination scores were
predicted by entorhinal hyperphosphorylated tau load independent of other
entorhinal loads (PG0.001) and by frontal pyroglutamylated amyloid-A load
independent of frontal non-pyroglutamylated amyloid-A load (P=0.01). Here,
we report an association between pyroglutamylated amyloid-A and hyper-
phosphorylated tau in human brain tissue and an influence of frontal
pyroglutamylated amyloid-A on both the severity of Alzheimer’s disease
neuropathology and clinical dementia. Our findings further support the notion
that pyroglutamylated amyloid-A may represent an important link between
amyloid-A and hyperphosphorylated tau and investigations into its role as
diagnostic and therapeutic target in Alzheimer’s disease are warranted.
10
TDP-43 Influences Cognition, Memory Loss and Hippocampal Atrophy
in Alzheimer’s Disease
Keith Josephs1, Jennifer Whitwell2, Stephen Weigand3, Melissa Murray4,
Nirubol Tosakulwong3, Amanda Liesinger4, Leonard Petrucelli5, David
Knopman1, Bradley Boeve1, Robert Ivnik6, Glenn Smith6, Clifford Jack2,
Joseph Parisi7, Ronald Petersen1, Dennis Dickson4. 1Mayo Clinic,
Department of Neurology; 2Mayo Clinic, Department of Radiology; 3Mayo
Clinic, Department of Health Science Research (Biostatistics); 4Mayo
Clinic, Department of Neuroscience (Neuropathology); 5Mayo Clinic,
Department of Neuroscience (Molecular Neuroscience); 6Mayo Clinic,
Department of Psychiatry (Neuropsychology); 7Mayo Clinic, Department
of Laboratory Medicine and Pathology
The aim of this study was to determine whether the TAR DNA-binding
protein of 43kDa(TDP-43) has any independent effect on the clinical and
neuroimaging features typically ascribed to Alzheimer’s disease (AD)
pathology, and whether TDP-43 pathology could help to shed light on the
phenomenon of resilient cognition that has been observed in AD. Three
hundred and forty-two subjects pathologically diagnosed with intermediate-
high probability ADwere screened for the presence and distribution of TDP-43.
In addition, we quantitatively measured the burden of TDP-43 in the dentate
gyrus of the hippocampus. All subjects had been classified as cognitively
impaired or cognitively normal, prior to death. Atlas-based parcellation and
voxel-based morphometry were used to assess regional atrophy on MRI.
Regression models controlling for age at death, apolipoprotein D4, Braak stage,
CERAD, Lewy bodies and vascular pathologies were utilized to explore
effects between TDP-43 and cognition or brain atrophy, stratified by Braak
stage. Additionally, we determined whether the effects of TDP-43 on outcome
variables were mediated by hippocampal sclerosis. One-hundred and ninety-
five (57%) cases were TDP-positive. After accounting for age at death,
J Neuropathol Exp Neurol � Volume 73, Number 6, June 2014 Abstracts
� 2014 American Association of Neuropathologists, Inc. 587
Copyright © 2014 by the American Association of Neuropathologists, Inc. Unauthorized reproduction of this article is prohibited.
Page 4
apolipoprotein D4, and the other AD related pathologies, TDP-43 had a strong
effect on cognition, memory loss, and medial temporal atrophy in AD. These
effects were not mediated by hippocampal sclerosis. The TDP-positive
subjects were 10X more likely to be cognitively impaired at death compared
to the TDP-negative subjects. Greater cognitive impairment and medial
temporal atrophy were associated with greater TDP-43 burden and more
extensive TDP-43 distribution. TDP-43 is an important factor in the
manifestation of the clinico-imaging features of AD and appears to be able
to overpower what has been termed resilient brain aging. TDP-43 therefore
should be considered a potential therapeutic target for the treatment of AD.
11
Novel Fluid Biomarkers for Brain Amyloid in Presymptomatic
Alzheimer Disease
Richard Perrin1, Hua Weng2, Kelley Coalier1, Anne Fagan1, Chengjie
Xiong1, David Holtzman1. 1Washington University School of Medicine;2Division of Biostatistics, Washington University School of Medicine
Background: Clinical trials for Alzheimer disease (AD) are now targeting
AA production or clearance to combat amyloid deposition. In this circum-
stance, low CSF AA42 may serve as an indicator of target engagement, but
will lose its utility as an independent surrogate marker for brain amyloid.
PET ligands Pittsburgh compound B (PIB) and florbetapir (Amyvid) may
still be effective for detecting plaques, but PIB is inconvenient to use at
distance from a cyclotron, florbetapir may have limited sensitivity for small
changes in plaque burden, and both are expensive. In this study, we sought
to identify novel fluid biomarkers for very early amyloid deposition.
Methods: Paired CSF and plasma samples, collected from 142 Knight
ADRC participants with normal cognition (Clinical Dementia Rating [CDR]
0) within 2.5 years of PET-PIB imaging, were analyzed using the 190MAP
biomarker discovery panel at Myriad/RBM (Luminex platform). Mean
cortical PIB binding potential [MCBP] above/below 0.18 was treated as a
categorical variable for receiver operating characteristic (ROC) analyses.
Logistic regression models were used to evaluate markers in combination.
Age, gender, education, and APOE-?4 status were treated as covariates.
Results: In multivariate ROC analyses, 22 plasma and 17 novel CSF
proteins yielded areas under the curve (AUC) 9 0.6 (max 0.662 & 0.687) for
predicting MCBP 90.18. CSF tau/AA42 ratio combined with p-tau181 was
the best predictor, with AUC = 0.963. As an alternative (e.g. for trials
targeting AA42), a combination of CSF tau, >-1-AT and adiponectin yielded
an AUC = 0.797. In plasma, a combination of apoA2, apoE, and PAI-1
yielded an AUC of 0.748.
Conclusions/Discussion: Many novel fluid proteins have potential as early
brain amyloid biomarkers. These may facilitate clinical trials that directly
target AA, aid screening for preclinical AD, and provide insights into the
pathophysiology surrounding very early plaque deposition.
12
Beclin1/BECN1 Interacts with Surface APP and Facilitates Its
Internalization and Sorting for Autophagosomal Degradation
Edward Plowey1, Wan Zhu1, Gayathri Swaminathan1. 1Stanford University
School of Medicine
Macroautophagy, hereafter designated autophagy, is a vesicular trafficking
pathway for autolysosomal degradation that is thought to protect neurons
from diverse stressors. Recent studies suggest that deficiencies in the
BECN1-PIK3C3 complex, an essential autophagy regulatory protein
complex, may be an important factor in age-related neurodegenerative
diseases including Alzheimer disease (AD). Studies in BECN1+/- mice and
cell line models have highlighted an important role for BECN1 in the
regulation of amyloid precursor protein (APP) metabolism and in reducing
the secretion of its toxic metabolite amyloid-beta. A better understanding of
the cellular and molecular mechanisms underlying BECN1- mediated APP
degradation is crucial for the design of novel therapeutic strategies to reduce
amyloid-beta secretion and toxicity in AD. We hypothesized that BECN1
interacts with APP and promotes its trafficking for autolysosomal degradation
in lieu of amyloidogenic metabolism in the endosomal pathway. Using co-
immunoprecipitations, we identified novel interactions of APP with the
autophagy regulatory proteins BECN1, PIK3C3, UVRAG and ATG16L1. We
further found that APP associates with BECN1 at the plasma membrane by co-
immunoprecipitation from cell-surface fractions and that BECN1 promotes
surface APP internalization and trafficking to autophagosomes. Mapping
studies using BECN1 and APP mutants indicated that the association between
APP and BECN1 is primarily mediated by the evolutionary conserved domain
of Beclin1 and by the C-terminus of APP . Furthermore, BECN1 binding to
APP was regulated by presence of ubiquitination sites, spanning lysines 649-
651, in APP C-terminus while mutation of APP endocytic motif (YENPTY)
had no effect. In summary, our studies reveal a novel functional interaction
between surface APP and BECN1 and its significance in regulation of APP
sorting from the cell surface for degradation.
13
Beta-amyloid Accumulation in Chronic Traumatic Encephalopathy
Thor Stein1, Victor Alvarez2, John Crary3, Gaoyuan Meng1, Ann McKee1.1Boston VA Medical Center; 2Boston University; 3Columbia University
Medical Center
Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease
induced by repeated mild traumatic brain injuries (TBIs). It is a tauopathy
characterized by neurofibrillary tangles and tau-positive processes that
preferentially involve the cortical sulci, medial temporal lobe, diencephalon,
and brainstem. In CTE the tau pathology is predominantly subpial,
perivascular, and within the sulcal depths. This tau pathology may be due
to axonal injury, disruptions of the blood brain barrier, and vascular
damageValterations that also have been linked to Alzheimer disease (AD).
In fact, trauma is a suspected risk factor for AD, and multiple mild TBIs
may play a causative role in the development of AD as well as CTE. Thus,
we examined our cohort of athletes and military veterans with CTE (n=92)
for beta-amyloid deposition with standard histology, immunohistochemistry,
ELISA, and APOE genotyping. We find that AA neuritic plaques occur in
37% of all cases of CTE and are significantly associated with age at death
and the presence of APOE D4 allele, but not with the duration of trauma
exposure, disease duration, or CTE stage adjusted for age. We also
examined sulcal versus gyral levels of AA and found that AA1-40, but not
AA1-42, is significantly increased within the sulcus in both AD and CTE
with AD subjects. The percentage of leptomeningeal vessels with cerebral
amyloid angiopathy is significantly elevated within the sulcus of subjects
with CTE and AA, but not in AD subjects alone. Overall, this suggests that
parenchymal beta-amyloid accumulation occurs independently of mild
traumatic brain injury and CTE, but that cerebral amyloid angiopathy is
exacerbated by trauma at the sulcal depths.
14
Single Episode of Severe Axonal Injury in Humans Can Lead to Tau
Pathology Resembling Chronic Traumatic Encephalopathy
Sarah Edgerton1, Sharon Shively1, Elliott Mufson2, Dushyant Purohit3,
Daniel Perl4. 1Henry M. Jackson Foundation for the Advancement of
Military Medicine; 2Rush University School of Medicine; 3Icahn School of
Medicine at Mount Sinai; 4Uniformed Service University, F. Edward Hebert
School of Medicine
Chronic traumatic encephalopathy (CTE) is a neurodegenerative disorder
associated with repetitive mild traumatic brain injury (TBI). In CTE, tau
proteins aggregate forming neurofibrillary tangles (NFTs) and astrocytic
tangles in a stereotyped distribution, favoring subpial sulcal depths,
perivascular regions and superficial neocortical layers. Some have suggested
that these tau aggregates develop following axonal damage. Therefore, we
tested the hypothesis that axonal damage in the human brain can give rise to
neurofibrillary and astrocytic tangle formation by analyzing postmortem
brain tissues from six schizophrenic patients who underwent prefrontal
Abstracts J Neuropathol Exp Neurol � Volume 73, Number 6, June 2014
� 2014 American Association of Neuropathologists, Inc.588
Copyright © 2014 by the American Association of Neuropathologists, Inc. Unauthorized reproduction of this article is prohibited.
Page 5
leucotomy. Because leucotomy involves severing axons leading to and from
the prefrontal cortex, this procedure represents a single, severe axonal injury
without external cortical impact in patients who survived at least another 40 years.
We examined cortical tissues at the lesion sites, prefrontal cortices rostral and
frontal cortices caudal to the lesion sites, temporal cortex and hippocampus with
immunohistochemistry for abnormal tau. Temporal cortex and hippocampus
revealed scant NFTs, consistent with age. In all 6 cases, significant abnormal tau
was detected in the gray matter adjacent to the lesion sites, with primarily
astrocytic tangles in depths of sulci and NFTs in superficial neocortical layers, but
not in the prefrontal and frontal cortices distant to the lesion sites. We conclude
that axonal damage from leucotomy leads to accumulations of abnormal tau in
gray matter adjacent to the lesion with features resembling CTE. Since significant
tau pathology was not detected in prefrontal cortices, the data do not support the
hypothesis that chronic neuronal deafferentation alone leads to abnormal tau
accumulation. Moreover, since leucotomy lacks external cortical impact, the data
suggest that selective accumulation of tau at depths of sulci may be related to
underlying axonal damage rather than mechanical stresses during TBI.
(Supported by the US Army Military Research and Materiel Command and
the CNRM.)
15
Glycans Modulate the Transmissibility of PrPSc and the sCJDMM2
and sFI Phenotypes
Laura Cracco1, Ignazio Cali1,2, Anya Hurley1, Liuting Qing1, Qingzhong
Kong1, Pierluigi Gambetti1. 1National Prion Disease Surveillance Center,
Case Western Reserve University; 2Second University of Naples
Sporadic fatal insomnia (sFI) and the subtype of sporadic Creutzfeldt-Jakob
disease (sCJD) identified as sCJDMM2 share methionine homozygosity at
codon 129 (129MM) of the prion protein (PrP) gene and scrapie PrP (PrPSc)
type 2 although they are associated with different phenotypes. Our data
suggest that the sFI and sCJDMM2 phenotypic heterogeneity is in part
related to the diversity of the PrPSc glycans in these two diseases.
To further investigate the role of glycans in phenotypic determination, we
transmitted sCJDMM2 and sFI to i) transgenic (Tg) mice expressing
normally glycosylated human (Hu) PrPC [Tg(HuPrPC)] and ii) Tg mice
expressing human PrP free of glycans [Tg(HuPrPglycKO)]; incubation
periods, histopathologies and PrPSc characteristics were compared.
Tg(HuPrPC) mice challenged with sCJDMM2 and sFI became symptomatic
631T93 and 554T60 days post inoculation (dpi), respectively. sCJDMM2-
inoculated mice showed large-vacuole spongiform degeneration (SD) and a
PrP immunostaining pattern similar to that of sCJDMM2. Minimal small-
vacuole SD was observed in half of the sFI-inoculated mice and was
associated with sFI-like PrP immunostaining. Proteinase K-resistant PrPSc
(resPrPSc) type 2 was detected in both groups of mice. In contrast,
sCJDMM2- and sFI-inoculated Tg(HuPrPglycKO) became symptomatic
278T36 and 354T155 dpi, respectively. Both displayed similar histopathol-
ogies characterized by widespread SD and PrPSc deposition in focal plaque-
like and large granules. In both, resPrPSc formed only one band of È19 kDa
matching the electrophoretic mobility of unglycosylated resPrPSc type 2.
In conclusion: 1) sCJDMM2 and sFI can be transmitted to Tg(HuPrPC)
mice, producing different histopathologies; 2) transmission to Tg mice
expressing human glycan-free PrP appears to abrogate the histopathological
differences of these two diseases, supporting a role of glycans in phenotype
determination; 3) in our model, PrP glycan ablation increases the trans-
mission efficiency of both sCJDMM2 and sFI.
(Supported by P01AG 14359, CDC UR8/CCU515004, NS052319 and
Charles S. Britton Fund).
16
Transmissibility and propagation of co-existing prions of sporadic
Creutzfeldt-Jakob disease into humanized transgenic mice
Ignazio Cali1,2, Wenquan Zou1, Laura Cracco1, Anya Hurley1, Tetsuyuky
Kitamoto3, Qingzhong Kong1, Pierluigi Gambetti1. 1National Prion Disease
Surveillance Center, Case Western Reserve University; 2Second University
of Naples; 3Graduate School of Medicine, Tohoku University, Sendai, Japan
About 40% of sporadic Creutzfeldt-Jakob disease patients with methionine
(M) homozygosity at PrP gene codon 129 show co-existence of the scrapie
prion protein (PrPSc) types 1 and 2 (sCJDMM1-2). To investigate the
mechanism of mixed PrPSc 1-2 types formation, we examined co-
occurrence, transmissibility, disease phenotype prevalence and brain
propagation of PrPSc using brain homogenates from a) sCJDMM1-2
harboring PK-resistant PrPSc (resPrPSc) types 1 and 2, b) in vitro mixed
types 1 and 2 individually harvested from separate regions of sCJDMM1-2
and c) in vitro mixed PrPSc from sCJDMM1 and sCJDMM2, following
intracerebral inoculation into transgenic mice expressing human PrPC-
129M. The ratios of type 1/type 2 were 50%/50%, 35%/65% and 10%/90%
in a), b) and c), respectively. Mice were sacrificed after 95, 131, 187 days
post inoculation (dpi). All mice showed only resPrPSc type 1. Mice
inoculated with PrPSc type 1-2 had incubation time, lesion profiles and
resPrPSc features identical to those of mice inoculated with sCJDMM1
(183T22 dpi) and different from those of sCJDMM2-challenged mice
(609T139 dpi). At 95 dpi, mice showed tiny amounts of resPrPSc type 1 in
the central brain with spongiosis and PrP immunostaining in the thalamus.
At 131 dpi, resPrPSc type 1 spread to the cerebral cortex and brain stem.
The lesion profile reflected the resPrPSc distribution. At 187 dpi, resPrPSc
type 1 affected the whole brain. We conclude that: 1) Mice reproduce PrPSc
type 1 and sCJDMM1 phenotype regardless of PrPSc types 1 and 2 ratios in
the inoculum. 2) Replication rate of type 2 is much slower than that of type
1 and is not accelerated by the presence of type 1. 3) In sCJDMM1-2, type 1
maintains the same infectivity, propagation and phenotype characteristics of
type 1 of sCJDMM1.
4) Topography and timing of PrPSc propagation are highly reproducible.
(Supported by P01AG14359, CDCUR8/CCU515004, NIHNS062787,
NS052319 and Charles S. Britton).
PLATFORM SESSION 3: INFLAMMATORY,
OPHTHALMIC, OTHER
Friday 2-4 PM, June 13, 2014
Fashion Ballroom
17
Transient Receptor Potential Melastatin 4 Expression in Human
Cerebral Infarcts
Rupal Mehta1, Svetlana Ivanova1, Cigdem Tosun1, Rudy Castellani1,
Volodymyr Gerzanich1, J Simard1. 1University of Maryland
Transient receptor potential melastatin 4 (TRPM4), a mammalian cation
channel, is transcriptionally upregulated in neural and vascular cells
following acute subarachnoid hemorrhage in humans and animal models.
Prior studies document a leading role of this molecule in cytotoxic edema
formation and necrotic cell death following diverse acute central nervous
system injuries. The expression of TRPM4 in human cerebral infarcts,
however, has not previously been systematically analyzed. In this study, we
evaluated expression of TRPM4 in postmortem specimens obtained from 15
patients within the first 31 days after clinical onset of focal cerebral
ischemia. Significant elevation of TRPM4 protein was found in neurons,
astrocytes and endothelial cells in infarcted cerebrum, relative to contrala-
teral and control tissues. Upregulation of TRPM4 protein was corroborated
using in situ hybridization for TRPM4 mRNA. Furthermore, co-association
of TRPM4 and sulfonylurea 1 (SUR1) was detected using co-immunopre-
cipitation and Forster resonance energy transfer (FRET) experiments. These
findings document upregulation of SUR1-TRPM4 ion channels during focal
ischemic stroke in humans. These new data indicate that SUR1-TRPM4
channel upregulation and activation are likely key molecular events leading
to cell death during acute stroke, suggesting that SUR1 may be a promising
novel treatment target for patients with acute cerebral infarction.
J Neuropathol Exp Neurol � Volume 73, Number 6, June 2014 Abstracts
� 2014 American Association of Neuropathologists, Inc. 589
Copyright © 2014 by the American Association of Neuropathologists, Inc. Unauthorized reproduction of this article is prohibited.
Page 6
18
Lymphocytic Hypophysitis: A Single Centre Experience of 11 Cases
Marc Del Bigio1, Angela Miller2, Jayantha Herath3. 1Pathology - University
of Manitoba; 2University of Manitoba; 3Ontario Forensic Pathology Service
In the province of Manitoba Canada (population 1.4 million) all neuro-
surgical procedures and almost all autopsies are done at a single center. We
did a retrospective review spanning the years 1996-2012, searching records
for documentation of inflammation in the pituitary (2228 glands from adult
autopsies, 1267 from pediatric autopsies, 339 surgical biopsies). Proven or
likely infectious causes and cases with predominantly neutrophilic inflam-
mation associated with hemorrhage or infarction were excluded. This left 11
cases with non-granulomatous predominantly T lymphocytic inflammation
(7 autopsy, 4 surgical). The autopsy cases ranged from 11-64 years and the
surgical cases 27-82 years (total 5 females including 1 pregnant). Among
the autopsy cases, 3/7 had a clearly unrelated cause of death and no history
of relevant symptoms; the pituitary inflammation was considered incidental.
One had a history of seizures; there was no anatomical cause of death. In the
7 autopsy cases, other endocrine organs were available for analysis; 4/4
adrenal glands, 4/5 thyroid glands, and 2/5 pancreases had T lymphocytic
inflammation within the parenchyma. In four cases the decedent had
exhibited pre-mortem clinical syndrome associated with that organ (38 year
female hypothyroidism; 49 year female hyperprolactinemia; 44 year male
Addison disease and hypothyroidism; 49 year female diabetes mellitus); in
the first three, pituitary dysfunction was considered contributory to the
deaths. Immunohistochemical staining showed reduced immunoreactivity
for some or all of the pituitary hormones in all of the cases. Although the
prevalence of autoimmune lymphocytic hypophysitis is low, we conclude
that examination of the pituitary gland is an important part of the autopsy in
individuals who die unexpectedly, particularly if they have a history of
endocrine disease or recent neurological symptoms.
19
Myelin Loss in Adult-onset Leukoencephalopathy/Leukodystrophy with
Axonal Spheroids is Secondary to Axonal Loss
Murad Alturkustani1,2, Julia Keith3, Lili-Naz Hazrati4, Lee-Cyn Ang1.1London Health Sciences Centre, University of Western, London, ON;2Department of Pathology, King Abdulaziz University and Hospital, Jeddah,
Kingdom of Saudi Arabia, 3Sunnybrook Health Sciences Centre, University
of Toronto, Toronto, ON; 4Tanz Centre for Research in Neurodegenerative
Diseases, Toronto, ON
Background: Whether the myelin loss in adult-onset leukoencephalopathy/
leukodystrophy with axonal spheroids (ALAS) is a primary demyelinating
process or secondary to axonal degeneration has not been clearly established.
The confluentmyelin loss with U-fibre sparing gives an impression of a primary
demyelinating/dysmyelinating disease. Although, the prevalence of axonal
spheroids would favor a primary axonal degeneration with secondary
demyelination, occasional axonal spheroids have been described in chronic
primary demyelination as in multiple sclerosis (MS). In spite of the recent
discovery of CSF1R mutation in ALAS, it is uncertain how this mutation
correlates with the observed pathology.
Methods: We examined neuropathological features in 5 ALAS cases (3 males:
2 females; age 39-61 years) and 3 chronic MS cases (1 male: 2 females; age
50-73 years). Special histochemical stains, immunohistochemical stains and
ultrastructural studies were used to study the axonal and myelin pathology.
Results: The white matter pathology in ALAS cases can be characterized as
3 evolving phases: 1) white matter with numerous spheroids in a
background of well-myelinated fibres or slight myelin pallor; 2) white
matter showing mixture of well-preserved myelinated fibres and degenerat-
ing fibres with sparse to moderate number of spheroids; and 3) leukodys-
trophy-like pattern of confluent myelin loss with relative preservation of the
subcortical U-fibres, few spheroids and myelinated fibres. No convincing
areas with demyelinated but relatively intact axons have been identified in
our ALAS cases. In contrast, the chronic MS plaques show complete myelin
loss with relatively preserved axons. Axonal spheroids are occasionally
present in these plaques but not in the areas with preserved myelin.
Conclusions: Our study supports the notion that the myelin loss in ALAS is
secondary to axonal degeneration.
20
Characteristic of neural tissue in ovarian teratomas associated to Anti-
NMDA receptor encephalitis (ANMDARE)
David Munoz1, Gregory Day2, Simin Laiq2, David Tang-Wai22.1St. Michael’s Hospital, University of Toronto; 2University of Toronto
Objective & Methods: ANMDARE is the most common form of paraneo-
plastic encephalitis that preferentially affects women of reproductive age;
over half have ovarian teratomas (OT). Most women with OT, however, do
not develop ANMDARE. We investigated the histological differences
between OT in 5 women with ANMDARE (mean age 28.2T8.6 years) and
all OT resected at a single hospital during 2013 (39 OT from 38 women,
mean age 34.8T10.0 years).
Results: Neural tissue was identified in 80% (4/5) of ANMDARE-
associated OT and 51.3% (20/39) of control OT. Dysplastic neurons, often
showing binucleation or multinucleation, were present in all cases with
neural tissue but not in any controls (p=0.0001). If found in the brain, one
case would have been diagnosed as a ganglioneuroblastoma, as dysplastic
neurons occurred together with mitotically active neuroblasts and maturing
neurons; the other 3 OT contained mature neurons and glial cells and would
have been called gangliogliomas. In one OT the area showing this change
was tiny, less than 300 um in diameter. Neural tissue was intimately
associated with inflammatory cell infiltrates in all four cases but not in any
controls (p=0.0001). The neural tissue often formed a rim around lymphoid
follicles, suggesting that the centrally-located inflammatory cells may have
focally obliterated underlying dysplastic neurons. Central nervous system
tissue in control OT often showed ferruginated neurons and/or Rosenthal
fibers, construed as degenerative/reactive changes.
Conclusion: We conclude that ANMDARE-associated OT differs from
ordinary OT in the presence of dysplastic neurons in neural tissue and
topographical relation of inflammatory infiltrates. The very small size of the
areas involved in some cases suggests that dysplastic neurons may be easily
missed. We hypothesize that the development of dysplastic neurons in OT
triggers the inflammatory response that results in the production of ANMDARE
and the partial obliteration of areas with dysplastic change.
21
Astrocytic Regulation of Synaptic NMDA Receptors
Junghyun Hahn1, Xianhong Wang1, Marta Margeta1. 1University of
California San Francisco
A growing body of evidence indicates that astrocytes regulate the formation
and function of excitatory synapses, but little is known about the effect of
glia on glutamate NMDA receptors (NMDARs). To investigate glial
modulation of neuronal NMDARs, we performed electrophysiological, cell
biological, and biochemical experiments on hippocampal neurons cultured
either alone, with a mixed population of glia, or with pure astrocytes. While
there was no significant change in EC50 of the NMDA-induced current
between various culture conditions, the maximal current density was twice as
large in mixed compared to neuronal cultures; a similar increase in NMDAR
current density was seen when neurons were cultured in the presence of pure
astrocytes, either directly or indirectly. The amplitude of NMDAR-mediated
(but not AMPA receptor-mediated) miniature excitatory postsynaptic currents
was significantly greater in mixed relative to neuronal cultures, resulting in a
significantly lower synaptic AMPA/NMDA current ratio when neurons were
cultured with glia; however, there was no difference in plasma membrane
expression of major (NR1, NR2A and NR2B) NMDAR subunits between
mixed and neuronal cultures. Astrocyte-induced potentiation of NMDAR
currents was limited to the synaptic pool of NMDARs; furthermore, the
Abstracts J Neuropathol Exp Neurol � Volume 73, Number 6, June 2014
� 2014 American Association of Neuropathologists, Inc.590
Copyright © 2014 by the American Association of Neuropathologists, Inc. Unauthorized reproduction of this article is prohibited.
Page 7
proportion of NR2B subunit-dependent NMDAR currents, but not NR2A-
dependent NMDAR currents, was greater in mixed than in neuronal cultures.
Taken together, these data indicate that astrocyte-mediated increase in the
neuronal NMDAR current (1) is postsynaptic; (2) is not due to an increase in the
total number of synapses, (3) is induced by one or more astrocyte-secreted
soluble factors, and (4) reflects posttranslational regulation of NR2B-containing
NMDAR channels already present at postsynaptic sites, presumably on a rapid
time scale. Given the role of NR2B NMDARs in synaptic plasticity and
neuronal survival, our findings suggest that NMDAR modulation is an
important mechanism by which astrocytes can impact neuronal circuits in both
normal and disease states.
22
A Novel Telomere Phenotype In Human Retinal Photoreceptors
William Bell1, Christopher Heaphy1, Ian Rosenthal1, Alan Meeker1, Charles
Eberhart1. 1The Johns Hopkins Medical Institutions
Many neoplasms maintain telomeres via a telomerase-independent mecha-
nism termed alternative lengthening of telomeres (ALT), but normal human
tissues are not known to utilize such pathways. We previously surveyed
over 6,000 different malignancies with telomere-specific fluorescence in situ
hybridization (FISH) and found that the ALT phenotype is particularly
common among neural neoplasms, but was never identified in the 541
benign neoplasms and 264 diverse non-neoplastic tissue samples examined.
We recently expanded our analysis to include ocular samples, and
unexpectedly identified ALT-like telomere DNA foci in normal retina.
Using rod and cone specific antibodies, it was determined that the phenotype
was largely restricted to rods. In total, 124 human retinas were examined,
including 8 fetal, 22 infant, 10 childhood and 84 adult eyes. The ALT-like
phenotype was fairly homogenous within each retina, but some variation
was noted from eye to eye within each age group. The ALT-like telomere
foci showed an age-dependent onset. They were never seen in fetal eyes,
and were very rare in infants and children. Our adult eye cohort included 38
cases with pathological conditions such as diabetic retinopathy, macular
degeneration, glaucoma and retinitis pigmentosa, and the ALT-like
phenotype was very prominent in these. Interestingly, we also analyzed
the eyes of two patients with an inherited short telomere syndrome caused
by reduced telomerase function. These both showed the ALT-like phenotype
in photoreceptors, raising the possibility that, like cancer-associated ALT,
this retinal phenotype is independent of telomerase activity. We analyzed eyes
from several rodents of varying ages, but these did not show the ALT-like
telomere phenotype. In summary, we identify ALT-like telomere DNA foci in
human retinal cells not present in any other normal tissue examined to date. The
process is not detected in children, and its function is not yet clear.
23
Intraocular Medulloepitheliomas in Children and Adults show Markers
of Retinal Development and Glioneuronal Differentiation
Matthew Rose1, Alia Rashid2, Frederick Jakobiec2. 1Dept. of Pathology,
Brigham and Women’s Hospital, Harvard; 2Dept. of Ophthalmology,
Massachusetts Eye and Ear Infirmary, Harvard
Intraocular medulloepithelioma is a rare tumor arising most often near the
ciliary body of the eye. It is frequently characterized by tubular and/or papillary
growth of pseudostratified neuroepithelial ribbons, sometimes mixed with
differentiating regions. While they generally exhibit a distinct morphology,
these tumors can display regions of heterologous differentiation. We seek to
further characterize the patterns of gene expression in medulloepithelioma to
determine whether these tumors exhibit immunohistochemical markers reflect-
ing their histogenetic origin. We report a series of five cases of medulloepi-
thelioma including three pediatric (ages 1, 6, and 8 months) and two adult cases
(ages 30 and 45 years), with four arising near the ciliary body and one arising
from a retinal coloboma. All tumors expressed S100. In addition, both of
the classic pediatric cases arising near the ciliary body showed a remarkably
similar immunohistochemical expression pattern with CRX labeling primitive
neuroectodermal units and GFAP andNeuN labeling areas of glial and neuronal
differentiation, respectively. One of these tumors was very small and involved
primarily the non-pigmented ciliary epithelium from the ora serrata to the iris,
offering a glimpse into the early stages of tumor growth. One adult case
likewise showed CRX and synaptophysin expression, while the other showed
only CRX expression without markers of glioneuronal differentiation. In
contrast, the last pediatric case appeared to arise from a coloboma and showed
areas of myogenic rather than glioneuronal differentiation, although it focally
showed primitive neuroectodermal morphology. With follow-up intervals
ranging from eight months to eleven years, all five patients are alive with no
reported recurrence of tumor following enucleation. Overall, these findings
highlight immunohistochemical markers of retinal development and glioneuro-
nal differentiation which are consistent with the origin of medulloepitheliomas
in the non-pigmented ciliary epithelium of the pars plicata or pars plana
interfacing with the peripheral retinal ora serrata.
24
Opthalmological Abnormalities in CTE
Victor Alvarez1, John Crary2, Nathalie Slick1, Brian Fry1, Thor Stein3, Ann
McKee3. 1Boston University School of Medicine; 2Columbia Presbyterian
School of Medicine; 3VA Boston Healthcare System, Boston University
School of Medicine
Repetitive concussive injury is associated with the development of chronic
traumatic encephalopathy (CTE), a progressive brain degeneration charac-
terized by hyperphosphorylated tau (p-tau) neurofibrillary tangles in the
brain (McKee et al., 2009, Goldstein et al., 2012, McKee et al 2013). CTE
produces symptoms of irritability, impulsivity, depression, memory loss,
and suicidality that may progress to dementia and parkinsonism in late
stages. The neuropathological changes of CTE are distinctive and easily
distinguished from other neurodegenerative diseases, including Alzheimer’s
disease. Key neuropathological features of CTE are p-tau neurofibrillary
tangles around small blood vessels, neuroinflammation, and deposition of
abnormal aggregates of TDP-43, a protein associated with ALS, alpha B
crystallin, a small heat shock protein, and p62, an autophagosome marker.
We have diagnosed CTE at post-mortem examination in over 100 former
football players, hockey players, boxers and military veterans of the Iraq
and Afghanistan conflicts exposed to blast injury (McKee et al 2013).
Currently, there is no method of detecting CTE during life and the diagnosis
can only be made at autopsy. Nothing is presently known about the eye
pathology of CTE but if a distinctive profile of ocular abnormalities were
identified, it would raise the possibility that CTE could be diagnosed during
life by eye examination. Our preliminary studies demonstrate that p-tau
inclusions, neuroinflammation and abnormal aggregates of the proteins
TDP-43, alpha B cystallin, and p62 are found post-mortem in the inner
plexiform layer of the retina in individuals with advanced CTE that were not
found in age-matched controls. These findings suggest that the ocular
pathology of CTE is unique and that methods of in vivo detection might be
developed to diagnose CTE opthalmologically during life.
PLATFORM SESSION 4: DEVELOPMENTAL/
PEDIATRIC
Friday 2-4 PM, June 13, 2014
Culture Ballroom
25
Development of the Hippocampal Formation in Human: Part
I-Pyramidal Cell Layer
Sara Cipriani1, Catherine Verney1, Jeannette Nardelli1, Anne-Lise Delezoide1,
Pierre Gressens1, Homa Adle-Biassette2. 1INSERM UMR 1141; 2Department
of Pathology, Lariboisiere Hospital, APHP & INSERM UMR 1141
This is the first detailed study describing the development of hippocampal
formation in human embryos and fetuses from 8 weeks of gestation (GW) to
J Neuropathol Exp Neurol � Volume 73, Number 6, June 2014 Abstracts
� 2014 American Association of Neuropathologists, Inc. 591
Copyright © 2014 by the American Association of Neuropathologists, Inc. Unauthorized reproduction of this article is prohibited.
Page 8
midgestation. Multiple immunohistochemical labelings were performed to
study the progenitors using Ki67 associated with nestin, SOX2, PAX6 and
TBR2, and post mitotic neuronal markers using NeuN, CUX1, SATB2,
CTIP2, TBR1, NeuroD1, doublecortin, CaBP, and Calretinin. Our results showed
the presence of a gradient of neurogenesis starting first in the entorhinal cortex
and extending toward the ammonic plate. The proliferation of Pax6+ or Sox2+
progenitors was already observed at 9 GW in the ventricular zone.
Intermediate-stage progenitors labeled by Tbr2 were present at 11 GW in the
subventricular zone. The density of both types of progenitors progressively
decreased around 20GW. Postmitotic neurons appeared during the embryonic
stage. In the ammonic plate Tbr1, CTIP2 and Cux1 labeled numerous cells, some
of which were colabeled with Sox2 and Pax6. They progressively migrated to the
deep and superficial layers of the ammonic plate until midgestation. The density
of SATB2-labeled neurons in the ammonic plate was lower compared to the
other layer markers and to the subicular / entorhinal cortical plates.
In conclusion, neurogenesis in the hippocampal formation starts during the
embryonal period. The pattern of expression of transcription factors
suggests that postmitotic neurons are produced directly from funding
progenitors and from intermediate-stage progenitors. The lamination of the
pyramidal layer follows an in an inside out gradient, producing a three-
layered ammonic plate compared to the entorhinal cortex.
The research leading to these results was performed in the frame of
DEVELAGE project ‘‘Pathways common to brain development and ageing:
defining strategies for preventive therapy and diagnostics’’ (HEALTH-F2-
2011-278486) and has received funding from the European Community_s7th Framework Programme (FP7/2007-2013).
26
Fetal Nucleus/fasciculus Solitarius: Synaptophysin Maturation
Harvey Sarnat1, Laura Flores-Sarnat1. 1University of Calgary and Alberta
Children’s Hospital
Background: The nucleus/fasciculus solitarius is the respiratory centre of the
brain, also known as the pneumotaxic centre. It consists of paired longitudinal
columns in the tegmentum of the medulla oblongata, extending to the cervical
spinal cord. A white matter core of longitudinal axons (fasciculus) is surrounded
by neurons (nucleus), a primitive arrangement. Afferent fibres to the nucleus
solitarius arise mainly from chemoreceptors and stretch receptors in respiratory
muscles and lung. Efferent axons descend the fasciculus to innervate spinal
motor neurons to the diaphragm and other respiratory muscles. This nucleus is
essential for fetal rhythmical respiratory movements observed by real-time
ultrasound and postnatal respiration.
Methods: Sections of medulla oblongata of 20 normal fetuses of 9-40 weeks
gestation were studied at autopsy by immunoreactivity to synaptophysin and
other markers of neuronal maturation: NeuN, calretinin, NSE. Three fetal
chromosomopathies, two preterm neonates with apnoea of prematurity and 2
cases of Mobius syndrome also were examined.
Results: Synaptogenesis in the nucleus solitarius begins early in the human fetus,
at 10-11 weeks gestation, and it is advanced by 15 weeks. Delayed synaptophysin
expression was found in 2 premature infants with apnoea but not in infants with
chromosomopathies; maturation of other neuronal markers was not altered. The
nucleus was bilaterally infarcted in 2 infants with Mobius syndrome.
Conclusions: Hypoxia, metabolic disturbances and other adverse events
affecting late 1st and 2nd trimester fetuses may impair the rate of formation
of synapses in the nucleus solitarius and explain some cases of apnoea of
prematurity and SIDS. Symmetrical watershed tegmental infarcts may
involve the nucleus solitarius to account for central respiratory insufficiency
in neonates with Mobius syndrome.
27
Radial Glia Defects and the Pathogenesis of Germinal Matrix
Hemorrhage.
Jennifer Cotter1, Mianzhi Tang1, Eric Huang1. 1University of California San
Francisco, Department of Pathology
Germinal matrix hemorrhage (GMH) is a life-threatening condition that
affects over 12000 infants per year in the US. Its pathogenesis has been
attributed to alterations in hemodynamics and/or vascular fragility, but the
mechanism of its development remains poorly understood. We evaluated
human autopsy tissues from the Pediatric Neuropathology Research Lab to
study potential developmental alterations in the setting of GMH. Brain
sections from preterm infants with GMH (n=5) and without (n=13), ranging
from gestational ages of 16 to 36 weeks were evaluated. Using stereology,
we found no differences in vascular branching or vascular density within the
germinal matrix (GM) between controls and GMH cases. Furthermore, in
situ hybridization for vasculogenic factors, VEGF, TGFbeta and integrin
beta8, showed no detectable differences in the expression of these genes in
the GM. To characterize how altered neurogenesis within the GM may
contribute to the pathogenesis of GMH, we performed immunohistochem-
istry for Ki-67, Nkx2.1, Sox2, Nestin, and NeuN. Consistent with previously
published data, human GMH cases showed reduced Ki-67 and Sox2 labeling
indices within the GM when compared to controls. Intriguingly, similar to
mouse ganglionic eminence (GE), human GM could be further sub-divided
into a medial compartment (MGE) with high Nkx2.1 expression and a
lateral compartment (LGE) with low Nkx2.1. Using Nestin as a marker for
radial glia, we found that in control cases, the MGE showed higher radial
glia density than the LGE. In contrast, GMH cases over 28 weeks
gestational age demonstrated decreased Nestin-positive radial glia not only
adjacent to hemorrhage, but also in the contralateral GM. The finding of
reduced radial glia density in bilateral GM of preterm infants with GMH
suggests that the developmental differences in radial glia between controls
and the brains of preterm infants with GMH most likely contribute to the
pathogenesis of GMH.
28
A Century of Brain Hemorrhages in Autopsied Premature Infants at a
Tertiary Pediatric Hospital
Marco Hefti1, Robin Haynes2, Rebecca Folkerth3, Felicia Trachtenberg4,
Joseph Volpe2, Hannah Kinney2. 1Department of Pathology, Beth Israel
Deaconess/Harvard Medical School; 2Boston Children’s Hospital; 3Brigham
and Women’s Hospital; 4New England Research Institutes
The care of premature infants in the 20th century is remarkable for technical
advances that have dramatically improved survival, but little is known about
changes in the neuropathology of the premature infant over this time frame.
We hypothesize that neuropathologic entities have changed over the last
century, disappearing because of improvements in care, or arising anew due
to unforeseen complications of new treatments and/or increased length of
survival. To begin to test this hypothesis, we examined germinal matrix
hemorrhage with intraventricular hemorrhage (GMH-IVH) and intraparen-
chymal cerebellar hemorrhage (CH) in 351 premature infants (gestational
age 24-37 weeks) autopsied at Boston Children_s Hospital from 1924 to
2010. There was a median of 39 cases/decade (range 16-66). Over the
course of the study, gestational age decreased from 31.6 (1924-1930) to 29.0
(2001-2010) weeks (pG0.001), and survival increased from 1.5 to 14.5 days
(pG0.001). The incidence of GMH-IVH increased from 2.7% before 1950
to 37.7% from 1970-1980, and then decreased to 15.4% after 1990
(pG0.001), as adjusted for infant gestational age and length of survival
time. The incidence of CH showed a significant linear trend, increasing
from 2.7% prior to 1950 to 20.5% after 1990 (p=0.005). The incidence of
GM-IVH increased 93-fold around the time of the introduction of positive
pressure ventilation into premature intensive care in the mid-1960s. The
increased incidence of GM-IVH in the 1970-1980s likely reflects
respiratory and hemodynamic imbalances complicating mechanical ven-
tilation; the subsequent decreased incidence likely reflects stabilization of
respiratory function with the use of surfactant beginning in the 1980s. In
contrast, the incidence of CH gradually increased into the 1990_s,
suggesting that factors other than those related to mechanical ventilation
are involved and require elucidation.
Abstracts J Neuropathol Exp Neurol � Volume 73, Number 6, June 2014
� 2014 American Association of Neuropathologists, Inc.592
Copyright © 2014 by the American Association of Neuropathologists, Inc. Unauthorized reproduction of this article is prohibited.
Page 9
29
Hippocampal Anomalies in Sudden Unexplained Death in Young
Children: An Extended Series.
Marco Hefti1, Jane Cryan1, Elisabeth Haas2, Marjorie Grafe3, Laura
Crandall4, David Patterson1, Lisa Teot1, Felicia Trachtenberg5, Hannah
Kinney1, Henry Krous2. 1Department of Pathology, Boston Children’s
Hospital; 2Department of Pathology, Rady Children’s Hospital San Diego;3Department of Pathology, Oregon Health and Sciences University; 4SUDC
Program, Hackensack, NJ; 5New England Research Institute, Watertown, MA
Sudden unexplained death in childhood (SUDC) is the sudden death of a
child older than 1 year that remains unexplained after a review of the
clinical history, circumstances of death, autopsy, and ancillary testing; its
incidence in children 1-3 years is 1.3/100,000. Previously, we reported a
putative new entity of SUDC associated with hippocampal/temporal lobe
(TL) maldevelopment with or without a personal and/or family history of
febrile seizures (FS) in a subset of children aged 1-6 (Kinney HC et al. Ped
Dev Pathol 2019; 12: 455-463). Sixty-four SUDC cases were accrued from
2002-2007 in an autopsy study of sudden unexpected death (77% SUDC,
23% explained); of the 49 SUDC cases, 46% with hippocampal sections
(12/26) had substantial microdysgenesis. From 2007-2011, we accrued 88
additional cases (SUDC, 88%). We tested the hypothesis that a larger
sample size confirms the observation of hippocampal anomalies associated
with SUDC.We report combined findings in the cohort of 151 cases (1-6 years)
based upon review of clinical records, autopsy and scene reports, microscopic
slides, and family surveys. The demise categories were: SUDC, 80% (n=121);
explained/known causes, 13% (n=19) (e.g., infection, accidents); undeter-
mined, 5% (n=7), and epilepsy, 3% (n=4). There was no difference in age at
death, male gender, or preterm birth among the groups. In the SUDC group,
49% (59/121) had a personal and/or family history of FS compared to 11%
(2/19) of known causes (p=0.003). Of the SUDC cases, 97%were discovered
after a sleep period, and 86% in the prone position. Hippocampal/TL review
revealed 43% (36/83) of SUDC cases had gross and/or microscopic
anomalies compared to 13% (2/16) of known causes (p=0.02). Of these
SUDC cases, 31% had a personal FS history, and 17%, a family FS history
only. Future research is needed towards identifying living young children at
risk for sudden death.
30
Construction of a Single Adenoviral Vector Carrying Both ZFN and
Donor for the Treatment of Lysosomal Storage Diseases
Qinwen Mao1, Weifeng Zhang2, Esther Bit-Ivan1, Eileen Bigio1, Haibin
Xia2. 1Northwestern University Feinberg School of Medicine; 2Shaanxi
Normal University, China
Many lysosomal storage diseases (LSDs) have devastating consequences
including neurodegenerative diseases. Although enzyme replacement ther-
apy is a potential treatment option, this approach needs repeated injection
over the lifetime of the patients. Gene-addition strategy using viral vectors
has the potential for long-term expression of the therapeutic protein,
however, serious adverse effects, e.g., immune response to in vivo
administered viral vectors, and insertional activation of proto-oncogenes,
can occur. An alternative to gene addition that can minimize the oncogenic
risk of gene therapy is targeted gene correction via homologous recombi-
nation. Zinc-finger nucleases (ZFNs) show promise as reagents that can
mediate high-frequency homologous recombination in the presence of a
donor. This technique has shown success in ex vivo correction of a disease-
causing mutation by using induced pluripotent stem cells, which can be
useful for the treatment of diseases affecting cells that can be removed and
returned to the patient. However, many LSDs might need in vivo gene
correction in affected organs, which requires the efficient introduction of
gene-targeting components (i.e., ZFNs and donor fragment) in vivo. We
utilized adenovirus, a high-efficiency and safe vector with sufficient size to
fit both ZFN and donor to mediate gene correction in vivo. We have
overcome the challenges of packing both ZFN and donor in a single
adenovirus, and produced ZFN expressing adenovirus with high titer. We
also show that this novel system efficiently mediates targeted genome
editing. In summary, adenovirus may be a promising vector for in vivo gene
correction in disease-affected organs in lysosomal storage diseases.
31
The KCa3.1 blocker TRAM-34 Reduces Activated Microglia and ASD
Like Behavior in a Rat Model of Neonatal HI Brain Injury
Mirna Lechpammer1, Yen Tran2, Philip Huebner2, Yi-Je Chen3, Robert
Berman4, Lee-Way Jin2, Heike Wulff3. 1University of California Davis
School of Medicine; 2Department of Pathology & Laboratory Medicine, UC
Davis; 3Department of Pharmacology, UC Davis; 4Department of
Neurosurgery, UC Davis
Neonatal hypoxia/ischemia (HI) causes Encephalopathy of Prematurity
(EOP), which is associated with neurobehavioral deficits and autism
spectrum disorders (ASD) in later life. We assessed the role of the
intermediate-conductance calcium-activated K+ channel KCa3.1 in micro-
glia activation after neonatal HI brain injury. We also evaluated the
neuroprotective efficacy of the selective small molecule KCa3.1 inhibitor
TRAM-34, developed by our group, at a molecular level and by behavioral
assessments in a rat model of EOP.
We investigated brain tissue from male Long Evans rats after selective
white matter (WM) injury produced in P6 by unilateral carotid artery
ligation (UCL) followed by severe hypoxia (UCL/HI). The immunocyto-
chemical analysis has shown an increased expression of KCa3.1 in activated
microglia (Iba1+) in rat WM in P10 following UCL/HI at P6. TRAM-34
(40 mg/kg i.p. every 12 hours for 3 days) initiated 12 hours after UCL/HI
inhibited microglial response at P10 as demonstrated by the reduced number
of activated microglia inWM compared to vehicle treated controls. Likewise, a
significant reduction (p=0.04) in WM injury (MBP staining) was observed
at P14 in TRAM-34 treated rats (40 mg/kg i.p. every 12 hours for 7 days)
compared to controls. When their behavior was assessed by the three-
chambered sociability test, young rats (P31-33; n=15) exposed to UCL/HI at
P6 exhibited resistance to change and impaired preference for social
novelty. Importantly, TRAM-34 has prevented this ASD-like behavior and
restored normal preference for social novelty as observed in healthy
controls.
Presented results indicate increased immunoreactivity of KCa3.1 in activated
microglia following HI pro-inflammatory stimuli in neonatal rat brain. Our data
also demonstrate feasibility of prevention/reversal of cognitive consequences of
EOP by in vivo pharmacological blockade of KCa3.1, which in turn may have
translational clinical potential for this as yet untreatable cause of neurocognitive
deficits, including autism and cerebral palsy.
32
Developmental Synaptic Plasticity Defects in a Mouse Model of Down
Syndrome
Christopher William1, Lubna Saqran2, Matthew Stern2, Matthew Frosch1,
Bradley Hyman3. 1Neuropathology Service, Massachusetts General
Hospital, Boston, MA; 2Department of Neurology, Massachusetts General
Hospital; 3MassGeneral Institute for Neurodegenerative Disease, MGH,
Boston, MA
Understanding the molecular basis for cognitive delay in Down syndrome
(DS) is a challenge that would be aided by assays of circuit function in
models of the disease. Synaptic plasticity is critical for circuitry refinement;
to explore whether defects in synaptic plasticity may contribute to
developmental impairment in DS, we have assessed visual system plasticity
in a partial duplication mouse model of DS, the Ts65Dn line.
Ocular dominance plasticity is the process by which loss of vision in one
eye, monocular deprivation (MD), causes changes in connectivity that result
in an increase in the area of primary visual cortex responsive to the non-
deprived eye and a strengthening of the relative magnitude of responses to
J Neuropathol Exp Neurol � Volume 73, Number 6, June 2014 Abstracts
� 2014 American Association of Neuropathologists, Inc. 593
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Page 10
stimulation of the non-deprived eye compared to stimulation of the deprived
eye. Trisomic and non-trisomic litter mate mice underwent MD via lid
suture over six days between P27 and P35. Expression of the immediate
early gene Arc was used to determine the width of the cortical domain
responsive to the non-deprived eye ipsilateral to that eye. To assess the
magnitude of cortical responses to stimulation of each eye, optical imaging
of intrinsic signals was performed on awake, head-fixed mice, before and
after MD. Following MD, trisomic mice fail to demonstrate an expansion of
the domain of visual cortex responsive to the non-deprived eye (trisomic
width, 944 T 77.89 microns, n=5; non-trisomic width, 1087 T 87.44 microns,
n=13; p=0.0028, T-test). Non-trisomic mice demonstrate strengthening of
responses to non-deprived eye stimulation (pre-MD dF/F, 0.37%, n=6; post-
MD, 0.52%; p=0.01, T-test), however, trisomic mice fail to demonstrate an
increase in response strength following MD (pre-MD, 0.5%, post-MD,
0.49%, n=9; p=0.21, T-test). These data suggest that Ts65Dn mice
demonstrate plasticity defects that will be used in future studies to explore
the molecular basis for developmental and cognitive impairment in DS.
POSTERS: DAY 1
10-10:30 AM, 4-4:30 PM, June 13, 2014
Foyer
33
An Interesting Case Of Sarcoid Myopathy
Luis Gonzalez-Cuyar1, Desiree Marshall1, Nina Bozinov1, Zackary Hoffer1,
Michael Weiss1, B. Distad1, C. Keene1. 1University of Washington
We report the case of a 69-year-old man with clinical history of sarcoidosis
initially diagnosed in his 20’s with lifelong weakness that has progressively
worsened over the last 2-3 years. Physical exam was notable for diffuse
weakness and wasting (proximal worse than distal) as well as finger flexor and
extensor weakness. MRI showed a nonspecific myopathy that involved the
pelvis as well as the bilateral thighs. Electromyography revealed a mild
predominantly chronic myopathy and laboratory studies revealed creatine
kinase of 53 U/L. The patient underwent a left vastus biopsy which was
characterized by myonecrosis with patchy lymphohistiocytic and granuloma-
tous inflammation, HLA-I upregulation and neurogenic atrophy in the setting of
endomysial fibrosis and moderate to focally severe fiber size variation. Rimmed
vacuoles, TDP-43 positive inclusions and ultrastructural evidence of sarcoplas-
mic filamentous inclusions were also identified. Chronic sarcoid myopathy
syndrome is characterized by symmetrical muscle weakness and wasting in the
limb girdle and proximal limbs with often normal serumCKand granulomatous
inflammation on muscle biopsy. Although rimmed vacuoles are a relatively
non-specific myopathic feature, examples of sarcoid myopathy in concom-
itance with features of inclusion body myositis (IBM) have rarely been
reported. Coexisting neurogenic features, as in this case, are often present.
34
Neuromuscular Pathology of Bannayan-Riley-Ruvalcaba Syndrome: A
Rare Case Report and Review of Literature
Keng-Chih Su1, Negar Khanlou1, Anthony Verity1, Jennifer Yi1.1Neuropathology Department, David Geffen School of Medicine at UCLA
BannayanYRileyYRuvalcaba syndrome (BRRS), now a category of PTEN
hamartoma-tumor syndromes (PHTS), is an autosomal dominant genoder-
matosis resulting from mutations in PTEN. A neuromuscular clinical
presentation is also seen in affected young children. However, reports
on associated neuromuscular pathology are rare in the literature. We report a
5-year-old with infantile cerebral palsy and clinical consideration of BRSS,
presenting with acute leg pain on exertion, left leg hypertrophy and
fatigability. Motor weakness was noted in the affected limb at examination.
MRI of the left leg showed focal edema and enhancement without mass
lesion. A left rectus femoris muscle biopsy was obtained. The fascicular
architecture was overall preserved while the epimysium was site of
angiolipoid hamartomas associated with extensive nodular lymphohistio-
cytic inflammation. Intra-tumoral vascular changes including perivascular
inflammation and intimal hyperplasia were frequently noted. Myofiber study
was abnormal including dysmaturation neuromyopathy, an unusual sub-
sarcolemmal pattern of intra-fiber lipid distribution without hyperlipidation,
neurogenic change and type II fiber smallness. Conclusion: To our knowledge
skeletal myofiber pathology observed in this biopsy was scarcely reported in
patients with BRRS. A direct association of dysmaturation phenomenon with
PTEN status cannot be ruled out and requires further investigation. This case
also underlines the importance of skeletal muscle biopsy not only in patients
with BRRS but also in young children with early neuromuscular symptoms.
The syndrome is known to be underdiagnosed because of its phenotypic
variability, its incomplete penetrance, and the frequency of its individual
components in the general population. While macrocephaly, intestinal poly-
posis and sub-mucocutaneous tumors are common findings, the neuromuscular
presentations are less recognized as heralding symptoms. In addition to access
to tumor pathology, the muscle biopsy allows for the diagnosis and study of
skeletal muscle damage in early stages of its progression and proactive clinical
management of its complications.
35
Novel Homozygous Cofilin-2 (CFL2) Mutation Causing a Congenital
Form of Nemaline Myopathy with Filamentous Inclusions
Leslie Bruch1, Sheraden Mundy2, Natalie Hauser2, Joseph Shen2.1University of Iowa; 2Children’s Hospital Central California
Nemaline myopathy most often presents as a congenital myopathy
characterized by hypotonia and muscle weakness; it is pathologically
distinguished by the presence of nemaline rods. Seven causative genes
have thus far been identified with 6 of the 7 encoding proteins associated
with sarcomeric thin filaments. The function of the seventh gene has not yet
been identified. Cofilin-2 (CFL2) encodes an intracellular protein that is
involved in the regulation of actin filament dynamics. Mutations in CFL2
are known to be responsible for nemaline myopathies in only two families,
both with consanguinity. We describe a novel homozygous mutation in
CFL2 presenting as congenital hypotonia with pathologic features showing
overlap between those of nemaline myopathy and other protein aggregate
myopathies. The proband initially presented at 3 weeks of age due to poor
oral intake and respiratory distress, but feeding difficulty had been present
since birth. He was born to consanguineous parents after an unremarkable
pregnancy. His weakness progressed to ventilator dependency, and he received
a tracheostomy and gastrostomy button placement. At 3.5 months of age he
had minimal movement of his extremities. CPK was elevated up to 780 U/L. A
left quadriceps muscle biopsy showed increased fiber size variation and
scattered fibers with inclusions composed of finely granular red-purple
material on trichrome as well as a few fibers with larger inclusions character-
istic of nemaline rods. No necrosis, inflammation, fiber type disproportion or
predominance was found. Electron microscopy demonstrated areas of
sarcomeric disarray with filamentous inclusions, mini-cores and occasional
nemaline bodies or rods. Sanger sequencing revealed a homozygous mutation
in exon 4 (c.353C9A, p.Ala118Asp). This new case represents the third family
described with mutations in CFL2 and further expands the clinical and
pathologic phenotype associated with this genotype.
36
Diagnostic Pitfall with Use of Alpha-dystroglycan Immunostain in
Perimortem Muscle Biopsies
Amanda Kan1, Sophelia Chan2. 1Department of Clinical Pathology, Tuen
Mun Hospital, Hong Kong; 2Department of Paediatrics and Adolescent
Medicine, Queen Mary Hospital
Abnormal glycosylation of alpha-dystroglycan (aDG) occurs in certain
forms of congenital muscular dystrophy. Immunostaining for aDG is a
convenient and useful tool in workup for congenital muscular dystrophy in
muscle biopsy. The degree of reduction of aDG immunolabelling often
Abstracts J Neuropathol Exp Neurol � Volume 73, Number 6, June 2014
� 2014 American Association of Neuropathologists, Inc.594
Copyright © 2014 by the American Association of Neuropathologists, Inc. Unauthorized reproduction of this article is prohibited.
Page 11
correlates with disease severity. However, we encounter two perimortem
muscle biopsies with no clinical evidence of congenital muscular dystrophy
but absence immunostaining for aDG. We propose the loss of staining or
alteration protein expression affecting the group of dystrophin and
dystrophin-associated complex at the terminal stage of life being physio-
logical or artifactual.
37
Unusual Pathologic Features in a Patient with Laing Early Onset Distal
Myopathy
Marta Margeta1, Grant de la Motte2, Nigel Laing3. 1University of California
San Francisco; 2Palo Alto Medical Foundation; 3University of Western
Australia
Laing early onset distal myopathy (MPD1) is a rare form of distal myopathy
caused by mutations in MHY7 myosin heavy gene. Clinical presentation of
MPD1 patients is fairly stereotypical (development of complete bilateral
foot drop in the early childhood, followed by a very slow clinical
progression in subsequent years); in contrast, the reported biopsy findings
are relatively nonspecific. Here, we present a patient with MPD1 whose
muscle biopsy showed distinctive light microscopic and ultrastructural
features. The patient, a 39 year old male, developed bilateral foot drop at
age 5, but is otherwise asymptomatic and physically active. Physical exam
showed bilateral weakness of ankle dorsiflexors (1/5), toe extensors (1/5),
and finger extensors (4+/5); creatine kinase level was within the normal
limits. The disease first developed in the patient_s paternal grandmother and
is transmitted in autosomal dominant fashion, with all affected family
members showing the same clinical phenotype. The quadriceps femoris
biopsy showed moderate variation in muscle fiber diameters, mild
endomysial fibrosis, scattered nuclear clumps, and type 1 fiber predom-
inance (85%), but no degenerating/regenerating fibers or rimmed vacuoles.
In addition, randomly distributed type 1 (but no type 2) fibers showed
abnormal invaginations of sarcolemma that were most readily apparent on
ATPase, NADH and Toluidine blue stains. On ultrastructural analysis, these
abnormal membrane invaginations were reminiscent of myotendinous
junctions, except for the degree of complexity and the lack of clustering
in a single area of the specimen. Genetic analysis of the patient and three
affected relatives showed heterozygous deletion of GAG triplet at position
4522-4524 of MHY7 gene, which results in a deletion of a glutamate residue
at position 1508 of the beta myosin heavy chain protein [c.4522_4524del-
GAG (p.Glu1508del)]. This case suggests that the spectrum of histopatho-
logic findings associated with MPD1 is wider than previously believed.
38
Granulomatous Fungal Myositis Presenting as Isolated Unilateral
Myalgia: A Case Report
Osama Elkadi1, Jiang Qian2. 1Albany Medical Center/College; 2Pathology,
Albany Med Ctr Hosp/APS
Fungal myositis is a rare but serious form of myositis, with very few cases
reported in the literature. It usually occurs in the setting of immunocom-
promise, especially in AIDS patients. The most common isolated fungal
organisms are aspergillus and cryptococcus. Here we report a case of
isolated fungal myositis without evidence of disseminated disease.
The patient is a 48 year-old African American female with history of
cryptogenic cirrhosis, status post liver transplant on immunosuppression. She
presented with left lower extremity pain, tenderness and mild swelling. MRI
showed increased STIR signals most evident in the flexor compartment,
suggesting myositis. After ruling out DVT and compartment syndrome, a left
gastrocnemius muscle biopsy was obtained, which revealed necrotic / regenerative
muscle fibers and a non-necrotizing, vaguely granulomatous inflamma-
tion with dense mononuclear infiltrates composed mainly of CD3 positive
T lymphocytes (CD4-dominant) and CD68 positive histiocytes with occa-
sional multinucleated giant cells. Among the inflammatory infiltrates were
multiple small spherical forms which were pale and slightly refractile on H&E
stain, negative on AFB, mucicarmine and alcian blue stains, but confirmed on
GMS and PAS-D stains to be yeast-form fungi, most consistent with
blastomyces species. The patient received systemic antifungal therapy,
amphotericin, followed by oral fluconazole. CSF and blood cultures were
negative, as was culture from the second muscle biopsy 23 days after the initial
diagnosis. Two and half months later, she had low-grade fever and abdominal
pain, but otherwise stabilized. Her HIV testing was negative. She had elevated
anti-nuclear antibody titer in the past, but anti-mitochondria antibody, smooth
muscle antibody and rheumatoid factor were all within normal.
This case illustrated that a high index of suspicion for infectious etiology
should be raised in inflammatory myopathy work-up in immunocompro-
mised patients, so that early accurate diagnosis can be achieved and
appropriate treatment promptly administered.
39
Regional Necrotic Myopathies: Border Zone Muscle Fiber Necrosis
Associated with Dermatomyositis Syndromes and Neoplasms
Chunyu Cai1, Rati Choksi2, Ali Alshehri2, Alan Pestronk2. 1Department of
Pathology and Immunology, WUSM; 2Department of Neurology,
Washington University School of Medicine
Introduction: Necrosis and regeneration of scattered muscle fibers are
common features of many active myopathies. We studied a series of patients
with acquired myopathies whose myopathology included an unusual pattern
of regional, rather than scattered, muscle fiber necrosis and regeneration.
Methods: Retrospective review of clinical, laboratory, myopathologic and
ultrastructual features of seven patients with acquired myopathies having
regional necrosis and regeneration of muscle fibers on muscle biopsy.
Results: Clinical features included proximal symmetric weakness with a
subacute onset (100%), dysphagia (83%), myalgias (100%), and a skin rash
(67%). Serum creatine kinase was often (83%) very high (91,600 U/L). An
associated malignancy was common (71%). Survival was less than one year
in 43%. Myopathology included regions of muscle fiber necrosis or
regeneration in border zone territories between intermediate-sized perimy-
sial vessels. Muscle fibers and connective tissue in regions of necrosis show
C5b-9 deposition and expression of the ischemia marker carbonic anhydrase
IX. In areas between the regions of necrotic fibers and perimysial vessels,
endomysial capillaries are enlarged and stain for alkaline phosphatase and
muscle fibers have upregulated MHC Class I. Intermediate-sized perimysial
veins had abnormal structure and increased cellularity, likely marginating
macrophages and polymorphonuclear leukocytes, in the wall. There were no
aggregates of mononuclear cells.
Conclusions: Regional necrotic myopathies (RNM) are a distinctive
myopathologic, often paraneoplastic, subgroup of dermatomyositis. Muscle
fiber damage may be due to ischemia in border zone regions between
intermediate perimysial blood vessels.
40
Unusual Presentation of Hereditary Sensory Autonomic Neuropathy
Armine Darbinyan1, Kenneth Hughes1, Mary Fowkes1. 1Pathology, Icahn
School of Medicine, Mount Sinai Medical Center, NY
We describe an unusual presentation of hereditary sensory autonomic neuro-
pathy in a young woman. The patient was diagnosed at age 9 with biopsy
proven autoimmune hepatitis and was treated with azathioprine. She remained
active and attended her 1st year of college. At age 18 she developed EBV
mononucleosis and subsequently diffuse paresthesias with progressive weak-
ness thought to be Guillann Barr Syndrome variant. She was treated with IVIG
with mild improvement. She then developed pancreatitis with autonomic
instability and became wheelchair bound with bladder incontinence. Neuro-
logic examination revealed intact CN2-12, profound sensory and propriocep-
tive loss, weak deep tendon reflexes, 3-4/5 motor strength of upper and lower
extremities, mild dysmetria, and inaccurate rapid alternating movements. A
motor nerve conduction study revealed absent sensory potentials consistent
with a diagnosis of predominantly sensory neuropathy or neuronopathy
J Neuropathol Exp Neurol � Volume 73, Number 6, June 2014 Abstracts
� 2014 American Association of Neuropathologists, Inc. 595
Copyright © 2014 by the American Association of Neuropathologists, Inc. Unauthorized reproduction of this article is prohibited.
Page 12
(ganglionopathy). She developed global encephalopathy in the context of
hepatic decompensation, worsening ascites, rising ammonia, with persistent
asterixis and expired two months following her initial EBV diagnosis.
Autopsy microscopic examination revealed moderate loss of dorsal root
ganglion neurons and diffuse axonal loss in the dorsal columns of the spinal
cord without associated inflammation. There was preservation of motor
neurons and axons in the descending corticospinal tract of the spinal cord. A
deltoid muscle section revealed scattered myocytes with moderate atrophy,
no myocyte necrosis, no increase in internalized nuclei, no increase in
endomysial or perimysial fibrosis, and no inflammation.
This histologic phenotype is most consistent with hereditary sensory
autonomic neuropathy which can have an associated component of muscle
weakness with atrophy as seen in this case. Acquired disorders would
unlikely present with selective neuronal loss as seen in this case. The finding
of preserved motor neurons and axons rules out hereditary motor and
sensory neuropathy. However, the clinical picture of autoimmune hepatitis
and pancreatitis has not been previously reported.
41
Paraneoplastic Sensory Neuronopathy In A 63-year-old Man Without A
Demonstratable Underlying Malignancy
Jenny Smith1, Jeremy Deisch1. 1Loma Linda University
Paraneoplastic disorders of the nervous system comprise a heterogeneous
group of conditions that are united by autoimmune damage to elements of
the central nervous system, mediated by antibodies directed against antigens
that cross react with both neoplastic cells and nervous system constituents
(i.e. onconeural antibodies). The prototypical example of paraneoplastic
nervous system damage is sensory neuropathy with or without central
nervous system damage. Many of these cases harbor anti-Hu antibodies. An
underlying malignancy is identified in most cases, usually small cell carcinoma
of lung origin. We present a case of paraneoplastic sensory neuronopathy with
minor components of limbic encephalitis and Purkinje cell damage, without
demonstrable malignancy by either thorough clinical investigation or autopsy
study. The patient was a 63-year-old man with a 45 year smoking history that
presented with a forty pound weight loss and three month history of weakness,
numbness, and parasthesias. All extremities were weak, most prominent in the
proximal legs. Deep tendon reflexes were decreased throughout. An EMG
demonstrated a prominent sensory axonal polyneuropathy. Radiologic and
endoscopic search for malignancy demonstrated FDG avid hilar and retro-
peritoneal lymphadenopathy, but was otherwise negative. Serum onconeural
antibody testing revealed anti-Hu, as well as Purkinje cell fluourescence. Anti-
Yo antibodies were not detected. A full autopsy was performed, and no
malignancy was identified. Neuropathologic examination demonstrated prom-
inent ganglionic depopulation of all dorsal root ganglia. Scattered small
aggregates of lymphocytes where present within the dorsal nerve roots and
ganglia. Aggregates of residual satellite cells (‘‘nodules of Nageotte’’) were
frequent. The spinal cord showed prominent degeneration of the dorsal
columns. Perivascular chronic inflammation limited to the basal ganglia was
noted; the brain was otherwise unremarkable. The cerebellum showed slight
Purkinje cell depopulation and Bergmann gliosis. This case demonstrates an
example of paraneoplastic sensory neuronopathy and encephalomyelitis with
clinical and pathologically occult malignancy.
42
Expression of SERPING1 is Increased in Reactive Astrogliosis
Associated with Neuroinflammation
Amber Nolan1, Nicole Croom1, Han Lee1, Marta Margeta1. 1University of
California San Francisco
Reactive astrogliosis was once thought of as a uniform, stereotyped response
to injury of the brain. However, recent gene expression profiling data
suggests that astrocytic reaction is heterogeneous, with gene expression
patterns that depend on the nature of the original insult and thus provide
candidates for new reactive astrocyte markers that will be clinically useful
in differentiation of equivocal pathologic states. SERPING1 (also known as
C1 inhibitor), a serine protease inhibitor which primarily functions to inhibit
the complement system, was recently shown to be preferentially expressed
in a mouse model of inflammatory brain injury compared to a mouse model
of brain ischemia. To asses if this association held true in human disease, we
analyzed expression of SERPING1 using immunohistochemistry on paraf-
fin-embedded tissue from surgical and autopsy cases of encephalitis,
cerebral ischemic infarct, and pathologically unremarkable brain tissue.
Our preliminary results replicate the existing mouse model data. Specifi-
cally, while control brain tissue exhibits patchy and weak SERPING1
staining in the cortical and hippocampal pyramidal neurons, brain tissue
from patients with encephalitis demonstrates strong cytoplasmic expression
of this protein in a population of reactive astrocytes (as confirmed by
staining for glial fibrillary astrocytic protein) and to a lesser extent in a
subpopulation of nearby neurons. In contrast, infarct tissue shows faint
cytoplasmic staining for SERPING1 in reactive astrocytes and neighboring
neurons. These results confirm that SERPING1 expression is upregulated to
a greater extent in inflammatory compared to ischemic astrogliosis and
suggest that SERPING1 may be a clinically useful marker of neuro-
inflammation in biopsies from patients with an unknown neuropathologic
process. Given the recently established role of complement in synapse
pruning, increased expression of SERPING1 by neurons and reactive
astrocytes may be important for limiting the excessive synapse loss in
neuroinflammatory conditions.
43
Two Cases of Fatal Cerebral Edema with CNS Angiitis
Denise Ng1, Harry Vinters1. 1University of California, Los Angeles
We report two cases of fatal cerebral edema arising as a complication of two
different types of central nervous system angiitis. CASE 1: A 27-year-old
male presented with flu-like symptoms, fever, truncal rash and myalgia after
treatment of cutaneous abscess. Six days after his initial presentation, he
developed diarrhea, nausea, vomiting, altered mental status and a witnessed
grand mal seizure. Despite initial CT head being unremarkable, he had
another seizure during a lumbar puncture. His repeat imaging showed severe
global cerebral edema with cerebellar tonsillar herniation. His other
laboratory investigations showed mildly elevated eosinophil count and
CSF protein of 406 mg/dL. His medical history includes previous episode of
meningoencephalitis with rash of unknown etiology 10 years previously.
Autopsy brain examination shows bilateral cerebellar tonsillar herniation
with midbrain compression and multifocal subacute vasculitis, consistent
with primary angiitis of the central nervous system. CASE 2: A 71-year-old
woman with past medical history of quadriplegia for severe spinal stenosis,
rheumatoid arthritis, osteoporosis, and hypertension presented with head-
ache and altered mental status for approximately 3 days. Initial CT head
showed right temporal lobe edema and right to let midline shift. She was
treated with steroids for presumed acute disseminated encephalomyelitis.
She became more obtunded and later hypothermic with unstable blood
pressures. Repeat imaging showed worsening cerebral edema. At autopsy,
the brain showed edema with Duret hemorrhages. Focally severe gran-
ulomatous angiitis in vessels immunoreactive for Abeta was diagnostic for
Abeta-related granulomatous angiitis. CONCLUSION: Although both
ABRA and PCNSV have distinct clinicopathological features, both cases
show that vascular injury can cause impairment of mechanisms important in
fluid regulation. Cerebral edema is an uncommon manifestation of vasculitis
in the absence of hemorrhage, and may be a result of impaired blood-brain
barrier function associated with the angiitis.
44
Autoimmune Polyglandular Syndrome Type 1 with Calcification in the
Cortical Gray and White Matter and the Basal Ganglia
Fahad Bafakih1, Paul Benson2, M. Beatriz Lopes1. 1University of Virginia;2Office of the Chief Medical Examiner of Virginia - Western Office
Abstracts J Neuropathol Exp Neurol � Volume 73, Number 6, June 2014
� 2014 American Association of Neuropathologists, Inc.596
Copyright © 2014 by the American Association of Neuropathologists, Inc. Unauthorized reproduction of this article is prohibited.
Page 13
Autoimmune polyglandular syndromes are rare endocrinopathies that are
associated with abnormal endocrine functions and nonendocrine auto-
immune dysfunctions. Autoimmune polyglandular syndrome (APS) type 1
presents in childhood and might show other manifestations of disease as
mucocutaneous candidiasis and ectodermal dystrophy. The disease is caused
by mutations in the autoimmune regulator gene (AIRE) coding for a
putative transcription factor. Autoimmune polyglandular syndrome type 2 is
seen in adults and is more common than type 1, presenting with
autoimmune thyroid disease, adrenal insufficiency and diabetes mellitus
type I, and is not associated with AIRE gene mutation. Autoimmune
polyglandular syndrome type 3 presents with autoimmune thyroid disease
and other autoimmune disease with the exception of adrenal involvement.
There is no known treatment for these diseases and management consistent
mainly of hormone replacement and supportive therapy.
Herein, we report an autopsy of a 27-year-old female with APS type 1 with
extensive calcification in the cortical gray and white matter and basal
ganglia. The clinical presentation during early childhood included
hypoglycemia, hypoparathyroidism, and adrenal crisis. She received
multiple hormonal replacement therapies. At age 17, she had an episode
of mental status changes thought at the time to likely be multifactorial, a
combination of hypoglycemia, HSV meningitis and, perhaps, adrenal
crisis. Head CT scan at that time showed extensive calcification of the
basal ganglia and scattered calcification of the cortical gray and white
matter located in the fronto-parietal lobes that had been documented prior
to this episode. The patient was lost in follow-up. At age 27, she was found
unresponsive at home and a forensic autopsy was performed. The
mechanism resulting the extensive calcification of the deep gray matter
is believed to be due to hormonal imbalance specifically hypoparathyroid-
ism and adrenal insufficiency.
45
Comparative Analysis of Neuronal Vulnerability of the Anterior
Cingulate Cortex in Hereditary and Sporadic Tauopathies
Adrian Oblak1, Jill Murrell1, Rose Richardson1, Francine Epperson1,
Bernardino Ghetti1. 1Indiana University School of Medicine, Dept Path
and Lab Med
In hereditary Frontotemporal Dementia and Parkinsonism linked to
chromosome 17 associated with the Microtuble Associated Protein Tau
(MAPT) mutations (FTDP-17MAPT), specific neuronal populations may be
more vulnerable than in sporadic tauopathies. We have focused on the
analysis of hereditary and sporadic tauopathies characterized by 4-repeat
(4R) tau. Brains of subjects carrying the following MAPT mutations:
IVS10+3, IVS10+16, and P301L were used as well as brains with a
neuropathologic diagnosis of corticobasal degeneration (CBD) and pro-
gressive supranuclear palsy (PSP). Histologic methods included hematox-
ylin and eosin with Luxol fast blue and Thioflavin S. For
immunohistochemistry, antibodies raised against tau protein (AT8, 4R tau
and 3R tau) and glial fibrillary acidic protein were used. Grey level index
acquisition was used to determine the relative density and distribution of
tau-immunoreactive (tau-ir) neurons within cortical layers of the anterior
cingulate cortex. Furthermore, neuronal loss and gliosis in the same area
was assessed. Tau-ir neurons were more frequently observed in layer II than
in layers I, III, V or VI for both the IVS10+3 and IVS10+16 mutation. In the
P301L mutation, tau-ir neurons were most numerous in layers II-III and VI
than in I and V. Overall, in cases with the IVS10+16 mutation, there were
more tau-ir neurons in all layers as compared to the cases with the IVS10+3
and P301L mutation. In CBD and PSP, tau-ir neurons were distributed
evenly throughout cortical layers. Overall fewer tau-ir neurons were
observed than in hereditary cases. The present findings demonstrate that
tau is differentially distributed throughout the anterior cingulate cortex in
the cases of hereditary and sporadic tauopathies examined. Cases of FTDP-
17MAPT are more likely to demonstrate susceptibility of cortical layers in
the anterior cingulate cortex when compared to sporadic tauopathies.
46
Brainstem Pathology in Frontotemporal Degeneration Associated with
the MAPT P301L Mutation
Melissa Gener1, Jill Murrell2, Adrian Oblak2, Bernardino Ghetti2. 1Indiana
University School of Medicine; 2Indiana University School of Medicine
Dept of Pathology and Lab Med
Among mutations in the Microtubule Associated Protein Tau gene, P301L is
one of the most frequent. We studied a case characterized by a long clinical
course, extremely severe cortical and subcortical atrophy, and prominent
involvement of the brainstem.
A 44-year-old woman presented with sudden-onset of delusions and halluci-
nations. Retrospectively, disease onset may have been insidious, beginning at
age 40. She was first treated for a psychiatric disorder; however, initial
symptoms were followed by a rapid cognitive decline. At age 46, imaging
studies revealed hypometabolism and atrophy of the frontal and temporal lobes,
bilaterally. She continued to deteriorate neurologically and was admitted to a
long-term nursing facility, where she died at 53 years of age.
The brain and spinal cord were obtained at autopsy. The brain was
extremely atrophic and weighed 652 grams. Atrophy was particularly severe
in the frontal and temporal lobes, as well as in the brainstem. Histological
examination revealed marked neuronal loss and gliosis in the frontal and
temporal cortices. In the midbrain, only a few neurons had survived in the
substantia nigra. There was a significant loss of myelinated axons in the
hemispheric white matter and in descending tracts. Immunohistochemistry
was carried out using a panel of antibodies to tau including AT8, 4 repeat,
and 3 repeat. Neuronal and glial tau were immunolabeled with AT8 and 4
repeat tau antibodies. Tau deposits were most numerous in the cortex of the
frontal and temporal lobes, amygdala, dorsal midbrain, locus coerleus,
median raphe nucleus, red nucleus, and the dorsal motor nucleus of vagus
nerve. DNA, obtained from autopsy brain tissue, revealed a C to T
nucleotide substitution at codon 301 resulting in a leucine for proline
change (P301L).
The significance of 4 repeat tau pathology, in the brainstem as it relates to
autonomic functions may need further investigation.
47
Effect Of Salvadora Persica Leaf Extract In Transgenic Drosophila
Model Of Parkinson_s DiseaseYasir Siddique1, Tanveer Beg2, Falaq Naz1, Smita Jyoti1. 1Dept of Zoology,
Aligarh Muslim University, Aligarh (UP), India; 2Biology Dept,Faculty of
Science, Jazan University, Jazan, Saudi Arabia
Background: There are various genetic models of PD based on alpha-
synuclein (>S) expression (mutant, or wild type) in mice as well as in flies.
The over expression of either wild type or mutant form of >S in transgenic
Drosophila leads to the formation of Lewy Bodies (LB) resulting in the loss
of dopaminergic neurons and behavioral abnormality. Plants having
medicinal properties have gained importance because of their beneficial
effect on humans. In this context the effect of Salvadora persica leaf extract
was studied on the transgenic Drosophila (Parkinson_s disease) model flies
expressing normal human alpha synuclein (h->S) in the neurons.
Methods: The leaf extract was prepared in acetone. The flies were cultured
on standard Drosophila food at 25-C. Crosses were set up using six virgin
females of UAS-Hsap/SNCA.F5B were mated to three males of GAL4elav.
The progeny expressing the human >-synuclein (PD flies) were exposed to
0.1, 0.5, and 1.0 Kl/ml of S. persica mixed in the diet for 24 days. Hsap/
SNCA.F strains were taken as control. The effect of extract was studied on
the climbing ability, behavioral pattern, oxidative stress and apoptosis in the
brain of PD model flies.
Results: The exposure of flies to 0.1, 0.5 and 1.0 Kl/ml showed a dose
dependent significant delay in the loss of climbing ability and activity
pattern, reduction in the oxidative stress and apoptosis in PD model flies.
Conclusion: S. persica leaf extract is potent in reducing PD symptoms.
J Neuropathol Exp Neurol � Volume 73, Number 6, June 2014 Abstracts
� 2014 American Association of Neuropathologists, Inc. 597
Copyright © 2014 by the American Association of Neuropathologists, Inc. Unauthorized reproduction of this article is prohibited.
Page 14
48
Effect Of Gingerol On The Oxidative Stress In The Brains Of
Transgenic Drosophila Model Of Parkinson_s Disease
Tanveer Beg1, Yasir Siddique2, Smita Jyoti2, Falaq Naz2, Rahul Sachdev2.1Biology Dept,Faculty of Science, Jazan University, Jazan, Saudi Arabia;2Dept of Zoology, Aligarh Muslim University, Aligarh (UP), India
Background: Oxidative stress is thought to be mechanistically involved in
PD pathogenesis. Gingerol is a component of ginger and may have anti-
oxidant properties. We studied the effects of gingerol supplementation on
oxidative stress in Parkinson_s disease (PD) model flies.
Methods: Drosophila expressing human alpha-synuclein (PD flies) were
exposed to 50, 100 and 150KM of gingerol mixed in the diet for 24 days. To
measure lipid peroxidation, brain homogenates (10 brains/group; five
replicates/group) were prepared in Tris HCl (20 mM), mixed with 1-
methyl-2-phenylindole, acetonitrile, methanol and HCl, and incubated at
45-C for 40 min prior to absorbance measurements at 586 nm. The protein
carbonyl content was estimated according to the protocol described by
Hawkins et al. (2009). Homogenates were mixed with 2, 4-dinitrophenyl
hydrazine and incubated for 20 min followed by addition of trichloroacetic
acid (TCA). Following incubation at -20-C for 15 min, mixtures were
centrifuged and the pellet obtained was washed twice by ice cold
ethanol:ethylacetate (1:1). Pellets were re-dissolved in guanidine hydro-
chloride and the absorbance was read at 370 nm.
Results: Gingerol supplementation resulted in a dose dependent significant
decrease in lipid peroxidation ranging from a 30% decrease at 50 KM
gingerol to a 59% decrease at 150 KM gingerol (pG0.05). Gingerol
supplementation also resulted in a dose dependent significant decrease in
protein carbonyl content ranging from a 17% decrease at 50 KM gingerol to
a 28% decrease at 150 KM gingerol (pG0.05).
Conclusion: Gingerol is potent in reducing the oxidative stress in the brains
of PD model flies. Gingerol should be validated in mammalian model
systems before use as a potential therapy for PD in humans.
49
Apigenin Extends Lifespan And Improves The Activity Pattern Of
Parkinson_s Disease Model Flies
Yasir Siddique1, Tanveer Beg2, Falaq Naz1, Smita Jyoti1, Rahul Sachdev1.1Dept of Zoology, Aligarh Muslim University, Aligarh (UP), India;2Biology Dept, Faculty of Science, Jazan University, Jazan, Saudi Arabia
Background: The Drosophila model for Parkinson_s Disease (PD) based on
wild-type alpha synuclein expression in flies were used in this study. A time
dependent loss of dopaminergic neurons and the formation of intracellular
aggregates of >S (Lewy bodies) have been reported in the PD model flies.
The effect of apigenin, an antioxidant found in most vegetables and fruits,
was studied on the life span and activity pattern of the PD model flies.Methods: Flies were maintained on standard Drosophila food at 25-C.
Crosses were set up using six virgin UAS-Hsap/SNCA.F5B females mated
to three GAL4elav males. The progeny expressing human >-synuclein (PD
flies) were exposed to 0.1, 0.5 and 1.0 Kl/ml of apigenin mixed in the diet.
Hsap/SNCA.F strains were used as controls. To determine lifespan, the
newly enclosed male flies (control and PD) were placed in culture tubes (10
flies per tube) containing 0.1, 0.5, and 1.0 Kl/ml of apigenin mixed in diet.
Flies were transferred to new diet every 3 days and the numbers of dead flies
were recorded at 3 days intervals until all flies had died. Motor activity was
monitored by using Drosophila activity monitors (DAMs) starting on the
12th day. Activity was recorded every hour for a total of 280 hrs.Results: The results obtained for lifespan determination showed that
apigenin extended the average lifespan of the male PD flies. A dose
dependent delay in the loss of activity pattern was observed in PD flies
exposed to 0.1, 0.5, and 1.0 Kl/ml of apigenin. No change was observed in
the activity pattern of control flies.Conclusion: Apigenin is potent in reducing PD symptoms in the Drosophila
model for PD.
(The grant (No.F.30-1/2013 (SA-II)/RA-2012-14-GE-UTT-858) received as
UGC Research Award (2012-14) from the University Grants Commission,
New Delhi is thankfully acknowledged).
50
Death of Neurons in the Substantia Nigra Prior to Incidental Lewy
Body Disease
Eric Richfield1, Kavita Prasad1, John Hedreen2. 1Robert Wood Johnson
Medical School/Rutgers Universtity; 2Mailman Research Center
We used the quantitative assessment of several measures from a cross
section through the substantia nigra of different groups of individuals.
Measures included counts of tyrosine hydroxylase (TH+) and neuromelanin
(NM+) expressing and non-expressing neurons, TH+ and phosphorylated >-
synuclein+ (p>SYN+) neurites, and three NM-related measures. The groups
included age-matched elderly controls, patients with Incidental Lewy body
disease (ILBD) and the Parkinson_s disease phenotype (PDP). We used one
tissue section at the level of the 3rd nerve stained for TH and p>SYN. We
divided all cases into seven distinct grades based on quantitative data. The
grades included control, asymptomatic individuals (PDP0a, PDP0b, and
PDP0c), and symptomatic PDP patients (PDP1, PDP2, and PDP3). The
grades demonstrated a progression of disease severity. Some measures
declined with progression/duration of disease (TH+/NM+ neurons), some
measures increased (ratio of p>SYN+/TH+ neurites), and many measures
were biphasic: increasing and then declining (NM-related). Various
measures of NM (representing loss of pigmented neurons) demonstrated
that cell death began at a grade of disease prior to the presence of Lewy
bodies. Cell death was also present in ILBD. The pathology of the PDP
measured in this poster demonstrates this is a dynamic and progressive
disease. The interpretation of post mortem findings will require assessment
of grade to be useful.
51
Effect of Lewy Bodies on Substantia Nigra Dopaminergic Neuron Cell
Health
Knarik Arkun1, Ann Rice2, Essie Komlada2, James Bennett2. 1Virginia
Commonwealth University Medical Center; 2VCU Parkinson’s and
Movement Center
Parkinson_s disease is the second most common neurodegenerative disease.
Lewy bodies and Lewy neurites with premature neuronal loss are hallmarks
of the disease. It is still unclear what triggers neuronal loss. In this study we
would like to determine if Lewy bodies are beneficial or deleterious to
neuronal health by measuring mtDNA copy numbers in cells with and
without Lewy bodies in the substantia nigra. Initial studies used paraffin
embedded H&E stained sections from the substantia nigra of four
Parkinson_s patients. 15 neurons with and without Lewy bodies by laser
capture microdissection (LCM) from each case in triplicate. DNA was
extracted and qPCR was performed for 4 genes (ND2, ND4, COX3 and
12S) to measure the neuronal well-being on the mitochondrial level. We
found no difference in the expression levels of all four genes between cells
with and without Lewy bodies in each case. However, there were
differences of mtDNA copy number expression between the cases and
between the genes. In summary, the preliminary data shows no difference in
mtDNA copy numbers in cells with and without Lewy bodies, which
indicates that Lewy body inclusions are not deleterious to mitochondria. A
subsequent study using immunohistochemistry for >-synuclein and fresh
frozen tissue is being conducted to elucidate the influence of the presence of
Lewy bodies on mtDNA copy number.
52
Evaluation of Lewy Pathology in Enteric Neurons from Living Patients
Annie Hiniker1, Ryan Gill1, Chadwick Christine1, Robert Nussbaum1.1University of California San Francisco
Abstracts J Neuropathol Exp Neurol � Volume 73, Number 6, June 2014
� 2014 American Association of Neuropathologists, Inc.598
Copyright © 2014 by the American Association of Neuropathologists, Inc. Unauthorized reproduction of this article is prohibited.
Page 15
Diminished GI motility, resulting in constipation, is often one of the earliest
clinical manifestations of Parkinson_s disease (PD) and can precede PD diagnosis
by years. Additionally, autopsy series clearly demonstrate the presence of Lewy
pathology in enteric neurons in almost all PD patients. We and others have
hypothesized that enteric neurons may show Lewy pathology prior to the
diagnosis of PD, making GI biopsies such as those obtained during colonoscopy a
potential diagnostic tool. To examine this hypothesis, we are examining all GI
surgical and biopsy specimens from patients with clinical diagnosis of PD at our
institution. As proof of principle, we first examined colonic resection specimens
from patients with an ICD-9 coded diagnosis of PD (332.0). Six resections from
patients with this diagnosis who also fit our criteria for PD were compared to
matched (age, gender, reason for resection) control resections. All resection
specimens demonstrated submucosal and myenteric neurons. Immunohistochem-
ical staining with anti-phosphorylated alpha-synuclein antibody revealed rare
Lewy bodies in neurons of 5 of 6 PD cases (predominantly myenteric plexus
neurons) and no Lewy bodies in the six matched control cases. We next searched
for all colonic biopsy specimens from PD patients; this yielded twelve biopsies.
However, only 4/12 biopsies demonstrated neurons. These samples are currently
being evaluated for Lewy pathology. Finally, an additional search for surgical
specimens from other GI locations known to demonstrate Lewy pathology at
autopsy, including salivary gland, esophagus, stomach, and small intestine, was
performed and yielded 27 additional cases, currently being evaluated for neuron
content. Our initial data suggest that Lewy pathology is present in the GI tract of
living patients but that random biopsies may be limited in their diagnostic utility
due to the rarity of diagnostic pathology.
53
Hippocampal sclerosis in Lewy body disease
Naoya Aoki1, Melissa Murray2, Kotaro Ogaki2, Shinsuke Fujioka2, Owen
Ross2, Dennis Dickson2. 1Mayo Clinic Neuropathology Laboratory,
Jacksonville, Florida; 2Mayo Clinic
Hippocampal sclerosis (HpScl) is a common neurodegenerative disorder in the
elderly, which occurs alone or accompanied by other disorders, especially
frontotemporal lobar degeneration with TDP-43 pathology (FTLD-TDP). It is
increasingly clear that TDP-43 pathology is present in most cases of HpScl. TDP-
43 pathology is also common in Alzheimer disease (AD) and has also been
reported in Lewy body disease (LBD). So far, no study has focused on the
frequency and characteristics of HpScl in LBD. Our goals were (1) to clarify the
pathological characteristics of HpScl in LBD, and (2) to determine the importance
of TDP-43 pathology in the diagnosis of HpScl. We examined 670 LBD cases
(381 diffuse LBD and 289 transitional LBD). All cases were evaluated with
thioflavin S fluorescent microscopy for AD pathology, as well as immunohis-
tochemistry for >-synuclein and TDP-43. HpScl was detected in 34 cases (5%).
Older age, higher Braak neurofibrillary tangle stage and Thal amyloid phase, as
well as the presence of TDP-43 pathology were associated with HpScl. There
was no difference in the frequency of HpScl between transitional and diffuse
LBD. TDP-43 pathology was detected in all HpScl cases and 116/493 (24%) of
cases without HpScl. All HpScl cases had a pattern of TDP-43 pathology
consistent with FTLD-TDP Type A; however, the pathology were restricted to
limbic and inferomedial temporal lobe in 85% of the cases. All HpScl cases had
TDP-43 pathology in the parahippocampal gyrus and 88% had neuronal
intranuclear inclusions. Fine neurites in CA1 sector were detected in all HpScl
cases. We conclude that HpScl in LBD is a TDP-43 proteinopathy associated
with older age and greater AD pathology, but not >-synuclein distribution. The
results suggest that neuronal loss in HpScl is not merely due to AD pathology,
but may potentially be due to the same underlying mechanism of FTLD-TDP.
54
Flow Cytometry Analysis of Synaptosomes from Human Brain Reveals
Changes Specific to Lewy Body and Alzheimer_s Disease
Nadia Postupna1, C Keene1, Caitlin Latimer1, Emily Sherfield1, Rachel Van
Gelder1, Jeffrey Ojemann1, Thomas Montine1, Martin Darvas1. 1University
of Washington
Synaptic dysfunction is thought to play an important role in the
pathophysiology of neurodegenerative diseases, such as Alzheimer_s disease
(AD) and Lewy body disease (LBD). To improve our understanding of
synaptic alterations in health and disease, we investigated synaptosomes
prepared from post-mortem human cerebral cortex, putamen, and two
regions of the caudate nucleus, dorso-lateral (DL) and ventro-medial (VM),
regions commonly affected in AD and LBD. We observed that the fraction
of synaptosomal particles with reactivity for dopamine transporter (DAT)
was significantly reduced in the putamen and VM caudate of patients with
neuropathological diagnosis of LBD. As expected, these differences also
were reflected in direct measurements of dopamine (DA) and its metabolite,
3,4-dihydroxyphenylacetic acid (DOPAC), in caudate and putamen of LBD
patients. The fraction of synaptosomal particles positive for amyloid A (AA)
was significantly increased in frontal cortical samples of patients with the
neuropathological diagnosis of severe AD, and was positively correlated
with disease progression. We also prepared synaptosomes from the striatum
of mice with severe loss of DA neurons (Slc6a3-DTR mice) and wild-type
littermate controls. We observed dramatically reduced levels of DAT-
positive synaptosomes in Slc6a3-DTR mice following exposure to diph-
theria toxin (DT). Striatal levels of DA and DOPAC in Slc6a3-DTR mice
also were reduced significantly following DT exposure. We conclude that
flow cytometric analysis of synaptosomes prepared from human or mouse
brain provides an opportunity to study dopaminergic and glutamatergic
synaptic content in tissue and detect pathological changes at the level of the
synapse in LBD as well as AD.
55
Coincident Alzheimer_s Disease Modifies Alpha-synuclein Pathology in
Lewy body Disease
Pallavi Gopal1, Jon Toledo2, Kevin Raible2, Erin Abner3, David Irwin2,
Johannes Brettschneider4, Steven Arnold5, Howard Hurtig5, Peter Nelson3,
Charles Adler6, Thomas Beach7, John Trojanowski2. 1Hospital of the
University of Pennsylvania; 2Center for Neurodegenerative Disease
Research; 3Sanders-Brown Center on Aging, University of Kentucky;4University of Ulm, Center for Neurodegenerative Disease Research;5Department of Neurology, University of Pennsylvania; 6Parkinson’s
Disease and Movement Disorders Center, Mayo Clinic; 7Banner Sun Health
Research Institute
Alzheimer_s disease (AD) and Parkinson_s disease (PD) are the two most
common, frequently co-occurring, neurodegenerative diseases. Dementia
with Lewy Bodies (DLB) is defined by dementia with fluctuating cognitive
symptoms and the appearance of a parkinsonian syndrome 91 year after
dementia onset. Staging systems have been proposed for tau and AA
deposits in AD as well as for alpha-synuclein pathology (ASP) in PD and
DLB although no consensus has been reached.
We studied the distribution of ASP in DLB subjects with coincident AD
(AD+DLB, n=313) and compared it to the distribution in PD cases with and
without AD (PD+AD, n=71; PD, n=134) from the University of Pennsylva-
nia (UPenn) and the Banner Sun Health Research Institute. Cases were
classified by ASP distribution into amygdala predominant, brainstem
predominant, limbic (with/ without brainstem involvement) and neocortical
using a modified Unified Staging System for Lewy Body Disorders scheme.
Dopamine transporter immunohistochemistry was performed on a subset of
the UPenn cohort.
Amygdala predominant ASP category was present in AD+DLB cases and
not PD cases. The limbic category presented a lower burden of brainstem,
subcortical and frontal ASP in the DLB cases compared to the PD cases. In
the neocortical category, PD only cases showed a lower burden of temporal
and angular cortex ASP than the PD+AD and the DLB only cases. PD and
PD+AD groups in the UPenn cohort showed a higher burden of ASP in the
substantia nigra compared to the DLB only group. The nigro-striatal
pathway, defined by dopamine transporter immunohistochemistry, was relatively
preserved in the DLB+AD groups compared to the PD only and PD+AD
groups.
J Neuropathol Exp Neurol � Volume 73, Number 6, June 2014 Abstracts
� 2014 American Association of Neuropathologists, Inc. 599
Copyright © 2014 by the American Association of Neuropathologists, Inc. Unauthorized reproduction of this article is prohibited.
Page 16
Conclusions: Presence of AD pathology modifies the burden and distribu-
tion of ASP in the alpha-synucleinopathies studied. The different patterns of
ASP spread may explain the heterogeneity observed when classifying the
different patterns of distribution of Lewy body pathology.
56
Clinicopathologic Correlations of FTLD-TDP Type B with High and
Low Burden of TDP-43 Positive Inclusions in the Dentate Gyrus
Esther Bit-Ivan1, Anne Koronkiewicz1, Melanie Peterson1, Alfred
Rademaker1, Mallory Ward1, Qinwen Mao1, Sandra Weintraub1, Nailah
Siddique1, Teepu Siddque1, M. Marsel Mesulam1, Eileen Bigio1.1Northwestern University Feinberg School of Medicine
The FTLD-TDP harmonized classification divides FTLD-TDP into four
groups, Types A through D, based on the location, type, and density of
TDP-43 positive inclusions, which correlate with clinical presentation and
genetic findings. Type B, which generally presents with behavioral bvFTD
+/- ALS, was observed to have few to numerous neuronal cytoplasmic
inclusions in the dentate gyrus, with density inversely proportional to
cortical TDP. To date, the significance of this difference in dentate gyrus
(DG) TDP-43 inclusion burden has not been studied. The aim of the current
study is determine whether DG TDP-43 inclusion burden correlates with
specific clinical or pathologic factors. Thirty-two cases with the final
diagnosis of FTLD-TDP Type B were selected and medical records were
reviewed. All 32 cases also either had both clinical and pathologic ALS or
ALS pathology without clinical ALS. H&E slides were assessed for
neuronal loss and gliosis (NL&G) of the hippocampal formation, dentate
molecular layer rarefaction, and degenerative changes in the upper and
lower motor neuron pathways. Immunohistochemical stains for TDP-43 of
the hippocampus and other regions were performed. Dentate gyrus
inclusions were graded as 0=none, 1=rare, 2=mild, 3=moderate or
4=frequent. Nine of 32 cases had low TDP-43 burden (Group 1, grades 0
to 2), and 23 cases had high TDP-43 burden (Group 2, grade 3 and 4). p62
immunostains were performed to look for C9orf72-specific pathology.
Results showed that Group 2 cases more commonly had dementia at onset
of disease (p = 0.007) and greater subicular NL&G (p = 0.012) than did
Group 1 cases. Other trends in Group 2 cases included lower brain weight
and greater CA1 NL&G. There was no correlation with duration of disease,
age, presence of memory problems, gender, cortical TDP pathology, or
C9orf72 hexanucleotide repeat pathology. Investigation into the significance
of these findings is warranted.
57
Clinicopathologic report of ocular involvement in ALS patients with
C9ORF72 Mutation
Eileen Bigio1, Amani Fawzi1, Esther Bit-Ivan1, Joseph Simonett1, Patryk
Purta1, Heather Moss2, Nailah Siddique1, Nicholas Volpe1, Teepu Siddque1.1Northwestern University Feinberg School of Medicine; 2University of
Illinois at Chicago
Recently, a GGGGCC hexanucleotide repeat expansion in intron 1 of the
C9orf72 gene was identified as the most common pathologic mutation in
familial and sporadic ALS/FTD, familial ALS, and familial FTD. Multiple
unique pathologic features have been identified in brains of c9orf72
mutation carriers (c9-ALS/FTD), including star and dot-shaped p62
positive, p-TDP-43 negative neuronal cytoplasmic and intranuclear inclu-
sions in the cerebellum, hippocampus, and neocortex. These inclusions also
contain dipeptide repeat proteins, likely formed from non-conventional,
non-ATG initiated translation of the expanded hexanucleotide repeat.
Neuro-ophthalmologic changes have been described in ALS patients, but
histopathologic studies of ocular involvement have been limited to studies
of oculomotor and trochlear nuclei. In our study of a patient with C9orf72
mutation, histologic examination of the brain revealed ALS, no FTLD-TDP,
and p62 positive inclusions typical of c9 FTD-ALS. Examination of visual
pathway related regions showed no histologic abnormality. p62 showed
inclusions in the occipital cortex, as has been reported in c9 cases, but the
remainder of the visual system had no p62 pathology and there were no
TDP-43 positive inclusions. Immunofluorescent labeling studies of retinal
sections demonstrated abundant dot and semi-lunar shaped p62-positive
inclusions that were localized to the inner nuclear layer (INL) in the macula
and peripheral retina. Most inclusions were found in a peri-nuclear location
and were seen at all levels of the INL, with rare inclusions also seen in the
inner plexiform and ganglion cell layer. No p62+ inclusions were seen in a
control retina. Inclusions were also labeled with antibodies to poly-GA
dipeptide repeat which co-localized with the p62 inclusions, and with
ubiquitin, but not ubiquilin-2 or TDP-43. This is the first report that
identifies disease-specific deposits of ALS/FTLD in the retinal tissue of a
patient with C9orf72 mutation, in whom corresponding ocular functional
deficits were identified prior to her passing.
58
Incidental, Insidious and Late Onset Neuronal Intermediate Filament
Inclusion Disease in an 85-Year-Old Male Y a Case Report
Jason Chiang1, Lananh Nguyen1, Nigel Cairns2, Oscar Lopez3, Julia Kofler4.1Univ Pittsburgh Medical Center Department of Pathology; 2Washington
University in St. Louis, Department of Neurology; 3University of Pittsburgh
Department of Neurology; 4Univ Pittsburgh Medical Center Department of
Pathology
Neuronal intermediate filament inclusion disease (NIFID), a subgroup of
frontotemporal lobar degeneration with FUS-positive inclusions (FTLD-
FUS), usually occurs in individuals younger than 60 years with short disease
duration (3-7 years). The inclusions are typically present abundantly in the
neocortex, hippocampus and basal ganglia.
Here we report incidental findings of NIFID in an 85-year-old male with a
19-year history of progressive memory deficits and depression, but no
significant motor symptoms except for mild action tremors. Neuropatho-
logic evaluation using NIA-AA criteria revealed a high level of Alzheimer’s
disease (AD) neuropathologic change (A3, B3, C3) and amygdala-predom-
inant Lewy body disease. In addition, autopsy revealed widespread presence
of round eosinophilic neuronal cytoplasmic inclusions, which were strongly
positive for alpha-internexin and p62 but largely negative for tau and alpha-
synuclein. The highest frequency of inclusions was found in amygdala and
claustrum. Within cortical regions, deeper layers of the primary visual
cortex were most densely affected, followed by pre- and postcentral gyri.
Other cortical areas showed only sparse inclusions. Moderate numbers of
inclusions were found in hippocampal CA3 and CA1 areas and substantia
nigra. Rare inclusions were seen in the basal ganglia, thalamus, inferior
olive, colliculi and medullary tegmentum. The inclusions exhibited variable
immunoreactivity for FUS, ranging from negative to weakly positive.
As the patient_s symptoms are sufficiently explained by the AD and Lewy
body pathologies, the NIFID changes appear to be an incidental finding of
uncertain significance. Several features including older age, longer disease
duration, absence of motor symptoms and limited cortical and basal ganglia
involvement distinguish this case from typical NIFID. Similar weak FUS
reactivity as in our case has been described for a few cases of NIFID in
older patients. In conclusion, this case broadens the spectrum of NIFID and
suggests that NIFID in older individuals may represent a biochemically and
phenotypically distinct variant.
59
Adult-Onset Alexander Disease in a Paraplegic African-American Male
with a Rare D138N Mutation in the GFAP Gene
Ki-Eun Chang1, Nancy Edwards2, Bibhuti Mishra3, Mark Hallett2, Abhik
Ray-Chaudhury4. 1Penn State College of Medicine/NIH; 2NINDS, NIH;3Inova Fairfax Hospital; 4NIH
Contrary to the fatal form of infantile Alexander Disease, Adult-onset
Alexander Disease (AOAD) is a unique variant, characterized by a protracted
clinical course, dominant mutation of the GFAP gene, atrophy of the brainstem
Abstracts J Neuropathol Exp Neurol � Volume 73, Number 6, June 2014
� 2014 American Association of Neuropathologists, Inc.600
Copyright © 2014 by the American Association of Neuropathologists, Inc. Unauthorized reproduction of this article is prohibited.
Page 17
and upper cervical spinal cord, and the presence of Rosenthal fibers on
histology. Although the overall incidence is rare, complications of AOAD often
mimic common and/or devastating disorders, subjecting the patient andmedical
caregivers to undue anxiety and clinical conundrum. Also, unfamiliarity with
the heritable pattern of AOAD may lead to improper follow-up of potentially
affected family members. Here, we report a case of AOAD in a 52 year-old
African-American man with relevant clinical history, MRI findings, histology,
and a GFAP mutation (c.382 G9A 9p.Asp28Asn) that has only been reported
once previously.
Our patient had an extensive medical history with complications attributable to
bulbar and pyramidal pathology such as paraplegia, chronic aspiration
pneumonitis, and recurrent urinary tract infections. MR imaging revealed
severe atrophy of the medulla and upper cervical cord. Final diagnosis was
confirmed by the presence of large number of Rosenthal fibers, scatteredmostly
in a perivascular pattern over multiple regions of the brain on post-mortem
examination. Foci of white matter demyelination were also observed. We
searched the current literature and mutation databases and found only a single
account of the samemutation in a middle-aged man. Interestingly, both patients
were older at symptom presentation and suffered mainly from pyramidal
involvement. The ethnicity of the other patient was not explicitly stated, which
is not an uncommon scenario in most reports describing AOAD. Not only does
this make our case potentially unique, but further highlights the principle that
genetic confirmation should be pursued if presented with characteristic MRI
findings in the right clinical context and should not be deterred by the age or
ethnicity of the patient.
60
GABA-ergic and Glycinergic Synaptic Deficit in Friedreich Ataxia
Arnulf Koeppen1, R Ramirez1, Alyssa Becker1, Joseph Mazurkiewicz2. 1VA
Medical Center; 2Albany Medical College
Progressive atrophy of large glutamatergic neurons of the dentate nucleus (DN)
is a characteristic central nervous system lesion of Friedreich ataxia (FRDA),
and loss of cerebellar output is the pathophysiological correlate of disabling
ataxia. Most afferent fibers in the DN derive from Purkinje cells that effect
inhibitory synaptic transmission by gamma-aminobutyric acid (GABA). In
addition, DN neurons receive inhibitory glycinergic impulses from intrinsic DN
nerve cells. Grumose degeneration in the DN of patients with FRDA consists of
clusters of abnormal axon terminals that react with antibodies to synaptophysin
and glutamic acid decarboxylase (GAD). Grumose degeneration is more
prominent in cases with partial preservation of large neurons but may be
entirely absent in cases of long disease duration. Enzymatic GAD activity is the
rate-limiting step in the biosynthesis of GABA, and GAD reaction product
identifies neuronal cell bodies, axons, and axon terminals as GABA-ergic.
Small GABA-ergic nerve cells in the DN are the principal source of GABA-
ergic afferents in the contralateral inferior olivary nucleus. Glycinergic neurons
are recognizable by their reaction with an antibody to the glycine transporter 2.
Positive-contrast immunohistochemistry and double-label immunofluorescence
of paraffin-embedded archival specimens of FRDA show that grumose
degeneration represents proliferation of GABA-ergic terminals and retraction
from neuronal plasma membranes. The proposed mechanism is loss of GABA-
A receptors due to failure of the postsynaptic protein gephyrin. Gephyrin
positions GABA-A and glycine receptors to the plasma membrane and anchors
them to the cellular cytoskeleton. Some gephyrin-positive small neurons remain
even in advanced cases and display reaction product of GABA-A and glycine
receptors. Persistence of small GABA-ergic neurons in the DN explains the lack
of transsynaptic degeneration of the inferior olivary nuclei in FRDA.
(Supported by National Institutes of Health, R01NS069454; and Friedreich’s
Ataxia Research Alliance).
61
Neurpathologic Features of Spinocerebellar Ataxia 5 (Lincoln’s Ataxia.)
Margaret Flanagan1, Luis Gonzalez-Cuyar2, Jake Hemingway2, Zachary
Hoffer2, Thomas Montine2, Thomas Bird2, C. Keene2. 1University of
Washington Medical Center; 2University of Washington
Spinocerebellar Ataxia type 5 (SCA5) belongs to a heterogeneous group of
autosomal dominant, progressive neurodegenerative disorders characterized
by ataxia and cerebellar degeneration. SCA5 is caused by mutations in the
Beta-III Spectrin gene (SPTBN2) located in chromosome 11. SCA5
progresses slower then other Spinocerebellar Ataxias and does not shorten
lifespan. Herein we report an 87-year-old man with a clinical diagnosis of
Spinocerebellar Ataxia type 5 (SCA5) diagnosed at age 48 who exhibited
slowly progressive truncal and extremity ataxia (onset age 25), dysarthria,
dysphagia, and intention tremor. His family history was significant for his
father, five siblings, two children, and other relatives with similar ataxic
symptoms. Postmortem examination revealed that the left half of the brain,
brainstem and cerebellum weighed 580 grams with the left posterior fossa
contents contributing 50 grams. Grossly the cerebellum was small with
atrophy of the anterior vermis and the cerebellar peduncles. The inferior
olivary nuclei appeared grossly unremarkable. Histologically there was
diffuse loss of Purkinje cells with ‘‘empty baskets’’ in most areas of
cerebellar cortex, a thinning of the molecular layer and mild granule cell
loss. The inferior olivary nuclei were gliotic with mild-to-moderate neuronal
loss. The basal pontine nuclei, red nuclei, cranial motor nuclei, posterior
columns, Clarke’s columns and spinocerebellar tracts were unaffected. This
is the second reported case of post mortem examination of SCA5 and,
similar to the case reported by Clark and Ranum, our impression was that
the pathology was that of a simple cerebellar cortical degeneration,
principally targeted to Purkinje cells with other changes in granular neurons
and inferior olives likely the result of long-term loss of Purkinje cells.
62
Neuropathological Features of Early Onset Huntington’s Disease with
Marked Cerebellar Atrophy
Caitlin Latimer1, Patrick Cimino2, Zachary Hoffer1, Louis Gonzalez-
Cuyar1, Thomas Montine1, Thomas Bird1, C Keene1. 1University of
Washington; 2Washington University
Early onset Huntington’s disease (EOHD), as its adult counterpart, is an
autosomal dominant disorder with anticipation caused by trinucleotide
(CAG) repeat expansion in the IT15 (Huntingtin) gene located in the short
arm of chromosome four. It is defined as Huntington’s disease arising before
age 21 and accounts for 5-10% of the total Huntington’s disease (HD) cases.
Cases arising in patients younger than ten years of age have also been
reported, and account for approximately 1% of the total cases. Clinically
these patients differ from the adult patients in presenting with myoclonus,
seizures, Parkinsonism and cognitive decline. Imaging but not neuro-
pathological evaluations of EOHD cases with cerebellar atrophy are
reported in the literature. Herein we report a case of a six-year-old boy
with paternally inherited EOHD of 169 CAG trinucleotide repeats who
presented at approximately age four with speech difficulties and devel-
opmental delay who progressed to medically intractable generalized tonic-
clonic seizures. Gross neuropathological examination revealed mild frontal
cortical atrophy, as well as atrophy of the caudate and putamen consistent
with gross Vonsattel grade 3. There was cerebellar cortical atrophy mainly
involving the medial folia (vermis). Microscopically, sections of the
striatum showed gliotic gray matter nuclei with moderate neuron loss and
gliosis corresponding to histologic Vonsattel grade 3 HD. There was
substantial Purkinje cell loss and mild Bergmann gliosis. Huntingtin positive
intranuclear inclusions were present in the striatum and frontal cortex. A
review of the English literature shows that out of the reported cases of
EOHD only four have been histopathologically characterized, all without
cerebellar atrophy.
63
Neurodegeneration in Bipolar Disorders
Ayako Shioya1, Kunimasa Arima2, Yukio Kakuta3, Takefumi Yuzuriha4,
Akira Tamaoka5, Shigeo Murayama6, Yuko Saito7. 1Dept Neuropath,
National Center Hosp. Neurol and Psyc; 2Dept of Psych, National Center
J Neuropathol Exp Neurol � Volume 73, Number 6, June 2014 Abstracts
� 2014 American Association of Neuropathologists, Inc. 601
Copyright © 2014 by the American Association of Neuropathologists, Inc. Unauthorized reproduction of this article is prohibited.
Page 18
Hospital of Neurology and Ps; 3Department of Pathology, Yokohama Rosai
Hospital; 4Department of Psychiatry, Hizen Psychiatric Center; 5Dept of
Neurol, Graduate School of Comprehensive Human Scienc; 6Brain Bank for
Aging Research, Tokyo Metropolitan Institute of Geronto; 7National Center
Hospital of Neurology and Psychiatry
Introduction: Neurodegeneration in mood disorder receives considerable
attention. We examined patients with bipolar disorder (BPD), who died in
late adulthood, in order to check any modification in age- related
neurodegeneration as in chronic traumatic brain encephalopathy.
Materials and Methods: Eleven consecutive autopsy cases in our brain
banks, who received definite clinical diagnosis of BPD, were employed for
this study. Serial six- um- thick sections were obtained from archival
paraffin blocks of representative areas. The sections were stained with
H.E., K.B. and Gallyas- Braak silver method, as well as immunocyto-
chemically with anti- phosphorylated tau, amyloid beta and alpha-
synuclein andibodies. Age and gender- matched controls were selected
for each case. Clinical information was retrospectively collected from
medical charts.
Results: All cases were males and average age of death was 69 years of
age. Average clinical course was 27 years. Four cases presented with
cognitive impairment. Brain weight ranged from 1,116 to 1,325 g except
for a case with hypoxic encephalopathy after hanging of suicidal attempt.
Neuropathological diagnosis included dementia with grain (2), argyro-
philic grain disease (2), corticobasal degenerarion (CBD) (1), Lewy body
disease (LBD) (1), hypoxic encephalopathy (1), cerebral infarction (1) and
unremarkable (3). All cases contained AGs with Stage 0.5 to III. Three
cases died in the 50s and one fulfilled morphological criteria of dementia
with Lewy body, limbic form. The other two cases, including one with
suicidal attempt, showed AGs, abundant in the brain stem and amygdala.
Two cases died in 60s and one showed AG preferentially in brain stem and
amygdala and another in limbic predominance. The cases who died after
70s presented AG in limbic predominance like controls, except for one
case with CBD.
Discussion & Conclusion: Our study showed that tauopathy or alpha-
synucleionopathy is a pathological background of a certain group of BPD.
64
Brain Biopsy in Dementia or Neurologic Decline of Unknown Etiology
Shino Magaki1, William Yong1, Negar Khanlou1, Harry Vinters1. 1Section
of Neuropathology, UCLA Department of Pathology & Lab Medicine
Brain biopsies have an uncertain role in the diagnosis of patients with
dementia or neurologic decline of unknown etiology. They are often
performed as a last resort after an exhaustive panel of less invasive tests
and procedures have failed to lead to a definitive diagnosis. The objective
of this study was to evaluate the sensitivity of brain biopsies in this patient
group through the retrospective analysis of 53 brain biopsies performed
for neurologic disease of unknown etiology at a single tertiary care
institution between December 2001 and December 2011. Patients with
known nonlymphomatous neoplasms thought to be associated with the
neurologic symptoms or with immunodeficiency were excluded from the
study. The clinical presentation, imaging and laboratory tests were
compared between diagnostic groups to identify factors more likely to
yield a diagnosis. Sixty two percent of the biopsies were diagnostic (33 out
of 53), with the most common histologic diagnosis of primary central
nervous system lymphoma (PCNSL) in 14 of 53 patients (26% of total)
followed by infarct in four cases (7.5%). A few of the patients were found
to have rare unexpected diseases such as lymphomatosis cerebri, neuro-
sarcoidosis, and neuroaxonal leukodystrophy. Complications from biopsy
were uncommon and included infection with abscess formation at the
biopsy site and hemorrhage. These results suggest that brain biopsies may
be useful in difficult cases in which less invasive measures have been
unable to reach a diagnosis.
(This study was supported in part by P50 AG16570).
65
An Autopsy Case of Granulomatous Amoebic Meningoencephalomyelitis
Caused by Balamuthia Mandrillaris in Japan
Hajime Miyata1, Kenju Hara2, Ken Saitoh3, Masae Ryufuku1, Haruka
Ouchi2, Ken Shibano2, Kenji Yagita4, Hideaki Ishiguro2. 1Neuropathology,
Research Institute for Brain and Blood Vessels - Akita; 2Neurology, Akita
Red Cross Hospital; 3Pathology, Akita Red Cross Hospital; 4Parasitology,
National Institute of Infectious Diseases
CNS infections caused by pathogenic free-living amoebae have mortality
rate over 90%. These include primary amoebic meningoencephalitis caused
by Naegleria fowleri and granulomatous amoebic meningoencephalitis
caused by Balamuthia mandrillaris and Acanthamoeba species.
A 69-year-old Japanese man developed fever in mid-summer followed by
transient unconsciousness on the next day. He has the clinical histories of
membranous nephropathy since the age 35, hypertension and appendix cancer
treated with the right hemicolectomy at the age 67. The possibility of basilar
artery thromboembolism was considered based on the initial CT scan showing
a hypodense area in the right mesial posterior temporal lobe. However, he
gradually complained of headache and nausea. CSF examination and cytology
2 weeks after the onset revealed lymphoplasmacytosis, elevated protein
(9200mg/dl) and decreased glucose (12mg/dl) contents, with negative culture
for bacteria, negative PCR tests for Mycobacterium tuberculosis, and negative
cryptococcal antigen. The possibility of metastatic cancer with carcinomatous
meningitis was also considered based on the clinical course and laboratory
examinations as well as the repeated CT scan showing enlargement of the le-
sion with partial contrast enhancement and obstructive hydrocephalus. The pa-
tient died 50 days after the onset. The autopsy brain and spinal cord showed
multiple foci of fresh hemorrhagic and non-hemorrhagic softening, histologi-
cally consisting of extensive necrosis and granulomatous inflammatory changes
with perivascular amoeba trophozoites and cysts immunohistochemically
positive for Balamuthia mandrillaris. Trophozoites showed a single nucleus
with occasional multiple nucleoli, and transmission electron microscopy
demonstrated triple-walled cysts. No obvious foci of amoebic infection were
detected in the visceral organs.
Eight of 10 reported cases with amoebic encephalitis in Japan since 1976 are
caused by Balamuthia mandrillaris. Amoebic infection, particularly Bala-
muthia mandrillaris, should be included in the differential diagnosis of non-
purulent meningoencephalitis showing lymphoplasmacytosis, elevated protein
and decreased glucose contents in CSF, with a space-occupying CNS lesion on
CT and MRI.
66
A 29-year-old Pregnant Woman with Worsening Left Hemiparesis,
Encephalopathy, and Hemodynamic Instability: A Case of SSPE
Gerald Reis1, Jana Ritter2, William Bellini2, Andrew Bollen1. 1University of
California San Francisco; 2Centers for Disease Control and Prevention
A 29-year-old G3P2 woman was transferred to this hospital for progres-
sively worsening encephalopathy, left hemiparesis, and hemodynamic
instability. Her symptoms started approximately 6 weeks earlier when she
developed weakness and gait problems. Examination at that time found left
lower extremity rigidity, hyperreflexia, and a positive Babinski sign. MRI
imaging of the brain and spine was unremarkable. Two weeks later she
developed encephalopathy and worsening left-sided dysfunction involving
both upper and lower extremities. Initial work-up for infectious and
autoimmune causes at an outside hospital was negative, except that the
cerebrospinal fluid (CSF) analysis showed an elevated IgG concentration of
25 mg/dL with Q 2 oligoclonal bands. She had an uncomplicated
spontaneous delivery of a preterm healthy infant at 34 weeks and 2 days,
but her cognitive function deteriorated further and she became hemody-
namically unstable. A repeat brain MRI demonstrated generalized volume
loss and multifocal cortical and subcortical T2 hyperintense lesions with
evidence of corticospinal tract degeneration. The clinical differential diagnosis
included inflammatory, vascular, infectious, neoplastic, paraneoplastic, and
Abstracts J Neuropathol Exp Neurol � Volume 73, Number 6, June 2014
� 2014 American Association of Neuropathologists, Inc.602
Copyright © 2014 by the American Association of Neuropathologists, Inc. Unauthorized reproduction of this article is prohibited.
Page 19
metabolic etiologies. She underwent a brain biopsy and additional CSF studies
at our institution. The brain biopsy showed characteristic viral inclusions of the
type seen in subacute sclerosing panencephalitis (SSPE), and this was
confirmed by both immunohistochemical and electron microscopic evaluation.
DNA sequence analysis at the Center for Disease Control demonstrated a close
relationship to genotype D7. The patient received treatment with intrathecal
interferon alpha 2B without improvement and died 2 months later. This case
documents an approximately 6-month progression to death in a pregnant patient
with SSPE.
67
Balamuthia Amoebic Encephalitis, Diagnostic Challenges from Surgical
Pathology to Autopsy: A Case Report
Keng-Chih Su1, Harry Vinters1, Negar Khanlou1, William Yong1, Annie
Wu1, Wun-Ju Shieh2, Dianna Blau2, Atis Muehlenbachs2. 1Neuropathology
Department, David Geffen School of Medicine at UCLA; 2Centers for
Disease Control and Prevention (CDC), Atlanta, GA
Balamuthia mandrillaris (BM), with a case mortality rate of 998% nationally,
is a fatal clinicopathologic mimic of treatable granulomatous encephalitides.
We report a case of central nervous system (CNS) Balamuthia infection
presenting initially with seizures. The decedent was a 63-year-old man
California resident with an uncomplicated medical history and fully active
until presentation. Post-ictal MRI of the brain with contrast showed multiple
enhancing tumors involving predominantly the right cerebellar hemisphere, left
gyrus, right temporal lobe, and left frontoparietal lobes. Initial brain biopsy was
reported as extensively necrotic and therefore interpreted as non-diagnostic. A
second biopsy targeting cerebellar lesion showed a necrotizing lymphohistio-
cytic lesion and abundant amoeba. Careful family interview revealed a history
of several recent camping trips in central California including a visit to a bat
cave. Patient deteriorated rapidly and died within two months of initial
presentation. The autopsy showed multifocal hemorrhagic necrosis involving
cerebral lobes and cerebellum. Post-mortem CNS samples were submitted to
the CDC in Atlanta for further analysis. These were positive for Balamuthia
mandrillaris by Real-Time PCR. This case illustrates the importance of detailed
clinical history in identification of fatal causes of granulomatous encephalitis
from those that are amenable to treatment. It also draws attention to
identification of the amoeba by ‘‘standard morphology’’ since there are no
special stains available to highlight the parasite in the tissue samples. California
remains among areas endemic for the amoebic encephalitis. Surgical
pathologists are to be aware of the possibility of such rare cases.
68
Fatal Seronegative Rickettsia rickettsii Meningoencephalitis in an Infant
Hope Richard1, Christine Fuller1. 1Virginia Commonwealth University
Health System
Rocky Mountain spotted fever is a tick-transmitted infection caused by
Rickettsia rickettsii. Patients typically present with fever, headache, and
rash; left untreated, complications include systemic microinfarcts secondary
to microvasculitis, and (meningo)encephalitis. Rapid diagnosis and treat-
ment are crucial to prevent permanent neurologic sequelae or death. Herein
we present a 3 month old female infant who was up to date on her vaccina-
tions and healthy until 2 days prior to admission when her mother noticed a
fever for which she was treated with acetaminophen. The following day a
targetoid rash developed on her palms and soles of the feet which sub-
sequently spread to the chest, at which time she was admitted to the hospital and
treated with antibiotics (ceftriaxone) with resolution of the rash. The fever
remained but was managed with anti-pyretics, and blood cultures remained
negative. On hospital day 4 the patient was noted to be pancytopenic and
lumbar puncture showed elevated WBCs (12-18/mm3), lactate (6.5 mmol/L),
and protein (207 mg/dL). Serology studies for numerous infectious agents in-
cluding Rickettsia were negative. Antibiotics for viral and bacterial meningitis
were started (Ceftriaxone, Vancomycin, and Doxycycline) and the patient was
intubated. Her status continued to decline, and the family decided to withdraw
care. At autopsy, the cerebrum appeared pale and edematous. The leptome-
ninges were grossly normal without exudate. On coronal sections, edema was
noted but there were no discrete intraparenchymal lesions or hemorrhages.
Microscopic examination revealed plump reactive-appearing vascular endo-
thelium together with numerous microglial nodules present within the spinal
cord, brain stem, cerebrum and cerebellum. Foci of chronic inflammation were
noted throughout the meninges, and rare perivascular mononuclear aggregates
and microinfarcts were seen. Petechia were absent. Routine bacterial, viral, and
fungal stains were negative; however, immunohistochemical staining was
positive for Rickettsial species, and confirmatory PCR studies yielded
Rickettsia rickettsii as the etiologic agent.
69
Amebic Meningoencephalitis with Acanthamoeba spp
Stewart Neill1, Christina Appin1, Daniel Brat1, Jeannette Guarner1.1Department of Pathology and Laboratory Medicine, Emory University
Background: Intracranial amebic infections are rare events that are nearly
universally fatal. They are caused by several species of free-living amoeba, with
significant inter-species variation as to usual routes of infection, disease course,
and inflammatory response. We present a case of Acanthamoeba CNS infection.
Case History: A 73 year-old male who was 4 months status post renal
transplant for end-stage renal disease presented with fever, fatigue and gait
instability and soon developed progressive neurologic decline. Head CT dem-
onstrated a rim-enhancing hypodensity in the right frontal lobe. An infectious
disease workup, including lumbar puncture, was non-diagnostic. Brain MRI
revealed diffusion restriction and T2/FLAIR signal within the cortices and
brainstem along with leptomeningeal enhancement. Brain biopsy demonstrated
abundant necrosis, a mixed inflammatory infiltrate, and amoebic cysts and
trophozoites. The patient expired 2 days following biopsy, 12 days after
presentation. Review of cerebrospinal fluid (CSF) cytology revealed amoeba.
Autopsy Findings: A complete autopsy found no evidence of extracranial
amebiasis. The brain showed leptomeningeal opacification with underlying
parenchymal necrosis, particularly around the base of the brain and
brainstem. Microscopic examination revealed amoebic trophozoite and cyst
forms within the leptomeninges and extending perivascularly into the
parenchyma. A moderate mixed granulomatous and necrotizing inflamma-
tory infiltrate was present. Morphology and immunohistochemistry were
indicative of Acanthamoeba spp.
Discussion: Acanthamoeba species usually trigger a focal granulomatous
encephalitis secondary to hematogenous dissemination from an extracranial
source. While meningeal involvement may occur, Acanthamoeba organisms
tend to cluster around parenchymal vessels and rarely are found in CSF
samples. Death typically occurs within a few weeks to a month. By contrast,
Naegleria spp. infections usually seed the CSF, produce a primary meningitis,
and quickly precipitate death. Our case shows that a primary meningeal in-
fection with secondary spread to the cortex is part of the spectrum of disease
of Acanthamoeba infections.
70
Lack of Findings to Support a Role for HPV in a Cohort of Focal Cortical
Dysplasia, Type IIB
Declan McGuone1, Kevin Shapiro1, Kevin Staley1, Anat Stemmer-
Rachamimov1. 1Massachusetts General Hospital, Harvard University,
Boston MA; 2UCSF School of Medicine, CA
Introduction: Focal cortical dysplasia (FCD) is increasingly recognized
as an important cause of medically refractory epilepsy. Neuropathologic
examination of surgical specimens in these patients reveals a combination
of architectural and cytologic abnormalities. FCD type IIB (FCDIIB) is specifi-
cally defined by focal abnormal cortical architecture with dysmorphic neurons
and balloon cells. Recently, two groups have independently reported high
risk human papilloma virus (HPV) type 16 in balloon cells in a high propor-
tion of human FCDIIB specimens, implying a potential mechanistic relation-
ship between high risk HPV infection during development and focal cortical
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Page 20
malformations (1-2). We sought to analyze an independent surgical cohort for
the presence of HPV 16 DNA.
Methods: All Focal cortical dysplasia cases reported over a 19 year period
were retrieved from the pathology files of the Massachusetts General Hospital.
The cases were reviewed independently by two neuropathologists for
histological confirmation and PCR for high risk HPV was performed on all
cases meeting diagnostic criteria for FCDIIB. In situ hybridization for HPV
was performed on a subset of these cases. All patient data were de-identified.
Results: Six patients with medically refractory epilepsy and biopsy proven
FCDIIB (age range 4 -48 years) were identified. HPV PCR for high risk
HPV failed to identify HPV nucleic acids in any of these cases. In situ
hybridization studies performed on a subset of patients were also negative.
Conclusion: We have not been able to identify high risk HPV nucleic acids in
any cases reviewed. These data imply mechanisms other than HPV infection
are also likely to be important in the pathogenesis of a subset of FCDIIB cases.
References:
1: Chen J et al. Detection of human papillomavirus in human focal cortical
dysplasia type IIB. Ann Neurol. 2012;72(6):881-92.
2: Liu S etal. Viral Infection and Focal Cortical Dysplasia. Ltr to the Editor
Ann Neurol. 2013.
71
A Tissue Microarray Approach to the Immunohistochemical Charac-
terization of Pituitary Adenoma
William McDonald1, Nilanjana Banerji1, Joel Money3, Kelsey McDonald4.1Allina Health; 2John Nasseff Neuroscience Institute; 3Hospital Pathology Asso-
ciates; 4Inst for Med Informatics, Biometry and Epidemiology, Essen, Germany
Pituitary adenomas are common tumors of the pituitary gland, but
institutions vary greatly in diagnostic strategy and no optimal diagnostic
algorithm has been defined. Tissue microarrays (TMAs) are collections of
tissue samples placed in an orderly array for the production of histological
slides. While laborious to construct, they allow rapid, inexpensive
comparison of multiple tumors under the same histological conditions.
Our goal is to use a TMA containing pituitary macroadenomas to choose
from immunohistochemical (IHC) stains of Pit-1, SF-1, anterior pituitary
hormones, and alpha subunit of human chorionic gonadotropin to create a
more efficient, cost-effective diagnostic algorithm. Thirty-eight pituitary
macroadenomas and six control cases (representing various tumor types and
normal pituitary) were selected for inclusion in the TMA. Correlation and
cluster analyses were performed using the R statistical program, and show,
for example, significant positive correlation between Pit-1 and prolactin,
growth hormone, and TSH (Pearson’s r: 0.42-0.93) and significant negative
correlation with SF-1 (Pearson’s r: -0.69), as expected. This suggests
internal consistency and opportunities for a more efficient panel. A
diagnostic algorithm using stepwise IHC staining to diagnose pituitary
adenomas is discussed.
72
CD1a Immunohistochemistry in Pituitary Lesions
David Pisapia1, Ehud Lavi1. 1Weill Cornell Medical College
Within the differential diagnosis of patients presenting with sellar or
suprasellar lesions identified radiologically is Langerhans cell histiocytosis
(LCH). CD1a staining is often used in the clinical setting to confirm the
presence of an abnormal proliferation of Langerhans cells on histological
sections and often contributes to the diagnosis of LCH. Here, we report that
the MTB1 monoclonal antibody to CD1a reacts to adenohypophyseal
epithelial elements and, particularly in inflammatory lesions, that this may
introduce diagnostic uncertainty. We show that immunohistochemistry for
CD1a shows positivity in a variety of settings including normal pituitary
tissue resected at autopsy, surgically resected non-neoplastic pituitary tissue,
and pituitary tissue that is found embedded within the context of
inflammatory lesions and proliferative lesions other than LCH. Moreover,
CD1a staining was found to be negative in null-cell pituitary adenomas
suggesting cross-reactivity may be caused by the presence of hormonally
derived antigens within adenohypophyseal cells. We propose that in the
setting of pituitary lesions, a panel of stains should be used including CD1a,
Langerin, BRAF-V600E, and synaptophysin in conjunction with morpho-
logical analysis before a diagnosis of Langerhans histiocytosis is rendered,
and that CD1a positivity by itself should be interpreted with caution.
73
Pituitary Adenomas: VUV (Very Unusual Variants)
Bette Kleinschmidt-DeMasters1, T Cummings2, M Lopes3. 1University of
Colorado Anschutz Medical Campus; 2Duke University Medical Center;3University of Virginia Health System
Background: Pituitary adenomas constitute more than 85% of sellar region
masses, are usually easily diagnosed on routine hematoxylin and eosin, and
show a homogeneous cell population. Interruption of this otherwise
mundane appearance by excessive fibrosis, microcalcifications, amyloid
deposition, architectural sinusoidal pattern, nuclear enlargement/pleomor-
phism, or interspersed cells with ganglionic metaplasia are well-known
features of adenomas as well as many other endocrine tumors and do not
engender surprise or misdiagnosis on the part of the pathologist. However,
occasional pituitary adenomas show histological features that extend beyond
these known variants and these are minimally illustrated in the literature.
Design: Review of the files of three neuropathologists practicing at centers
with large numbers of sellar region masses to identify morphological
variants they have encountered.
Results: Five cases of adenomas were identified that met study criteria: 3
gonadotroph adenomas with (one each) osseous metaplasia, CAM5.2
immunohistochemistry (IHC)+ fibrous bodies, and abundant eosinophilic
intralysosomal proteinaceous deposits (confirmed by EM), one mixed
prolactinoma-growth hormone-alpha subunit-IHC+ adenoma with over-
whelming benign inflammatory infiltrates and lymphoid follicle formation,
and one densely-granulated GH adenoma with numerous interspersed small
nerve twigs (despite intraoperative correlation of no involvement of dura or
cavernous sinus). The gonadotroph adenoma further showed extensive
invasion on neuroimaging and loss of E-cadherin IHC.
Conclusion: Very unusual variants (VUVs) happen, even within otherwise
very histologically-mundane pituitary adenomas. These can give pause
during the routine examination of adenomas and thus are worth highlighting
for neuropathologists.
74
Stellate Amyloid Deposition in a Densely Granulated-Somatotroph
Type Pituitary Adenoma
Nitin Agarwal1, Priyanka Singh2, Jean Eloy1, James Liu1, Ada Baisre1.1Rutgers New Jersey Medical School; 2Wayne State University School of
Medicine
The authors describe a unique case of stellate amyloid deposition in a densely
granulated somatotroph type (growth-hormone producing) pituitary adenoma
and review the literature on amyloid deposition in endocrine-active pituitary
adenomas. A 54-year-old acromegalic man with hypertension and obstructive
sleep apnea presented with a pituitary macroadenoma. Endocrinologic work-up
revealed elevated serum growth hormone and insulin-like growth factor-1. The
patient underwent complete removal of the tumor via an endoscopic endo-
nasal transsphenoidal approach resulting in biochemical remission. Pathologic
examination revealed a growth hormone producing pituitary adenoma with
abundant stellate amyloid deposition. Amyloid deposition involving the pitu-
itary gland usually occurs as part of a systemic disorder, but it can occasio-
nally be seen within pituitary adenomas, either as nodular/spheroid or more
rarely as stellate deposits. The presence of amyloid has been described more
commonly in prolactinomas and somatotroph (growth hormone-producing)
adenomas. Growth-hormone producing pituitary adenomas are commonly
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Page 21
characterized by spheroid pattern of deposition; however, histological analysis
of the case presented here reveals a growth hormone producing adenoma with
abundant stellate amyloid deposits.
75
Sellar Atypical Teratoid Rhabdoid Tumor (AT/RT)YA Rare Tumor of
Middle Aged Women
Derick Aranda1, Mark Jentoft1, Joseph Parisi1. 1Mayo Clinic
Atypical Teratoid Rhabdoid Tumor (AT/RT) is a rare tumor that typically
occurs in the posterior fossa of young children, usually under 2 years of age.
There have been infrequent reports of CNS AT/RT outside the posterior
fossa and in adults; occurrence in the sella region is rare with 7 previously
reported cases, curiously all in woman. We describe 2 additional cases of
sellar AT/RT in 2 middle age (36 and 47-year-old) women that clinically
and radiologically mimicked pituitary adenoma. Histologically, the neo-
plasms demonstrated high cellularity and malignant features with foci of
hemorrhage and necrosis; identification of a subset of large pleomorphic
cells with abundant eosinophilic cytoplasm suggestive of rhabdoid cells
prompted consideration of AT/RT that was confirmed by immunoprofile and
loss of INI1 expression. Follow-up is available in only 4 of the 7 previously
reported cases, with death in 3 (3-30 months) and survival in 1 (6 months).
With this limited data, definite conclusions regarding prognosis are difficult.
Our cases both showed response to chemoradiation at 4 and 11 month
followup. Although rare, when confronted with a sellar lesion with unusual
histological features, the pathologist should consider the possibility of AT/
RT. The addition of these two cases to the already existing literature of
sellar AT/RT will aid in the understanding of this rare and unusual entity.
76
Salivary Gland Rests in Rathke Cleft Cysts. A Review of the Literature
Dibson Gondim1, Gregory Bosh1, Atul Agarwal1, Daniel Fulkerson1, Jose
Bonnin1. 1Indiana University School of Medicine
Salivary gland rests were found in approximately 3.4 per cent of pituitary
glands examined in a large autopsy series, and both benign and malignant
salivary-like tumors involving the sellar region have been reported. A 16-year-
old female developed visual loss in the left eye over a 3-day period. Her visual
acuity was 20/200 on the left eye and normal on the right. An MRI scan
revealed a 1.7x 1.5 x 1.3 cm bilobed peripherally enhancing cystic mass in the
sella turcica. The lesion extended to the suprasellar cistern and there was some
mass effect on the optic chiasm. A subsequent CT scan showed a large aerated
sphenoid sinus and bright punctate densities in the sellar region. In the
differential diagnosis, craniopharygioma and Rathke cleft cyst were considered.
Because of the rapid progression of her visual loss, a transsphenoidal resection
of the lesion was performed. The cyst contained a greenish mucinous fluid.
Histopathological examination revealed fragments of adenohypophysis and a
cyst lined by cuboidal, focally ciliated, epithelium. The cyst wall contained
multiple islands of serous acinar glands compatible with salivary gland rests.
Two years later she was found to have bilateral pheochromocytomas, which
were resected. An identical twin also had bilateral pheochromocytomas,
resected at 6 years of age and later was found to have an asymptomatic sellar
cyst. Although Rathke cleft cysts involving the sellar region are not uncom-
mon and despite the relatively frequent occurrence of salivary gland rests in
the pituitary gland, such rests are rarely observed in the cyst walls. Unlike
some cases of craniopharyngioma, Rathke cleft cysts have not been linked to
any genetic abnormalities and are not known to be part of one of the familial
tumor syndromes.
77
A Rare Craniopharyngioma Recurred 21 years Later in Lumbosacral
Dura, with Multiple Local and Cerebral Ectopic Recurrences
Osama Elkadi1, Jiang Qian2. 1Pathology and Lab Med, Albany Med Coll;2Pathology, Albany Med Ctr Hosp/APS
Craniopharyngioma is a histologically benign tumor in the suprasellar
region arising from the epithelial remnants of craniopharyngeal duct. It is
classified into adamantinomatous and papillary types. Recurrence is not
uncommon, and most occur in the original surgery site. Here we report a
rare craniopharyngioma case in a 28 years-old male with local ectopic and
distant/metastatic recurrences.
At age 4y, this patient presented with a suprasellar mass and underwent
subfrontal resection. The mass was diagnosed as adamantinomatous
cranipharyngioma (ACP). 3 years later suprasellar recurrence occurred,
treated with resection and radiation. At age 10y, the patient presented with a
right temporal lobe cystic mass, and at age 14y, a left frontal lobe mass, both
diagnosed as ACP. At age 25y, the patient complained of increasing lower back
pain, and MRI study revealed an intradural heterogeneously enhancing mass in
the thecal sac at the L5-S1 level. Resection specimen demonstrated classic
features of ACP: ribbons and nests of columnar and squamoid epithelial cells
with peripheral palisading, in a loose reticulate stroma, myxoid cysts, and wet
keratin composed of ‘‘ghost’’ cells and calcifications. 3 years after the last
surgery, he was tumor-free at the sellar region and recurrence sites, but
developed seizures, sleep disorders, and endocrinopathy.
Ectopic local recurrence of craniopharyngioma is uncommon, and distant/
metastatic spread is even rarer with very few cases reported. Most of these
recurrences are hypothesized to be due to seeding along the surgical pathway, or
along the cerebrospinal fluid to a distant location. Since such recurrences can
occur many years after the initial diagnosis, and no clinical or pathological
parameters can reliably predict their occurrence, long-term follow-up with
multidisciplinary approach is warranted. For many tumors, metastasis is a sign
of malignancy, but its biological significance in craniopharyngioma remains
to be elucidated and study of more such cases is needed.
78
Pineoblastomas in Adults: Outcomes in a Series of Twelve Patients
Melissa Gener1, Aaron Cohen-Gadol1, Jamie Van Gompel2, Jeremy
Cardinal1, Fredric Meyer2, Mohammad Ariai2, Mark Jentoft2, Jose Bonnin1.1Indiana University School of Medicine; 2Mayo Clinic
Pineoblastomas are uncommon primitive neurectodermal tumors and most
occur in children. They are exceedingly rare in adults. Few published case
reports or small series analyzed the various aspects of these tumors in adult
and pediatric patients. We report a series of 12 pineoblastomas in adults
from 2 institutions over a period of 24 years. The clinical, radiologic, and
pathologic features, and the clinical outcomes were studied and compared
with previously reported cases in children and adults. Our patients ranged
from 24-81 years of age and all but 1 presented with symptoms of
obstructive hydrocephalus. Records of the radiological findings were
available in all patients, but the actual neuroimaging studies were available
only in 3. Ten patients had pineal masses on initial imaging and 11 had
evidence of hydrocephalus. One patient had dissemination along the CSF
pathways on follow-up imaging. Three cases had gross total resection, while
subtotal resection was performed in 3, and diagnostic biopsies were obtained
in 6 cases. Pathologically, the tumors had the classical morphological and
immunohistochemical features of pineoblastomas. Postoperatively, ten
patients received radiotherapy and chemotherapy was also given to five of
them. When compared with previously reported cases, several differences
were noted in clinical outcomes. Of our 12 patients, only 5 died of disease
(average length of survival 118 months). Five patients are alive with no
evidence of disease (average length of follow up 92 months). One patient
died of unrelated causes and one was lost to follow up. The general
consensus is that patients with subtotal resections or diagnostic biopsies
have a much worse prognosis. Of our 9 patients with biopsy or subtotal
resection, 5 are alive, and 3 died of disease. Although our series is small, the
data suggests that pineoblastomas in adults have a less aggressive clinical
course than in the pediatric population.
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79
Lack of BRAF-V600E Mutation in Papillary Tumor of the Pineal Re-
gion (PTPR)
Patrick Cimino1, Joseph Corbo1, Arie Perry2, Sonika Dahiya1. 1Washington
University School of Medicine; 2University of California San Francisco
Background: Papillary Tumor of the Pineal Region (PTPR) is an extremely
rare central nervous system (CNS) tumor with a variably aggressive clinical
behavior, corresponding to WHO grade II-III. Very little is known about the
genetic mutations comprising PTPR. Recent studies have shown that other
papillary tumors harbor BRAF-V600E mutations, namely papillary thyroid
carcinoma and papillary craniopharyngioma, the latter of which is a midline
CNS papillary tumor like PTPR. For this study, we hypothesized that PTPR
may contain the BRAF-V600E mutation and that it may be found at high
frequencies like other midline papillary tumors.
Design: A search of our institutional files from 2004-2014 showed a total of
12 PTPR cases occurring in 10 patients. Chart review was performed to ob-
tain demographics and pertinent clinical information. Of these 10 patients, 7
had additional material to be used for immunohistochemistry (IHC). IHC was
performed using an anti-BRAF-V600E antibody (Spring Bioscience) utilizing
a Benchmark Ultra instrument (Ventana Medical Systems Inc.).
Results: All 7 patients presented with symptoms of obstructive hydrocephalus.
The patient age range was 1-60 years (average 29.9 years). There was a 3:4
male to female ratio. Initial magnetic resonance imaging characteristics tended
to include partially cystic masses with heterogeneous post-contrast enhance-
ment. The tumor size ranged from 1.1-4.4 cm (average 2.5 cm). IHC for BRAF-
V600E demonstrated negativity in all 7/7 (100%) of cases.
Conclusions: In our cohort, none of the 7 PTPR cases harbored the BRAF-
V600E mutation. This rate is unlike that of other midline papillary tumors,
and suggests that these tumors despite their papillary phenotype may have a
distinctive molecular background.
80
Bifocal Papillary Tumor of the Pineal Region (PTPR) with Unusual
Cytogenetic Features
Murat Gokden1, Bret Mobley2, Warren Sanger3, Hilary Nickols2. 1University
of Arkansas for Medical Sciences; 2Vanderbilt University School of
Medicine; 3University of Nebraska Medical Center
PTPR is an uncommon neoplasm codified in the 2007 World Health
Organization classification as grade II-III due to variable biologic behavior.
Cytogenetic and molecular diagnostic studies are rare, yielding no definitive
genetic signature. Here, we report a case of PTPR with a bifocal presentation
and unusual cytogenetic features.
A 25-year-old man presented with headache, disconjugate gaze and confusion.
A mass in the pineal region and a smaller mass in the suprasellar region, with
identical imaging characteristics, were identified. The former extended through
the aqueduct partially into the 4th ventricle, was subtotally resected due to
extensive adhesions to ependymal surfaces and showed typical PTPR histology.
Cytogenetics revealed losses of chromosomes 3, 7, 10 and 14, additional losses
of chromosomes Y and 18, and gains of chromosomes 3, 8 and 9. He is stable,
receiving radiation therapy 6 months post-surgery.
This case has 2 unusual features: 1. Two separate mass lesions at presentation,
2. Losses of chromosomes 3, 7, 10, 14, 18 and Y, and gains of chromosomes 3,
8 and 9. Although leptomeningeal and craniospinal spread have been rarely
reported, to our knowledge, only one previous report of synchronous pineal and
suprasellar region masses exists, showing subsequent leptomeningeal dissem-
ination. Our case also presented as bifocal lesions in these locations. It is yet to
be seen whether it represents early phase of dissemination. Losses of
chromosomes 10 and 22, and gains of chromosomes 4, 5, 8 and 11 have been
reported more commonly. Gains of chromosomes 8 and 9 with loss of 10 in our
case are compatible with prior reports, supporting a primary role of these
changes in tumor etiology. We also identified unique losses of chromosomes 3,
7, 14, 18 and Y, adding to the available data and underscoring the genetic
variability associated with the biology of these unusual neoplasms.
81
The Utility of OCT4, CD117, and PLAP in Diagnosing Germinoma with
Crush Artifact in the Central Nervous System
Zhe Piao1, Daniel Won2, Eric Stiner2, Todd Goldenberg2. 1Kaiser Permanente
at Fontana, CA; 2Department of Neurosurgery, Kaiser Permanente Medical
Center, Fontana
Background: Germinoma is the most common intracranial germ cell
neoplasm. It is extremely challenging to make a diagnosis, particularly in a
small specimen with severe crush artifact. The goal of this study was to
evaluate the diagnostic utility of OCT4, CD117, and PLAP for germinoma
with severe crush artifact.
Design: A total of 5 germinomas, 2 from the 3rd ventricle, 2 from
suprasellar region, and 1 from pineal region, were included in this study.
Immunostains of OCT4, CD117, and PLAP were performed on formalin-
fixed, paraffin-embedded tissue. The positivity of crushed tumor area was
compared with non-crushed tumor area in each slide.
Results: Four of 5 germinomas showed severe crush artifact. A few tumor
cells showed positivity for OCT4, CD117, and PLAP in the background of
severe crush artifact. The germinoma tumor cells without crush artifact
showed strong positivity for OCT4, CD117, and PLAP. This result indicates
that the positive cells in the crush artifact area are the germinoma tumor
cells. The results of tumor positivity are summarized in the table 1. Among
3 markers, OCT4 and PLAP were better than CD117 in terms of positivity.
Conclusion: By using a panel of immunostains for OCT4, CD117, and
PLAP, one can make a diagnosis of germinoma with severe crush artifact.
82
Aggressive Juvenile Xanthogranuloma of Posterior Cranial Fossa and
Temporal Bone: A Case Report
Nishant Tiwari1, Guy Marshall1, Frank Gannon1. 1Baylor College of
Medicine, Houston, TX
Background: Juvenile xanthogranuloma (JXG) is a histiocytic disease of the
non-Langerhans cell type. The intracranial JXGs have been known to present
without cutaneous or systemic lesions. We present a case of a young adult
(oldest reported) with an extra axial posterior fossa and temporal bone JXG.
Case Presentation: 20 year-old male presented to ENT service with a
6 month history of gradual onset of headache, vertigo and progressive hear-
ing loss with pulsatile tinnitus in his left ear. Multidirectional spontaneous
nystagmus was also noted. Pre-op MRI of the brain showed a large T2
isointense and T1 hyperintense mass in the posterior cranial fossa with direct
erosion of temporal bone and obliteration of the left transverse-sigmoid sinus
and jugular bulb.
Pathology: The lesion consisted mainly of benign histiocytes with minor
sub-population of lipidized forms; occasional multinucleated giant cells and
pleomorphic cells. Admixed with the histiocytes were abundant spindled
fibroblasts and think ropy collagen, Larger thick collagen strands give an
overall nodular appearance. Lesion also shows minor but significant areas
with hemorrhage and granulation tissue with patchy areas of dystrophic
calcification. The lesion also shows entrapment of degenerating bone,
skeletal muscle and adipose tissue suggesting the infiltrative growth of the
lesion. No cellular atypia or mitosis was present.
Abstracts J Neuropathol Exp Neurol � Volume 73, Number 6, June 2014
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Page 23
Follow up and progression: Surgical intervention was pursued and led to a
significant resolution of symptoms with small residual disease. Tumor has
since gradually grown over 10 month at all residual foci.
Conclusions: The intracranial JXGs in adults behave differently from the
pediatric counterparts which are known to involute with time. Surgical
resection without gross-total resection is likely to be inadequate. Cortico-
steroids, chemotherapy and radiation have been administered in such cases
to achieve resolution.
83
Non-Psammomatous Melanotic Schwannoma in Meckel’s Cave
Zachary Hoffer1, Gordana Juric-Sekhar1, Caitlin Latimer1, Jing Zhang1, Lia
Halasz1, Manuel Ferreira1, C. Dirk Keene1, Luis Gonzalez-Cuyar1.1University of Washington
Melanotic schwannomas are rare neuroectodermally-derived tumors that are
typically associated with spinal roots, generally at the cervical and thoracic
levels. However, rarely, melanocytic schwannomas present as skull base
masses, and less than a handful of cases have been reported in association
with the trigeminal nerve. Given the rare occurrence of trigeminal melanotic
schwannomas as well as the different biological behavior and treatment
modalities required, it is important for the neuropathologist to distinguish
between melanocytic schwannoma and malignant melanoma, which are
nearly identical based on histology and immunohistochemistry. Here, we
report the case of a 60-year-old man who presented with one year of right-
sided facial numbness and sharp shooting pain typical of trigeminal
neuralgia. Magnetic resonance imaging revealed a 2.5 cm heterogeneously
enhancing lesion in Meckel_s cave. The patient underwent surgical resectionand intraoperatively the mass was dark brown to black. Histopathologically,
the mass was a pigmented epithelioid neoplasm with low mitotic activity
that lacked psammoma bodies and adipocyte differentiation. Immunohis-
tochemically, it was positive for S100, Melan-A and HMB-45. In addition,
immunohistochemical staining for collagen type IV revealed a delicate
basement membrane surrounding numerous individual cells which favored a
diagnosis of melanotic schwannoma over malignant melanoma. The patient
underwent postoperative radiation therapy, and has been followed for two
years with surveillance imaging without evidence of recurrence. This case is
one of only a handful of cases of melanotic schwannoma involving the skull
base, and illustrates the diagnostic challenges faced when distinguishing it
from the more common malignant melanoma.
84
Salivary Duct Carcinoma Presenting as a CP Angle Mass
Stewart Neill1, Kelly Magliocca1, Patricia Hudgins2, Matthew
Schniederjan1. 1Department of Pathology and Laboratory Medicine, Emory
University; 2Department of Radiology, Emory University
Background: The cerebellopontine angle (CPA) is a unique location within
the CNS with a well-defined differential diagnosis for masses. Schwanno-
mas and meningiomas are most common, but other primary and metastatic
lesions have been reported, including some salivary gland neoplasms. We
present the case of a patient with a salivary duct carcinoma (SDC) presenting
as a CPA mass.
Case History: The patient was a 75-year-old male with progressive left
facial pain and weakness. MRI had shown a left enhancing CPA and internal
auditory canal mass that was interpreted as a schwannoma at an outside
facility. Radiation therapy was pursued, but the tumor progressed and the
patient presented to our hospital for biopsy and tumor debulking. Review of
previous MRI studies revealed an ipsilateral parotidectomy defect with no
mass in the parotid bed. CT scans of the chest, abdomen, and pelvis did not
show a likely primary mass.
Pathologic Findings: Microscopic examination revealed an epithelioid neo-
plasm organized in variably sized nests with focal comedo-type necrosis,
reminiscent of breast carcinoma. Neoplastic cells showed granular eosinophilic
cytoplasm and atypical nuclei with prominent nucleoli. Immunohistochemistry
revealed the tumor to be positive for CK7, CK5, androgen receptor, and Her2,
and focally positive for GCDFP. The tumor was negative for CK20, TTF-1,
napsin, PSA, prostein, p40, CDX-2, villin, synaptophysin, and chromogranin. A
FISH assay for Her2/neu amplification was negative.
Discussion: SDC is an aggressive salivary gland neoplasm most often found
in the parotid gland of older men. Whereas other salivary gland neoplasms
have been reported as metastatic or possible primary tumors at the CPA,
SDC has not been reported per our literature review. The pathologic findings
in this case indicate SDC, and the radiologic findings are suggestive of prior
parotidectomy. This entity may be added among the extended differential
diagnosis of lesions found at the CPA.
85
Radiation-Induced Atypical Meningiomas Exhibit Higher Recurrence
Rates Than Sporadic Meningiomas of the Same Grade
Sarah Martin1, Eyas Hattab1. 1Department of Pathology, Indiana University
School of Medicine
It is widely known that radiation-induced meningiomas overall tend to
behave more aggressively, are more likely to recur, and have higher
histologic grades than sporadic ones. However, studies comparing radiation-
induced and sporadic meningiomas, grade for grade, are lacking. The aim of
our study was to compare the clinical behavior of radiation-induced atypical
meningiomas to that of sporadic atypical meningiomas and answer the
question of whether the ‘‘history of prior irradiation’’ has any added value.
Our institution_s archives were searched from 1986 to 2008 for meningi-
omas that qualified as atypical/grade II by the 2007 WHO grading criteria.
One hundred twenty-five such patients were identified. The clinical medical
records for these patients were reviewed. Eight (6%) patients were found to
have had prior cranial radiation within the field of meningioma for various
other CNS malignancies, including astrocytoma, germinoma and medullo-
blastoma. The median latency time from radiation to development of
meningioma was 23 years, ranging between 14 and 25 years. Recurrence
data for all 125 patients was obtained. Seven of the eight (87.5%) patients with
radiation-induced meningiomas had tumor recurrence, while only 29.1% of
non-radiation-induced meningiomas recurred. Pearson chi-square analysis
demonstrated a statistically significant difference between the two groups
(p=.001). Three of the patients with radiation-induced meningiomas had more
than one recurrence. Our results demonstrate striking differences in clinical
behavior within a cohort of grade II meningiomas. The presence of prior
radiation puts the patient at higher risk for recurrence compared with other
patients with meningiomas of the same grade. Such information is helpful in the
risk stratification of such a heterogeneous group of tumors. Finally, while
histologic criteria have long been the primary means of predicting tumor
behavior, perhaps clinical criteria such as the presence of prior irradiation
should also be taken into consideration in the grading of these tumors.
86
WHO Grade I Meningiomas with Atypical Features: Correlation of
Histopathology with Clinical Outcome
Declan McGuone1, Ariel Marciscano2, Andrzej Niemierko1, William Curry1,
Fred Barker II1, Robert Martuza1, Kevin Oh1, Jay Loeffler1, Helen Shih1,
Anat Stemmer-Rachamimov1. 1Massachusetts General Hospital, Harvard
University, Boston MA; 2The Johns Hopkins Hospital, Baltimore, MD
Introduction: WHO grade I meningiomas with G2 atypical features, not
fulfilling 2007 WHO criteria for grade II meningioma, may behave more
aggressively than WHO grade I meningiomas without atypical features. We
evaluated prognostic significance of atypical features in WHO grade I
meningiomas.
Methods: All cases of WHO grade I meningioma with G2 atypical features
(increased cellularity, sheeting, high N/C ratio, necrosis, prominent nucleoli)
were reviewed and compared to cases without atypical features. Clinical
data were reviewed. Cox regression and Kaplan-Meier (K-M) survival
analysis was performed.
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Results: 148 cases were retrieved (n =77 with G2 atypical features, n=71
with no atypical features). Median patient follow up was 37.5 months. 30
patients had progression/recurrence (P/R) after initial treatment and 22 of
30 (73%) of these had atypical features. The 1-year and 5-year P/R rates were
9.6% vs 1.4% and 30.8% vs 13.8 % for tumors with and without atypical
features. Foci of necrosis (hazard ratio [HR], 10.5; 95% CI, 2.9 to 37.8),
prominent nucleoli (HR, 6.3; 95% CI, 1.8 to 21.7) and sheeting (HR, 3.8; 95%
CI, 1.2 to 11.6) were associated with increased risk of P/R. The median MIB-1
index was higher (pG0.001) in cases with atypical features (4.2%) versus those
without (1.9%). The % of patients with MIB-1 proliferative rates 9 3% at
diagnosis was 65% for patients with atypical features and 17% for thosewithout
(pG0.001). Patients without grade I Simpson resection had an increased P/R risk
(pG0.001) compared to those with grade I resection.
Conclusion: WHO Grade I meningiomas with atypical features have an
increased risk of P/R compared to WHO grade I meningiomas without atypical
features. Most cases correlate with a 93% MIB1 proliferation index. These
findings support documenting atypical features in WHO grade I meningiomas
as these patients may benefit from additional surgery and radiation.
87
Rhabdoid-Like Meningioma: A Case Report
Caterina Giannini1, Jonathan Fratkin2, Josephine Wyatt-Ashmead2, Patrice
Abell Aleff3. 1Mayo Clinic College of Medicine; 2University of Mississippi
Medical Center, Jackson, MS; 3Mayo Clinic
Rhabdoid meningiomas (RM) are highly aggressive tumors, classified as
WHO grade III. They are composed of loosely cohesive cells with abundant
eosinophilic cytoplasm, eccentric nuclei, and hyaline paranuclear inclusions.
By electron microscopy (EM), these consist of intermediate filament whorls
often entrapping lysosomes and other organelles. Cytoplasmic inclusions
frequently stain with vimentin and, at times, with cytokeratin or GFAP. In
absence of EM, RM is frequently an H&E diagnosis. Rhabdoid cytology
may be focal, present at first diagnosis or at recurrence, and often becomes
increasingly prominent with subsequent resections suggesting that rhabdoid
differentiation represents a morphologic marker of malignant transforma-
tion. Clinically aggressive RM typically demonstrates independent histo-
logical features of anaplasia. The behavior of RM with only focal rhabdoid
features and/or without other malignant features remains indeterminate. A 57-
year-old man presented with a generalized tonic-clonic seizure. MRI
demonstrated a right temporoparietal well-circumscribed homogeneously
enhancing mass 2.7�2.7�2.8 cm, associated with a peripherally enhancing
cyst 1.8�1.7�1.2 cm and marked surrounding vasogenic edema. The tumor on
H&E showed patternless growth and presence of cytoplasmic eosinophilic
inclusions consistent with rhabdoid differentiation. Mitotic activity was low,
and the tumor did not show macronucleoli, necrosis, or small cell trans-
formation. There was no evidence of parenchymal brain invasion. To our
surprise, under EM, the cytoplasmic inclusions did not correspond to the whorls
of intermediate filaments typical of RM but rather to complex cytoplasmic
invaginations with scattered intercellular junctions. Our findings prompt
caution in making a diagnosis of RM (WHO grade III) simply based on optic
microscopy appearance in absence of EM confirmation of rhabdoid differ-
entiation in a tumor which does not show features of anaplasia. Additional cases
are under study to evaluate the frequency of these findings since, if not an
isolated phenomenon, this observation could highly impact diagnosis,
classification, and grading of RM at large.
88
Leptomeningeal Melanomatosis With Signet-Ring Cell Features
Mimicking Leptomeningeal Carcinomatosis: A Postmortem
Examination
Sarah Martin1, Andrew Fabiano2, Robert Fenstermaker2, Richard Cheney1,
Jingxin Qiu1. 1Roswell Park Cancer Institute Department of Pathology;2Roswell Park Cancer Institute Department of Neurosurgery
We present the case of a 63-year-old man clinically diagnosed with
leptomeningeal carcinomatosis, who upon postmortem examination was
found instead to have leptomeningeal melanomatosis with signet-ring cell
features. This patient presented with no known history of cancer and six
months history of anorexia, weight loss and fatigue, followed by two weeks
of confusion and difficulty with speaking and ambulating. Brain MRI
showed multiple variably sized contrast-enhancing lesions and diffuse
abnormal leptomeningeal contrast enhancement. Full body CT imaging
revealed no detectable lesions elsewhere in the body. Antemortem CSF
cytology was diagnosed as metastatic adenocarcinoma on multiple occa-
sions based upon the signet ring cell morphology. Immunohistochemical
studies were not performed. The patient expired despite treatment with
Temodar, whole brain radiation, and intrathecal methotrexate. Postmortem
examination of the brain revealed no gross abnormality. Microscopic
examination showed a subdural collection of discohesive tumor cells with
marked nuclear pleomorphism, hyperchromasia, and frequent signet-ring or
rhabdoid morphology, as well as a striking, diffuse infiltration of tumor cells
in the leptomeninges. Intraparenchymal deposits were also seen in many
areas. General autopsy also identified tumor metastases in the larynx and
testes. Tumor cells were immunoreactive for melanoma markers (S100,
Melan-A, Tyrosinase and HMB-45) and negative for cytokeratins and
mucin. A diagnosis of leptomeningeal melanomatosis with signet-ring cell
features was rendered. The patient had no known history of melanoma and
no primary lesion was discovered at autopsy. While most patients with
metastatic melanoma do have a known history, in a small percentage no
primary site is identified. We discuss possible etiologies for this phenom-
enon and emphasize the potential pitfall of signet-ring melanoma clinically
and cytologically mimicking adenocarcinoma. Melanoma with signet-ring
cell features should be included in the differential diagnosis for cases of
undiagnosed suspected adenocarcinoma.
89
Primary Malignant Melanoma of the Leptomeninges with GNA11
(Q209L) Mutation: Case Report and Literature Review
Michael Lynch1, G. Timothy Reiter1, Joseph Drabick1, Charles Specht1.1Penn State - Hershey Medical Center
We report the case of a 64-year-old female without significant past medical
history who presented with abdominal pain, weight loss, new onset back and
bilateral leg pain, and trouble walking. Magnetic resonance imaging (MRI)
revealed a well-defined, 1.6 cm enhancing intradural extramedullary mass at
T11. Numerous smaller enhancing leptomeningeal nodules surrounded the
brain, cervical spinal cord, and cauda equina. Surgery was recommended for
the lesion at T11 to decompress the spinal cord and obtain a tissue
diagnosis. Intraoperative findings included widespread deposition of
melanin within the exposed arachnoid membrane and tumor. Histologically,
the resected tumor is malignant melanoma. Immunohistochemically, the
tumor is positive for Melan-A (Mart-1), HMB-45, and microphthalmia
transcription factor (MITF). Next generation sequencing of this tumor
shows a GNA11 (Q209L) mutation. Dermatologic, gynecologic, and
ophthalmologic evaluation revealed no primary tumor outside the central
nervous system (CNS). Activating mutations in the Gq alpha subunit of
GNAQ or GNA11 can lead to constitutively activated mitogen-activated
protein kinase (MAPK) and protein kinase C (PKC) pathways; this may
occur without BRAF or RAS mutations. Previous studies have shown that
mutations in either GNAQ or GNA11 are often found in uveal melanoma.
Primary CNS melanomas are rare, but the few reported analyses have
demonstrated frequent mutations in GNAQ or GNA11. These mutations are
not common in cutaneous melanoma. Understanding this molecular distinction
is important for proper diagnosis and has potential future therapeutic
implications. As an example, recent studies have shown that PKC inhibitors
in combination with MEK inhibition lead to sustained MAPK pathway
inhibition and tumor shrinkage in vivo. Evaluation for GNAQ and GNA11
mutation status can thus provide biological information that is of significant
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� 2014 American Association of Neuropathologists, Inc.608
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Page 25
utility for treatment planning when malignant melanoma is encountered in the
meninges. We aim to highlight the molecular profile and histologic differential
of these tumors.
90
Analysis of Select Angiogenic Markers in Melanoma Brain Metastases
Dimitri Trembath1, Stergios Moschos2, Anna Snavely3, Evan Bradler4,
Nana Nikolaishvilli-Feinberg3, Bentley Midkiff 4, Jonette Werley5, Michal
Krauze6, Ronald Hamilton5. 1Department of Pathology and Lab Medicine,
UNC-Chapel Hill; 2Department of Medicine, UNC-Chapel Hill; 3Lineberger
Comprehensive Cancer Center, UNC-Chapel Hill, NC; 4The University of
North Carolina School of Medicine, Chapel Hill, NC; 5Department of
Pathology, UPMC, Pittsburgh, PA; 6Department of Medicine, UPMC,
Pittsburgh, PA
Background: We have previously demonstrated that the presence of intra-
tumoral hemorrhage and lack of immune infiltrates in craniotomy specimens
of melanoma brain metastases (MBM) are associated with shorter overall
survival (OS), defined as time from craniotomy to death. We hypothesize
that immune checkpoint protein(s), angiogenic proteins, cytokines, hypoxia,
and the density of mature vs. immature blood vessels (MBV, IBV) are
important prognostic factors.
Methods: Craniotomy resections of melanoma brain metastases were reviewed
for the presence/absence of tumor, normal brain, immune infiltrate, and gliosis.
These specimens were then stained for angiogenic/hypoxic factors (bFGF,
VEGF, HIF1>), blood vessel density (CD31), PD-L1, and for immature
(CD31+SMA-) or mature blood vessels (CD31+SMA+). Each marker was
analyzed in the different compartments described above using an Aperio
imaging system and Definiens Tissue Studio.
Results: An average of 44 cases was analyzed for each of the 7 stains.
Treating each variable as continuous using Cox proportional hazards, none
were associated with OS. When survival information was used to define the
optimal cut-point for each variable between cases with long versus short OS,
high tumor expression of PD-L1 and bFGF, and low tumor expression of HIF1>
were associated with worse OS (unadjusted p G 0.05; hazard ratios 1.92, 2.2,
and 2.1 respectively). PD-L1 showed significantly higher expression in tumor
compared to normal brain and there was a significant inverse association
between PD-L1 expression in tumor and immune infiltrate.
Conclusions: Our results suggest that neither blood vessel density nor
maturity within MBM is a significant prognostic factor. Tumor response to
hypoxia by up-regulation of HIF1> may paradoxically be a favorable
prognostic factor. More importantly, high expression of PD-L1 in MBM is
an adverse prognostic factor, and may be related to the tumor_s immuno-
suppressive effects in the brain microenvironment, raising the possibility of a
new therapeutic target.
91
Epithelioid Schwannoma of a Spinal Nerve Root
Rachael Vaubel1, Howard Chang2, Karen Fritchie1, Mark Jentoft1. 1Mayo
Clinic, Rochester, MN; 2Sparrow Health System, Lansing, MI
Even though the diagnosis of schwannoma is usually straightforward in
lesions with classic features, tumors with predominantly epithelioid
morphology or marked myxoid change may present a diagnostic challenge.
We present a case of a slow-growing, dumbbell-shaped mass present within
a thoracic neural foramen. Histologic examination revealed a proliferation
of epithelioid cells in an abundant myxoid background raising the possibility
of chordoma or chondrosarcoma. However, immunohistochemical studies
showed the tumor cells to exhibit strong and diffuse reactivity for S100 and
collagen IV while cytokeratin and brachyury were negative. This immuno-
phenotype, in conjunction with ultrastructural studies showing long-spaced
collagen and enveloping cytoplasmic processes, confirmed its schwann cell
origin. The diagnosis of malignant peripheral nerve sheath tumor was
considered but the lack of mitoses, necrosis and low Ki-67 labeling index
supported the diagnosis of epithelioid schwannoma. This case illustrates the
need for awareness of the epithelioid variant of schwannoma at this location
to avoid misclassification as a malignant mesenchymal neoplasm.
92
Intracranial Angiolipoma in a 23 year Old Male with Sturge-Weber
Syndrome
Christopher Jones1, Aaron Wagner1, Gary Pearl1. 1Orlando Health
Angiolipomas of the central nervous system (CNS) are rare neoplasms.
There are approximately 100 reported cases in the medical literature. They
most commonly occur in the extradural space of the thoracic spine. Less
commonly, they may arise in the cavernous sinus and the orbit. Rarely (È10
cases) they have been reported in the parasellar space.
The intracranial manifestations of Sturge-Weber Syndrome are typically
characterized by diffuse leptomeningeal vascular malformations, historically
but incorrectly termed angiomata. They can be identified by contrast
enhanced magnetic resonance imaging (MRI) as a diffuse leptomeningeal
enhancement, most commonly of the superior convexities, that may fill the
sulci and cause atrophy of the underlying parenchyma. Large intracranial
neoplasms are not associated with the syndrome. To our knowledge, the
development of an intracranial angiolipoma in a patient with Sturge-Weber
Syndrome has not previously been reported.
We present a case of a large 11 cm angiolipoma in a 23 year old male with
Sturge-Weber syndrome. The mass is seen on MRI as a solid and bilobed
enhancing mass with a suprasellar epicenter. The tumor fills the bilateral
anterior temporal extra-axial space connecting in the midline across the
perimesencephalic cistern and prepontine cistern. The tumor fills the
perimesencephalic cistern and completely encases the Circle of Willis,
optic chiasm and pituitary gland, compressing the brainstem.
Stereotactic core needle biopsy was performed which revealed mature fat
and blood vessels. Immunohistochemistry confirmed the presence of CD31-
positive vasculature and S100-positive adipocytes. The tissue did not
demonstrate staining with anti-HMB45, mitigating against angiomyolipoma.
93
Intracranial Osteosarcoma Arising in Fibrous Dysplasia
Christine James1, Darnell Josiah1, Patrick Bacaj1, Charles Rosen1,
Kymberly Gyure1. 1West Virginia University
Fibrous dysplasia is a generally benign fibro-osseous proliferation occurring
in bone. The skull and facial bones are commonly affected, particularly in
the polyostotic form of fibrous dysplasia. Malignant transformation is
extremely rare (G1% of cases) and is often associated with prior radiation
therapy. We report an unusual case of spontaneous osteosarcoma arising in a
patient with a prior history of pathologically confirmed fibrous dysplasia. A
42-year-old man presented to the emergency department with a five-day
history of progressive vision loss in his left eye. He had a history of multiple
previous surgeries for craniofacial fibrous dysplasia. Imaging studies
revealed extensive involvement of the craniofacial bones with fibrous
dysplasia, initially thought to be unchanged when compared to his prior
imaging studies. He subsequently underwent a left frontotemporal craniot-
omy, posterior orbitotomy, and clinoidectomy to decompress the optic
nerve. A soft tissue mass was discovered growing medial to the optic nerve
and involving the medial orbit. The mass was debulked, and sections
revealed a high-grade sarcoma with focal osteoid formation. Although rare,
malignant transformation should be considered in the differential diagnosis
of patients with a history of fibrous dysplasia, particularly in those with
rapid progression of their symptoms.
94
Epstein-Barr Virus-Positive Primary CNS Lymphomas Associated with
Intracranial Mass Lesions in Immunocompetent patients
Yasuo Sugita1, Koichi Ohshima1, Jun Masuoka2, Yoshizo Kimura3, Koichi
Higaki3, Susumu Nakashima4. 1Department of Pathology, Kurume University
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� 2014 American Association of Neuropathologists, Inc. 609
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Page 26
School of Medicine; 2Department of Neurosurgery, Saga University Faculty
of Medicine; 3Department of Pathology, St Mary_s Hospital; 4Department of
Neurosurgery, St. Mary_s Hospital
The Epstein-Barr virus (EBV) has been implicated in the pathogenesis of
some primary CNS lymphmas (PCNSLs) in immunocompetent patients. To
investigate the role of EBV in pathogenesis for PCNSLs associated with
intracranial mass lesions, the present study assessed three unusual cases.
Case 1 was a 66-year-old man with a history of gait disturbance.
Neuroimagings (NIs) revealed a solid and a cystic lesion in the posterior
fossa. Histologically, the solid tumor showed a proliferation of pleomorphic
immunoblastic-like cells. The cystic tumor showed keratinous debris, which
was consistent with an epidermoid cyst (EC). Case 2 was a 57-year-old woman
with gait and hearing disturbances. NIs revealed a cystic mass in the
cerebellopontine angle. Histologically, the tumor showed keratinous debris,
which was consistent with an EC. In addition, atypical lymphocytes scattered
adjacent an EC without forming a mass. Case 3 was a 77-year-old man with a
history of head injury. NIs revealed a right frontal-temporal subdural lesion.
Histological examinations showed atypical lymphocytes conglomerated in the
thick outer membrane of the organized chronic subdural hematoma (CSH).
Immunohistochemically, atypical lymphocytes of all these cases were positive
for CD20, and negative for CD3. On in situ hybridization, atypical lymphocytes
in all cases showed positive signals for EBV-encoded small RNAs. Based on
these findings, the proliferations of atypical lymphocytes in all cases were
diagnosed as EBV-positive PCNSLs. It is well known that ECs and CSHs cause
severe inflammatory reactions in the surrounding tissues. Therefore, these
results indicated that long-standing chronic inflammation caused by intracranial
masses and EBV infections have contributed to the pathogenesis of PCNSLs. In
addition, Cases 2 and 3 may be an earlier-stage of lymphoma when compared
with Case 1. This underscores the need for careful attention to the potential
presence of atypical lymphocytes during the pathologist_s review of the
intracranial mass lesions.
95
An Unusual Case of an EBV-positive CNS Lymphoma in
an Immunocompetent Adult
Brian Bockelman1, Cristina Vincentelli1, Vathany Sriganeshan1, Amilcar
Castellano-Sanchez2. 1A.M. Rywlin M.D. Department of Pathology Mount
Sinai Medical Center; 2Herbert Wertheim College of Medicine Florida
International University
CNS diffuse large B-cell lymphomas comprise approximately 2-3 percent of
all brain tumors and less than 1 percent of all non-Hodgkin lymphomas.
These rare neoplasms are usually not associated with Epstein-Barr virus in
immunocompetent patients. We present a case of a 59 year old woman with
a two week history of progressive left upper and lower extremity weakness
while vacationing with her husband in the United States. An MRI revealed
scattered ring-enhancing lesions in the right inferior frontal gyrus, right
thalamus and lentiform nucleus extending through the corona radiata to the
centrum semiovale, and left hypothalamus. There was effacement of the
right lateral ventricle, third ventricle and ambient cistern with a 5 mm
leftward midline shift. Additionally observed was extensive vasogenic
edema around the lesions. The patient was taken to surgery and a biopsy
was performed. Microscopic examination revealed brain tissue with reactive
gliosis and areas with a dense angiocentric infiltrate with associated
necrosis. The infiltrate was composed of a pleomorphic population of cells
including small lymphocytes, histiocytes, medium to larger atypical cells
with irregular nuclear contours, as well as scattered large cells with
vesicular nuclei. The large atypical cells were positive for CD45, CD20
(weak), CD79a, PAX5, MUM1, and CD30. Additionally, EBER in situ
hybridization was positive. The diagnosis of EBV-positive CNS diffuse
large B-cell lymphoma was made. The fact that the patient is not
immunocompromised along with histological findings of relatively scattered
neoplastic cells in an abundant background of T lymphocytes and focal
angioinvasion, which are not the characteristic features of this entity, made
this a challenging case. The clinical presentation, imaging, and microscopic
findings along with the differential diagnosis are discussed.
96
Lymphomas in Intraoperative Consultations (IOC) in Neuropathology
Murat Gokden1, Melody Harrison1. 1University of Arkansas for Medical
Sciences
Many times, IOC results in a change in surgical procedure and/or handling
of the tissue. We have encountered several such instances over the years,
especially with the IOC diagnosis of unsuspected lymphoma. Based on this
observation, we reviewed our lymphoma diagnoses in IOC.
Neuropathology files were searched for cases with a final diagnosis of
lymphoma in 2000-2014. Clinical findings, history, radiology reports and
operative reports of these cases were reviewed. Cases with no mention of
lymphoma as a possibility until neuropathology was involved were identified.
A total of 71 cases with a final diagnosis of lymphoma were identified.
Nineteen of these had no mention of lymphoma in their diagnostic work-up
before neuropathology was involved. IOC was performed in 15, with a
diagnosis such as ‘‘atypical lymphoid infiltrate’’ or ‘‘favor lymphoma’’ that
initiated additional work-up. In these 19 patients (age range: 22-78 years;
mean age: 61 years; male:female=1:4), most common radiologic diagnoses
were metastatic carcinoma, glioma, meningioma, or a combination of these.
Most common location was cerebral hemispheres. Unusual locations were
trigeminal nerve, cerebello-pontine angle, dura-based with infiltration into bone
mimicking meningioma, and diffuse meningeal, mimicking meningioma en
plaque. The final diagnosis in 17 cases was diffuse large B-cell lymphoma. One
marginal zone lymphoma presented mimicking meningioma en plaque and one
follicular lymphoma presented mimicking a meningioma.
These results emphasize the frequency of unexpected presentations in IOC
and the importance of approaching cases with an open mind. The absence of a
consistent presentation pattern may add to the potential problem. Even though
other unexpected diagnoses are made in IOC, lymphomas can be particularly
surprising to pathologists, radiologists and clinicians alike, emphasizing the
direct immediate impact and the need for consistet use of IOC.
97
Divergent Glioneuronal Differentiation in Metastatic Intracranial
Neuroendocrine Carcinomas
Boleslaw Lach1, Suhita Joshi2, Naresh Murty3, Nasim Huq4. 1McMaster
University, Hamilton Health Sciences; 2Greater Niagara General Hospital,
Niagara Health System; 3Department of Neurosurgery, McMaster
University; 4Clinical Surgery, McMaster University
Metastatic intracranial neuroendocrine carcinomas usually display a
phenotype of primary tumours. We present three cases of metastatic
carcinomas with different patterns as well as variable degree of divergent
glioneuronal differentiation in intracranial lesions.
Patient #1: 77 yo. male with a history of multiple resections of squamous
cell carcinomas and a Merkle cell carcinoma(MCC) of the head, was
admitted for removal of a large WmeningiomaW. The tumour displayed
remarkable degree of pleomorphism, reminiscent of GBM, and immunoreac-
tivity for synaptophysin(SYN),CD56,tubulin(TBL)and Tau. It was negative for
GFAP, neurofilaments (NF),keratins(CK) and chromogranin (CHG). Review of
the skinMCC revealed scattered NF+ ganglionic cells and immunoreactivity of
small cells for many CK and neuronal markers (SYN,CHG,NF,CD56,Tau) as
well as a small area of GFAP+ cells. Lymph node metastasis was SYN+,CK+
and CHG+, with no ganglionic or glial cells.
Patient #2: 71 yo. female with intracerebral occipital tumour. The resection
specimen was a highly pleomorphic tumour displaying wide-spread
reactivity for CK (AE1/3), SYN, NF, CHRG, GFAP, Tau, p53,and TTF-1.
The tumour was negative for EMA and subgroup of CK(7,19,20).
Carcinoma of lung was discovered post-operatively.
Abstracts J Neuropathol Exp Neurol � Volume 73, Number 6, June 2014
� 2014 American Association of Neuropathologists, Inc.610
Copyright © 2014 by the American Association of Neuropathologists, Inc. Unauthorized reproduction of this article is prohibited.
Page 27
Patient #3: 77 yo. male with known small cell carcinoma(SCC) of lung.
Resection specimen showed scattered neoplastic cells positive for GFAP.
Otherwise immunohistochemistry revealed rectivity for SYN, CHG, Tau
and CD56 as expected from SCC of lung.
These cases demonstrate the ability of poorly differentiated extracranial
neuroendocrine tumours to differentiate to glial and ganglionic cells,
occasionally mimicking primary tumours of the central nervous system.
98
Experimental Photothrombotic White Matter Infarct with Marked
Motor Deficit: A New Animal Model
Min-Cheol Lee1, Hyoung-Ihl Kim2, Kyung-Wha Lee1, Young Kim1,
Hyung-Sun Kim2. 1Department of Pathology, Chonnam National University
Medical School; 2Gwangju Institute of Science and Technology
We describe a new method for inducing a circumscribed subcortical
capsular infarct (SCI), which results in persistent motor impairment in rats
as a model to study post-stroke recovery. Photothrombotic destruction of the
posterior limb of the internal capsule (PLIC) was performed using a low
energy green laser and Rose Bengal in Sprague Dawley rats (male; n=38;
250-300g). Motor performance of all animals was assessed using forelimb
placing, forelimb use asymmetry, and single pellet reaching test scores.
Based on the degree of motor recovery, rats were dichotomized into either
the poor recovery group (PRG) or the moderate recovery group (MRG).
Imaging assessment of the impact of subcortical capsular infarct on brain
metabolism was done using 18FDG microPET. Photothrombotic lesioning
with low light energy selectively disrupted circumscribed capsular fibers.
MRG demonstrated recovery of motor performance after one week but PRG
showed a persistent motor impairment for more than 3 weeks. Damage to
PLIC more effectively produced a severe motor deficit. Histological
examination revealed that PRG had complete, full thickness destruction of
the axon bundles in the anterior part of the PLIC. MRG show a partial lesion
in the same area. Analysis of PET data revealed decreased regional glucose
metabolism in the ipsilesional motor and bilateral sensory cortex and
increased metabolism in the contralesional motor cortex and bilateral
hippocampus during the early recovery period after SCI. These behavioral,
histological and functional imaging findings support the usefulness of this
novel SCI rat model for investigating motor recovery and the mechanism
underlying SCI.
99
Cerebral Biopsies in Posterior ‘‘Irreversible’’ Encephalopathy
Syndrome (PIES)
Hannes Vogel1, Jennifer Ziskin1, Gregory Moes2. 1Stanford University;2Kaiser Permanente
Posterior reversible encephalopathy syndrome (PRES) occurs when the
posterior cerebral circulation fails to autoregulate in response to acute
changes in blood pressure. Hyperperfusion causes disruption of the blood
brain barrier and vasogenic edema, most commonly in parieto-occipital
regions but without infarction. Pathological studies have reported fibrinoid
vascular necrosis. Clinicians may neglect the possibility of PRES in cases in
which hypertension is overshadowed by other considerations or atypical
radiographic findings. We present three cases of acute parieto-occipital
infarction which were biopsied for clinical considerations other than
hypertension. Case 1 is a 49 yo male who presented with acute neurological
deficits and a blood pressure of 190/112. MRI demonstrated a rim enhancing
lesion in the occipital lobe, cerebellum and punctate lesions in deep gray
and white matter and frontal lobes. Because of poor dentition, a cerebral
abscess was suspected in the occipital lobe lesion. The biopsy showed recent
infarction without infection. Case 2 was a 44 yo female with headache, left-
sided weakness, and a generalized tonic-clonic seizure. Blood pressure
was elevated to 205/121. MRI upon admission demonstrated enhancing
parieto-occipital brain lesions with surrounding vasogenic edema. Concern
for infection led to a stereotactic biopsy of the larger right parieto-occipital
lobe lesion which demonstrated laminar necrosis without infection. Case 3
was a 20 year old female with recently documented hypertension, who
developed sudden deficits and unresponsiveness, A CT showed left basal
ganglion hemorrhage. Blood pressures to 220/173 were documented. She
developed new lesions of both parietal lobes which were biopsied for
possible vasculitis, which showed recent infarction without vasculitis. In all
cases, the final clinical diagnosis was PRES with superimposed infarctions,
thus we revise the term to reflect an irreversible condition. Neuropatholo-
gists should seek a history of severe hypertension when biopsies of contrast-
enhancing or tumefactive lesions of parieto-occipital regions only show
recent infarction.
100
Histopathological Features of Intracranial Vascular Involvement in
Neurofibromatosis Type I, Ehlers-Danlos Type IV, and FMD
Bette Kleinschmidt-DeMasters1, Seth Lummus1. 1University of Colorado
Anschutz Medical Campus
Background: Recent studies suggest shared epidemiologic characteristics,
common pathological weakening of arterial walls, and clinical outcomes
amongst the nonatherosclerotic cerebrovascular arteriopathies. Few studies
directly compare histological features of intracranial meningeal and
parenchymal vasculature in major arteriopathies that affect CNS, i.e.,
fibromuscular dysplasia (FMD), Ehlers-Danlos type IV (ED-IV, vascular
type), and neurofibromatosis type I (NF1).
Methods: Three adult autopsy cases of FMD in patients succumbing from
basilar artery aneurysm rupture, vertebral artery dissection, and Moyamoya
disease, all known patterns of FMD central nervous system (CNS)
involvement, were studied with focus on intracranial rather than extracranial
vascular changes. FMD was only confidently identified in autopsy speci-
mens when multiple sections (optimally the entire Circle of Willis) were
subjected to microscopic examination. A fourth FMD case of a massive,
subcutaneous scalp cirsoid aneurysm showed classic Wstring-of-beadsW gross
appearance and microscopic medial hypertrophy. Direct comparison of
FMD intracranial vascular changes was made with those in 1 autopsy patient
with ED-IV and 4 autopsy patients with NF1.
Results: All three disorders involved cerebral vessels, albeit each with
distinctive histological features and distribution, despite shared clinical and
epidemiological characteristics. Disordered collagen within the muscularis
was confined to FMD, best seen on picrosirius red histochemistry. Ehlers-
Danlos type IV showed aneurysmal formation and eccentric intimal
thickening of Circle of Willis vasculature but no obvious abnormalities of
muscularis. Extensive leptomeningeal smaller-caliber arterial disease was
confined to NF1 and particularly affected spinal cord. Fibrocellular smooth
muscle intimal proliferation within parenchymal cerebral arteries was
confirmed on smooth muscle actin immunohistochemistry in Moyamoya.
Conclusions: Cranial/intracranial artery involvement is not rare in these
conditions, but requires extensive sampling to fully appreciate features.
PLATFORM SESSION 5: TUMORS 2 - MOLECULAR
PHENOTYPES
Saturday 8-10 AM, June 14, 2014
Fashion Ballroom
101
Chromosome Band 7q34 Deletions Resulting in KIAA1549-BRAF and
FAM131B-BRAF Fusions in Pediatric Low Grade Gliomas
Jacquelyn Roth1, Mariarita Santi1, Avrum Pollock1, Brian Harding1, Lucy
Rorke-Adams1, Laura Tooke1, Jaclyn Biegel1. 1Children_s Hopsital of
Philadelphia
The majority of low grade gliomas (LGGs) in children are characterized
by constitutive activation of the MAPK pathway through a variety of
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Page 28
mechanisms, including mutations in BRAF and KRAS, inactivation of NF1,
and KIAA1549-BRAF, FAM131B-BRAF and SRGAP3-RAF1 gene fusions.
The KIAA1549-BRAF fusion is typically the result of a 2.0 Mb tandem du-
plication in 7q34 and is most common in pilocytic astrocytoma (PA). In the
present study, single nucleotide polymorphism (SNP)-based array analysis of
three LGGs demonstrated deletions in 7q34 that resulted in a BRAF fusion.
One low grade neuronal-glial tumor had three deletions in 7q33 and 7q34. The
most proximal deletion encompassed the 3‘ end of KIAA1549 while the most
distal deletion included exons 3-7 of BRAF. RT-PCR analysis demonstrated
a fusion between exon 15 of KIAA1549 and exon 9 of BRAF. SNP array
analysis of a dysembryoplastic neuroepithelial tumor (DNT)/ganglioglioma
(GG) revealed a 2.6 Mb deletion which included the 5‘ end of BRAF and
extended to the 3‘ end of FAM131B. A PA displayed two deletions, which
were 15 kb and 450 kb in size, with the most proximal deletion encompassing
exons 4-7 of BRAF. Subsequent SNP array analysis of a recurrent PA from
this patient yielded two additional deletions in 7q34, the most distal of which
included the 3‘ end of FAM131B. RT-PCR analyses confirmed a fusion
between exon 2 of FAM131B and exon 9 of BRAF in both the DNT/GG and
PA. The presence of fusion transcripts in these three LGGs highlights the
utility of SNP array analysis to identify deletions that are suggestive of fu-
sion proteins, and confirms that such fusions are not restricted to PA. BRAF
fusions can result from multiple non-overlapping deletions suggesting variant
complex mechanisms of formation.
102
A Clinicopathologic Study of Hypothalamic Pediatric Low-Grade
Gliomas with BRAF V600E Mutation
Cheng-Ying Ho1, Gary Mason2, Ashley Campbell1, Mahtab Tehrani3, Brent
Orr4, Roger Packer2, Fausto Rodriguez5. 1Divison of Pathology, Children’s
National Medical Center; 2Department of Neurology, Children’s National
Medical Center; 3Department of Pathology, Inova Fairfax Hospital;4Department of Pathology, St. Jude Children’s Research Hospital;5Department of Pathology, Johns Hopkins Hospital
Background: BRAF V600E mutation is frequently associated with pleomor-
phic xanthoastrocytomas (PXAs) and gangliogliomas (GGs). It is also de-
tected in È5% of other pediatric low-grade gliomas (PLGAs), including
pilocytic astrocytomas (PAs), pilomyxoid astrocytomas (PMAs) and diffuse
astrocytomas (DAs). The aim of this study was to evaluate the clinicopathologic
features of non-PXA/GG PLGAs that harbor the BRAF V600E mutation.
Design: After excluding PXAs and GGs, we performed a retrospective
analysis of 18 BRAF V600E PLGAs from five institutions. Approximately
half of the BRAF V600E tumors were located in the hypothalamus/optic
chiasm (9/18, 50%). To investigate the association between the muta-
tion and clinicopathologic features of tumors at this anatomic site, 9 V600E
and 8 non-V600E (fusion or wild-type) hypothalamic PLGAs were evalu-
ated. Thirteen cases had available clinical information and follow-up for
over a year. 14 (8 V600E and 6 non-V600E) specimens were available for
microscopic review.
Results: The BRAF V600E hypothalamic PLGAs appeared to affect infants
(under one year of age) predominantly (56%, 5/9). Our analysis revealed
similar histologic features in all hypothalamic BRAFV600E tumors (100%,
9/9): a monophasic dense compact architecture without microcystic or pilo-
myxoid patterns. Rosenthal fibers and eosinophilic granular bodies were rare
to absent. Because the classic features of PAs were absent, nearly all hypo-
thalamic BRAF V600E tumors were initially classified as low-grade astrocy-
tomas. All 13 cases in the study received a subtotal resection or biopsy of the
tumor. Ten of 13 patients had post-operative chemotherapy. Tumor progression
or recurrence was observed in 86% (6/7) of BRAFV600E PLGAs, 25% (1/4)
non-V600E PAs and 100% (2/2) non-V600E PMAs.
Conclusions: BRAF V600E mutation is commonly present in the hypo-
thalamic region of infants. Hypothalamic BRAF V600E PLGAs appear to
be associated with a unique histologic pattern, and have a tendency for a
more aggressive clinical course.
103
Identification of Molecular and Pathologic Subsets of Low Grade
Gliomas and Glioneuronal Tumors by microRNA profiling
Heather Ames1, Marıa Vizcaıno-Villalobos2, Fausto Rodriguez1. 1Johns
Hopkins Medical School, Department of Pathology; 2Universidad Nacional
Autonoma de Mexico, Department of Cell Biology
Low-grade (WHO I-II) gliomas are tumors of the central nervous system
that often have good prognosis following total resection, however they
can create many neurological complications due to mass effect, and may be
difficult to resect depending on anatomic location. They may also contain
neuronal components to variable extent. With these characteristics, low-
grade gliomas and glioneuronal tumors represent a valuable pool from which
to identify potential molecular targets for early stages of tumorigenesis in the
brain. MicroRNAs have been identified as mechanisms of epigenetic gene
regulation in cells Y pathways that are inherently targetable and amplifiable due
to their simple nucleic acid structure. Given the importance of microRNA
expression to tumor development, NanoString technology was applied to
formalin-fixed paraffin-embedded tissues (n=45) to quantify the global
expression of over 800 microRNAs in nine types of low-grade neoplasms of
the brain: subependymal giant cell astrocytoma (SEGA) (n=6), pilocytic
astrocytoma (n=6), pleomorphic xanthoastrocytomas (n=7), gangliogliomas
(n=6), dysembryoplastic neuroepithelial tumor (n=5), angiocentric glioma
(n=3), pediatric oligodendroglioma (n=3), pediatric diffuse astrocytoma (n=3),
rosette forming glioneuronal tumor (n=2) and non-neoplastic brain controls
(n=4). Raw data was normalized using nSolver, filtered for minimum ex-
pression threshold, and log2 transformed prior to analysis. MeV software was
used to generate hierarchical clusters following significance evaluation via
significant analysis of microarrays (SAMs). Hierarchical clustering sepa-
rated tumors from non-neoplastic brain. These differentially expressed
microRNAs included many that have been previously identified as altered in
tumors of neural origin and important in neural differentiation. When
looking at individual tumors, SEGAs clustered sharply together, consistent
with a unique microRNA expression signature in this tumor subtype in
particular, compared to other low grade glial and glioneuronal tumors. In
summary, low-grade gliomas show alterations in microRNA expression
patterns that may provide insights into their biology and/or make these
tumors molecularly targetable.
104
Cytogenetic Progression of Oligodendroglioma Assessed Using Single
Nucleotide Polymorphism Array
David Nauen1, Andrew Guajardo1, Fayez Jabboure1, Peter Burger1,
Christopher Gocke1. 1Johns Hopkins
The prognosis of oligodendroglioma (ODG), a relatively common infiltrat-
ing glioma, differs markedly between the typical tumor (WHO Grade II) and
its anaplastic counterpart (WHO grade III). ODG is characterized by altera-
tions, generally loss, of chromosome arms 1p and 19q. While this hallmark
abnormality has been a focal point of investigation, additional cytogenetic
changes that may underlie the progression of the tumor to higher grade have
been less studied. Single nucleotide polymorphism (SNP) array is widely used
in diagnosis of glial tumors. Although routine clinical reporting is limited in
this context to chromosomes 1 and 19, SNP array data provides information
on the status of all chromosomes. To assess mechanisms of pathogenesis and
progression of ODG we review SNP array data for all such tumors assayed
at our institution since 2011, when microarray analysis entered routine use. We
confirm that chromosomal abnormalities in grade II ODG are not limited to 1p
and 19q. A number of other abnormalities are noted, with loss of heterozy-
gosity (LOH) in chromosomes 4 and 9 frequent. We find a marked increase
in the average number of chromosomal abnormalities for grade III v grade II
ODG (average 3.5 v 0.9), and that additional abnormalities recur in anaplastic
ODG at high frequency. A number of chromosomes show LOH to different
Abstracts J Neuropathol Exp Neurol � Volume 73, Number 6, June 2014
� 2014 American Association of Neuropathologists, Inc.612
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Page 29
extent among different chromosomes, which may reflect distinct subpopula-
tions during tumor progression. These findings may have implications for the
increased mortality associated with grade III oligodendroglioma and may
ultimately inform the search for more effective therapies.
105
Next Generation Sequencing and Immunohistochemistry for EGFR,
p53 and Mutant IDH1 in High-Grade Gliomas
Lyndsey Emery1, William Motley2, Donald O’Rourke1, Steven Brem1,
Robert Daber1, Maria Martinez-Lage1. 1Hospital of the University of
Pennsylvania; 2Perlman School of Medicine (University of Pennsylvania)
Background: Key genomic alterations in high-grade gliomas include TP53,
IDH1, and EGFR. We report the correlation of next generation sequencing
(NGS) in detecting point mutations and amplifications compared with
routine immunohistochemistry.Methods: Eighty-three high-grade gliomas were analyzed over 12 months.
Immunohistochemical staining for mutated IDH1 (R132H), p53 and EGFR
was performed and rated by qualitative or semi-quantitative scoring (0-3+).
DNA from formalin-fixed paraffin embedded tissue was evaluated using a
47-gene panel via Illumina Mi-Seq.Results: 81 tumors had perfect correlation between IDH1 R132H-specific
staining and mutational status by sequencing (71 negative, 10 positive). One
case did not stain with R132H-specific antibody, but had an R132L mutation
by sequencing. 31 samples had TP53 mutations by NGS, of which 25 had
moderate-strong p53 staining, 5 had a subset of p53-positive cells and one
sample showed no staining. Among the 50 samples without TP53 mutations,
12 had moderate-strong p53 staining, 34 had a subset of p53-positive cells
and 4 samples were negative. 31 samples had disease-associated EGFR
mutations and/or amplification and 2+ or 3+ membranous EGFR staining.
Two cases with EGFRvIII variant mutations had 1+ staining. No cases with
mutations/amplification of EGFR showed negative EGFR staining. Among
33 samples with no NGS-detected EGFR mutations/amplifications, staining
was variable, ranging from 1+ to 3+. Interestingly, of the 23 samples with
2+ or 3+ EGFR staining within this subset, 1 had a mutational ‘‘variant of
unknown significance’’ in EGFR; 9 had ‘‘variants of unknown significance’’
within other genes, 6 of which had mutations/amplifications in PDGFRA.
Conclusions: NGS offers powerful complementary information in high-
grade gliomas, which is specific and, potentially, more sensitive than classic
immunohistochemistry. Furthermore, NGS could identify novel mutation-
based subgroups among tumors with or without p53/EGFR staining. Applica-
tion of these findings to outcome data could provide additional prognostic
information and identify new therapeutic targets.
106
Evaluation of Targeted Next Generation Sequencing (NGS) for
Assessment of Variations in Gliomas
Ada Baisre1, Nitin Agarwal1, Helen Fernandes2, Anjali Seth3. 1RUTGERS-
New Jersey Medical School; 2Weill Cornell Medical College-New York-
Presbyterian Hospital; 3University Hospital
Introduction: Molecular markers including 1p/19q co-deletion (LOH),
MGMT promoter hypermethylation, 10q (PTEN) loss and mutations in IDH
1&2 are currently used for diagnostic, prognostic and therapeutic purposes
in a variety of CNS gliomas. More recently, next generation sequencing (NGS)
is being used and numerous genomic abnormalities are being identified in
several types of cancers. In this study we have stratified glioma specimens
using these molecular markers. In addition, we used targeted NGS to detect
differences between GBMs and other gliomas.
Materials and Methods: Formalin fixed paraffin embedded tissue (FFPE)
from patients (n= 82) diagnosed with gliomas have been included in this
study. Oligodendrogliomas, oligoastrocytomas, astrocytomas (non-GBM tu-
mor group) and glioblastomas (GBM) were assessed for allelic status of
chromosomes 1p, 19q and 10q by capillary electrophoresis. IDH1 and IDH2
mutation was also assessed using real time PCR and melt curve analysis.
MGMT promoter methylation was assessed by pyrosequencing. A subset of
these glioma specimens (n=49) were subjected to NGS using the Ion Torrent
Personal Genome Machine (PGM) platform. Genomic DNA libraries were
prepared using the Life Technologies Cancer panel.
Results: A majority (79%) of the non-GBM tumor group harbored IDH
mutations in comparison to GBMs (29%). Although 44% of the non-GBM
specimens co-expressed molecular markers such as 1p/19q co-deletion,
MGMT promoter methylation and IDH mutations, none of the GBMs co-
expressed these markers collectively. Genomic variants using NGS were
observed in all groups of gliomas in TP53, PIK3CA, IDH, MET and APC
genes. Variants in KIT, SMAD4, FLT3, FLT3, STK11, FGFR3, PDGFRA,
KDR, FBXW, PTPN1, BRAF and RBI were also observed at varying fre-
quencies in GBMs and LOH-positive oligodendrogliomas but were absent
in the remainder of the non-GBM group. 33% of LOH-positive oligodendro-
gliomas and 25% of non-GBM harbored alterations in the SMO gene that
were entirely absent in the GBMs.
107
Differential Expression of Genes in Primary and Recurrent GBM
Suggests a Transition Toward More Aggressive Molecular Subtype
Gerald Reis1, Wood Matthew1, Jason Huse2, Joanna Phillips1. 1University of
California San Francisco; 2Memorial Sloan-Kettering Cancer Center
Introduction: Glioblastoma (GBM) is the most common primary malignant
brain tumor in adults and is molecularly heterogeneous. Despite advances in
therapy, disease progression is often relentless and prognosis remains poor.
It has been suggested that tumors may acquire a more aggressive and poten-
tially more uniform molecular profile at recurrence. To investigate this ques-
tion we analyzed the gene expression pattern of GBM at initial diagnosis and
at recurrence.
Methods: The population consisted of 32 patients, 18 of which were
male and 14 female (mean age: 59.8 and 54.4 years, respectively). There
were 30 newly diagnosed (NEW) and 10 recurrent (RECUR) GBM, including
7-paired samples. The average time to recurrence was 494 days. RNA was
extracted from formalin-fixed paraffin-embedded (FFPE) material, and
integrity was verified with Agilent Bioanalyzer. Select genes implicated in
GBM (n=173) were tested using the nCounter NanoString Analysis System.
Pairwise and between-group comparisons were made using Wilcoxon and
Mann Whitney tests.
Results:While the majority of the genes tested (154 genes; 89%) showed no
significant change, OLIG2, CD44, and GPNMB were among the differ-
entially expressed genes. OLIG2 was significantly lower in the recurrent
group (NEW= 1937+/-349, RECUR=676+/-314; p=0.004) while CD44 was
significantly higher (NEW=2410+/-313, RECUR=5183+/-1605; p=0.0282),
suggesting a shift toward a more mesenchymal subtype. The expression of
GPNMB was significantly higher in recurrent GBM (NEW=796+/-418,
RECUR=1347+/-481, p=0.0085), raising the possibility of poorer progno-
sis in recurrent disease. OLIG2, CD44, and GPNMB showed no significant
difference on pairwise comparison (P=0.38, 0.69, and 0.09, respectively),
though the sample size is small.
Conclusion: The observed changes in the OLIG2, CD44, and GPNMB
expression would suggest a transition towards a more aggressive molecular
phenotype in recurrent GBM. In addition, they raise the possibility that primary
GBM progression reflects a convergence of molecular subtypes.
108
Reprogramming Cell Circuits in Glioblastoma
Mario Suva1, Anoop Patel1, Bradley Bernstein1, David Louis1. 1Massachusetts
General Hospital
Developmental fate decisions are dictated by master transcription factors
(TFs) that interact with cis-regulatory elements to direct transcriptional
programs. In glioblastoma (GBM), a subset of stem-like tumor-propagating
J Neuropathol Exp Neurol � Volume 73, Number 6, June 2014 Abstracts
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Page 30
cells (TPCs) appears to drive tumor progression and underlie therapeutic
resistance, yet remain poorly understood. We identified a core set of neuro-
developmental TFs (POU3F2, SOX2, SALL2, OLIG2) essential for GBM
propagation. These TFs coordinately bind and activate TPC-specific regula-
tory elements, and are sufficient to fully reprogram differentiated GBM cells
to Finduced_ TPCs, recapitulating the epigenetic landscape and phenotype
of native TPCs. We reconstruct a network model that highlights critical
interactions and identifies novel therapeutic targets for eliminating TPCs.
Finally, using single-cell RNA-seq, we show that this network displays a
gradient of activity in primary human GBM, thus supporting the relevance
of our findings in vivo. Our study establishes the epigenetic basis of a de-
velopmental hierarchy in GBM, provides detailed insight into underlying gene
regulatory programs, and suggests attendant therapeutic strategies.
PLATFORM SESSION 6: MUSCLE, NERVE,
INFECTIOUS
Saturday 8-10 AM, June 14, 2014
Culture Ballroom
109
Motor Nerve Biopsy
Arthur Hays1, Dale Lange2. 1Therapath; 2Hospital for Special Surgery, New
York, NY
Background: Sural nerve biopsy is of limited utility, particularly when the
disorder is predominantly or purely motor, such as in motor neuron disease
(MND), multifocal motor neuropathy (MMN), chronic inflammatory
demyelinating polyneuropathy (CIDP) and other motor neuropathies
(MN). When confronting this differential, motor nerve biopsy can
potentially help to distinguish motor neuropathies from MND (Riva N et al.
Ann Neurol 2011;69:197-201).
Materials & Methods: Biopsy of a motor nerve and muscle were performed
in 46 patients. Depending on the distribution of weakness, biopsy was per-
formed on the gracilis muscle and the motor branch of the internal obturator
nerve or the pronator teres muscle and its motor nerve supply. Nerve samples
were evaluated by routine histology, semithin sections and teased myelinated
fibers. Muscle biopsies were prepared by standard methods.
Results: The typical findings in MND included loss of myelinated fibers
(sometimes patchy) and sparse myelin debris. Motor neuropathies were iden-
tified by nerve fiber loss and excessive regenerative clusters of myelinated
fibers or segmental remyelination or both. The differential clinical diagnosis
was MND vsMMN or MN in 17 patients because of a non-diagnostic work up.
Of these, 11 biopsies yielded a diagnosis of MN rather than MND, 5 had
probable MND and one suggested CIDP. Twelve patients met clinical criteria
of MND, and the motor nerve was consistent with MND in 9, axonal MN in
2 and equivocal in one. Two were thought to have MMN, but the pathology
suggested MND in one and equivocal in the other. Eight of the motor nerve
biopsies had no abnormalities. Finally, samples of two other patients suggested
CIDP, and one had an inflammatory myopathy.
Conclusions: Motor nerve biopsy is useful in confirming the clinical suspi-
cion of MND and can provide evidence of a potentially treatable neuropathy
such as MMN and CIDP.
110
Treatment with ActRIIB-mFc Improves Lifespan, Behavior and
Pathology in the Acta1 H40Y Murine Model of Nemaline Myopathy
Jennifer Tinklenberg1, Hui Meng1, Lin Yang2, Edna Hardeman3, Scott
Pearsall4, Robert Fitts5, Michael Lawlor6. 1Medical College of Wisconsin,
Milwaukee, WI, USA; 2University of Kentucky, Lexington, KY, USA;3School of Medical Sciences, UNSWAustralia, Sydney, Australia; 4Acceleron
Pharma Inc., Boston, MA, USA; 5Marquette University, Milwaukee, WI, USA;6Medical College of Wisconsin/Children’s Hospital of Wisconsin
Nemaline myopathy (NM) is a congenital muscle disease that can cause a
range of clinical symptoms, including perinatal death due to respiratory in-
sufficiency in severe cases. NM is one of the three main types of congenital
myopathy, and it is associated with mutations in nine genes (NEB, ACTA1,
TPM3, TPM2, TNNT1, CFL2, KBTBD13, KLHL40, and KLHL41). De-
spite the clinical and genetic heterogeneity seen in human NM patients, it is
consistently diagnosed on muscle biopsy by the presence of cytoplasmic
rod-like structures (nemaline rods) composed of cytoskeletal material. The
interference with skeletal muscle contraction by nemaline rods provides
one mechanism for muscle weakness, but there is little correlation between
the number of nemaline rods observed and symptomatic severity. Myofiber
smallness is also found in many cases of NM and may represent a cause of
weakness that can be counteracted by treatment. As we have used ActRIIB-
mFc (an inhibitor of myostatin signaling) to promote hypertrophy and in-
crease strength in our prior murine work, we believe that this agent could
dramatically improve the weakness seen in NM mice through myofiber hyper-
trophy. In this study, we tested the efficacy of ActRIIB-mFc treatment in the
Acta1 H40Y mouse model of nemaline myopathy, which develops weakness
and nemaline rod formation and in which half of male hemizygote mice die
between 1-3 months of life. Treatment of Acta1 H40Ymice has thus far shown
dramatic improvements in lifespan, animal mass, and open field activity and
more modest trends toward increased forelimb grip strength in ActRIIB-mFc
treated mice. Our early pathological studies also indicate increased muscle
mass (across all major muscles) and increased myofiber size in ActRIIB-mFc
treated Acta1 H40Y mice. These preliminary studies demonstrate the substan-
tial potential of ActRIIB-mFc in the treatment of NM.
111
Keap1/Nrf2 Stress Response Pathway in Autophagic Vacuolar Myopathies
Steve Duleh1, Xianhong Wang1, Marta Margeta1. 1University of California
San Francisco
Nrf2, the transcriptional master regulator of antioxidant stress response, is
regulated through interaction with its cytoplasmic inhibitor, Keap1. Under
basal conditions, Keap1 targets Nrf2 for proteasomal degradation; stimuli
that activate Nrf2 signaling lead to dissociation of Keap1/Nrf2 complex,
Nrf2 translocation into the nucleus, and increase in the transcription of Nrf2-
regulated genes. p62/SQSTM1 Y an adapter protein that accumulates following
autophagy inhibition and can serve as a diagnostic marker for human auto-
phagic vacuolar myopathies (AVMs) Y was recently shown to compete with
Nrf2 for Keap1 binding, resulting in Nrf2 pathway activation. In this study,
we examined whether Keap1 can serve as an alternative diagnostic marker
for human AVMs and whether Nrf2 activity is increased in these disorders.
Immunohistochemical staining was performed on formalin-fixed, paraffin-
embedded tissue from 47 muscle biopsies divided into five groups: normal
control muscle, chloroquine- or colchicine-treated non-AVM control muscle,
chloroquine or colchicine AVM, polymyositis, and inclusion body myositis
(IBM). In drug-induced AVMs and IBM, but not in control muscle groups
or polymyositis, Keap1 antibody labeled the same sarcoplasmic structures as
antibodies against p62 and LC3-II (an autophagosome marker that also binds
p62); in fact, Keap1 can be used as an alternative diagnostic marker for both
AVMs. The sequestration of Keap1 into p62- and LC3-II-positive protein ag-
gregates was associated with increased protein level of Nrf2 target genes
Nqo1 and Hmox1 in AVM compared to the control muscle. Similarly,
chloroquine treatment of C2C12 muscle cells in vitro led to increase in
protein levels of LC3-II and p62 and to nuclear translocation of Nrf2. Taken
together, our findings indicate that autophagy impairment leads to
upregulation of Nrf2 signaling in human AVMs; future work will show
whether Nrf2 activation in this setting is beneficial or harmful, as recently
shown for Nrf2-induced redutive stress in the >B-crystallin model of
protein aggregation cardiomyopathy.
Abstracts J Neuropathol Exp Neurol � Volume 73, Number 6, June 2014
� 2014 American Association of Neuropathologists, Inc.614
Copyright © 2014 by the American Association of Neuropathologists, Inc. Unauthorized reproduction of this article is prohibited.
Page 31
112
A Novel MTM1Mutation in a Case of X-linked Myotubular/Centronuclear
Myopathy
Nitin Agarwal1, Helio Pedro2, Karen Valdez-Gonzalez2, Madhuri Hegde3,
Ada Baisre1. 1Rutgers New Jersey Medical School; 2Hackensack University
Medical Center; 3Emory University
We are reporting a case of X-linked myotubular/centronuclear myopathy
[XLMTM] with a novel MTM1 mutation in a 5-week-old baby boy born
with severe hypotonia. After extensive testing with normal results, includ-
ing SMN1/2 copy number analysis, acid alpha-glucosidase enzyme assay,
chromosomal microarray, Prader-Willi methylation analysis, very long chain
fatty acid profile, pipecolic acid, urine organic acids, plasma amino acids, and
complete myotonia evaluation, a muscle biopsy was performed. The biopsy
was composed of over 50% Type 1 myofibers, which were slightly larger than
the Type 2 fibers. Several fibers, mostly Type 1, either had a single centrally
placed nucleus or an area seemingly bare on H&E and myofibrillar ATPases
(pH 9.4, 4.6 & 4.3). However these areas showed accumulation of oxidative
enzymes and mitochondria that were emphasized with NADH, PAS, acid
phosphatase and Gomori-Trichrome. These classical features of myotubular/
centronuclear myoapathy prompted molecular/genetic testing. Incidentally a
few small foci of extramedullary hematopoiesis were noted in the muscle.
When the biopsy revealed findings suggestive of XLMTM, the family re-
called additional information in their family history. The patient_s maternal
grandmother had had a stillborn son and one of her brothers had also been
stillborn. This history seemed to be consistent with diagnosis of an X-linked
condition. MTM1 gene testing was then ordered. Sequence analysis of the
entire coding region of the MTM1 gene identified a c.142_143delGA muta-
tion in exon 4. This is a two nucleotide deletion that is predicted to result in a
shift of the open reading frame leading to the introduction of a premature stop
codon. This is to our knowledge the first report of such mutation in XLMTM,
and although novel, it is of the type predicted to cause disease.
113
Congenital Myasthenic Syndrome with Vacuolar Changes and Tubular
Aggregates Caused by Mutations in DPAGT1
Carolyn Rysgaard1, Duygu Selcen2, Katherine Mathews1, Andrew Engel2,
Steven Moore1. 1The University of Iowa; 2Mayo Clinic, Rochester, MN
Congenital myasthenic syndromes (CMS) are genetically and phenotypi-
cally heterogeneous disorders that present a diagnostic challenge to both the
neurologist and muscle pathologist. We present a CMS case with diagnos-
tic clues observed in a muscle biopsy. The patient was first evaluated for
hypotonia and delayed motor milestones at 12 months of age. She had vari-
able but largely stable motor skills until age 12 years when she presented to
clinic with worsened weakness and fatigability affecting her limb-girdle mus-
culature and sparing ocular and bulbar muscles. At age 12 years, a quadriceps
biopsy revealed marked fiber size variation, type II fiber predominance and
vacuolar changes. Electron microscopy demonstrated small tubular aggregates
(TA) and increased lysosomes, confirmed by LAMP2 immunofluorescence.
The differential included Pompe disease; however, acid alpha-glucosidase
(GAA) enzyme activity was normal. The diagnosis of CMS was reached after
finding a decremental response to repetitive nerve stimulation and identify-
ing compound heterozygous mutations in dolichyl-phosphate N-acetyl glucos-
amine phosphotransferase (DPAGT1) (Selcen et al. Neurology, 2014, in press).
Involved in glycosylation and export of acetylcholine receptor (AChR) sub-
units, DPAGT1 regulates the expression of AChR at the motor endplate. As
in this case, previously published patients with DPAGT1 mutations presented
in childhood with limb-girdle weakness and minimal ocular or bulbar in-
volvement. Limb-girdle pattern myopathy in patients with CMS has also been
associated with mutations in DOK7 and GFPT1. Muscle biopsy TAs are a
hallmark of at least two limb-girdle pattern CMS genotypes, DPAGT1 and
GFPT1 (also linked to defective glycosylation and decreased AChRs). So
while routine muscle biopsies in CMS are generally nondiagnostic, the presence
of TAs in the appropriate clinical context can suggest the diagnosis of CMS
and guide clinical management. Vacuolar changes with lysosomal proliferation
appear to be a novel finding in this patient; their significance is undetermined.
114
Identification of a Novel Polyomavirus in a Pancreatic Transplant
Recipient with Retinal Blindness and Vasculitic Myopathy
Phyllis Faust1, Nischay Mishra2, Roy Rhodes3, Marcus Pereira4, James Pipas5,
Komal Jain6, Amit Kapoor2, Thomas Briese8, W. Lipkin2. 1Columbia
University, Department of Pathology and Cell Biology; 2Columbia University,
Center for Infection and Immunity; 3Rutgers Robert Wood Johnson Medi-
cal School, Department of Pathology; 4Columbia University, College of
Physicians and Surgeons; 5University of Pittsburgh, Department of Biologi-
cal Sciences; 6Columbia University, Mailman School of Public Health;7Columbia University, Epidemiology
A 33-year-old woman was admitted to hospital with 3-week history of
fatigue, myalgias, decreasing visual acuity and progressive weakness. Her
medical history was notable for Type 1 diabetes mellitus, peripheral neuro-
pathy and retinopathy leading to pancreas transplantation 11 months earlier.
She lived in New Jersey, and was evacuated through sewage-contaminated
floodwaters in the aftermath of Superstorm Sandy in October of 2012. Her
illness began two weeks thereafter. On hospital admission, her creatine kinase
was initially normal but increased, peaking at over 8000 U/L. Serum assays by
PCR for HIV, EBV, parvovirus and CMV, and for antibodies to influenza,
adenovirus, mycoplasma, HTLV and HHV-6 were negative. Her vision de-
teriorated to detection of only bright light; retinal mapping showed acute
macular ischemia due to thrombosis. She developed necrotic plaques on her
face, scalp and hands. A muscle biopsy showed microvasculitis and micro-
thromboses in endomysial capillaries, widespread endothelial cell atypia and
viral particles in endothelial cell nuclei. Immunostains for cytomegalovirus,
herpes simplex virus, adenovirus and BK/JC virus were negative. High-
throughput sequencing of nucleic acid from the muscle biopsy revealed a
novel polyomavirus with greatest homology to chimpanzee polyomaviruses.
In situ hybridization demonstrated viral genome in endothelial cells in mus-
cle and skin biopsies. RNA transcripts encoding large T, small T and a novel
T antigen were detected in muscle. After steroid and plasmapheresis treat-
ments, her muscle strength improved but blindness persisted. Blood collected
10 months after illness onset revealed viral DNA in serum, no viral mutations,
and antibodies to VP1 and VP2 capsid proteins. New Jersey polyomavirus
(NJPyV-2013) is a novel polyomavirus that appears to have tropism for
vascular endothelial cells. Whether this infection represents reactivation re-
lated to immunosuppression or a newly acquired infection is unknown. Its
prevalence and scope of tissue tropism in human infections will require
application of diagnostic tests for NJPyV-2013.
115
Neisseria Elongata Encephalitis Presenting as an Enhancing Brain Mass
Jennifer Cotter1, Daniel Kerrigan2, Atis Muehlenbachs3, Sherif Zaki3, Andrew
Bollen1. 1University of California San Francisco, Department of Pathology;2Pathology Consultants, Springfield, OR; 3National Center for Emerging and
Zoonotic Infectious Diseases
Neisseria elongata is a commensal organism typically present in human oral
flora, but has been associated with invasive disease, including endocarditis
and osteomyelitis. A 25-year-old woman presented with a one-month history
of a progressively severe headache. There were some associated visual
changes, including ‘‘seeing black’’ when standing. CT imaging demonstrated
a large attenuation in the left frontal lobe, with midline shift. MRI showed
an enhancing left frontal lobe mass in the subcortical white matter, with
surrounding edema. An initial biopsy obtained via left frontal craniotomy
showed mild astrogliosis. A second biopsy performed three weeks later dem-
onstrated mixed inflammation with prominent plasma cell and macrophage
components, in a perivascular distribution. Vascular involvement by this in-
flammation was present, without fibrinoid necrosis. The surrounding paren-
chyma contained reactive gliosis, microglial activation, and microvascular
J Neuropathol Exp Neurol � Volume 73, Number 6, June 2014 Abstracts
� 2014 American Association of Neuropathologists, Inc. 615
Copyright © 2014 by the American Association of Neuropathologists, Inc. Unauthorized reproduction of this article is prohibited.
Page 32
proliferation. The leptomeninges were involved by a macrophage-predominant
infiltrate. Overall, the pattern of chronic inflammation was concerning for an
infectious etiology, but organisms were not identified by a spectrum of special
and immunohistochemical stains (AFB, PAS, GMS, Steiner, Gram, Toxo-
plasma, HSV, and EBV). Cultures collected from brain tissue and CSF at the
time of the second biopsy showed no growth over six weeks. Consultation was
sought from the Centers for Disease Control and Prevention. Immunohisto-
chemistry for Treponema spp, other spirochetes, free-living ameba, Mycobac-
terium spp, and Tropheryma whipplei was negative. No molecular evidence of
Treponema pallidum was identified by PCR. Paneubacterial 16S rDNA PCR
and sequencing detected DNA with 99% homology to Neisseria elongata. In
reviewing the neuropathology literature, Neisseria elongata infection was the
presumed cause of a brain abscess in a single case report of a patient with
positive blood cultures. Herein we present the first neuropathologic evidence of
CNS involvement by this organism. The apparent induction of microvascular
proliferation may account for the MRI finding of gadolinium enhancement.
116
Pathology of HTLV-1 Infection in the Brain
Jiancong Liang1, Jenny Libien1, Marcello DiStasio2, Yuetsu Tanaka3.1Department of Pathology, SUNY Downstate Medical Center; 2SUNY
Downstate Medical Center; 3Department of Immunology, University of the
Ryukyus, Japan
Human T-lymphotropic virus type 1 (HTLV-1) infection has been shown to
cause progressive spastic paraparesis (HAM/TSP), likely due to spinal cord
damage initiated by the infiltrating HTLV-1-infected T cells. Although
neurologic and radiologic abnormalities of the brain have been described in
HTLV-1 patients, little is known about the underlying pathology in these
individuals. We characterized the brains and spinal cords of three HTLV-1
patients who died of adult T-cell lymphoma/leukemia (ATLL) and
compared them to three brains and spinal cords of age and gender matched
patients with no evidence of neurologic disease. One of the three HTLV-1
patients had a clinical diagnosis of HAM/TSP and none had central nervous
system (CNS) involvement with ATLL. On postmortem neuropathologic
exam, perivascular cuffing by chronic inflammatory cells, a characteristic
finding reported in HAM/TSP, was present in the spinal cords of two
patients and in the brain of the one patient with HAM/TSP. We assessed
microglial activation and microglial nodule formation using CD68 immu-
nohistochemical stain with quantification by color deconvolution. Microglial
nodules were seen in all three brains. Brainstem, cerebellar white matter/
dentate nuclei, and spinal cord showed marked microglial activation, while
basal ganglia and cerebral white matter exhibited mild to moderate microglial
activation, and cerebral and cerebellar cortex and hippocampus did not have
elevated microglial activity compared to control brains. By immunofluor-
escence, HTLV-1 antigens Tax and Rex were detected using Lt-4 and Rec-6
antibodies, respectively, in a few microglia and astrocytes of the brainstem,
indicating HTLV-1 infection of non-neuronal cells in the CNS. These findings
provide a neuropathologic basis for the clinical symptoms and radiologic
abnormalities related to the brains of HTLV-1 patients, and suggest that direct
viral infection of the cellular components of the CNS may contribute to the
pathogenesis of neurologic disease in HTLV-1 infection.
PLATFORM SESSION 7: TUMORS 3 Y OTHER
Saturday 2Y4 PM, June 14, 2014
Fashion Ballroom
117
Altered Receptor Tyrosine Kinase Regulation Promotes Growth Factor
Adaptability in Nf2-mutant Schwann Cells
Christian Davidson1, Ching-Hui Liu1, Jeremie Vitte2, Marco Giovannini2,
Andrea McClatchey1. 1Massachusetts General Hospital; 2University of
California-Los Angeles
Schwannomas are a major source of morbidity in patients with neuro-
fibromatosis type 2 (NF2). Moreover, the sheer number of schwannomas
often precludes effective surgical management in these patients. This under-
scores the need for efficacious medical intervention driven by precise knowl-
edge of the aberrant signaling pathways driving schwannoma formation.
We have previously reported that Nf2 deficiency promotes the ability of
Schwann cells to grow without their requisite growth factor, neuregulin. We
now demonstrate that, even prior to neuregulin independence, neuregulin-
dependent Nf2-/- Schwann cells have altered receptor tyrosine kinase (RTK)
signaling, as revealed by Western analysis and RTK-targeted drugs. In addi-
tion, we also show differential expression of RTKs in murine and human
schwannoma cells, and that this difference results in differential pharmaco-
dynamic responses to targeted therapies. Furthermore, these altered RTK
dynamics facilitate the ability of schwannomas to adapt to alternative growth
factors to fuel their proliferation. Lastly, we present signaling analysis that
provides insight into how growth factor adaptability facilitates neuregulin
independent proliferation. Collectively, our data establishes a framework for
future studies aimed at both biomarker identification and rational design of
clinical trials in NF2 patients.
118
Aberrantly Expressed ErbB4 Promotes Malignant Peripheral Nerve
Sheath Tumor Pathogenesis
Stephanie Brosius1, Stephanie Byer1, Amber Moon1, Kevin Roth1, Steven
Carroll2. 1University of Alabama at Birmingham; 2Medical University of
South Carolina
Malignant peripheral nerve sheath tumors (MPNSTs) are the most common
malignancy associated with neurofibromatosis type 1. We have presented
evidence that dysregulated signaling by the growth factor neuregulin-1
(NRG1) promotes MPNST pathogenesis. Curiously, MPNSTs may express
both erbB3, the only NRG1 receptor found in non-neoplastic Schwann cells,
and erbB4, a second NRG1 receptor with distinct functional characteristics.
Thus, we hypothesize that aberrant erbB4 expression is common in MPNSTs
and that it promotes tumorigenesis via actions distinct from those regulated
by erbB3. We found that erbB4 was expressed in 9/9 human MPNST lines
and 27/30 (90%) surgically resected MPNSTs. ErbB4 was also uniformly ex-
pressed in MPNSTs arising in genetically engineered mice that develop these
tumors (P0-GGFA3; Trp53+/- mice). To establish the function of ErbB4, we
generated P0-GGFA3; Trp53+/-; Erbb4flox/flox mice and ablated Erbb4 in
MPNSTs derived from these mice with Ad5CMV-Cre-eGFP. Compared to
non-ablated controls, Erbb4 null MPNST cells demonstrated decreases in
both proliferation and viability. Orthotopic allografts of Erbb4 null cells also
had smaller volumes compared to control grafts. Erbb4 knockdown in human
MPNST cells similarly inhibited DNA synthesis and cell viability. Interest-
ingly, Erbb4 ablation did not disrupt Ras or MAPK activation. Antibody
arrays instead indicated that erbB4 regulates the PI3K/Akt/mTOR signaling
cascade and the phosphorylation of multiple STAT proteins and other mole-
cules that promote oncogenesis. We conclude that aberrantly expressed erbB4
promotes the proliferation and the survival of MPNSTs via the activation of
key non-Ras dependent signaling cascades. ErbB4 is thus a candidate for tar-
geted therapy in MPNSTs.
119
Succinate Dehydrogenase (SDH) Deficiency in Non-familial Pituitary
Adenomas
Mark Curtis1, Stacey Mardekian2, Markku Miettinen3, Edward Andrews2.1Thomas Jefferson University Hospital; 2Department of Pathology,Thomas
Jefferson University Hospital; 3Laboratory of Pathology, National Cancer
Institute, United States
Succinate dehydrogenase (SDH) deficiency is pro-oncogenic in a variety of
tumors, including extra-adrenal paragangliomas, a subset of gastrointestinal
Abstracts J Neuropathol Exp Neurol � Volume 73, Number 6, June 2014
� 2014 American Association of Neuropathologists, Inc.616
Copyright © 2014 by the American Association of Neuropathologists, Inc. Unauthorized reproduction of this article is prohibited.
Page 33
stromal tumors, and renal cancers. Whereas SDH deficient tumors typically
occur in the setting of germline mutations, SDH deficient tumors also appear
sporadically. Several families with germline mutations in the genes en-
coding SDH have been associated with pituitary adenomas. SDH is an inner
mitochondrial membrane-bound, multimeric enzyme that plays a critical
role in the Kreb cycle and can transfer electrons directly to the ubiquinone
pool. The SDH complex consists of four subunits: SDHA, SDHB, SDHC
and SDHD. In order to determine whether SDH deficiency plays a role in
sporadic, non-familial pituitary adenomas, we analyzed 37 pituitary adenomas
for SDH deficiency from patients with no known familial tumor syndrome
and without other known SDH deficiency associated neoplasms. SDH defi-
ciency was determined by immunohistochemistry, since the loss of any of
the SDH subunits results in the loss of SDHB expression, owing to destabiliza-
tion of the entire SDH complex. Of the 37 pituitary adenomas analyzed, 15
patients were female and 22 male. The mean age of the patients was 53 years
(range 27-85). Two pituitary adenomas showed complete loss of SDHB stain-
ing. Both of these were in males aged 56 years and 27 years. In the 56 year-old,
the tumor also showed loss of SDHA staining, indicating the basis of the loss
of SDHB. In the literature, SDHA deficiency correlates with an SDHA muta-
tion. Our identification of SDH deficiency in 5.4% of the pituitary adeno-
mas analyzed suggests SDH deficiency may be a relatively common factor
contributing to the development of pituitary adenomas in patients not sus-
pected of having a syndrome associated with pituitary adenomas.
120
Immune Cell Infiltrates in Sparsely Granulated and Densely Granulated
Growth Hormone Pituitary Adenomas
Jian-Qiang Lu1, Benjamin Adam1, Robert Broad2, Constance Chik3.1Department of Laboratory Medicine and Pathology, University of Alberta;2Department of Surgery/Neurosurgery, University of Alberta; 3Department
of Medicine, University of Alberta
The tumor immune microenvironment can influence tumor development and
outcome. Immune cell infiltrates in pituitary adenomas are rarely examined.
Sparsely granulated growth hormone (SG-GH) pituitary adenomas are dis-
tinct from densely granulated GH (DG-GH) pituitary adenomas, as SG-GH
adenomas have special properties such as the formation of intracytoplasmic
fibrous bodies and different biologic behavior. The cause of these distinc-
tions and specifically fibrous body formation remains enigmatic. This study
was to examine immune cell infiltrates in SG-GH adenomas, compared with
those in DG-GH adenomas. We examined consecutive cases of SG-GH (n =8)
and DG-GH (n=6) adenomas diagnosed between 2009 and 2013; cases with
concurrent inflammatory disorders, previous operations (including recurrences)
or hemorrhage of the pituitary were excluded from this study. Quantitative
analysis was performed by counting and averaging the numbers of immunor-
eactive cells in 10 È 30 consecutive high-power fields (HPFs). The numbers
of CD68-immunoreactive macrophages were found to be significantly higher in
SG-GH (8.73 T 3.73 per HPF) than DG-GH (4.00 T 2.38 per HPF; p G 0.001,
two-tailed t-test) adenomas. There were no statistically significant differences
between SG-GH and DG-GH adenomas in infiltrates of CD4-immunoreactive
T-cells (4.39 T 3.79 per HPF and 2.74 T 2.80 per HPF, respectively; p = 0.38,
two-tailed t-test) and CD8-immunoreactive cytotoxic T-cells (4.42 T 4.56 per
HPF and 3.26 T 2.02 per HPF, respectively; p = 0.53, two-tailed t-test). No
difference was seen between two groups in low Ki-67 proliferation index or
p53 nuclear immunoreactivity. Our results suggest that SG-GH adenomas
possess more macrophage infiltrates, compared to DG-GH adenomas, which
may contribute and/or be secondary to the formation of fibrous bodies and other
properties of SG-GH adenomas. Since tumor-infiltrating macrophages have
been found to be immunosuppressive and tumor supportive, our observa-
tion helps understand the more aggressive growth of SG-GH compared with
DG-GH adenomas.
121
Histological Predictors of Progression and Radiosensitivity in Cranial
Atypical Meningioma after Total or Subtotal Resection
Chunyu Cai1, Sam Sun2, Richard Perrin1, Clifford Robinson3, Michael
Chicoine4, Albert Kim4. 1Department of Pathology and Immunology,2Washington University School of Medicine; 3Department of Radiation
Oncology, Washington University School of Med; 4Department of
Neurosurgery, Washington University School of Med
Introduction: Atypical meningiomas (AM), WHO grade II, are histologically
heterogenous and exhibit a broad range of clinical aggressiveness. The neces-
sity of adjuvant radiation following gross total resection (GTR) or subtotal
resection (STR) remains controversial. The goal of the current study is to assess
clinicopathological features associated with progression of cranial AM fol-
lowing resection and with the efficacy of adjuvant radiation therapy (ART).
Methods: Fifteen clinicopathological parameters were analyzed from a
total of 210 AM patients who underwent either primary GTR (151 patients,
45 months mean follow-up), or primary STR (59 patients, 67 months mean
follow-up) at Barnes Jewish Hospital. The impacts of ART on progression
were assessed by Kaplan-Meier analysis.
Results: The risk factors for disease progression differed between patients
who underwent GTR and STR. After GTR, 13/151 patients (8.6%) experienced
recurrence (median 47.0 months). Multivariate analysis identified mitotic in-
dex (MI) Q8HPF (p = 0.006) and brain invasion (p = 0.001) as predictors of
recurrence. Kaplan- Meier analysis demonstrated no difference in progression-
free survival (PFS) or overall survival (OS) after GTR vs. GTR/ART (p = 0.9,
p = 0.9). After STR, 27/59 patients (46%) experienced recurrence (median
30 months). Compared to STR alone, ART post STR significantly improved
PFS in AMs without spontaneous necrosis (p=0.001), but had no such effect
in AMs with spontaneous necrosis (p=0.6).
Conclusions: AM recurrences post GTR are uncommon; after GTR, ART
should be reserved for cases with brain invasion or MI Q8/10HPF. Post STR,
ART significantly improves PFS but only for tumors without spontaneous ne-
crosis. The latter finding indicates that spontaneous necrosis may be used as
a biomarker for ‘‘triaging’’ patients to receive ART post STR, and suggests
that tumoral ischemia might confer radioresistance.
122
Meningiomas That Meet Grade II by 3 Criteria Have an Increased Rate
of Recurrence
Christina Appin1, Matthew Schniederjan1, Stewart Neill1, Robert Press1,
Roshan Prabhu1, Ian Crocker1, Daniel Brat1. 1Emory University School of
Medicine, Atlanta, GA
Background: Meningiomas are graded according to the World Health Orga-
nization (WHO) criteria as grade I, II or III. While grade I meningiomas are
considered benign, grade II and III tumors recur more frequently and have a
worse prognosis. Criteria for classification as grade II include 1) brain inva-
sion; 2) specific histologic patterns (chordoid and clear cell); 3) increased mi-
toses; and 4) the presence of at least 3 of 5 atypical features (increased
cellularity, sheet-like growth, prominent nucleoli, ’spontaneous’ or ’geographic’
necrosis and small cells with a high nuclear to cytoplasmic ratio). The purpose
of this study was to determine whether meningiomas that meet more than one
criterion for grade II are more aggressive than those that meet only one criterion.
Design: Seventy-nine grade II meningiomas resected at Emory University
Hospitals from 1999-2010 were included. Slides, pathology reports, and patient
charts from each case were reviewed. Meningiomas were grouped according
to number of histopathologic criteria met to establish a grade II diagnosis and
correlated with time to recurrence and survival data. Median follow-up time
was 3.2 years. Statistical analysis was performed using Fisher’s exact test and
SAS-JMP software.
Results: Meningiomas that met 3 criteria (n=8) for classification as a grade
II neoplasm had a higher recurrence rate (87.5%) than those that only met
one (n=43) or two (n=26) criteria (30.2%; p=0.00397 and 30.7%; p=0.0112,
J Neuropathol Exp Neurol � Volume 73, Number 6, June 2014 Abstracts
� 2014 American Association of Neuropathologists, Inc. 617
Copyright © 2014 by the American Association of Neuropathologists, Inc. Unauthorized reproduction of this article is prohibited.
Page 34
respectively). No significant difference in recurrence rates were noted for
meningiomas that met one criterion compared to those that met two. Within the
timeframe of follow-up, time to recurrence and patient survival did not differ
between study groups.
Conclusion: Meningiomas that meet 3 criteria for grade II have a higher
recurrence rate than those that meet 1 or 2 criteria.
123
NHERF1/EBP50 is a Marker of Ependymoma
Maria-Magdalena Georgescu1, Paul Yell1, Ping Shang1, Kimmo Hatanpaa1,
Lauren Langford2, Charles White 3rd1, Jack Raisanen1. 1Universit of Texas
Southwestern; 2MD Anderson Cancer Center
NHERF1/EBP50 (Na+/H+ exchanger 3 regulating factor 1; ezrin-radixin-
moesin (ERM) binding phosphoprotein 50), an adaptor molecule composed
of two tandem PDZ domains and a carboxyl-terminal ERM-binding re-
gion, is predominantly localized at the apical plasma membrane of normal
epithelia and has been recently implicated in the progression of various
human malignancies. We generated NHERF1-deficient mice and described
structural defects of the intestinal brush border membrane, as well as lacta-
tion deficits. We report here that non-obstructive hydrocephaly also de-
velops with partial penetrance in NHERF1-deficient mice. Examination of
mouse and human brain tissues revealed strong NHERF1 expression at
the apical plasma membrane of ependymal cells, suggesting contribution of
these cells to the development of hydrocephaly, perhaps through abnormal
cilia motility. Based on these findings and on our previous functional and
mechanistic studies showing a tumor suppressor role for NHERF1 by de-
localization from the apical plasma membrane, we analyzed the expression
and localization of NHERF1 in a series of tumors of ependymal origin. Re-
markably, we found a robust staining for intracytoplasmic lumens (ICLs) in
100% of ependymomas (n=13), including the cases with negative EMA stain-
ing. A similar but focal staining pattern was also present in subependymomas
(n=7) and in all but one of the anaplastic ependymoma cases examined (n=5).
True rosettes were highlighted by NHERF1 staining in both ependymomas
and anaplastic ependymomas. This staining was not present in other tumors,
including meningioma, schwannoma, brainstem glioma and oligodendroglioma,
and was only rarely seen in glioblastoma (2/10 cases). These preliminary data
denoting NHERF1 as marker for ependymoma will be validated on a higher
number of cases. Since we have also characterized and reported alterations
of NHERF1 in glioblastoma and colorectal cancer, the differential diagno-
sis, functional implications and in vitro modeling for therapeutic testing will
be discussed.
124
A Novel Medulloblastoma Model Mimicking Human Disease
Guo Zhu1, Sherri Rankin2, Lionel Chow3, Chunxu Qu2, David Ellison2,
Suzanne Baker2. 1St. Jude Children’s Res. Hosp. and The University of
Tennessee HSC; 2St. Jude Children_s Research Hospital; 3Cincinnati
Children_s Hospital Medical Center
PTEN and TP53 are recurrently mutated tumor suppressor genes in human
medulloblastoma. Pten loss induces diverse outcomes in different devel-
opmental contexts. To investigate Pten function in early postnatal brain de-
velopment and tumorigenesis, we conditionally inactivated Pten in neural
stem/progenitor cells in neonatal brain using Nestin-CreER transgenic mouse.
Pten inactivation created a perivascular arrangement of hyperplastic atypi-
cal undifferentiated cells in the cerebellum that did not progress to neoplasia
during the lifespan of the mouse. Co-deletion of Pten and Trp53 cooperated
to produce fully penetrant medulloblastomas originating from cells in these
perivascular locations. Pten / Trp53 double knock-out medulloblastomas showed
a neuronal immunophenotype and a vascular network with a hemangiopericytic
morphology. The neuronal immunophenotype included immunoreactivity for
GabaAR>6, which was absent in tumors arising from Tp53 knockout alone.
EdU pulse-chase experiments demonstrated a perivascular cancer stem
cell population in double knock-out medulloblastomas. The Pten and Trp53
double knock-out medulloblastomas showed recurrent somatic inactivating
mutations in the tumor suppressor gene Ptch1. Gene expression profiles
showed that this model recapitulated the subgroup of human medullo-
blastomas with de-regulated SHH signaling. The models presented here
show that Pten loss is sufficient to drive the formation of a pre-neoplastic
Fperivascular niche_ that can be transformed into medulloblastoma by addi-
tional mutations. We conclude that Pten normally acts to prevent ongoing
proliferation of a normally undetectable stem cell/progenitor niche in post-
natal cerebellum capable of acting as the cell of origin for the SHH subgroup
of medulloblastoma.
PLATFORM SESSION 8: NEURODEGENERATIVE
2 - ALS, FTD, PD, OTHER
Saturday 2Y4 PM, June 14, 2014
Culture Ballroom
125
Incidental Brain Pathologies in Prospectively Followed Normal Elderly
Brain Bank Volunteers
Brittany Dugger1, Joseph Hentz2, Charles Adler2, Marwan Sabbagh1, Holly
Shill1, Sandra Jacobson1, John Caviness2, Christine Belden1, Erika Driver-
Dunckley2, Kathryn Davis1, Lucia Sue1, Thomas Beach1. 1Banner Sun
Health Research Institute; 2Mayo Clinic, Scottsdale Arizona
We recently investigated the clinicopathological outcomes of initially nor-
mal elderly subjects who enrolled in our brain and body donation program
(Dugger et al. J Neuropathol Exp Neurol. 2014). In addition to the defin-
ing histopathology for certain neurodegenerative disorders, other patholo-
gies may exist within the brain, including cerebral white matter rarefaction
(CWMR), argyrophilic grains (Arg), cerebral amyloid angiopathy (CAA), and
glial tauopathies. Furthermore, deposits of proteins that define certain dis-
eases, such as TAR DNA binding protein-43 (TDP-43), may exist but cases
lack corresponding clinical features during life. We sought to determine the
frequencies of these pathologies in a prospectively-assessed, community-based
autopsy series. We utilized the same 119 cases from our previous study, all
having normal cognitive and movement disorder assessments at study entry.
Of these cases, 52% were female, median age at study entry was 83.5 years
(range 67 to 99), and median duration from first visit until death was 4.3 years
(range 0-10). All 119 cases contained at least one of the examined patholo-
gies. With respect to the 87 subjects who were still clinically normal at death,
47 (54%) had CWMR, 22 (25%) Arg, 37 (43%) CAA, 8 (9%) glial tauopathies,
and 41 (47%) TDP-43. Of the 30 who converted to a clinicopathologically
defined neurodegenerative disease by the time of death, 27 cases (90%) had
CWMR, 12 (40%) with Arg, 19 (63%) with CAA, 6 (20%) with glial tauo-
pathies, and 15 (50%) with TDP-43. Pathology groups are not mutually exclu-
sive; particular overlap was found. Although limited by a relatively small sample
size, these other pathologies found within initially normal elderly subjects
represent a rough estimate of the incidence that exist within brains of elderly
individuals over a defined time period.
126
Neuropathologic Analysis Of 59 Centenarian Brains
Masaki Takao1, Shigeo Murayama1, Hiroyuki Sumikura1, Akane Nogami1,
Akiko Uchino1, Yuta Nakano1, Hiroyuki Hatsuta1, Maki Obata1, Nobuyoshi
Hirose2. 1Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology;2Department of Geriatric Medicine, School of Medicine Keio University
Purpose: To describe neuropathologic background of the centenarian brains.
Materials and Methods: From 1972 to 2013, we obtained 59 centenarian
brains out of 8538 autopsy cases in our hospital. We reviewed their medical
records and analyzed neuropathology using standard protocols and staging
methodologies.
Results: The mean age at death was 101.7 T 2.1 y (range; 100-111). There
were 11 men and 48 women. In 43 individuals that we could obtain CDR
Abstracts J Neuropathol Exp Neurol � Volume 73, Number 6, June 2014
� 2014 American Association of Neuropathologists, Inc.618
Copyright © 2014 by the American Association of Neuropathologists, Inc. Unauthorized reproduction of this article is prohibited.
Page 35
scores (0-0.5, 19 cases; 1-3, 24 cases), high likelihood AD cases were 0 in
CDR 0-0.5 and 5 in CDR 1-3. The brain weight of men (1212.3 T 28.4 g)
was heavier than that of women (1066.6 T 13.6 g). 53 cases (89.8%) be-
longed to Braak NFT stages I-II (n=14) and III-IV (n=39). Only 6 cases
(10.1%) were stage V. There were no brains of stage VI. Senile plaques (SPs)
grading of CERAD was as follows: none in 10, sparse in 21, moderate in 11
and frequent in 17 cases. According to NIA-Reagan criteria of Alzheimer
disease (AD), low, intermediate and high likelihood ADs were 12 (20.3%),
9 (15.2%) and 6 (10.2%) cases, respectively. NFT predominant pathology
(NFT stage = III-VI/CERAD SP grading = none or sparse) was seen in 19 cases
(32.2%). There were NFT stage I-II/moderate SPs in 2 cases, and NFT stage
III-IV/frequent SPs in 11 cases. Although Lewy body (LB) pathology was ob-
served in 19 (32.2%) cases, 17 cases remained in incidental or pre-symptomatic
condition. Tufted astrocytes were rarely seen (n=3, 5.1%). Argyrophilic grains
were present in 34 cases (57.6%). 23 cases (39.0%) had cerebral infarcts.
Conclusions: In the centenarian brains, advanced AD pathology as well as
LB pathology may be uncommon condition.
(Supported in part by CBSN, MHLW and Daiwa Securities Health
Foundation.)
127
Association Between Hippocampal Sclerosis of Aging (HS-Aging)
Pathology and Sulfonylurea Drug Exposure in NACC
Peter Nelson1, Erin Abner1, Walter Kukull2, Sarah Monsell2, Eseosa
Ighodaro1, David Fardo1. 1University of Kentucky; 2University of Washington
Hippocampal sclerosis of aging (HS-Aging) is a prevalent brain disease of
the elderly with no known environmental risk factors. HS-Aging is currently
defined by pathological manifestations: neuron loss, gliosis, and atrophy in
the hippocampal formation, not associated with Alzheimer_s-type plaques
and tangles. HS-Aging is among the most prevalent neuropathologic features
of advanced old age. Substantial disease-specific cognitive impairment is di-
rectly associated with HS-Aging when comorbid pathologies are taken into
consideration. We tested the hypothesis (based on a human genomic screen
beyond the scope of this Abstract) that exposure to sulfonylurea drugs is as-
sociated with altered risk for HS-Aging pathology. Sulfonylureas are a popu-
lar class of orally administered anti-diabetic medication. Data were obtained
from the National Alzheimer_s Coordinating Center (NACC) database with
both detailed longitudinal drug history and postmortem data. The study sam-
ple was 624 patients who died after age 85, between 2010-2013, with longi-
tudinal drug history and autopsy data (n=108 with HS-Aging pathology, n=517
without HS-Aging pathology). ‘‘Sulfonylurea use’’ indicated self-reported
use of any sulfonylurea drug at any longitudinal visit. Crude OR for use of
any sulfonylurea for individuals with HS-Aging pathology was 2.14 (95%
CI: 1.06Y4.68, p=0.03); age-adjusted OR=2.19 (95% CI: 1.04Y4.63, p=0.04).The higher HS-Aging pathology in persons taking sulfonylurea medication
was not apparently associated with the patients_ year of pathological diagno-sis, nor did sulfonylurea users have higher burden of AD pathology. HS-Aging
pathology does not appear to be associated directly with diabetes per se be-
cause history of diabetes has a null association with HS-Aging pathology Y for
self-reported diabetes (age-adjusted OR=1.08 (95% CI: 0.58-2.03). These data
provide preliminary support for the hypothesis that among elderly human
subjects, sulfonylurea use may cause or exacerbate HS-Aging pathology. This
study also underscores the importance of pathology-based stratification of
dementia etiology.
128
The Role of the Unfolded Protein Response in Sporadic and Lrrk2-Driven
Parkinson_s Disease
Annie Hiniker1, Scott Oakes1. 1University of California San Francisco
Delineating the mechanisms leading to dopaminergic neuronal death in
Parkinson_s disease (PD) is an unsolved problem that is critical to the de-
velopment of effective PD therapeutics. A large body of evidence points to
a key role for protein misfolding and aggregation in PD; however, activation
of the unfolded protein response (UPR), an essential network of intracellular
signal transduction pathways that reacts to misfolded proteins and modulates
the cell_s response, has not been fully assessed. We are exploring the role of
the UPR in PD using a multifaceted approach. First, we are assessing the
activation status of the UPR in a cohort of 20 PD patients and 20 controls
(not significantly different in age, gender, brain weight, or postmortem inter-
val) using immunohistochemical evaluation of a panel of proteins known to
be upregulated or phosphorylated under UPR activation. Second, we are ex-
ploring the possibility that Lrrk2, the gene most commonly mutated in genetic
PD, may be important in triggering the UPR through an interaction with the
ER transmembrane kinase/RNase Ire1a. Ire1a is a master regulator of the UPR
that allows cells to adapt to remediable stresses but signals apoptosis under ex-
treme stress conditions. Our lab has built a series of powerful genetic tools to
independently control Lrrk2 and Ire1a and test their effects on cell survival.
Finally, we will apply our immunohistochemical panel for UPR activation to a
small cohort of PD patients with known Lrrk2 mutations. Better small molecule
inhibitors against components of the UPR, including Ire1a, have recently be-
come available. Therefore, if we find that neurodegeneration in PD is related to
activation of UPR-induced apoptosis, we are positioned to rapidly test whether
modulating the UPR has therapeutic benefit in pre-clinical models of PD.
129
The Basal Forebrain and Hypothalamus are Involved in a Subset of
Patients with Amyotrophic Lateral Sclerosis (ALS)
Matthew Cykowski1, Hidehiro Takei1, Paul Schulz2, Suzanne Powell1.1Houston Methodist Hospital; 2University of Texas Medical School at Houston
Background: Amyotrophic lateral sclerosis (ALS) is associated with fronto-
temporal cognitive impairment and autonomic nervous system (ANS) dys-
function. Given the weight loss, changes in metabolism, and autonomic
dysfunction observed in ALS, and changes in cognition, we hypothesized that
there would be neuropathologic involvement of basal forebrain and hypo-
thalamus in ALS patients.
Materials and Methods: Autopsy materials and records from 29 ALS patients
were studied with IRB approval. Anatomic regions evaluated for TAR DNA-
binding protein (TDP-43)-positive inclusions and neurites included the lat-
eral septal area (LSA), bed nucleus of the stria terminalis (BNST), ventral
pallidum (VP), ventral striatum including Islands of Calleja (VS/IsC),
substantia innominata (SI) including nucleus of the diagonal band (NDB) and
nucleus basalis (NB), medial hypothalamic preoptic (HPO) and tuberal levels
(HTL), including the paraventricular nucleus (HPV), posterior (PHA) and lat-
eral (LHA) hypothalamic areas, mammillary body and adjacent tuberal nu-
clei (MB/TN), and supraoptic nucleus (SON).
Results: Patients (23 males, 6 females) had a mean age + standard devia-
tion (SD) of 62.1 +/- 8.51 years and a mean brain weight + SD of 1344.5 +/-
145.6 grams. Five (of 24) cases had hypothalamic involvement, including
LHA (4 cases), PHA (3), HTL (3), MB/TN (3), and PO/PV (1). Five (of 22)
cases had involvement of small or medium-sized neurons in SI/NDB/NB; a
single case had filamentous inclusions in the NDB. Seven (of 21) cases had
involvement of VS/IsC. BNST and LSA were involved in six (of 17) and one
(of 10) cases, respectively. VP was not involved (18 cases).
Conclusions: Hypothalamic and basal forebrain involvement occurred in
three patients with only cord, brainstem, and/or agranular frontal cortex in-
volvement, whereas in five other patients it was associated with more
widespread TDP-43 deposition. This observation raises the possibility that
hypothalamic/basal forebrain TDP-43 deposition may precede deposition in
other well-known locations for ALS pathology.
130
Methylation of RAN Translated Glycine-Arginine Dipeptide Repeats in
C9ORF72 FTLD and ALS
Dennis Dickson1, Kevin Bieniek2. 1Mayo Clinic; 2Mayo Clinic Graduate School
We have previously described repeat-associated non-ATG (RAN) trans-
lation of the expanded GGGGCC hexanucleotide repeat in C9ORF72
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Page 36
frontotemporal dementia and amyotrophic lateral sclerosis (c9FTD/ALS).
However, the cytotoxicity of the generated dipeptide repeats (DPR) remains
to be determined. One potential mechanism is through arginine methylation
of glycine arginine repeats. With endogenous RGG/RG motif-containing pro-
teins facilitating cellular pathways such as DNA damage signaling, transcrip-
tion, pre-mRNA splicing, translation, and apoptosis, it is conceivable that
generation of the (GR)n DPR can disrupt equilibrium in these systems. We
observed arginine methylation of neuronal cytoplasmic inclusions in c9FTD/
ALS with immunohistochemistry. Immunoreactivity was observed for mono-
methylarginine as well as symmetric and asymmetric dimethylarginine. These
lesions corresponded to anatomical regions of high DPR neuropathologic bur-
den, including the cerebellum and hippocampus. In addition, methylarginine-
immunopositive neuronal cytoplasmic inclusions were often ‘‘star-shaped’’ in
morphology, similar to DPR and p62/sequestosome-1 in c9FTD/ALS.
Immunohistochemistry of serial sections in the hippocampus with polyclonal
antibodies specific to dimethylarginine and the (GR)n DPR revealed colocali-
zation of these epitopes suggestive of direct arginine methylation of this DPR
repeat. Arginine methylation of RAN translated (GR)n DPR appears to be
a novel and prominent neuropathologic feature of c9FTD/ALS that may have
important implications for disease mechanism and future treatment strategies.
131
C9orf72 Hypermethylation Influences Repeat Expansion Associated
Pathology in ALS/FTD
Elaine Liu1, Jenny Russ1, Kathryn Wu1, Donald Neal1, Eunran Suh1, Anna
McNally1, David Irwin1, Vivianna Van Deerlin1, Edward B. Lee1.1University of Pennsylvania
Hexanucleotide repeat expansions of C9orf72 are the most common genetic
cause of amyotrophic lateral sclerosis and frontotemporal degeneration.
The mutation consists of a large intronic GGGGCC repeat expansion which
is associated with reduced C9orf72 expression, leading to the suggestion
that haploinsufficiency contributes to disease. The repeat expansion is also
associated with the accumulation of potentially toxic RNA and protein
aggregates, supporting the hypothesis that the C9orf72 mutation may cause
disease through a toxic gain of function. CpG methylation is known to pro-
tect the genome against unstable DNA elements and to stably silence inap-
propriate gene expression. C9orf72 promoter methylation has recently been
associated with the repeat expansion mutation. We report here detailed char-
acterization of C9orf72 promoter methylation from human peripheral blood
and brain tissue of repeat expansion mutation carriers. Based on studies in
lymphoblastoid cell cultures from repeat-expanded and non-expanded ALS
patients, we found that C9orf72 methylation leads to transcriptional silencing
which can be reversed by the DNA methyltransferase inhbitor, 5-aza-2’-
deoxycytidine. C9orf72 promoter methylation also significantly reduces cel-
lular vulnerability to oxidative and autophagic stressors, accumulation of RNA
foci, and accumulation of dipeptide repeat protein aggregates. These results
indicate that epigentic silencing of mutant C9orf72 allele may modulate dis-
ease pathogenesis in amyotrophic lateral sclerosis and frontotemporal degen-
eration linked to hexanucleotide repeat expansions.
132
A Loss of Function Mutation in the C9ORF72 Mouse Ortholog Results
in Motor System Degeneration
Daniel Mordes1, Naoki Suzuki2, Johnny Salameh3, Morag Stewart4, Asif
Maroof2, Steve Han3, Robert Brown3, Kevin Eggan5. 1Massachusetts General
Hospital; 2Harvard Stem Cell Institute, Harvard University; 3Department of
Neurology, University of Massachusetts Medical School; 4Program in Cellu-
lar and Molecular Medicine, Boston Children_s Hospital; 5HHMI, Harvard
Stem Cell Institute, Harvard University
A hexanucleotide repeat expansion at C9ORF72 has recently been found in
a significant fraction of patients suffering from amyotrophic lateral sclerosis
(ALS). However, it remains to be determined whether this mutation acts
through a gain of function or loss of function mechanism. We have recently
shown that the mouse C9ORF72 ortholog was most highly transcribed in the
neuronal populations that are sensitive to degeneration in ALS and fronto-
temporal dementia. Here we show that heterozygous and homozygous mice
harboring a loss of function mutation in the ortholog of C9ORF72 are viable,
survive to adulthood and initially display motor system functionality similar
to their wild type litter mates. However, as heterozygous animals aged, we
found they displayed a significantly increased rate of mortality. Death in het-
erozygous animals was associated with declining motor function that was
accompanied by muscle atrophy. Homozygous mutant animals displayed a
similar but accelerated and quantitatively more severe phenotype. Immuno-
histochemical analysis of CNS tissue for ALS-associated pathology will be
presented. Overall, these findings support the hypothesis that reduced
C9ORF72 function and haploinsufficiency resulting from the repeat expan-
sion that many patients harbor contributes directly to the development of ALS.
POSTERS: DAY 2
Saturday 10Y10:30 AM, 4Y4:40 PM, June 14, 2014
Foyer
133
Autopsy Neuropathology of a Case of Microcephaly-Thin Corpus
Callosum Syndrome
Malak Abedalthagafi1, David Urion2, Elizabeth Engle2, Hannah Kinney2,
Rebecca Folkerth1. 1Brigham and Women’s Hospital- Harvard University;2Boston Children_s Hospital- Harvard University
A syndrome of microcephaly and thin corpus callosum in patients with
spastic quadriparesis and global cognitive deficits has been described on the
basis of neuroimaging in families of Arab heritage. Recently, one such dis-
order was mapped to 8q23.2-q24.12 in 4 members of 3 consanguineous
Bedouin families (Halevy et al, 2012. Pediatr Neurol 46:363). The underly-
ing neuropathology of the syndrome, however, has not been reported, and
thus the neuroanatomic substrate is poorly understood. We performed autopsy
evaluation of an 18-year-old woman with spastic quadriparesis and global de-
lay with microcephaly-thin corpus callosum with the additional clinical fea-
ture of medically refractory epilepsy. She was of Pakistani origin, and had a
sibling with a similar neurologic disorder by family report, and death at age
7. We found profound microcephaly (brain wt 350g, expected 1100g), with
sparing of the cerebellum. The temporal lobes were also distportionately small.
The corpus callosum was razor-thin throughout its length, and disproportion-
ately smaller than the hypoplastic white matter of the parietal, frontal, and
occipital lobes. A small white matter bundle resembling a Probst bundle was
noted in the periventricular frontal region, suggesting that the thin corpus
callosum was due to dysfunctional axonal guidance across the midline. De-
scending corticospinal tracts through the brainstem bilaterally were hypoplas-
tic, suggesting defective axonal guidance of the pyramidal system. Cerebral
cortical abnormalities included persistent vertical cortex, poor gray-white dis-
tinction with prominent interstitial white matter neuron population, and fo-
cal subarachnoid glioneuronal heterotopia. Basal nuclei were unremarkable.
Death was due to respiratory infection complicating a neurologically debili-
tated state. The major pathology was developmental in origin and not ac-
quired. We postulate that it is due to a mutation in a gene critically involved in
both neuronal development (proliferation, migration) and axonal targeting.
The gene defect is under investigation.
134
Rhombencephalosynapsis in a Patient with Goldenhar Syndrome
Melissa Gener1, Stephanie Slemp1, Justin Richey1, Dean Hawley1, Jose
Bonnin1. 1Indiana University School of Medicine
Goldenhar syndrome (facioauriculovertebral sequence, FAV sequence) is
a rare genetic disorder characterized by anomalies in the eyes, ears, and
vertebral column. Central nervous system anomalies have been reported in
approximately 50% of cases. They range from mild hydrocephalus to severe
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Page 37
malformations, including Arnold-Chiari malformation, with or without
syringomyelia or hydromyelia, encephalocele, holoprosencephaly, arhinence-
phaly, lissencephaly and others. Cerebellar abnormalities have been reported
in association with Goldenhar syndrome. We report a case of an 11-year-old
female with this condition. Neuroimaging studies revealed ventriculomegaly
and diffuse white matter loss, particularly in the peritrigonal region, atrophy
of the corpus callosum, hypoplasia of the middle ear, fusion of the ossicles,
hypoplasia of the right external auditory canal and absence of the right tem-
poralis muscle. Fusion of the cerebellar hemispheres was also documented.
A CT scan of the spine showed focal levoscoliosis in the lumbar region,
centered at L3-L4 as well as multiple segmentation anomalies of the mid-
thoracic vertebral bodies and S-shaped scoliosis of the thoracic spine. She had
esophageal atresia with tracheoesophageal fistula as well as a history multiple
gastrointestinal surgical procedures including a Nissen fundoplication and
G-tube placement. She also had a horseshoe kidney with multiple episodes of
urinary tract infections. The patient was admitted because of severe abdomi-
nal distention following two days of diarrhea. She deteriorated rapidly and went
into cardiac arrest. Resuscitation efforts were unsuccessful. An autopsy con-
firmed the presence of multiple anomalies in the spine, absence of right pinna,
bicuspid aortic valve, horseshoe kidney and hydrocephaly. Examination of the
hindbrain revealed absence of the cerebellar vermis and fusion of the cerebellar
hemispheres and dentate nuclei. Although cerebellar hypoplasia has been ob-
served in association of Goldenhar syndrome, to our knowledge, rhombencepha-
losynapsis has not been previously reported in association with this syndrome.
135
Characterization of Neuropathologic Findings in a 16 month-old Female
with Pfeiffer Syndrome
Bret Evers1, Dennis Burns1, Charles Timmons2, Veena Rajaram2. 1UTSW;2UTSW/CMC
Pfeiffer syndrome, a rare genetic disease caused by mutations in members
of the fibroblast growth factor receptor (FGFR) family, is characterized by
multiple developmental anomalies, namely craniosynostoses, mid-face hypo-
plasia, digit abnormalities, and mental retardation. Currently, the neuropatho-
logic findings in Pfeiffer syndrome have been limited to those found in four
fetal cases. Here, we describe the neuropathologic abnormalities observed in
a 16 month-old female with a confirmed S351C mutation in FGFR2. Gross
autopsy findings of the CNS included megalencephaly, hydrocephalus, tem-
poral lobe enlargement with hippocampal dysmorphogenesis, atrophy of the
corpus callosum, absence of the septum pellucidum, Chiari type I malforma-
tion, and caudal deviation of the brainstem with a small pons. Microscopically,
foci of polymicrogyria and cerebral white matter neuronal heterotopias were
observed, indicative of a neuronal migration defect; and sections through
the hippocampi revealed moderate to severe disorganization of the hippo-
campal pyramidal cell layer and dentate gyrus. Additionally, brainstem sec-
tions showed generalized white matter atrophy of the cerebral peduncles, basal
pons, and medullary pyramids. These various findings can be explained by the
role of FGFR2 in the development and differentiation of the CNS. Our studies
not only further characterize the neuropathology of Pfeiffer syndrome but
also are the first to provide details on its postnatal course.
136
Novel Nonsense Mutation of FLNA in a 26 year Old Female with
Periventricular Nodular Heterotopias and Severe Emphysema
Patricia kirby1, Erica Savage2, Benjamin Darbro2. 1University of Iowa Hospi-
tals and Clinics, Dept of Pathology; 2University of Iowa College of Medicine
Numerous mutations of the filamin A gene (FLNA) have been reported in
the English literature with the most common association being periven-
tricular nodular heterotopias (PVNH). As filamin A is integral in cell cyto-
skeleton formation, mutations also result in non-CNS abnormalities including
cardiac, skeletal, platelets, pulmonary, gastrointestinal, soft tissue and uro-
genital pathology. PVNH together with pulmonary disease is uncommon,
presenting almost exclusively in infants with a spectrum of tracheobroncho-
malacia, atelectasis, pulmonary cysts and congenital emphysema. Pulmonary
hypertension and oxygen dependence are reported in rare survivors.
We report a 26 year old female with Scheuermann_s kyphosis in whom
bilateral PVNH and severe emphysema were found at autopsy. She had
presented for surgical correction of progressive kyphosis to ameliorate
worsening dyspnea. Her past medical history was notable for moderately
severe aortic and mitral incompetence, macrothrombocytopenia, joint laxity
and prior inguinal and hiatus hernia repairs. She was of normal intelligence
and had no dysmorphic facial features, extremity anomalies or history of
seizures. Her post-operative course was complicated by an abrupt onset of
pulmonary hypertension with congestive cardiac failure. A saddle embolus
was suspected but not identified on emergent surgical exploration. She de-
veloped a refractory bleeding diathesis with subsequent multiorgan failure.
Death occurred on post-operative day 14.
Autopsy revealed severe pulmonary emphysema and diffuse bilateral PVNH
with glomeruloid blood vessels. Whole exome sequencing was performed
on DNA extracted from peripheral blood. An average of 100x coverage was
obtained across the targeted exonic regions. Focused analysis of the FLNA
gene revealed a novel nonsense mutation in exon 11 that is similar to those
known to cause PVNH (NM_001456.3 c.1675G9A, p.Q559*).
This patient_s numerous pathologies expand the phenotypic presentation of
FLNA cases in the literature.
137
Cortical and Leptomeningeal Angiomatosis Associated Epilepsy in a
68 Year Old Female: A Case Report
Nishant Tiwari1, Daniel Grimmer1, J Goodman1, Meenakshi Bhattacharjee2.1Baylor College of Medicine, Houston, TX; 2University of Texas Medical
School, Houston, TX
Sturge Weber Syndrome (SWS) can be classified clinically based upon the
extent of disease and location of the angiomatosis. Sporadic type III SWS is
the CNS selective entity, associated with isolated leptomeningeal and cortical
involvement without facial port wine stain. These patients frequently present
with refractory epilepsy and migraine headaches. Symptoms usually develop
early, and more than 95% cases are symptomatic by 5 years. Very rarely have
patients presented at older ages.
We present a 67 year old woman who developed epilepsy at age 52. She
does not have migranous headaches, port wine stains or glaucoma, or sig-
nificant family history. MRI showed linear enhancement, with cortical cal-
cifications and atrophy in the left frontal lobe. Biopsy of the lesion in the
non-eloquent cortex was performed.
Pathologic examination showed increased cortical parenchymal and menin-
geal vasculature, and associated gyral calcifications associated with the cortical
vessels. Immunohistochemistry was performed to better define the pathology.
GFAP highlighted reactive astrocyosis. Neu-N staining showed mild dysplas-
tic features, and phosphorlylated neurofilament revealed rare stained neurons.
The pathologic features were consistent with a diagnosis of SWS with associ-
ated cortical dysplasia.
To the best of out knowledge, this case appears to be the oldest presenta-
tion and diagnosis reported in the english literature. In SWS Type III, the
diagnosis of purely CNS disease can be delayed due to lack of clinical suspi-
cion. However, the recently described GNAQ somatic mutation (c.548GYA,
p.Arg183Gln) seen in up to 88% of patients with SWS may help in recognition
of a wider spectrum of the disease.
138
Neuropathology of a Case of Joubert Syndrome with an Unusual Ge-
netic Background
Douglas Miller1, Eric Destrampe2, Carl Stacy2. 1University of Missouri
School of Medicine; 2Dept of Pathology & Anatomical Sciences, U Missouri
School of Medicine
A 3 year old died unexpectedly. He carried a diagnosis of Joubert Syndrome
(JS), with multicystic kidneys, retinal dystrophy, epilepsy, ptosis, hypospadias,
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Page 38
and brain abnormalities. He had been unable to walk or talk, had severe de-
velopmental delay, and had episodic tachypnea (a feature of some cases of
JS). He allegedly watched television but did not track a light or finger vi-
sually. He was hypotonic with normal deep tendon reflexes. Imaging had dis-
closed vermian aplasia and a ‘‘molar tooth’’ conformation of the midbrain
and pons in axial images. Genetic testing revealed heterozygosity for two dif-
ferent mutations in the CEP290 gene and an unrelated deletion from 1p21.3.
Neuropathological examination confirmed vermian aplasia with dilatation of
the aqueduct and fourth ventricle but no cisterna magna cyst. The midbrain
was short rostro-caudally with thickening and elongation of the undecus-
sated superior cerebellar peduncles (giving the ‘‘molar tooth’’ appearance).
The corticospinal tracts did not decussate in the medulla, consequently there
were no pyramids; the pontine pyramidal tracts were small and laterally dis-
placed. The oculomotor nerve fascicles arose from dispersed large neurons
not discrete nuclei, curved laterally around the lower cerebral peduncles and
then medially, emerging into the subarachnoid space within heterotopic neuro-
glial tissue in which they were myelinated by oligodendrocytes, not Schwann
cells. The basis pontis nuclei were hypoplastic and the inferior olivary and
dentate nuclei were dysplastic. There was focal foliar dysplasia. In addition
to posterior fossa abnormalities, there were multiple foci of cortical dysplasia,
patchy abnormal myelination of the hemispheric white matter, and absence of
the optic radiations and striae of Gennari.
There are few descriptions of the neuropathological abnormalities of JS,
none from a child with this genetic background. Our case shares many
features with published descriptions and clearly fits the syndrome but has
additional abnormalities which may reflect the unusual genetics.
139
BRAFV600E Mutation is Not Associated with Focal Cortical Dysplasia
Sonika Dahiya1, Devon Haydon1, Jeffrey Leonard1, David Gutmann1,
Robert Schmidt1. 1Washington University School of Medicine
Introduction: BRAFv600e mutation is common in low-grade CNS tumors
with nearly half of gangliogliomas (GG) harboring this point mutation.
Nevertheless, although one-third of GGs may be associated with focal
cortical dysplasia (FCD) and both of these are included in the mTORopathy
spectrum, the role of this specific mutation in FCD has remained rather
unexplored. Furthermore, while this mutation may be present in both the
glial and neuronal components, it is more frequent in the latter. In the
current study, we investigated the role of BRAFV600E mutation in FCD
presenting either as isolated lesions and/or collision lesions which had
concurrent GG.
Design: We performed immunohistochemistry for BRAFv600e on eleven
cases of isolated FCD cases and five cases with collision lesions (FCD and
ganglioglioma). Immunostaining was also done for phospho-S6 (p-S6; marker
of mTOR activation).
Results: While all of FCD alone (0/11) cases were negative for this point
mutation, two cases with collision lesions (2/5 cases) showed expression of
the mutant protein limited to GG areas only. All the cases in our cohort,
including both the components in collision lesions, were positive for p-S6
expression.
Conclusions: Expression of p-S6 in all our cases is consistent with the
notion that both FCD and GG exhinit mTOR signaling activation. However,
the lack of BRAFv600e may be a signature of neoplasia.
140
Development of the Hippocampal Formation in Human: Part II-
Dentate Gyrus
Sara Cipriani1, Catherine Verney1, Jeannette Nardelli1, Pierre Gressens1,
Homa Adle-Biassette2. 1INSERM UMR 1141; 2Department of Pathology,
Lariboisiere Hospital, APHP & INSERM UMR1141
This is the first detailed study describing the development of hippocampal
formation in human embryos and fetuses from 8 weeks of gestation (GW) to
midgestation. Multiple immunohistochemical labelings were performed to
study the progenitors using Ki67 associated with nestin, SOX2, PAX6 and
TBR2, and post mitotic neuronal markers using NeuN, CUX1, SATB2,
CTIP2, TBR1, NeuroD1, doublecortin, CaBP, and Calretinin. Our results
showed the presence of SOX2/Ki67 double-labeled cells in the ventricu-
lar zone of the hippocampal formation next to the hem from 9 GW. The
secondary dentate matrix, a germinative matrix located adjacent to the VZ
of the dentate neuroepithelium was present around 11 GW. It consisted of
proliferative cells composed of Pax6+, Sox2+ and Tbr2+ progenitors and
migratory cells. It extended tangentially towards the dentate gyrus follow-
ing a subpial migration route and established the proliferative tertiary den-
tate matrix in the hilus. The dentate gyrus became progressively identifiable
from 13 GW. Dentate granule cells were composed of two main postmi-
totic neurons, labelled by Cux1 and CTIP2 transcription factors markers. In
conclusion, the histological stages of formation of the dentate gyrus in hu-
man are roughly similar to that described in rodents. The pattern of ex-
pression of the transcription factors is different from the pyramidal layer of
the hippocampus and from the neocortex. Animal studies suggest that all
granule cells appear to project to CA3, forming the mossy fibres. The present
study suggests that the densely packed granule cells in human are composed
of different neuronal subtypes during development. Neuronal subtypes and
connections of the dentate gyrus have yet to be investigated.
The research leading to these results was performed in the frame of
DEVELAGE project ‘‘Pathways common to brain development and ageing:
defining strategies for preventive therapy and diagnostics’’ (HEALTH-F2-
2011-278486) and has received funding from the European Community_s7th Framework Programme (FP7/2007-2013).
141
Aprosencephaly-Atelencephaly in a Neonate with Severe Facial features
of Holoprosencephaly
Nitin Agarwal1, Ada Baisre1. 1Rutgers New Jersey Medical School
We report a case of the very rare atelencephaly/aprosencephaly spectrum,
also termed aprosencephaly (XK) syndrome with severe craniofacial features
of holoprosencephaly. The case is that of a baby girl born at 34 weeks of
gestation to a 21-year-old mother without prenatal care and past medical his-
tory of a ‘‘previously abnormal fetus aborted during the first trimester’’. On
external examination, craniofacial abnormalities typically seen in holoprosen-
cephaly were severe, including one fused anterior/posterior fontanelle, anop-
thalmic cyclopia, arhinia, and hypoplastic mouth. Internal examination of the
cranial vault showed absence of the anterior cranial fossa, orbits and periorbi-
tal structures, with a hypoplastic middle cranial fossa with absent sella turcica
and pituitary gland. The cerebral hemispheres were also absent and the cra-
nium was filled with approximately 500 cc of translucent-yellow fluid. A
poorly formed diencephalon and relatively preserved infratentorial structures
and spinal cord were identified. The general autopsy also revealed hypoplasia
of the adrenal glands and pulmonary hyaline membranes. There was a normal
female karyotype [46XX].
142
Shaken Baby Y Review of Old Cases
Roland Auer1. 1Universite de Montreal
Shaken baby syndrome continues to be diagnosed based on a triad of retinal
hemorrhage, subdural hemorrhage and encephalopathy. As part of a move to
close medicolegal cases that were still open, the author was asked to review
a case from 1991 by the police and a defense attorney. Two questions were
posed. The first was to determine whether the diagnosis could be sustained
after consultative review. The second was whether the case would be inter-
preted differently now 23 years after the diagnosis of shaken baby had first
been entertained based on subdural hemorrhage, retinal hemorrhage and
encephalopathy. Clinical history revealed a 5 day duration of a low grade fe-
brile illness with sudden deterioration, gasping for air and cardio respiratory
arrest. Blood cultures were taken and antibiotics were administered in hospital
but the child rapidly died. Review of the case revealed severe hemorrhagic
Abstracts J Neuropathol Exp Neurol � Volume 73, Number 6, June 2014
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Page 39
bronchopneumonia in all 5 lobes of the lungs, with little aeration. Hemor-
rhage was also seen in the kidneys, adrenal glands, retina, leptomeninges of
the optic nerve and subdural space. A severe global ischemic encephalopathy
was found, with ischemic necrosis comprising acidophilic neurons in most
brain regions examined. Because of the presence of the triad, the father was
charged in the death of his 5-month-old daughter, as he was the last caregiver
prior to bringing her to hospital. The science done over the past 20 years has
undermined the biophysics of producing the triad by shaking. Retinal and
subdural hemorrhage once thought to be pathognomonic of shaken baby is
now known to have many causes such as infection and reperfusion hemor-
rhage after cardiac arrest, as in the present case. A review of 8 local cases
shows that hemorrhages can occur from numerous causes other than trauma.
These facts are important to avoid wrongful convictions of innocent parents.
143
Toddler with Microcephaly and Basal Ganglia Calcifications:?
Aicardi-Goutieres Syndrome
Veena Rajaram1, Esther Bit-Ivan2, Russell Fetzer3, Jason Wang1, Naseem
Uddin1. 1UT Southwestern/ Children’s Medical Center, Dallas; 2Feinberg
School of Medicine, Northwestern University; 3UT Southwestern Medical
Center, Dallas, TX
Aicardi-Goutieres syndrome (AGS) is an inherited progressive encephalop-
athy characterized by basal ganglia calcifications with cerebrospinal fluid
(CSF) lymphocytosis and increased interferon-> level relative to the serum
levels. Clinically, the patients have microcephaly with developmental delay/
regression, spasticity, dystonia, abnormal eye movements and epilepsy. Other
clinical findings include feeding difficulties, recurrent mild fever, chilblains,
and transient elevation in liver enzymes. Imaging and neuropathology studies
report bilateral basal ganglia calcifications with calcifications in the white
matter, thalami, dentate nuclei and small vessel calcifications. Mutations in
TREX1, RNASEH2B, RNASEH2C, RNASEH2A and SAMHD1 genes are
thought to account for over 90% of these cases. We report a case with clinical
and neuropathological findings most consistent with AGS. The patient was
a 20-month old boy with microcephaly, feeding difficulties and developmental
lag noticed at 7 months of age. He had developmental delay and developed
spastic quadriparesis with dystonia and alternating exotropia. Further neuro-
logical evaluation was pending. He had recurrent fever with bronchiolitis. He
presented with a few days of fever, severe respiratory distress and unrespon-
siveness. CT scan at this time showed marked hydrocephalus with symmetric
dystrophic calcifications in the basal ganglia, cerebral periventricular white
matter and deep cerebellar nuclei. He had mildly elevated liver enzymes.
Investigations for TORCH and other infections were negative. He continued
to deteriorate and care was withdrawn. At autopsy, grossly, he had micro-
cephaly with dilated lateral ventricles, atrophy and yellow discoloration of the
basal ganglia. Histologically, there was neuronal loss with gliosis in the basal
ganglia and thalami, white matter loss with gliosis in the cortex and cerebel-
lum and diffuse parenchymal and small vessel calcifications. Though a CSF
analysis was not performed, in the absence of an infectious etiology, the clini-
cal and histological findings are most consistent with AGS. Genetic testing for
the above genes is in process.
144
Mesial Temporal Sclerosis with Dysplastic Dentate Fascia Neurons: A
Case Report.
Matthew Wood1, Arie Perry2. 1University of California, San Francisco;2University of California, San Francisco, Division of Neuropathology
Background: Hippocampal sclerosis (HS) is the most common finding in
surgical specimens for medically refractory epilepsy. In some cases, a second
seizure-associated lesion is identified (dual pathology). HS associated with
focal cortical dysplasia (FCD IIIa) is one example, although in such cases
dysplasia is typically restricted to neocortex. Rare cases of HS have been re-
ported showing dentate fascia granular cell dispersion combined with CD34-
positive balloon cells, with or without associated neocortical FCD. Here, we
describe an additional example of dual HS/FCD with CD34-positive balloon
cells and dysplastic ganglion cells in the dentate fascia.
Case Report: A 33 year-old right-handed woman presented with medically
refractory seizures. MR imaging showed abnormal left hippocampal T2 hyper-
intensity, architectural distortion, and atrophy. Electroencephalographic moni-
toring during two seizures indicated a left hemispheric origin. The patient
underwent surgical resection of the left hippocampus, temporal lobe tip, and
amygdala. Sections showed marked neuronal loss and gliosis involving the
CA1 and CA4 regions, along with granule cell dispersion, consistent with HS.
Dysmorphic ganglion cells and balloon cells were noted within and imme-
diately surrounding the dentate fascia. A subset of dysmorphic neurons were
neurofilament-positive, and a subset of the balloon cells expressed GFAP.
In addition, focal CD34-positive balloon cells with atypical arborizing pro-
cesses were identified. The left temporal tip resection showed focally jumbled
neurofilament-positive neurons with slightly enlarged cell bodies, but no CD34-
positive population (FCD IIa).
Summary: We report a rare case of epilepsy-associated HS combined with
neocortical FCD IIa, with dysmorphic ganglion-like cells and CD34-positive
balloon cells in the dentate fascia. Whether this reflects a purely
developmental process or involves secondary changes associated with HS
remains unclear.
145
Glycogen Storage Disease Type III: Neuropathologic Phenotype
Associated with Mutations in the AGL Gene
Kathy Newell1, Robert Reynders2, Jill Murrell3. 1KU School of Medicine,
Dept of Pathology and Laboratory Medicine; 2KU School of Medicine,
Department of Neurology; 3IU School of Medicine, Department of
Pathology and Laboratory Medicine
Glycogen storage disease type III (GSD III), caused by a deficiency of
glycogen debranching enzyme, affects liver, skeletal muscle, and heart.
Central nervous system (CNS) involvement has not been described to our
knowledge. We present the neuropathologic findings in a 27 year-old woman
diagnosed with GSD III at age 1-1/2 years during a metabolic disorder workup.
AGL gene mutations were later identified. She developed end-stage cirrhosis,
underwent orthotopic liver transplant at age 24, and died at age 27 with
invasive aspergillosis and Pneumocystis pneumonia while on chronic immu-
nosuppressive therapy. Neurologic examination in the last week of her life
documented brisk biceps, brachioradialis, and patellar deep tendon reflexes.
A full autopsy confirmed glycogen storage in the heart and skeletal muscle.
Histological sections from the fixed brain were stained with hematoxylin
and eosin with/without Luxol fast blue. Periodic acid Schiff (PAS) stains
with/without diastase were performed on select sections. Multiple brain stem
nuclei, including cranial nerve nuclei VI, VII, XII, dorsal motor nucleus of
X, spinal trigeminal nucleus, and the lateral reticular nucleus, and spinal cord
anterior horn cells contained numerous neurons with vacuolated, clear cyto-
plasm with fine eosinophilic deposits that were PAS-positive and diastase
sensitive, compatible with glycogen. Ultrastructural evaluation of the de-
posits is underway. The cerebral cortex and deep nuclei did not show ob-
vious neuronal storage. White matter myelin was preserved. Multifocal brain
abscesses contained branching septate hyphae, confirmed as Aspergillus
fumigatus from postmortem cultures. Frozen brain tissue was reserved for
confirmation of the AGL gene mutation. Autopsy neuropathological evalua-
tion remains an essential tool in the study and documentation of rare dis-
orders, such as glycogen storage disease.
146
Inadvertent Intrathecal Vincristine Administration with Widespread
Axonal Injury Demonstrated by APP Immunohistochemistry
Jesse Kresak1, Marie Rivera-Zengotita1, Martha Burt1, Anthony Yachnis1.1University of Florida
Vincristine is a Vinca alkaloid chemotherapeutic agent used to treat
hematologic and some solid-organ neoplasms. As a microtubule inhibitor,
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Page 40
an unfortunate side-effect of this drug is disruption of axonal transport.
Thus, the drug is intended for intravenous use only. We report a 59-year old
man with diffuse large B-cell lymphoma who inadvertently received intra-
thecal vincristine. The patient experienced progressive neurologic decline
despite attempts at CSF lavage with fresh frozen plasma and died five days
after the incident. Grossly, there was evidence of prior shunt placement, the
brain was mildly swollen, and the white matter appeared congested. Histo-
logical study revealed pallor of the centrum semiovale, focal perivascular
hemorrhages, and widespread axonal spheroids that were demonstrated by
immunohistochemical study for amyloid precursor protein (APP). There was
subependymal spongiosis and focal hydropic-like change of the ependyma.
Proximal axon segments of anterior horn neurons showed many APP-reactive
spheroids as they exited the spinal cord. Anterior spinal nerve roots also con-
tained APP-positive swellings. No significant pathologic changes were iden-
tified in the gray matter. In particular, there was no Purkinje cell loss. No
evidence of residual lymphoma was identified. This case illustrates diffuse
axonal injury caused by toxic disruption of axonal transport and emphasizes
the need for continued awareness of this preventable medical error.
147
Leptomeningeal Transthyretin Amyloidosis: A Case Study
Jennifer Ziskin1, Anna Okumu2, Christopher Adams2, Edward Plowey1.1Stanford University Medical Center, Department of Pathology; 2Stanford
University Mass Spectrometry, Stanford, CA
Background: Transthyretin amyloidosis is usually a systemic disease,
however, rare mutations are associated with leptomeningeal amyloidosis
that may lead to dementia and ataxia. Case reports of leptomeningeal
transthyretin amyloidosis associated with the Tyr69His variant of trans-
thyretin (TTR) are rare and do not discuss the neuropathologic features of
the disease. Characterization of the associated histopathologic features is
important to elucidate the role of leptomeningeal amyloidosis in neuro-
degeneration and dementia.
Design: We report a case of leptomeningeal amyloidosis in a 72 year old
man with no significant family history who suffered from dementia and ataxia.
A complete autopsy, including brain examination, was performed. Mass
spectroscopy (MS) was employed to analyze the leptomeningeal amyloid.
Results: Histologic sections revealed systemic amyloidosis affecting the
heart, lungs and other visceral organs. Widespread vascular and extrava-
scular amyloid was documented in the leptomeninges. The amyloid ex-
tended into superficial cortical penetrating vessels and was prominently
deposited in subpial and subependymal distributions throughout the brain.
Other conspicuous neuropathologic findings included neocortical molecular
layer gliosis, gliosis of the alveus and fimbria and cerebellar cortical
atrophy. In addition to immunoreactive hippocampal neurons, a phospho-tau
immunostain (AT8) revealed neocortical threads. No significant amyloid-
beta immunoreactivity was seen. TTR gene sequencing performed on the
paraffin embedded tissue identified a point mutation in exon 3 encoding a
Tyr69His mutation. MS performed on the amyloid in paraffin block cores
demonstrated abundant TTR with an 8-fold higher concentration of variant
Tyr69His TTR compared to wild-type TTR.
Conclusions: Mutant TTR is a rare cause of leptomeningeal amyloidosis.
We demonstrate the utility of MS in identifying transthyretin variant Tyr69His
in a patient with leptomeningeal amyloidosis. We report additional neuro-
pathologic features including phospho-tau positive neocortical threads and in-
jury to hippocampal outflow structures, factors which may contribute to the
dementia phenotype.
148
3R Predominant Tauopathy with Globular Glial Inclusions
Stewart Neill1, Jonathan Glass2, Allan Levey2, Monica Parker3, Deborah
Cooper2, Marla Gearing1. 1Department of Pathology and Laboratory
Medicine, Emory University; 2Department of Neurology, Emory University;3Department of Medicine, Emory University
Background: Numerous sporadic and familial neurodegenerative disorders
involving aggregations of the microtubule-associated protein tau have been
reported over the past several decades. Most of these tauopathies have shown
a predominance of 4-repeat (4R) tau isoforms, the major exception being the
3R predominant Pick disease. The globular glial tauopathies (GGT) are 4R
tauopathies showing small round tau-positive inclusions in white matter glia.
We report a case displaying similar inclusions with a predominance of 3R tau.
Case History: The patient was a Caucasian male who initially presented to
our facility at age 82 with short-term memory loss that progressed to include
behavioral disinhibition and agitation. No family history of dementia was
noted. A clinical diagnosis of mixed Alzheimer_s and vascular dementia was
made. The patient_s memory loss and behavioral problems progressed until
his death at age 89.
Autopsy Findings: The brain showed marked cortical atrophy of the frontal,
parietal, and temporal lobes; the hippocampus, amygdala, and entorhinal
cortex were severely affected. Microscopic examination showed neuronal
loss and gliosis in atrophic limbic areas; sections of atrophic cortex showed
primarily superficial spongiosis. A lacunar infarct was noted along with
moderate small-vessel thickening. Special and immunohistochemical stains
documented findings sufficient for diagnoses of probable Alzheimer_s disease
(CERAD criteria) and neocortical Lewy body disease. TDP-43 immunohisto-
chemistry revealed deposition in numerous supratentorial locations. Tau im-
munostains revealed the most striking findings: neurofibrillary tangles in
cortical, deep gray, brainstem, and spinal cord structures, along with prominent
astrocytic and oligodendroglial inclusions in white matter. These inclusions
were diffusely 3R tau-positive and 4R tau-negative by immunohistochemistry
and displayed a distinct morphology with numerous small round inclusions
clustered around glial nuclei. No Pick bodies were seen.
Discussion: The finding of widespread 3R globular inclusions in white
matter glia appears novel. It may expand the range of 3R tauopathies, and
GGTs in particular.
149
Childhood Neurodegenerative Disease with Widespread Tauopathy
Dibson Gondim1, Jill Murrell1, Adrian Oblak1, Deborah Sokol1, Laurence
Walsh1, Gregory Bosh1, Ruben Vidal1, Michel Goedert2, Bernardino Ghetti1,
Jose Bonnin1. 1Indiana University School of Medicine; 2Medical Research
Council Laboratory of Molecular Biology (UK)
Severe accumulation of pathologic tau protein in neurons throughout the
cerebral cortex and subcortical structures occurs in several adult-onset spo-
radic and genetically determined neurodegenerative diseases. On the contrary
tau is less known to accumulate in diseases of childhood. Tau deposits have
been observed in a number of unrelated conditions, including Niemann-Pick
disease type C, pantothenate-kinase-associated neurodegeneration, subacute scle-
rosing panencephalitis, postencephalitic parkinsonism, SLC9A6-related men-
tal retardation, and chronic traumatic encephalopathy. We report the case of a
14-year-old male with a neurodegenerative disease characterized by severe
tau deposition. The child had no significant developmental or neurological
problems until age 2 when speech and cognition started to deteriorate and was
diagnosed as having autistic spectrum disorder. Multiple MRIs did not reveal
brain abnormalities until age 11, when generalized cortical atrophy, ventricu-
lomegaly, thinning of the corpus callosum and atrophy of the brainstem were
documented. Since then, he developed behavioral problems, gait abnormali-
ties, dysphagia, constant drooling, mild protrusion of the tongue and slight
ptosis. He also had some cogwheeling, marked rigidity in both lower ex-
tremities and tended to fall backward. Extensive work-up did not reveal any
genetic and mitochondrial disorders, enzymatic abnormalities, or storage dis-
eases. An EEG confirmed the presence of severe slowing in the background
and bifrontal epileptiform discharges that became generalized at times. Later
in his course, he developed severe spasticity and mutism. He died at age 14. At
autopsy, the brain weighed 1040 grams. Cerebrum, cerebellum and brainstem
were atrophic. By histology and immunohistochemistry, numerous neuro-
fibrillary tangles, tau-positive neurons, astrocytic plaques and neuropil threads
were seen throughout the brain. DNA was extracted from liver, postmortem.
Abstracts J Neuropathol Exp Neurol � Volume 73, Number 6, June 2014
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Page 41
The MAPT gene was sequenced and no mutation was found. Further chro-
mosomal and molecular genetic studies are in progress to better define the
cause of this disorder and the pathogenesis of the severe tauopathy.
150
Creutzfeldt-Jakob Disease: Review of the Past Twenty Three Year
Experience
Francine Epperson1, Adrian Oblak1, Jill Murrell1, Rose Richardson1, Brenda
Dupree1, Pedro Piccardo2, Pierluigi Gambetti3, Bernardino Ghetti1. 1IU
School of Medicine, Dept of Pathology and Laboratory Medicine; 2Food
and Drug Administration; 3Case Western Reserve University
The aim of this report is to review the work of the last 38 years devoted to
identifying prion diseases (p.d.) in the neuropathology laboratory at Indiana
University School of Medicine, Department of Pathology and Laboratory
Medicine. This analysis might be useful for planning resources needed
for the development of a prion-dedicated laboratory in an academic setting.
We have summarized the experience related to Creutzfeldt-Jakob disease
(CJD) between 1991-2014, dividing these 23 years in two periods, before
(1991-1996) and after (1997-2014) the development of the National Prion
Disease Pathology Surveillance Center (NPDPSC). Between 1991 and 2014,
a total of 256 cases (243 autopsies and 13 brain biopsies) were obtained to
rule out a diagnosis of CJD. There were 117 cases from Indiana, 129 from
22 other states and 10 from two foreign countries. Prionopathies were diag-
nosed in 195 cases, including 168 sCJD (155 autopsies, 13 biopsies), 24 fCJD,
one GSS, one FFI, and one variably protease-sensitive prionopathy (VPSPr).
Sixty one cases were negative for p.d., and included diagnoses of AD, DLB,
FTD/MND, other neurodegenerative disease, and cancer. Prior to the develop-
ment of the NPDPSC (1991-1996), 48 cases were studied (46 prionopathies
and 2 other). Between 1997 and 2014, 208 cases were received, 64 were con-
firmed CJD from Indiana and 85 from other states. The cases from Indiana
were received from the following counties: 9 each from Marion and Allen, 4
each from Delaware and Johnson, 2 each from nine counties, and 1 each from
20 counties. The recent discovery of VPSPr and its clinical similarity to other
degenerative diseases highlights the urgency of recognizing that at least one
laboratory for prion diseases should be available in every state to develop
accurate epidemiological data related to prionopathies in the US.
151
Gerstmann-Straussler-Scheinker Disease PRNP A117V: Prion Protein
Deposition in Neurosensory Retina
Kathy Newell1, Francine Epperson2, Masaki Takao2, Martin Farlow3,
Frederick Unverzagt4, Bernardino Ghetti2. 1KU School of Medicine, Dept
of Pathology and Laboratory Medicine; 2IU School of Medicine, Dept of
Pathology and Laboratory Medicine; 3IU School of Medicine, Department
of Neurology; 4IU School of Medicine, Department of Psychiatry
Gerstmann-Straussler-Scheinker disease (GSS) is a neurodegenerative
disease associated with mutations in the Prion Protein (PRNP) gene and
characterized by deposition of prion protein (PrP) in the brain. In sporadic
and variant Creutzfeldt-Jakob disease (sCJD, vCJD), deposition of PrP in
the retina has been reported, but limited information is available about
retinal involvement in hereditary prionopathies. We studied a 41-year-old
woman carrying the A117V mutation in PRNP. The proband presented with
amnesia and dysphasia, followed by mild fine tremor in the right hand. Eight
months later, saccadic pursuit eye movements, mild lower extremity
weakness, mild ataxia, and generalized hyperreflexia were noted. Neuropsy-
chological testing revealed severe general cognitive dysfunction, and the
mini-mental status exam score was 13/30. She died at age 42. The brain and
eyes were obtained at autopsy. The brain was moderately atrophic, and mild
spongiform change was observed in the cerebral cortex and basal ganglia.
PrP deposits in the form of unicentric and multicentric plaques were wide-
spread. The cytoarchitecture of the retina was well preserved, but PrP immuno-
positive deposits were numerous in the outer plexiform layer (OPL). The
deposits were aligned in the retinal layer that corresponds to the synapses
between axons of photoreceptor cells and processes of cells of the inner nu-
clear layer. No PrP-immunopositivity was seen in the corneoscleral coat, the
uvea, or the optic nerve. A similar pattern of retinal involvement was observed
in GSS associated with the F198S mutation. Deposition of PrP in the retina has
also been reported in sCJD and vCJD in both the OPL and inner plexiform layer
(IPL). In these cases, there was a florid deposition in the IPL, but this was
absent in GSS patients. The clinical and biological significance of PrP depo-
sition in the retina has not been fully investigated.
(Funding source: P30AG010133)
152
Familial Creutzfeldt-Jakob Disease Associated with the PRNP E200K-
129V Haplotype: Report of a New Kindred
Adrian Oblak1, Jill Murrell1, Rose Richardson1, Francine Epperson1,
Bernardino Ghetti1, Wei Chen2, Daniel Bonnin1, Martin Farlow3, Pierluigi
Gambetti2. 1Indiana University School of Medicine, Dept Path and Lab Med;2Case Western Reserve University; 3Indiana University School of Medicine,
Dept of Neurology
Familial prionopathies are neurodegenerative diseases caused by mutations
of the Prion Protein (PRNP) gene. They include familial Creutzfeldt-Jakob
disease (fCJD), Gerstmann-Straussler-Scheinker disease and Fatal Familial
Insomnia. Approximately 20 mutations have been reported to be associ-
ated with fCJD and they are transmitted in an autosomal dominant pattern.
Clinical and neuropathologic features of fCJD are comparable to those of
sporadic CJD. We report a family in which four members have the PRNP
E200K-129V haplotype and died of the disease. All four subjects carried
methionine in the normal PRNP allele. The oldest subject, a female, died at
85 years. Her mother, three of her sisters, and a brother were also reported
to have died of the same disease. Three of her daughters died of fCJD at
ages 56, 55 and 51 years of age. Neuropathologic examination revealed mild
to moderate cerebral atrophy with preferential involvement of the frontal
and temporal cortices and the hippocampus. There was extensive prion pro-
tein (PrP) immunopositivity with a synaptic pattern in the cerebral cortex,
basal ganglia, amygdala, hippocampus and parahippocampal gyrus, cerebel-
lum and midbrain. Intraneuronal PrP immunopositive inclusions were pro-
minent in the cerebral cortex, basal ganglia, entorhinal cortex and dentate
nucleus of the cerebellum. Neuronal loss, gliosis and spongiform changes
were observed in the same regions. Alzheimer disease pathology was also
present in two members of the family. The E200K-129M haplotype is the
most common form of fCJD while there are only five reported cases of
E200K-129V haplotype. The presence of intraneuronal PrP immunoposi-
tive inclusions appears to be a consistent finding in subjects with the E200K
mutation; however, their presence needs to be further investigated in other
prionopathies.
(Funding sources: P30AG010133; NIH P01 AG-14359, Charles S. Britton
Fund and CDC UR8/CCU515004)
153
Gerstmann-Straussler-Scheinker Disease Associated with the P102L-129M
Haplotype: Clinical and Pathologic Heterogeneity
Daniel Bonnin1, Jill Murrell1, Francine Epperson1, Matthew Frosch2, E
Tessa Hedley-Whyte2, Bernardino Ghetti1. 1Indiana University School of
Medicine - Department of Pathology; 2C.S. Kubik Laboratory for
Neuropathology - Massachusetts General
Gerstmann-Straussler-Scheinker disease (GSS) is an autosomal dominant
prionopathy frequently presenting with cerebellar ataxia and subsequent
cognitive decline. GSS associated with the P102L-129M haplotype in the
Prion Protein (PRNP) gene has clinical and neuropathologic characteristics
that may occur in various combinations and with differing degrees of se-
verity. A 41-year-old female presented with a four to six week history of
cognitive decline. The subject’s condition deteriorated rapidly with short-term
memory deficit, difficulty processing information and dysphasia. She died
five months after the onset of symptoms. An autopsy was carried out. The
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Page 42
subject’s father had an initial presentation interpreted as amyotrophic lateral
sclerosis and a clinical course of 2.5 years. He died at age 62. He was neuro-
pathologically and genetically reported to have the P102L-129M haplotype
of the PRNP gene associated with GSS. The subject and two of her three
siblings carried the same haplotype. The subject’s brain revealed no signifi-
cant cortical atrophy or white matter loss, weighing 1,385 grams. Histologi-
cally, there were marked spongiform changes in the frontal and temporal
lobes, cingulate gyrus, basal ganglia and entorhinal cortex. Immunohistochem-
ical stains for PrP revealed numerous unicentric and multicentric plaques in
the cerebral cortex, deep grey matter nuclei, substantia innominata, hippo-
campus, entorhinal cortex, cerebellum, and midbrain. In the spinal cord, there
was moderate loss of myelinated fibers in the posterior and lateral columns, as
well as neuronal loss in the anterior horns. The spinal cord changes contrasted
with those seen in the subject’s father, in which severe loss of anterior horn
neurons and pyramidal tract degeneration was observed. In the two patients
examined, the neuropathologic features in the brain were similar, while age
of symptom onset, initial clinical manifestations and disease duration were
significantly different.
154
Neuronal Tau and Parenchymal PrP in Gerstmann-Straussler-
Scheinker Disease Associated with the PRNP Q217R Mutation
Adrian Oblak1, Jill Murrell1, Rose Richardson1, Francine Epperson1,
Bernardino Ghetti1. 1Indiana University School of Medicine, Dept Path
and Lab Med
Previous studies have shown that in Gerstmann-Straussler-Scheinker disease
(GSS) neurons may be severely affected by deposition of tau protein in
many cortical and subcortical gray matter regions. Severe tau deposition has
been shown in GSS associated with the F198S-129V haplotype and other
prionopathies. We now report the results of neuropathologic studies in
three individuals carrying the Q217R-129V haplotype and belonging to one
family. A male, his son and daughter died at age 59, 50 and 64, respectively.
Both siblings had been diagnosed as suffering from GSS. Histologic studies
of the three brains were carried out using the following methods: hematoxylin
and eosin with Luxol fast blue (H&E/LFB), Bodian, Woelke-Heidenhain and
Thioflavin S. For immunohistochemistry, antibodies against tau, amyloid beta,
>-synuclein, glial fibrillary acidic protein, and prion protein (PrP) were used.
Microscopically, PrP immunostaining and Thioflavin S, revealed abundant,
unicentric, multicentric and diffuse amyloid plaques in frontal, temporal, pa-
rietal and occipital cortical regions. Amyloid and diffuse PrP immunopositive
plaques were also observed in basal ganglia, thalamus, hippocampus, brain
stem, pons, medulla, cerebellum and dentate nucleus. Tau immunohistochem-
istry revealed neurofibrillary tangles, neuropil threads and neurites of the
crown surrounding PrP immunopositive amyloid cores in cortex, hippocam-
pus, striatum, thalamus, substantia nigra, and locus coeruleus. In the white
matter, tau-immunoreactive axons were also present. Neuronal loss and gliosis
were apparent in the regions affected by PrP and tau pathology. Neuronal loss
was particularly severe in the substantia nigra. Lewy bodies and Lewy neu-
rites were present in the substantia nigra of the father. The present study
shows that there is a consistent coexistence of intraneuronal tau deposition in
the presence of parenchymal PrP diffuse and amyloid plaques in Gerstmann-
Straussler-Scheinker disease associated with the Q217R mutation.
155
The Presence of Total Tau in Peripheral Tissues of Alzheimer_s Disease
Brittany Dugger1, Charisse Whiteside1, Chera Maarouf1, Thomas Beach1,
Travis Dunckley2, Bessie Meechoovet2, Alex Roher1. 1Banner Sun Health
Research Institute; 2Tanslational Genomics Research Institute
Tau is one of the main protein aggregates within the brains of Alzheimer_s
disease (AD) patients; however, it has not been extensively examined within
human peripheral organs. The purpose of our study was to determine the levels
of total Tau in areas amendable for biopsy as compared to the brain within
AD cases. We examined human postmortem tissue from the abdominal skin,
liver, scalp, sigmoid colon, and submandibular gland for total Tau in 18 AD
cases and 2 non-demented control cases- NC. Tissues were subject to Western
blots analyses and enzyme-linked immunosorbent assays. Frontal gray matter
of NC and AD were used as a frame of reference for each respective group.
The brain had the highest levels of total Tau, having an average of 4150ng/mg
total protein for NC and 2482ng/mg total protein for AD, followed by the
submandibular gland (136ng/mg NC, 117ng/mg AD), sigmoid colon (21ng/mg
NC, 22ng/mg AD), liver (12ng/mg NC, 19ng/mg AD), scalp (19ng/mg NC,
14ng/mg AD), and abdominal skin (10ng/mg NC, 20ng/mg AD). These re-
sults demonstrate that Tau is present in measurable quantities within these
peripheral tissues but not to the levels that are detected within the brain. Future
studies investigating different phosphorylated species of Tau are planned.
156
Neuropathologic Assessment of Alzheimer’s Disease Neuroimaging Initia-
tive (ADNI) Participants
Nigel Cairns1, Richard Perrin1, Erin Householder1, Deborah Carter1,
Benjamin Vincent1, John Morris1. 1Washington University School of Medicine
Introduction: The mission of the Alzheimer_s Disease Neuroimaging Ini-
tiative (ADNI) is to define the progression of Alzheimer_s Disease. A major
goal of the ADNI study has been to collect and validate data such as MRI
and PET images, cerebral spinal fluid, and blood biomarkers as predictors of
the disease in autopsy-confirmed cases. The objectives of the ADNI Neuro-
pathology Core are to facilitate autopsy consent, brain collection, and per-
form standardized neuropathologic assessments of all ADNI participants who
come to autopsy at the 58 ADNI sites in the USA and Canada.
Methods: The ADNI-NPC maintains a central laboratory to provide uni-
form neuropathologic assessments using the operational criteria for the classi-
fication of AD and other pathologies defined by the National Alzheimer
Coordinating Center (NACC). Results: Since the inception of the NPC in
2008 the autopsy rate is 36/54 (66.7%). AD was present in all cases and the
second most frequent comorbidity was Lewy body disease. Additional pa-
thologies included: hippocampal sclerosis, TDP-43 proteinopathy, argyrophilic
grain disease, small vessel disease and infarcts. Multimodal correlations were
observed in the clinical, biomarker, imaging, and neuropathologic data [1].
Conclusions: The Neuropathology Core has established procedures to co-
ordinate collection of brains from all ADNI sites and undertake standardized
neuropathologic assessments. The NPC will facilitate clinical and multimodal
biomarker correlates of neuropathology in the ADNI cohort.
Reference: Toledo JB and Cairns NJ et al. Clinical and multimodal biomarker
correlates of neuropathology. Acta Neuropathol. Commun. 2013;1:6.
157
The Dominantly Inherited Alzheimer Network (DIAN): The Essential
Role of the Neuropathology Core
Nigel Cairns1, Richard Perrin1, Erin Householder1, Deborah Carter1,
Benjamin Vincent1, John Morris1. 1Washington University School of
Medicine
Background: The Dominantly Inherited Alzheimer Network (DIAN) is a
collaborative effort of international Alzheimer disease (AD) centers that
are conducting a multifaceted prospective biomarker study in individuals
at-risk for autosomal dominant AD (ADAD) [1]. Neuropathology is per-
formed on participants who come to autopsy to determine the distribution
and severity of lesions and the presence of co-morbidities which may influence
clinical, cognitive, imaging and biochemical measures of disease progression.
Methods: The Neuropathology Core maintains a central laboratory to
provide uniform neuropathologic assessments defined by the Na-
tional Alzheimer Coordinating Center (NACC). The DIAN-NPC maintains
a state-of-the-art brain bank of DIAN-derived brain tissue to promote
biomarker and multi-disciplinary clinico-pathologic studies.
Results: Since the implementation of the DIAN Neuropathology Core
(DIAN-NPC), there have been 10 deaths of DIAN participants or family
members, 2 of whom have clinical, biomarker, and neuroimaging data. Of
Abstracts J Neuropathol Exp Neurol � Volume 73, Number 6, June 2014
� 2014 American Association of Neuropathologists, Inc.626
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Page 43
10 autopsies, the neuropathologic diagnoses include: AD (100%) and de-
mentia with Lewy bodies (40%). Although the overall numbers to date are
small, these data demonstrate that the Neuropathology Core has established
the administrative organization to harvest brains from DIAN participants
who come to autopsy at the participating sites.
Conclusions: The Neuropathology Core has: (1) implemented a protocol to
solicit permission for brain autopsy in DIAN participants at all 11 sites in
the USA, Europe, and Australia, who die; (2) established procedures to send
brain tissue to the Neuropathology Core for a standardized and uniform
neuropathologic assessment; and (3) determined the presence of co-existent
pathologies with AD in the autopsied cases. It is possible that these co-
morbidities may contribute to the variance in DIAN data.
Reference: Bateman RJ, et al. Dominantly Inherited Alzheimer Network.
Clinical and biomarker changes in dominantly inherited Alzheimer’s
disease. New England Journal of Medicine 2012; 367: 795-804.
158
Alzheimer Disease and Diffuse Lewy Body Disease Coexist in a PSEN1
N135S Mutation Carrier
Bernardino Ghetti1, Jill Murrell1, Martin Farlow2, Frederick Unverzagt3,
Adrian Oblak1, Francine Epperson1, Rose Richardson1, Shannon Risacher4,
Andrew Saykin4, John Morris5, Nigel Cairns5. 1Indiana University School of
Medicine, Dept Pathology and Lab Medicine; 2Indiana University School of
Medicine, Dept of Neurology; 3Indiana University School of Medicine, Dept
of Psychiatry; 4Indiana University School of Medicine, Dept of Radiology;5Washington University in St. Louis School of Medicine
The neuropathologic phenotype of Alzheimer disease (AD) associated with
PSEN1 mutations is not uniform. To illustrate this characteristic, we de-
scribe the case of a male, who showed gait difficulties at age 39. When
examined at age 41, he was repetitive and had word finding difficulties.
Subsequently, he developed generalized seizures and a rapid decline, re-
quiring full-time nursing care. On examination at 42, his movements were
apraxic, but tremor was absent. Spasticity predominantly involved the lower
extremities. His speech was strained and spastic; he had bilateral Babinski
signs. His Clinical Dementia Rating was 3.0, consistent with severe dementia.
At baseline and follow-up, [18F]FDG and [11C]PiB PET showed generalized
hypometabolism and a positive amyloid signal, most evident in the striatum.
He died at age 43. At autopsy, the brain weighed 1530 grams. For histology,
hematoxylin and eosin with Luxol fast blue and Thioflavin S were used. For
immunohistochemistry, antibodies against tau, amyloid beta (AA), glial fibril-
lary acidic protein, and >-synuclein were used. AA cored plaques and diffuse
deposits were seen in the neocortex and hippocampus, while diffuse AA de-
posits were predominant in the striatum and cerebellum. AA angiopathy was
severe. Tau-immunopositive neurons and neuropil threads were numerous in
the cerebral cortex, dorsal pontine gray and raphe. >-synuclein immunoposi-
tive Lewy bodies and neurites were abundant in frontal and cingulate cortices
and substantia nigra. DNA was extracted from brain tissue; the Presenilin 1
(PSEN1) gene was sequenced, revealing an A to G point mutation predicting
an amino acid substitution of asparagine (N) to serine (S) at residue 135. The
neuropathologic phenotype associated with the PSEN1 N135S mutation has
been reported previously; however the present case is noteworthy for the co-
existence of Diffuse Lewy Body Disease with severe AD.
(Funding sources: P30AG010133, U19AG032438)
159
Familial Dementia Associated with the Novel PSEN1 F176V Mutation
Bernardino Ghetti1, Adrian Oblak1, Rose Richardson1, Francine Epperson1,
Jill Murrell1. 1IU School of Medicine, Dept Pathology and Laboratory
Medicine
The Presenilin 1 (PSEN1) gene is known to have over 180 mutations. We
report a case in which a novel mutation has been identified. A history of
presenile dementia was traced back three generations preceding that of the
proband. The subject, a female, showed symptoms of memory impairment
at the age of 59 years. Following a neurological examination, it was con-
cluded that she was in the early stages of Alzheimer disease. Her short term
memory progressively deteriorated in the ensuing years. At age 69, her
mini mental status exam score was 20. At age 70, a computed tomography
scan revealed mild diffuse cerebral atrophy and at age 71, a positron emis-
sion tomography scan with flurodeoxyglucose revealed hypometabolism in
the posterior parietal region of the left cerebral hemisphere. Her cognitive
status continued to deteriorate and she died at age 77. At autopsy, the brain
weighed 838 grams. DNA was extracted from brain tissue and the PSEN1
gene was sequenced. The molecular genetic analysis revealed a TTT9GTT
point mutation predicting an amino acid substitution of phenylalanine (F)
to valine (V) in the PSEN1 gene at residue 176. The brain was severely atro-
phic. There was moderate to severe atrophy of the head of the caudate nu-
cleus and severe atrophy of the hippocampus and parahippocampal cortex.
For neuropathology, histological methods included hematoxylin and eosin
with Luxol fast blue, Bielschowsky and Thioflavin S. For immunohistochem-
istry, antibodies against tau, amyloid beta (AA), and >-synuclein were used.
Numerous A-amyloid immunopositive plaques and numerous tau immuno-
positive neurons and neuropil threads were seen throughout the cerebral
cortex. The hemispheric white matter showed marked loss of myelinated fi-
bers. Amyloid angiopathy and parenchymal AA deposition were severe in the
cerebellum. Additional studies on this kindred are needed to clarify the
clinical and pathologic phenotypes associated with the novel PSEN1 F176V
mutation.
160
Neuropathologic Phenotype of Dementia Associated with PSEN1 H163R
Mutation
Bernardino Ghetti1, Jill Murrell1, Adrian Oblak1, Rose Richardson1, Jordan
Grafman1, Alan Lerner3. 1IU School of Medicine, Dept Pathology and
Laboratory Medicine; 2Rehabilitation Institute of Chicago; 3Case Western
Reserve University
Mutations in Presenilin 1 (PSEN1) gene are numerous; however not for all
of them has the associated neuropathology been investigated. We describe
the neuropathologic phenotype in an individual affected by an early-onset.
A 45-year-old man began experiencing depression and symptoms of cog-
nitive impairment, following the death of a brother. At the age of 48 years,
he was diagnosed as having frontotemporal dementia (FTD). At age 52, a
neurological exam revealed severe aphasia. A positron emission tomography
scan with flurodeoxyglucose showed generalized hypometabolism in the ce-
rebral hemispheres with greater decrease in the left frontal, temporal and pa-
rietal lobes. A computed tomography revealed a volume loss greater in the left
temporal lobe. At age 53, he was hospitalized and discharged with a diagno-
sis of FTD, associated with behavioral disturbance and agitation. The patient
died at age 55. At autopsy, the brain weight was 1130 g. For histology, he-
matoxylin and eosin with Luxol fast blue, Bielschowsky and Thioflavin S
were used. For immunohistochemistry, antibodies against tau, amyloid beta
(AA), glial fibrillary acidic protein, and >-synuclein were used. Numerous AA
immunopositive plaques, tau-immunopositive neurons, neuropil threads, and
neurites surrounding plaque cores were seen in the cerebral cortex. Amyloid
angiopathy and diffuse parenchymal AA deposits were severe in the cerebel-
lum. Tau immunopositive neurons were numerous in the substantia nigra, in
the dorsal pontine gray and in the raphe. >-synuclein immunopositive Lewy
bodies and neurites were numerous in the amygdala, the adjacent temporal
cortex and the basal forebrain. In these areas, the neuropil showed spongi-
form-like changes. DNA was extracted from brain tissue and PSEN1 was
sequenced revealing a CAT9CGT point mutation predicting an amino acid
substitution of histidine (H) to arginine (R) at residue 163. The PSEN1 H163R
mutation has been previously reported; however the neuropathologic pheno-
type associated with this mutation had not been documented.
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Page 44
161
Oxidative Damage is Correlated with Mitochondrial Abnormalities in
Aging but not Alzheimer Disease
George Perry1, Rasha Shammas1, Xiongwei Zhu2, Xinglong Wang2,
Hyoung-gon Lee2, Rudy Castellani3, Akihiko Nunomura4. 1The University
of Texas at San Antonio, San Antonio, Texas; 2Case Western Reserve
University, Cleveland, Ohio; 3University of Maryland, Baltimore, MD,
USA; 4University of Yamanshi, Yamanshi, Japan
Alzheimer disease (AD) and aging are marked by oxidative damage and
mitochondrial abnormalities. Since mitochondria can play a critical role in
oxidative damage, we conducted this study to identify the relationship of
oxidized RNA, 8-hydroxyguanosine (8OHG), and mitochondrial DNA
(mtDNA) accumulation in AD and aging individuals. Abnormalities were
examined by using densitometry of hippocampal pyramidal neurons: mtDNA
accumulation as a marker of mitophagy and oxidative damage by 8OHG.
Among aging individuals, oxidative damage and mtDNA were highly corre-
lated (correlation coefficient = 0.86). While both 8OHG and mtDNA were
at higher levels in AD individuals, they were uncorrelated (correlation coef-
ficient = 0.06). In contrast, as we found before, oxidative damage was inversely
correlated with amyloid-A; it was unrelated in normal aging individuals. These
results suggest that oxidative damage is directly related to mitophagy in aging
individuals. With the onset of AD, amyloid-A plays a strong antioxidant role.
These findings indicate that the onset of AD is marked by a pleotrophic
change in oxidative stress, one characterized by a change from mitochondria
to amyloid-A dependency.
George Perry is supported by the Semmes Foundation, and by a grant from
the National Institute on Minority Health and Health Disparities
(G12MD007591) from the National Institutes of Health.
162
Screening for Pathology Consistent with Chronic Traumatic
Encephalopathy in Neurodegenerative Diseases
Kevin Bieniek1, Ann McKee2, Dennis Dickson3. 1Mayo Graduate School,
Department of Neuroscience; 2Center for the Study of Traumatic
Encephalopathy, Boston University; 3Department of Neuroscience, Mayo
Clinic Florida
Chronic traumatic encephalopathy (CTE) is a progressive neurodegenerative
disease linked to subconcussive repetitive traumatic brain injury. Neuropa-
thologically, CTE is defined by deposition of hyperphosphorylated tau in
neuritic threads and neurofibrillary tangles, with variable axonal pathology and
transactive response DNA-binding protein 43 (TDP-43) pathology. In its
earliest stages, CTE pathology is focal in convexity frontal lobe, at the depths
of sulci and perivascular. CTE can occur in other neurodegenerative diseases.
While CTE often lacks amyloid-A and >-synuclein pathology, Alzheimer_sdisease (AD) and Lewy body disease (LBD) pathology have been reported
with CTE pathology. Upper and lower motor neuron disease, amyotrophic
lateral sclerosis (ALS), has also been reported in CTE. While current studies
focus on further characterizing this disease in cohorts of athletes and military
veterans, there are no studies that have screened for CTE pathology in neu-
rodegenerative diseases. The Mayo Clinic Jacksonville Brain Bank currently
holds over 6,500 brains from individuals with memory and/or motor disorders.
We identified 350 men that were at risk for CTE (based upon gender, age,
brain weight, and no primary tauopathy) and retrospectively reviewed available
medical records for history of involvement in contact sports or documented
head trauma. We screened these cases with tau immunohistochemistry and
found 10 (3%) with pathologic features compatible with CTE. All cases had
primary diagnoses of AD, LBD, ALS or frontotemporal lobar degeneration.
CTE-related tau pathology was not detected in 56 disease and aged-matched
women.We also screened 68 individuals with ALS, and found 5 additional men
with pathology consistent with CTE. This study demonstrates the importance of
screening for CTE in individuals with history of involvement in contact sports
or documented head trauma even though they have other concomitant neu-
rodegenerative pathologies.
163
‘‘APP and AA-immunoreactive Plaques’’ in Traumatic Brain Injury:
An Underappreciated Neuropathological Finding?
Ross Reichard1, Cristiane Ida1. 1Mayo Clinic
Amyloid precursor protein (APP) is an integral membrane protein highly
expressed in neuronal synapses. Although its function is not fully understood, it
has been implicated as a regulator of synapse formation, neural plasticity and
iron export. APP proteolysis generates beta amyloid (AA), including amyloid
fibrillar isoforms (AA40 and AA42), which form the amyloid plaques seen
in neurodegenerative diseases, especially in Alzheimer disease. Studies have
demonstrated that, in addition to the characteristic diffuse traumatic axonal
injury (dTAI) APP-immunoreactive axonal spheroids/bulbs, AA deposition
may be seen within short time (hours) of the traumatic event . We report two
insightful autopsy cases that illustrate ‘‘APP and AA -immunoreactive
plaques’’ in a setting of fatal traumatic brain injury. Both individuals did
not have significant past neurological history and were involved in road traffic
accident: 1) 50-year-old woman who sustained multiple skull and cervical
fractures and blunt force trauma of the head with diffuse subarachnoid
hemorrhage (SAH) with intraventricular extension, and multiple cerebral
acute contusions, and survived for 3 days; histologically, in addition to dTAI
associated with global hypoxic-ischemic brain injury, numerous cortical tau-
negative, variably AA-immunoreactive ‘‘APP-immunoreactive plaques’’ were
identified; 2) 53 year-old man who suffered skull fractures and blunt force
trauma to the head, with diffuse SAH, extensive cerebral contusions and
survived for 6 hours; histologically, besides dTAI and Alzheimer disease
neuropathologic changes distinct cortical tau-negative, variably AA-immunor-
eactive ‘‘APP-immunoreactive plaques’’ were present. These cases illustrate a
plaque morphologically ‘‘invisible’’ on H&E stains, highlighted by immu-
nostaining for APP, which may be underappreciated in severe traumatic brain
injury. These findings also support the view that induction of APP is a
response to neuronal stresses that, although possibly protective, may progress
to a neurodegenerative disease process in susceptible individuals, and sug-
gesting a pathophysiological association between Alzheimer disease and
traumatic brain injury.
164
Myopericytoma Involving The Orbit In A 78-year-old Female
Jenny Smith1, Jeremy Deisch1. 1Loma Linda University
Myopericytomas are uncommon tumors of presumed perivascular myoid
origin. According to the World Health Organization (WHO), myopericytomas
occur as part of a spectrum of tumors arising from perivascular contractile cells,
including myofibroma/myofibromatosis, glomus tumors, and ‘‘true’’ heman-
giopericytomas. Myopericytomas typically affect adults, but examples in
pediatric and elderly patients have been reported. The subcutaneous tissues of
distal extremities are most often affected, but nearly all superficial anatomic
sites may be affected. In the central nervous system, one presumed cerebral
hemispheric parenchymal tumor and one thoracic epidural mass have been
reported. Otherwise, there are no reports of myopericytomas involving the
nervous system. We report a case of a myopericytoma involving the orbit in a
78-year-old woman with a three-year-history of a slowly progressive right eye
pain, bulging, and vision loss. An MRI demonstrated a 5.1 cm well circum-
scribed heterogeneously enhancing mass in the right orbit, encasing the optic
nerve. Biopsy revealed a richly vascular mesenchymal neoplasm with
numerous thin-walled, variably sized sinusoidal vessels and a bland prolifer-
ation of spindled monotonous cells with scant to moderate amounts of
eosinophilic cytoplasm. Significant cytologic atypia was lacking, and mitotic
figures were not increased. By immunohistochemistry, the tumor cells were
strongly and diffusely positive for vimentin and patchy positive for smooth
muscle actin (SMA). CD31/CD34 immunostains highlighted the lesional blood
Abstracts J Neuropathol Exp Neurol � Volume 73, Number 6, June 2014
� 2014 American Association of Neuropathologists, Inc.628
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Page 45
vessels. S-100, cytokeratin, EMA, neurofilament, and GFAP immunostains
were negative. The tumor was treated with radiotherapy, resulting in decreased
enhancement and a decrease in tumor size by 1.5 cm during ten months of
follow-up. This case demonstrates the first reported example of a myoper-
icytoma involving the orbit, expanding the already wide differential diagnosis
of orbital region tumors. Neuropathologists should be aware of this entity, as
orbital region tumors often fall under the purview of neuropathologists.
165
An Unusual Presentation of Gliosarcoma: A Case of Primary Tumor
Arising in the Optic Nerve.
Yevgeniy Sychev1, Luis Gonzalez-Cuyar1, Raghu Mudumbai1, C. Dirk
Keene1. 1University of Washington
Gliosarcoma is a subtype accounting for a small percentage of glioblastoma
multiforme, a highly malignant central nervous system tumor. While glio-
blastomamultiforme is themost common primarymalignant tumor in the brain,
it is encountered only rarely in the optic nerve. Gliosarcomas commonly arise in
the temporal lobes and until now there have been no reports of this entity as a
primary optic nerve tumor. Here we report a case of an optic nerve gliosarcoma.
A 90 year old demented woman presented with one year history of progressive
proptosis, neovascular glaucoma, blindness and ocular pain. She underwent
enucleation following diagnosis of optic nerve tumor. Microscopically the
tumor demonstrated effacement of the normal nerve, invasion of the retina
and a biphasic architecture demonstrating foci of pleomorphic epithelioid and
spindle cells. Electron microscopy demonstrated abundant intermediate
filaments but no myofibers, sarcomeric differentiation, melanosomes or pre-
melanosomes. The neoplasm was negative for melan-A, HMB45, tyrosinase,
synaptophysin, alpha smooth muscle actin, epithelial membrane antigen. AE1/
AE2 pan-cytokeratin cocktail showed focal intermediate positivity. S-100 and
vimentin immunostaining was strongly positive in both spindle and glial
populations, while GFAP immunostaining was primarily limited to glial
portions. Multiple foci of mGFAP negative cells stained strongly positively
for reticulin. These features are characteristic of gliosarcomas encountered in
the brain.
166
The Prognostic Value of EGFR Amplification in MGMT Methylated
Glioblastomas
Seema Shroff1, Katharine McNeill2, Irina Mikolaenko1, David Zagzag1,
Matija Snuderl1. 1NYU Langone Medical Center; 2Laura and Isaac
Perlmutter Cancer Center, NYU
Background: Glioblastoma (GBM) is the most common malignant brain
tumor of adults with a 5-year survival G5% from diagnosis. MGMT gene
promoter methylation is the most frequently performed molecular test in
neuropathology clinical practice. The use of EGFR gene amplification as a
prognostic maker is not well established. We investigated the prognostic
role of EGFR amplification in subsets of patients with glioblastoma. We
specifically sought if there was additional prognostic value of EGFR status
in patients with MGMT methylated GBM.
Methods: We performed a retrospective analysis of 87 adult patients with
GBM. We analyzed MGMT, EGFR, IDH1 R132H, p53 and BRAF V600E
status and correlated with clinical data.
Results: Our cohort consisted of 77 patients (51 males and 26 females) with
median age of 63 (8-88). Complete clinical, pathologic and molecular data
were available for 20 patients. Median survival for the cohort was 4 months
(range 1-24). MGMT was methylated in 9/30 patients (30%) with median
progression free survival (PFS) of 8 months (range 4-24), compared to
MGMT non-methylated patients (70%)(median 4.5, range 1-12, p-value =
0.03). EGFR was amplified in 10/23 (43%) patients with median PFS of
4.5 months (range 3-24). EGFR non-amplified patients (57%) showed PFS
of 4 months (range 1-10). PFS in patients with MGMT methylation who had
EGFR amplification was 6.75 months (range 4-24) in comparison with
EGFR non-amplified, PFS = 4 months (range 4, p-value = N.S.). PFS in
patients with no MGMT methylation who had EGFR amplification was
4.5 months (range = 3-7) compared to EGFR non-amplified tumors (PFS=
3.25 months, range 1-10).
Conclusions: MGMT methylation status is a superior predictive marker in
GBM. EGFR amplification in MGMT methylated GBMs does not have
additional prognostic value.
167
Improved Adenoviral Transduction of Glioblastoma Cells by Aptamer
Modification
Qinwen Mao1, Hao Chen2, Esther Bit-Ivan1, Eileen Bigio1, Haibin Xia2.1Northwestern University Feinberg School of Medicine; 2Shaanxi Normal
University, China
Adenovirus type 5 (Ad5) is one of the most commonly used vector systems for
gene and viral therapy for glioblastoma. However, targeting of adenovirus to
human glioblastoma remains a challenge due to the low expression level of
CAR (coxsackievirus and adenovirus receptor), the known adenovirus receptor,
in glioma cells. To improve the targeting efficiency of Ad5 to glioblastoma,
transductional retargeting strategies, including genetic capsid modification
and adaptor-based strategy, have been used. The latter involves the use of a
molecular bridge to retarget the Ad from its native primary receptor to a
different cell surface receptor. Aptamers are single-stranded oligonucleotides
that bind at high affinity to a target molecule, and are good candidates for
targeted cancer therapy. In this study, to construct an aptamer-modified Ad5,
we first genetically modified the hypervariable region 5 (HVR5) of Ad hexon
with biotin acceptor peptide (BAP), which would be metabolically biotinylated
during virus production in HEK293 cells. Then the biotin labeled aptamer was
attached to the modified Ad through avidin-biotin binding. The aptamers used
in this study include AS1411 and GBI-10. The former is a DNA aptamer that
targets nucleolin, a nuclear matrix protein found on the surface of cancer cells.
The latter is a DNA aptamer that can recognize the extracellular matrix protein
tenascin-C on the surface of human glioblastoma cells. To examine if aptamer-
modification of the hexon protein could improve the adenoviral transduction
efficiency in gliomas, glioblastoma U251 cells were transduced with aptamer-
modified Ads. Our results show that the transduction efficiency of AS1411- or
GBI-10-modified Ad in U251 cells is approximately 4.1-fold or 5.2-fold higher
than that of the control vectors. The data indicate that aptamer modified
adenovirus would be a useful tool for glioblastoma gene and viral therapy.
168
Overexpression of Eg5 Correlates with High Grade Astrocytic Neoplasm
Liqiong Liu1, Xichun Liu2, Marcus Mare2, Aaron Dumont2, Haitao Zhang2,
Dong Yang2, Zhenggang Xiong2. 1Louisiana State University; 2Tulane
University
Objective: To investigate the relationship between Eg5 expression and
histopathological grade of astrocytoma for potential application of Eg5 as a
diagnostic marker and a therapeutic target of astrocytomas.
Methods: Eg5 expression was evaluated by immunohistochemical exami-
nation on 92 specimens including 25 cases of glioblastoma (WHO grade
IV), 22 cases of anaplastic astrocytoma (WHO grade III), 20 cases of diffuse
astrocytoma (WHO grade II), and 21 cases of pilocytic astrocytoma (WHO
grade I). The histopathological characteristics and Eg5 expression level of
each tumor were assessed under microscope and by image analysis
computer software. Correlation between Eg5 expression and histopatho-
logical grade of astrocytoma was statistically analyzed.
Results: Astrocytic tumors exhibited significant correlation of expression of
Eg5 with higher WHO histopathological grades (pG0.001). Eg5 is expressed in
51%-98% (mean: 76.88%) of neoplastic cells in glioblastoma, 34%-57%
(mean: 43.59%) of neoplastic cells in anaplastic astrocytoma, 6%-36% (mean:
18.60%) of neoplastic cells in diffuse astrocytoma, and 2%-28% (mean:
13.48%) of neoplastic cells in pilocytic astrocytoma.
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� 2014 American Association of Neuropathologists, Inc. 629
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Page 46
Conclusions: Overexpression of Eg5 associates with high-grade astrocytic
neoplasm, and it may represent an independent diagnostic and prognostic
factor in grading astrocytic tumors and predicting prognosis of astrocytic
tumor patients.
169
Detection of CD133 Expression in U87 Glioblastoma Cell Line Using
Novel Anti-CD133 Monoclonal Antibodies
Esther Bit-Ivan1, Haibin Xia2, Eileen Bigio1, Qinwen Mao1. 1Northwestern
University Feinberg School of Medicine; 2Shaanxi Normal University, China
In glioblastoma, CD133 identifies a subpopulation of stem-like tumor cells,
named CSCs, which are able to initiate tumor growth and are highly resistant
to conventional chemo-radiotherapy. However, some studies show that some
CD133-negative glioma cells are also able to self-renew and retain tumorigenic
potential. It remains obscure whether CD133 is a reliable CSC marker in
gliomas and whether a population of cancer stem cells that do not express
CD133 at all even exists. These conflicts might be due to the detection limit of
currently available anti-CD133 antibodies. In this study, we generated novel
anti-human CD133 monoclonal antibodies (McAb) using two recombinant
extracellular domains of human CD133, CD133 ectodomain 1 (amino acid 171
to 420) and CD133 ectodomain 2 (amino acid 507-716). Immunofluorescence
microscopy and Western blot analysis revealed that at least two antibodies
(C1E3 and C1E4) were directed against CD133 ectodomain 1, and four of them
(including C2E1) were directed against ectodomain 2. Similar to the
commercially available anti-CD133 antibodies, C1E3 only detected glycosy-
lated full length CD133 band in Caco-2 cells (a human colorectal adenocarci-
noma line) but failed to detect any CD133 expression in the human
glioblastoma cell line, U87. Interestingly, C2E1 McAb, which revealed both
glycosylated or non-glycosylated full length CD133 bands in Caco-2 cells,
detected high levels of non-glycosylated full length CD133 protein in U87 cells,
which previous studies had shown were devoid of CD133 expression. In
addition, CD133 overexpression led to aberrant glycosylation of CD133 in U87
cells. Moreover, both C1E3 and C2E1 antibodies suppressed cell proliferation
when incubated with Caco-2, or U87 cells overexpressing CD133. These novel
antibodies might be of significant value for further exploration of the expression
and function of CD133 in cancer stem/progenitor cells, and their usefulness in
cancer therapeutics deserves further exploration.
170
Recurrent Glioblastoma Is Associated With Increased Expression of
Mesenchymal Markers
Matthew Wood1, Gerald Reis2, Joanna Phillips2. 1University of California,
San Francisco, Department of Pathology; 2Department of Pathology,
Division of Neuropathology
Background: Glioblastoma (GBM) is a molecularly heterogeneous disease
with a uniformly poor prognosis due to invasiveness and resistance to
therapy. A number of studies have focused on the heterogeneity of GBM at
initial presentation, but few have characterized whether heterogeneity is
retained at recurrence. To begin to address this question, we generated a
tissue microarray (TMA) for analysis of paired primary and recurrent GBM.
Design: We identified recurrent GBM cases diagnosed between 1996 and
2013, and reviewed clinical data to obtain population characteristics and
therapeutic histories. Up to 3 tissue cores from primary and recurrent tumors
were assembled in tissue microarrays. Arrays were immunostained for a
number of markers including Ki67, CD34, phosphorylated S6 kinase
(pS6K), YKL40, phosphorylated STAT3 (pSTAT3), CD44, OLIG2, EGFR,
and IDH1R132H.
Results: The study population included 14 male and 10 female patients
(N=24), with mean age at diagnosis of 53 years (range 31 to 73). The mean
time to recurrence was 531 days (range 75 to 2411). As expected, primary
tumors exhibited a diversity of phenotypes, including mutant IDH1 (15%;
3/20), robust EGFR expression (45%; 9/20), a range of Ki67 positive cells
(2-60%), and a mesenchymal phenotype (34%; 6/18), denoted by robust
expression of at least two mesenchymal markers (pSTAT3, YKL40, or CD44).
Fifteen primary and recurrent GBM cases had adequate tissue for analysis of
paired samples. At recurrence there was an increase in tumors with a
mesenchymal phenotype (27% vs. 80%), including one IDH1 mutant tumor.
A single IDH1 mutant tumor showed reduced mesenchymal marker expression
at recurrence.
Conclusions: We generated a tissue microarray of paired primary and
recurrent GBM for analysis of molecular heterogeneity and mesenchymal
phenotype characteristics. At recurrence a significant subset of tumors
acquired expression of mesenchymal markers. Studies to determine whether
this reflects a change in overall tumor heterogeneity are ongoing.
171
Genomic Sequencing Reveals PI3KCA Mutations in Two Cases of
Glioblastoma with Sarcomatous Differentiation
Lyndsey Emery1, Elizabeth Azzato1, Robert Daber1, Maria Martinez-Lage1.1Hospital of the University of Pennsylvania
Background: Gliosarcomas are a rare subset of glioblastoma (GBM)
characterized by a biphasic appearance with mesenchymal differentiation,
accounting for approximately 1-5% of GBM diagnoses1. Phosphoinositide
3-kinase, catalytic, alpha polypeptide (PIK3CA) is a member of the PI3K
family of enzymes, which function in numerous roles in the PI3K/AKT/
mTOR signaling pathway, including cell growth, proliferation, differ-
entiation, intracellular trafficking and survival. In turn, these enzymes are
commonly identified as mutated in numerous cancers. PIK3CA mutations
are present in approximately 11% of glioblastomas2. Here we present two
cases of WHO grade IV malignant gliomas, a gliosarcoma and a
glioblastoma with prominent sarcomatous features, with PIK3CA mutations
identified by genomic sequencing.
Cases: Case 1 is from a 71-year-old male who underwent tumor resection
with pathology demonstrating gliosarcoma, WHO grade IV. Next-generation
sequencing using a panel of 47 genes identified a missense mutation in TP53
(p.R273P, c.818G9C) and an additional missense mutation in PIK3CA
(p.H1047R, c.3140A9G). Case 2 is from an 81-year-old female who underwent
tumor resection with pathology demonstrating glioblastoma, WHO grade IV,
with focal sarcomatous features. Interval imaging showed tumor progression
and she underwent a second resection, which demonstrated recurrent/residual
glioblastoma. This specimen showed more prominent sarcomatous differ-
entiation. Her original tumor specimen was submitted for genomic sequencing,
which identified amplification of EGFR and an additional missense mutation
PIK3CA (p.G1049S, c.3145G9A).
Conclusions: To our knowledge, PI3KCA missense mutations in similar
amino acid regions have not been described in gliosarcomas or glioblasto-
mas with prominent sarcomatous differentiation. Further investigation is
needed to determine if PI3KCA mutations are common in sarcomatous
malignant gliomas, which may provide insight into the pathogenesis of this
rare subset of glioblastomas. Furthermore, the mutation identified in Case 1
has been shown to predict response to PI3K/AKT/mTOR inhibitors, opening
possibilities for targeted therapy in patients with high grade gliomas with
sarcomatous differentiation3.
172
Glioblastoma with Melanoma-like Histology and Widespread
Extracranial Metastases. A Case Report with EM Analysis.
Michael Presta1, Rami Al-Rohil1, Walter Jacobson2, Julie Pilitsis2, Jiang
Qian3. 1Pathology, Albany Medical College/Center Hospital;2Neurosurgery, Albany Medical College/Center Hospital; 3Pathology,
Albany Med Ctr Hosp/APS
Glioblastoma (GBM) is an aggressive astrocytoma with poor prognosis. Clas-
sic GBM is readily recognizable pathologically, but occasional cases pose
diagnostic challenges due to their unusual features. Local spread and recurrence
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occur commonly in GBM, but extracranial metastasis is quite rare. Here we
report a case of GBM with multiple systemic metastases, with supporting
electron microscopy (EM) study. The patient was a 55 year old male who
presented with three weeks of bilateral frontal headaches, without vision
changes, sensory or motor deficits, and an unremarkable physical examina-
tion. MRI identified a right frontal enhancing mass and 3 small enhance-
ments in the left fronto-parietal region. CT of the internal organs found no
pathology. He underwent a right frontal gross total resection with no
residual enhancement on post-op imaging. Resection specimen revealed a
high grade tumor composed of sheets of melanoma-like, round epithelioid
cells arranged perivascularly, with mitotic activity, microvascular prolifer-
ation, and extensive necrosis. Tumor cells stained strongly for S100 and
vimentin, with limited GFAP and p53 expression, and stained negative for
epithelial and melanocytic markers. Further EM study supported a glial
origin of the tumor, showing intermediate filaments without melanin
pigment. GBM was diagnosed, and the patient was treated with Temozo-
lomide. Follow-up MRI at 3 months identified 12 enhancing areas in both
cerebral hemispheres and the right cerebellum. PET scan revealed multiple
pulmonary, intra-peritoneal and soft tissue masses in the trunk. The largest
lung mass was biopsied, confirmed to be metastatic GBM. The patient died
shortly thereafter, less than 5 months following initial brain surgery. While
the adverse impact of extracranial spread of GBM on overall survival is
debatable, its presence should be recognized so that proper clinical
management can be planned. For unusual GBM cases like ours, with over-
lapping features with melanoma, EM is a useful adjunct in aiding diagnosis.
173
Prevalence, Pathology, Prognostic Factors, and Survival in Latino
Americans with Glioblastoma
Maryam Shabihkhani1, Yalda Behbahanian1, Kourosh Naeini2, Diviya
Gupta1, Bowen Wei1, Gregory Lucey1, Lauren Hanna1, Desiree Sanchez1,
Sergey Mareninov1, Timothy Cloughesy3, William Yong1. 1Department of
Pathology, University of California, Los Angeles; 2Department of Radiology,
University of California,LosAngeles; 3Department of Neurology, University
of California, Los Angeles
There is limited data regarding the prevalence, pathology, prognostic
factors, and outcome in Hispanic/Latino Americans. Given that Latinos
comprise the largest and fastest growing minority group in the US,
understanding the characteristics of glioblastoma in this population is an
important public health concern. A literature search was conducted using
Google Scholar and PubMed. Survival statistics and clinical and demo-
graphic variables were also extracted from the Survival, Epidemiology and
End Results (SEER) database for patients diagnosed with glioblastoma
(GBM) from 1973 to 2010. Descriptive statistics were used to describe the
population and survival was analyzed using Kaplan-Meier curves and
proportional hazard models. This study included 45,187 GBM patients, of
whom 83.6% were non-Latino white, 7.6% were Latino, 5% were African
American, and 3.9% were Asian/Other. There was no statistical significance
in median age, gender, surgery, and radiotherapy between groups. Improved
prognosis in Latinos and non-Latinos is associated with age G60 years, use
of radiation, and gross total resection. One year survival rate is 31.5% in
non-Latino populations and 35.9% in Latinos (p value= 0.6). The SEER
database showed no difference in the prevalence of either giant cell
glioblastoma or gliosarcoma between Latino and non-Latino populations.
We did not identify literature regarding the prevalence of MGMT meth-
ylation or IDH1 mutations in Latinos. While 7.6% of GBM patients in the
SEER database are Latino, it has been reported that 1.9% of Cancer Therapy
Evaluation Program (CTEP) clinical trial patients are Hispanic suggesting
that they may be under-represented. More detailed evaluation and
comparison of sub-groups within the Latino population and against other
ethnic groups may be informative. Additional molecular data regarding
GBMs in Latinos is desirable.
174
Glioblastoma Presenting As Lung Metastasis: A Unique Case Report
And Review Of The Literature
Denise Ng1, Annie Wu1, Yalda Behbahanian1, William Yong1, Neda
Moatamed1, Negar Khanlou1, Phioanh Nghiemphu1, Linda Liau1, Harry
Vinters1. 1University of California, Los Angeles
We report a case of glioblastoma (GBM) presenting as pleural effusions
originally considered a mesothelioma. CASE REPORT: The patient was a
54-year-old woman with no significant prior medical or surgical history. She
presented with acute shortness of breath after strenuous exercise, prompting
an emergency room consultation. Chest x-ray revealed a large left pleural
effusion with radiologic consideration of mesothelioma. Patient underwent
repeated thoracenteses. Malignant cells of undetermined origin were noted
on cytologic analysis of the pleural fluid. Patient was originally scheduled
for PET scanning, however, she began to complain of dysgeusia, heralding a
tonic clonic seizure with loss of consciousness. Head CT revealed a diffuse
T2 hyperintense, non-enhancing 2.1 cm mass in the medial right temporal
lobe of the brain. Concomitant thoracic PET scan showed hypermetabolic
areas in the ribs, vertebrae and lungs. Patient underwent a bronchoscopy and
biopsy of the lung lesion, which was interpreted as malignancy not
otherwise specified. Meanwhile, she underwent resection of the newly
discovered brain lesion. Histopathologic examination showed a GBM,
WHO grade IV. In view of these findings, prior pleural fluid samples and
lung biopsies were reevaluated for possibility of a metastatic glioma. All
specimens showed GFAP immunopositive tumor cells. Additional MRI
revealed a space-occupying lesion in the lower cervical and upper thoracic
spinal canal with continuity with the left pleural space. CONCLUSION:
This case is unique in its presentation with respiratory symptoms due to the
lung metastases, but also reminds pathologists of the metastatic potential of
primary brain tumors. Molecular profiling of glial tumors has been used as a
therapeutic guideline in recent years. Detailed studies are required to
determine their significance in identifying tumors with greater metastatic
potential. These molecular characteristics, including those pertaining to this
case, will be further discussed.
175
VE1 Immunoreactivity Patterns in Epithelioid Glioblastomas Positive
for BRAF V600E Mutation
Bette Kleinschmidt-DeMasters1, Nicholas Foreman2, Seth Lummus3.1University of Colorado Anschutz Medical Campus; 2The Children’s
Hospital Colorado;3University of Colorado Dept. of Pathology
Background: Epithelioid glioblastomas (E-GBMs) are one of several GBM
types not currently mentioned in the WHO 2007 classification system.
However, fifty percent of these manifest BRAF V600E mutation, compared
to a small percentage of ordinary GBMs, suggesting that they may possess a
unique genetic signature - better qualifying them as variants rather than a
pattern. Further, a targeted therapy for tumors with BRAF V600E mutation,
vemurafinib, may make testing BRAF status important for treatment. It is
unclear whether BRAF VE1 immunohistochemistry (IHC) can substitute for
Sanger sequencing in these tumors, or if the IHC pattern differs between
E-GBMs and other mutated tumor types, gangliogliomas (GG) and anaplastic
pleomorphic xanthoastrocytomas (a-PXA). Finally, proof of principle has yet
to be reported that E-GBMs with this mutation might respond to vemurafinib.
Design: We conducted VE1 IHC on our previously studied cohorts of
E-GBMs, GGs, and a-PXAs (all known to possess the mutation) and compared
the patterns of immunostaining.We also report the results of two patients recently
treated with vemurafinib - one pediatric a-PXA and one of the E-GBMs.
Results: All E-GBMs manifested strongly diffuse cytoplasmic immunor-
eactivity, with uniform intensity in 7/8 and diffuse positivity in the 8th, with
scattered more-intensely immunoreactive tumor cells. GGs demonstrated far
more intense immunoreactivity in the ganglion, than glial, tumor compo-
nent. One E-GBM patient with initial gross total resection quickly recurred
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Page 48
within 4 months, required a second resection, and then was placed on
vemurafinib; she remains tumor-free 23 months later without neuroimaging
of residual disease. One pediatric a-PXA recurred despite drug therapy and
required stereotactic radiosurgery, but also survives 32 months later.
Conclusions: E-GBMs manifest the same diffuse strong IHC immunor-
eactivity pattern seen in melanoma and, although anecdotal, can respond to
targeted therapy.
176
‘‘Gliomatosis encephali’’ as a Novel Category of Brain Tumors: The
First Autopsy Case Report of Gliomatosis Cerebelli
Asa Nakahara1, Toshikazu Yoshida2, Masanobu Yazawa2, Takashi Ehara3,
Jun Nakayama4, Akiyoshi Kakita5, Ryosuke Ogura5, Mika Asakawa6, Emi
Suzuki-Kouyama6, Kiyomitsu Oyanagi6. 1Shinshu Univ. Sch. of Med.;2Dept. of Med. (Neurol.), Fujimi-kogen Med. Center; 3Dept. of Pathol.,
Shinshu Univ. Sch. of Med.; 4Det. of Molecular Pathol., Shinshu Univ.
Graduate Sch. of Med.; 5Dept of Pathol., Brain Res. Inst., Univ. of Niigata;6Dept. of Brain Disease Res., Shinshu Univ. Sch. of Med.
Gliomatosis cerebri is a rare diffuse glioma that is neither mass-forming nor
necrotic, and does not disrupt existing structures. Gliomatosis occurring in the
cerebellum is known as gliomatosis cerebelli, and only three such cases
examined by biopsy have been reported. Here we describe the first autopsy
findings of a patient who was diagnosed as having gliomatosis in the
cerebellum. Neuropathological examination identified the tumor cells as being
positive for glial fibrillary acidic protein, vimentin and nestin, with atypical
nuclei that were cashew-nut- or dishcloth-gourdshaped. These tumor cells were
dense in the right cerebellum, but also spread broadly throughout the brain
including the left cerebrum and optic nerve. Mitotic figures were frequently
seen in the cerebellum, brain stem and cerebrum. Scherer_s secondary
structures were evident not only in the cerebellum but also the cerebrum. No
necrosis, microvascular proliferation or destruction of anatomical structures
was detected in the whole brain. Differences in the origin of the tumors of the
gliomatoses cerbri and cerebelli suggests these tumors are different types of
brain tumors. Thus the findings support that the gliomatosis cerebelli is a novel
type of brain tumor classification. Furthermore, by the similarities of the his-
tological features among the tumors, it appears appropriate to establish a novel
category of ‘‘gliomatosis encephali’’ which includes both gliomatosis cerebri
and gliomatosis cerebelli.
177
Astrocytomas as Secondary Tumors in Patients Treated for
Medulloblastoma: A Case Series
Dilys Chen1, Marco Hefti1, Sandro Santagata2, Rolf Pfannl1. 1Department of
Pathology, Beth Israel Deaconess/Harvard Medical School; 2Department of
Pathology, Boston Children’s Hospital
The increasing number of medulloblastoma survivors after aggressive multi-
modality therapy makes understanding long-term sequelae critically important.
We report the largest series of patients with astrocytomas occurring after
treatment for medulloblastoma to date (n=5), and the longest reported latency.
Medulloblastoma was diagnosed at a mean age of 3.5 years (range 2 to 6) and
the secondary astrocytoma a mean of 14 years later (6 to 30). Of our cases,
three were glioblastomas (WHO Grade IV) and two anaplastic astrocytomas
(Grade III). Four cases were in the posterior fossa, while one was in the right
temporal lobe. Four patients died of their secondary tumor, with a mean
survival of 10.8 months, while one of the two anaplastic astrocytoma patients
was alive at 8 months post-diagnosis. The right temporal lobe tumor had
chromosomal analysis performed by array-based comparative genomic hybrid-
ization and was found to have only an 8.4MB single copy loss of 9p21.3-9p21.1
resulting in a loss of CDKN2a which is rare in medulloblastomas, but common
in high grade astrocytomas. It is unlikely that any of these tumors were
sporadic, as high grade gliomas, particularly in the posterior fossa, are rare in
children and young adults. In addition three of our cases showed clear
histological changes consistent with previous radiation effect adjacent to the
tumor. It is highly unlikely that any of these tumors were derived from the
original medulloblastoma cells, given the long latency and the absence of
residual/recurrent medulloblastoma in the interim, although this cannot be
completely excluded. Radiation-induced glioblastomas are uncommon but are
known to occur in patients with prior therapy for medulloblastoma in child-
hood. Although these cases are rare, these examples demonstrate the need for
adequate surveillance.
178
ImmunoFISH is a Reliable Technique for the Assessment of 1p and 19q
Status in Oligodendrogliomas.
Peter Gould1, Celine Duval2, Marie de Tayrac3, Fran0ois Sanschagrin2,
Karine Michaud1, Stephan Saikali1. 1Hopital de l’Enfant-Jesus du CHU de
Quebec; 2CHU de Quebec; 3Universite de Rennes
We developed an immunoFISH technique for the study of oligodendroglio-
mas by combining a classical immunohistochemistry technique using MIB-1
antibody with a standard FISH technique using commercial 1p36 and 19q13
chromosomal probes on the same section.
This technique permits an analysis of 1p and 19q status restricted to the
actively proliferating tumour cell population, which may be advantageous
for small tissue samples with a mixture of tumour and non-tumour cells.
Validation was performed on a series of 36 pre-selected oligodendrogliomas
(12 grade II, 21 grade III and 3 grade IV) and compared to the results
previously obtained by FISH.
ImmunoFISH technique appears easy to perform and to analyse and is little
more time-consuming than the FISH technique. Inter-observer reliability of
immunoFISH is high when detecting deletions by the ratio method (1p, J =
0.71; 19q, J = 0.72) but higher when using the combination method (1p, J =
0.86; 19q, J = 0.95).Compared to FISH, immunoFISH exhibits a very high
sensitivity (È 100 %) and a high specificity (È 90 %) for 1p and /or 19q
deleted cases. The sensitivity decreases slightly for non-deleted cases (È 85 %)
as does specificity (È 60 % for 1p and È 85 % for 19q). For unbalanced cases
the sensitivity remains high for both 1p (È 90 %) and 19q status (È 100 %) but
specificity decreases (È 50 % for both 1p and 19q status). There was no
significant difference between FISH and immunoFISH results calculated on
60, 40 or 20 cells, regardless of the method of calculation used (combination
or ratio) or the type of chromosomal status studied (Chi-square test not
significant). Our study demonstrates the reliability of the immunoFISH
technique in the study of 1p and 19q status in oligodendrogliomas and
emphasizes its advantage in poorly cellular tumour specimens.
179
A Case of Bone-Only Extraneural Metastatic WHO Grade II
Oligodendroglioma
Zachary Hoffer1, Desiree Marshall1, Luis Gonzalez-Cuyar1, C. Dirk Keene1,
Theodore Burke1, Marc Chamberlain1, Donald Born2, Margaret Flanagan1.1University of Washington; 2University of Washington, Stanford University
Metastases to the brain are the most common form of intracranial malignancy;
however, extraneural metastases of primary intracranial neoplasms are very
uncommon. Examples of primary intracranial tumors exhibiting extraneural
spread are meningiomas and hemangiopericytomas in adults and medulloblas-
tomas and ependymomas in pediatric patients. Gliomas rarely metastasize, but
when they exhibit extraneural spread it is more commonly originating from
glioblastomas and gliosarcomas. Here we report the case of a 48-year-old man
who presented with headaches and a seizure prompting imaging which revealed
a non-contrast enhancing left parenchymal frontal tumor. Approximately one
year later the patient underwent resection of a WHO grade II oligodendro-
glioma. The patient did well after surgery and was expectantly managed for five
years until he developed primary site tumor recurrence; review of the original
pathology showed the tumor was co-deleted for chromosomes 1p and 19q.
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Standard dose temozolomide therapy was administered for one year, and the
patient did well for an additional three years with stable radiographic disease
until he developed subacute progressive lower back pain prompting imaging.
Plain radiographs and thoracolumbar magnetic resonance imaging revealed
osteosclerotic lesions distributed in multiple thoracic vertebrae and the sacrum.
Computerized tomography of the chest, abdomen and pelvis confirmedmultiple
metastases but no peripheral primary site of disease. A biopsy of the sacral lesion
showed an epithelioid tumor composed of neoplastic cells with prominent
nucleoli and eosinophilic cytoplasm that were immunoreactive to GFAP and
S100 and co-deleted for 1p and 19q. IDH-1 (R132H) testing by immunohis-
tochemistry in the brain primary and sacral tumor was negative. Although the
histology was slightly different, taken together the immunohistochemical and
molecular features were consistent with metastatic oligodendroglioma. Recogniz-
ing the rarity of extraneural metastatic oligodendrogliomas, it is unclear if im-
munohistochemically wild type IDH-1 (R132H), such as our case, have an
increased propensity to metastasize.
180
Alpha-Internexin Immunoexpression in Oligodendrogliomas Y Potential
Diagnostic and Pathogenetic Relevance.
Suash Sharma1, Dustin Gertsch1. 1Medical College of Georgia, Georgia
Regents University
With the exception of 1p19q codeletion in oligodendrogliomas, no other
markers reliably differentiate prognostically distinct oligodendrogliomas from
diffuse astrocytomas. We evaluated immunoexpression of alpha-internexin
(INA), a neuron-specific gene that encodes a 66-kd neurofilament-interacting
intermediate filament protein and is one of the most differentially expressed
genes between mutually exclusive 1p19q-codeleted and EGFR-amplified high-
grade gliomas, in oligodendrogliomas and associated mini-gemistocytes.
Thirteen archival cases of oligodendrogliomas of all histologic grades were
immunostained for alpha internexin, with autopsy brain tissue as positive
control. The staining of tumor cells were interpreted as 1+ (G10% positive
cells), 2+ (11-50%) and 3+ (950%), while carefully excluding the known
immunostaining of native neurons and axons. Extensive (3+) staining with INA
was seen in 5/13 (38%) oligodendrogliomas. While some staining with INA
was seen in 7/7 (100%) oligodendrogliomas with 1p19q codeletion and in 2/3
(66%) without the codeletion, however 910% cell staining was seen in only 4/7
(57%) oligodendrogliomas with codeletion (comparable to Buckley et al).
Minigemistocytes were stained in 11/12 (82%) with INA. Extensive (3+)
staining was identified in 3/6 (50%) high-grade oligodendrogliomas (grades 3
or 4), as compared to 2/7 (29%) grade-2 oligodendrogliomas. To conclude, our
preliminary study showed extensive immunoexpression (950% tumor cells) of
alpha-internexin in 38% oligodendrogliomas. Although more selective than
the literature, its positivity in oligodendroglial mini-gemistocytes, and higher
proportion of high-grade oligodendrogliomas suggests that it may be of
diagnostic value and further support evidence of neuronal differentiation.
181
Ki-67 and GFAP Dual Stain Employed in Surgical Neuropathology
Paul Mckeever1, Sandra Camelo-Piragua1, Kristina Fields1, Jonathan
Mchugh1. 1University of Michigan Department of Pathology
Background: Both glial fibrillary acidic protein (GFAP) and Ki-67 markers
are used extensively in surgical neuropathology. Distinguishing neoplastic
from other proliferating cells is important to determining proliferative
activity of a tumor. Does staining one tissue section for both GFAP and Ki-
67 help make such distinctions?
Design: Twenty gliomas and ten other lesions were used to compare the value
of single GFAP and Ki-67 immunostaining versus dual staining (DS) for Ki-67/
GFAP. Ki-67 stained the tissue first, and its hard reaction product retained the
proliferation index during additional staining. From a specimen block, Ki-67/
GFAP DS section and individual serial sections stained for either Ki-67 or
GFAP were used to quantify Ki-67/GFAP +/+, +/-, -/+ , -/- cells, and to
quantitatively compare these cell types. A comment was included if any stains
enhanced interpretation or enabled diagnosis.
Results: Ki-67/GFAP DS outperformed serial sections of single stains in
identifying individual GFAP+ proliferating and non-proliferating cells. Ki-
67/GFAP DS provided better information about specimens containing well
mixed populations of GFAP positive and GFAP negative cells: Mixed glial
and neuronal tumors, oligoastrocytomas, and margins of astrocytomas. In
mixtures of astrocytes and other cells, Ki-67/GFAP DS highlighted the
population of proliferating GFAP+ astrocytes when present. Ki-67/GFAP
DS increased accuracy of counting proliferation indices of astrocytomas and
ependymomas by excluding proliferating GFAP negative cells associated
with small vessels and leukocytes. Ki-67/GFAP DS has been used for half a
year on various diagnostic problems. It has been particularly helpful with
fibrous tumors invading brain versus gliosarcoma, anaplastic astrocytoma
versus glioblastoma, and margin of diffuse astrocytoma versus reactive
changes. Cases will be illustrated.
Conclusions: Ki-67 and GFAP dual staining is most useful in evaluating
lesions containing mixed populations of GFAP positive and GFAP negative
cells. In these situations, dual staining was superior to sections of single stains.
182
Methylthioadenosine Phosphatase Expression in Pilocytic Astrocytomas
and its Relationship with Oncogene-Induced Senescence
Aline Becker1, Cristovam Scapulatempo-Neto1, Weder Menezes1, Carlos
Clara1, Ricardo Oliveira2, Helio Machado2, Marileila Varella-Garcia3,
Luciano Neder4, Rui Reis5. 1Molecular Oncology Research Center, Barretos
Cancer Hospital, Brasil; 2Ribeirao Preto School of Medicine, University of
Sao Paulo/FMRP-USP; 3Division of Pathology National Institute of Cancer,
Braga, Portugal; 4Ribeirao Preto Medical School - FMRP/USP; 5Molecular
Oncol Res Center, Barretos, Brasil and ICVS, Univ. Minho, PT
Background: Pilocytic astrocytomas (PAs) are the foremost glioma in children
and in general presents an indolent course. The main involved molecular
mechanism is constitutive activation of MAPK pathway, mostly through
KIAA-BRAF (K:B) fusion. This molecular alteration may trigger oncogene-
induced senescence (OIS), a mechanism recently implicated in the benign
behavior of PAs. In fact, an increased expression of methylthioadenosine
phosphatase (MTAP) gene has been referred in astrocytes of dementia and
ageing animal models, related to the phenomenon of senescence. In contrast,
loss of MTAP expression is related to poor prognosis in leukemias and other
malignancies, including glioblastomas. Thus far, the role of MTAP in PAs is
unknown. Herein, we aimed to assess MTAP expression and its role in the
biologic behavior of PAs.
Methods: A cohort of 69 patients (1.2:1 M/F, median 11.6 years-old), was
evaluated to assess the expression of MTAP by immunohistochemistry in
FFPE on two tissue microarrays (TMAs) platforms and correlated with
clinicopathological and molecular data of K:B fusion by fluorescence in situ
hybridization (FISH), with a customized dual-target dual-color probe.
Results: More than 95% of the PAs (66/69) showed overexpression of
MTAP, contrasting to the faint reaction in the astrocytes of the adjacent
non-neoplastic cerebellar cortex. The MTAP overexpression was positively
correlated with cerebellar lesions (p=0.025) and the presence of K-B fusion
(p=0.028). No other significant differences were noted.
Conclusions: To best of our knowledge, this is the first study that shows an
overexpression of MTAP in PAs with a reduced expression in adjacent non-
neoplastic tissue. This pattern of expression reinforces a positive relation-
ship between constitutive activation of MAPK pathway through K-B fusion
and the OIS phenomenon. This fact could be one of the mechanisms
responsible for the indolent behavior of PAs, but further studies with larger
cohorts are necessary to confirm this relationship. Support: PAIP
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183
Immunohistochemical Characteristics of Centyrin & DARPin Targets
in Brainstem Gliomas and Correlation with Molecular Markers
Viktor Zherebitskiy1, Sakir Gultekin1, Cynthia Hawkins2, Christopher
Corless3, Kellie Nazemi1, Charles Keller1. 1Oregon Health and Science
University; 2The Hospital for Sick Children/ University of Toronto; 3Knight
Diagnostic Laboratories/ Oregon Health and Science University
Brainstem gliomas are deadly due to their location. They occur mainly in
the pediatric and adolescent population. They are not readily amenable to
surgical treatment and respond poorly to combined radiation and chemo-
therapy. Centyrins and DARPins belong to scaffold proteins family. They
have many pharmacologic advantages over monoclonal antibodies currently
used for targeted therapies. It is important to confirm that their effector
proteins have specific targets in the gliomas. We examined tissue from 17
DIPG cases (6 surgical biopsies, 2 autopsy cases and 9 in TMA archival
material) studying distribution of 7 antigenic targets (IL4, IL4R, IL13,
IL13RA1, IL13RA2, EGFR and MET/HGFR) using immunohistochemistry.
Two neuropathologists (VZ & SHG) interpreted the results using semi-
quantitative scoring system. The tumor material was also screened for
variety of molecular targets including CDKN2A, EGFR, IGF1R, MET,
MGMT, NF1, MYCN, PDGFRA, PTEN, RB1, P53, H3F3A, HIST1H3B
and ATRX. We found that 86% of DIPGs were positive for IL4 and only
7% of them showed positive immunostaining for IL13. However, their
receptors (IL4R, IL13RA1 and IL13RA2) were expressed in 75-85% cases.
In about a half of the positive cases the expression was strong and global
(925% of positive tumor cells). The oncogenes (EGFR and MET) were
expressed in about 40% of cases. There was no straightforward correlation
between potential centyrin and DARPin targets studied by immunohisto-
chemistry and molecular tumor markers. CONCLUSION: Our study showed
fairly high and frequent expression of IL4 and IL13 receptors in the
brainstem gliomas. These data can be used in designing specific centyrin/
DARPin-based drugs for targeted therapies of DIPGs. Further studies are
needed to find correlations between centyrin/DARPin targets and molecular
makeup of the brainstem gliomas.
184
Adult Brainstem Gliomas: A Case Series With Radiological,
Pathological, And Clinical Correlation
Kimmo Hatanpaa1, Gregory Martin1, Jack Raisanen1, Chan Foong1, Bruce
Mickey1, Charles White1, Robert Oberle1. 1UT Southwestern Medical Center
Brainstem gliomas are common in children and classifiable based on
radiological and histopathological features into two clinically relevant
groups: diffusely infiltrating pontine gliomas, which are associated with an
unfavorable prognosis, and dorsal exophytic gliomas, which are associated
with a favorable prognosis. In contrast, brainstem gliomas are rare in adults,
and the clinical significance of radiological and histopathological features is
less well established.
We reviewed the imaging findings, histopathological features, and clinical
outcome in a series of 17 adult patients with histologically proven brainstem
gliomas. The series consisted of 6 histologically classic pilocytic astrocy-
tomas (WHO grade I), 1 diffuse astrocytoma (WHO grade II), 5
unclassifiable low-grade astrocytomas (WHO grade I or II), 1 anaplastic
astrocytoma (WHO grade III), and 4 glioblastomas (WHO grade IV). The
radiological features that were analyzed included the presence and pattern of
contrast enhancement and whether the tumor was intrinsic or exophytic.
High-grade (WHO grade III-IV) gliomas were associated with a signifi-
cantly shorter total survival compared with low-grade (WHO grade I-II)
gliomas (p=0.0005). Specifically, all 6 patients with pilocytic astrocytomas
were alive after a median follow-up of 7 years, whereas 4 of the 5 patients
with high-grade tumors were dead after a median follow-up of 7.5 months.
Four of the five patients with unclassifiable low-grade tumors were alive
after a median follow-up of 3 years. None of the radiological variables was
significantly associated with survival. Our data suggests that standard MRI
techniques are poor predictors of clinical outcome and supports a low
threshold for pursuing histological diagnosis in adult patients with suspected
brainstem gliomas.
185
Pediatric Brainstem Tumors with Features of Angiocentric Glioma:
Report of Two Cases
Marie Rivera-Zengotita1, Jesse Kresak2, David Pincus3, Anthony Yachnis2.1University of Florida; 2Department of Pathology, University of Florida;3Department of Neurosurgery, University of Florida
Angiocentric glioma is a rare low grade neuroepithelial tumor with
characteristic angiocentric growth pattern and ependymal differentiation. It
typically affects children and young adults that present with chronic
intractable seizures and a cerebral lesion. Such tumors arise most commonly
in the frontoparietal or temporal regions as solid T2 hyperintense areas that
occasionally show a Wstalk-likeW extension to the adjacent ventricle. We
report the clinicopathologic features of two pediatric patients with low-
grade brainstem tumors that showed histopathological and immunohisto-
chemical features of angiocentric glioma. The first patient, a 5 year old girl,
presented with double vision, headache, and nausea and was found to have
papilledema on exam. Imaging studies revealed a T2 bright, non-enhancing
lesion of the midbrain that caused aqueductal obstruction and hydro-
cephalus. The second patient was a 6 year old boy that had a non-enhancing
diffuse pontine lesion that was bright on T2/FLAIR images and had a large
exophytic component projecting into the fourth ventricle. Histologic
examination of both cases revealed a neoplasm composed of monomorphous
bipolar spindle cells, with nuclei containing granular (WcrispW) chromatin,
that were arranged in a distinctive angiocentric growth pattern. Tumor cells
were immunoreactive for GFAP and showed a perinuclear dot-like pattern
of reactivity for EMA. Only a rare mitosis was identified and the Ki-67
(MIB1) labeling index was low. The brainstem location and histologic
features of these tumors are similar to a previously reported angiocentric
glioma-like tumor that arose in the midbrain (Covington et al. Pediatr
Neurosurg 2009;45:429-33). On follow-up, both patients reported here are
alive with stable residual disease after 6 years (first patient) and 5 months
follow-up. These findings suggest that brainstem tumors with angiocentric
glioma-like features may represent a distinctive subtype of low grade glioma
that should be included in the differential diagnosis of brainstem/posterior
fossa lesions in the pediatric population.
186
Composite Atypical Ganglioglioma (GG)-Pleomorphic Xanthoastrocytoma
(PXA), Recurrent: A Case Report
Areli Cuevas-Ocampo1, Luis Moral1. 1Baystate Medical Center/Tufts
University School of Medicine
Composite GG/PXA is a rare entity displaying histologically a GG adjacent to a
PXA, with the second component recognized at presentation or recurrence. It
shares clinicopathologic features of both individual tumors and when anaplasia
is present it is usually associated with the PXA elements. We report a case of a
composite GG/PXA presenting as atypical GG and recurring twice as PXA. The
patient is a 24-year-old man who developed left-sided arm numbness and
tingling. Imaging studies revealed a 5.4� 3.6� 3.1 cm solid/cystic enhancing
right parietal mass. Gross total tumor resection was performed.Microscopically
the hypercellular tumor had papillary formations, eosinophilic granular bodies,
neoplastic cells with glial and neuronal phenotypes, no neurocytes, and up to
3 mitoses/10 HPFs. Microvascular proliferation or necrosis was not seen.
Pleomorphic, xanthomatous cells and the classic reticulin network were absent.
Frequent tumor cells were positive for GFAP and synaptophysin, some for p53
and few expressed CD34 and NF, with a Ki-67 index of 3%. The first and second
recurrences occurred five and ten months later and exhibited the characteristic
histopathologic findings of PXA with similar immunohistochemical results as
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above, except for only scattered synaptophysin positive tumor cells. Ganglion
cells were not identified. Mitoses, necrosis or microvascular proliferations were
not found in both recurrences. The original and recurrent tumors were positive
for BRAFV600Emutation.We are reporting this case as a composite GG/PXA
presenting as atypical GG and recurring with the classical histologic features
of PXA. It suggests the possibility that mitoses, papillary formations and p53
immunoreactivity in someGG/PXAs, present in the GG component in this case,
may be associated with aggressive clinical behavior. It also emphasizes the
existing overlap between PXA and GG and supports the notion that PXA may
correspond to a glioneuronal rather than a pure astrocytic neoplasm.
187
Molecular Analysis of Pilomyxoid Astrocytoma and Variable Tendency
Toward Maturation to Pilocytic Astrocytoma
Bette Kleinschmidt-DeMasters1, Andrew Donson2, Nicholas Foreman2.1University of Colorado Anschutz Medical Campus; 2Children’s Hospital
Colorado
Background: PMA was codified in WHO 2007 as a variant of PA, although it
was given a different grade (WHO grade II) due to more aggressive behavior.
Occasional reports have shownmaturation of PMA to PA or intermediate forms
of PMA-PA, validating the concept of keeping them within the PA spectrum.
Additional information is needed regarding the clinical and biological
relationships between PMA and PA.
Design: We reviewed our clinical and histological experience with pure
PMAs (n=8), and analyzed gene expression using Affymetrix U113plus2
microarray chips. Findings were contrasted with PA gene expression profiles
(n=10). Those 92-fold overexpressed were identified and subsequently
analyzed using the web resource DAVID (Database for Annotation, Visual-
ization and Integrated Discovery) and GSEA (Gene Set Enrichment Analysis).
Results: Clinical behavior varied considerably in our cohort; PMAs
involving optic chiasm or cerebellum did significantly better and 4/4
patients survived, albeit with deficits. Diencephalic syndrome, seen in 4/4
PMAs centered in hypothalamus, was associated with demise in all cases. 1
of these 4 PMAs underwent autopsy and both maturation towards PA and
transformation to GBM was identified within the cerebrospinal tumor
deposits. In contrast, one surviving non-diencephalic PMA patient has
undergone 5 subsequent surgical excisions, with documented progressive
maturation towards PA over time. Many genes overexpressed in PMA
versus PA were cell-cycle and mitosis-related. After ranking most differ-
entially-expressed genes in PMAs, we identified upregulation of IMP3 (45-
fold), (as reported, JNEN 2013:72:442), as well as key molecules in nervous
system development, HMGA2 (16-fold) and EPHB2 (7-fold) (all
pG0.00001).
Conclusions: PMAs have very variable behaviors and definite biological
differences.
188
BRAF Testing in Pleomorphic Xanthoastrocytoma: Insights from 3
Pediatric Cases
David Pisapia1, Ehud Lavi1. 1Weill Cornell Medical College
The presence of BRAF alterations is becoming increasingly recognized in a
variety of pediatric central nervous system tumors. Moreover, the existence
of small molecule inhibitors that target this mutated receptor may offer
therapeutic options in more aggressive lesions in addition to surgery,
conventional chemotherapy, and radiation. Certain entities such as pleo-
morphic xanthoastrocytoma (PXA), ganglioglioma (GG), and pilocytic
astrocytomas (PCA) frequently show BRAF alterations and in histologically
ambiguous cases, such molecular analysis may be a helpful adjunctive study
in formulating a differential diagnosis. Here we highlight three informative
cases that ultimately harbored BRAF alterations. In the first case the finding
of a BRAF-V600E mutation was used to confirm the presence of a recurrent
PXA with sarcomatous features where both the histology and location were
distinct from the original tumor. In the second case, the presence of the
BRAF-V600E mutation was used on limited biopsy tissue to support the
notion that the astrocytic component of the lesion represented a tumor along
the spectrum of PXA, GG, or PCA as opposed to the spectrum of diffusely
infiltrating astrocytomas. Finally, a previously unreported CCDC6-BRAF
fusion protein was found in the third case, which showed definitive
histological features of the PXA/GG spectrum of tumors. This report
highlights the diagnostic utility of BRAF mutations in addition to reporting
a novel BRAF fusion protein that is postulated to act with functional
similarity to that of BRAF-V600E. We find that targeted sequencing of this
gene can be of great utility, particularly in diagnosing tumors that lie within
the PXA/GG spectrum and in cases with histological ambiguity. Such
testing is not only useful diagnostically, but also may serve as the basis for
therapeutic decision making and the ability to refine prognosis.
189
Cerebellar Pleomorphic Xanthoastrocytoma in a Patient with
Neurofibromatosis Type 1: A Case Report.
Hidehiro Takei1, Meenakshi Bhattacharjee2. 1Houston Methodist Hospital;2University of Texas Medical School at Houston
Pleomorphic xanthoastrocytoma (PXA) is an uncommon tumor of young
adults, typically occurring supratentorially. It is generally considered to be a
low grade, circumscribed tumor treated by surgical resection, with a
relatively favorable outcome. Cases of cerebellar PXA have been rare, and
cases associated with neurofibromatosis type 1 (NF1; PXA-NF1) are even
rarer, with only 2 cases having been reported to date. We present here a
third case of PXA-NF1 with unusual features.
The patient was a 33-year-old woman presenting with a history of headache for
about 6 weeks. Her medical and family history was significant for NF1. Brain
MRI revealed a 3.4 cm ill-defined lesion with a gyriform enhancing pattern in
the left cerebellum, mimicking gangliocytoma. The patient had gross total
resection of the lesion, and had an unremarkable postoperative course.
Histologically, the lesion showed typical PXA (WHO grade II) features
characterized by a cellular astrocytic proliferation with bizarre, pleomorphic
tumor giant cells, some multinucleated, abundant eosinophilic granular bodies,
and a typical intercellular reticulin network. Immunohistochemically, scattered
synaptophysin positive tumor cells were identified. Notable however, the
majority of tumor showed growth in the subpial compartment, with thickening
of the cerebellar folia externally. P53-immunostaining was negative. Three
months following surgery, local recurrence was detected, and radiation therapy
was given. One year after the first surgery, she underwent surgical resection of
the recurrent/residual tumor. Histologically, the recurrent tumor showed very
similar features to the initially resected tumor, with additional radiation-related
changes. All 3 reported cases of cerebellar PXA-NF1 including ours, showed
recurrence. The reported cases of supratentorial PXA-NF1 have not been
associated with recurrence, and thus, exhibit the same behavior as sporadic
non-NF1-PXA. In contrast, cerebellar PXA-NF1 may not have such s favor-
able outcome.
190
Anaplastic Pleomorphic Xanthoastrocytoma: Report of TwoDiverseCases
Suash Sharma1, Ravi Raghavan2. 1Medical College of Georgia, Georgia
Regents University; 2Loma Linda University Medical Center
We profile two cases of anaplastic pleomorphic xanthoastrocytoma (APXA),
a rare malignant variant for which diagnostic criteria are not well
established in the WHO classification. Case 1: A 7-year old female
presented with a large right fronto-parietal cystic mass with mural nodule.
The tumor was mostly densely cellular and consisted of pleomorphic
anaplastic astrocytic cells exhibiting frequent mitotic activity (7 per 10 hpf),
palisaded necrosis, microvascular proliferation a Ki-67 labeling index of
20%, and negative IDH1. Differential diagnosis was between glioblastoma
and APXA. Given the interspersed areas of lower cellularity, abundant
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eosinophilic granular bodies (EGBs), focally increased peri-/inter-cellular
reticulin, xanthomatous and pleomorphic cells, and relative circumscription,
the findings were most consistent with an APXA. Case 2: A 65 year-old
male presented with a large left temporal, partially enhancing tumor with
mass effect. Histopathology revealed a glial neoplasm with relatively sharp
borders, and composed of GFAP-immunoreactive and focally CD34-
positive markedly pleomorphic astrocytic cells with gemistocytic forms,
bizarre giant cells, high mitotic activity, vascular endothelial proliferation,
and necrosis with pseudopalisading. Interspersed were mildly sclerotic areas
of lesser cellularity and mitotic activity, focal xanthomatous change, and
reticulin staining. EGBs were scant or absent. An admixed neuronal/
ganglionic component was not identifiable, although rare giant cells were
focally NFP-positive. Losses on chromosome 10 (PTEN/DMBT1) or evidence
of EGFR amplification characteristic of de-novo glioblastomas were absent, but
gains on chromosome 7 were present. Overall impression was that of a high-
grade glioma, indistinguishable from glioblastoma, that in view of imaging,
histology and longer survival was best regarded an APXA. This patient
survived for 5 years. To conclude, characteristic histology especially EGBs,
with reticulin and CD34 expression, in the clinical context of slow-growing and
circumscribed tumors can facilitate a diagnosis of APXA, with its implications
of greater prognostic variability (including longer survival) as compared to
conventional glioblastomas.
191
Anaplastic Pilocytic Astrocytoma of the Cerebellum with a BRAF
V600E Mutation
Ada Baisre1, Nitin Agarwal1, Anjali Seth2, James Liu1. 1Rutgers-New
Jersey Medical School; 2University Hospital
We report a case of pilocytic astrocytoma with anaplastic features and a BRAF
codon 600 mutation (V600E). Pilocytic astrocytoma (PA) is a relatively indo-
lent, WHO Grade I neoplasm of children and young adults, arising commonly
in the cerebellum, although it can arise from other locations as well. Anaplastic
features are rarely seen in pilocytic astrocytomas and the criteria are not well
established. Previous studies have shown that the biologic behavior of such
tumors is similar to that ofWHOGrade III astrocytomas, hence the survival rate
is decreased compared to typical PAs. Fusion variants involving BRAF and
KIAA1549 have been found inÈ80% of pilocytic astrocytomas. BRAF V600E
mutations, although not common, can also be found in PAs, but have been seen
more frequently in PAs located in the supratentorial compartment. Our case is
that of a 30-year-old man who presented with sudden loss of consciousness and
was found to have hydrocephalus due to a 2.4 � 2.6� 4.2 cm, partially cystic,
heterogeneously enhancing mass within the cerebellar vermis. A midline
suboccipital craniectomy was performed and gross total resection of the lesion
was achieved. Histopathological examination showed a tumor composed of
highly cellular areas mixed with low cellular areas of classic pilocytic
astrocytoma. The highly cellular areas were histologically variable, including
spindle, epithelioid, and focally chordoid morphology. The mitotic activity in
these areas wasÈ1-2� 10 HPF and a focus of necrosis was identified surrounded
by microvascular proliferation (glomeruloid tufts). Both anaplastic features and
the presence of the BRAF V600E mutation are uncommon findings in pilocytic
astrocytomas. Therefore, it is not clear whether the BRAF V600E mutation in
our case played a role in the development of these anaplastic features, and
hence, a more aggressive behavior with a probable decreased survival.
192
Low Grade Glioneuronal Neoplasm of the Third Ventricle With
PIK3CA Mutation. A Case Report and Review of the Literature
Patrick Malafronte1, Laurence Davidson1, Brett Theeler1. 1Walter Reed
National Military Medical Center
Low-grade glioneuronal neoplasms are a heterogeneous group of tumors.
While their histologic and clinical features are often distinct, occasional
cases present in unusual sites with overlapping histologic appearances. In
such settings it can be difficult if not impossible to definitively classify
lesions, leading to frustration on the part of treating clinicians. Several
ancillary tests are available to assist in differentiating histologically similar
neoplasms, but these have not been extensively studied in this group of CNS
tumors. We present a case of a 35 year old man presenting with a one week
history of headache and intermittent, slowly progressive horizontal diplopia.
MRI demonstrated a non-enhancing T2 hyperintense lesion within the body
and posterior third ventricle with involvement of bilateral thalami and
associated hydrocephalus. Microscopic sections revealed a neoplasm
composed of oligodendroglioma-like cells with focal fibrillar and perivas-
cular pseudorosettes in a mucinous microcystic background. There were
many areas of microvascular proliferation. The neoplastic cells stained
focally with GFAP. Synaptophysin reactivity was largely restricted within
and around rosettes. The MIB-1 index was G2%. IDH-1 and p53 IHC were
negative. Molecular analysis demonstrated intact 1p19q and no BRAF
mutation (V600E). PIK3CA mutation analysis detected a mutation in exon 9
(E545K, c.1633G9A). PIK3CA mutations have mostly been reported in high
grade gliomas; however, they can also be seen in some rosette-forming
glioneuronal tumors (RGNT). Other tumors in the differential for this case
(DNET, pilocytic astrocytoma) have not been extensively examined for
PIC3CA mutations, but given the potential therapeutic benefit of PI3K/
AKT/mTOR inhibitors, such study seems indicated, especially for use in
recurrent or unresectable tumors. In addition, the discovery of potential
recurrent molecular abnormalities may help to better classify this group of
understudied neoplasms.
193
Multinodular and Vacuolating Neuronal Lesions: An Evolving
Classification of Low-Grade Neoplasms of the Cerebrum
Lyndsey Emery1, Donald O’Rourke1, Maria Martinez-Lage1. 1Hospital of
the University of Pennsylvania
Background: Low-grade glioneuronal tumors include gangliogliomas,
dysembryoplastic neuroepithelial tumors and papillary glioneuronal tumors.
However, current classification does not necessarily encompass the entire
spectrum of low-grade lesions with neuronal differentiation. Recently,
twelve cases were reported as ‘‘multinodular and vacuolating neuronal
tumors’’ exhibiting similar presentations, radiographic findings, histopatho-
logic features and outcomes1,2. Here, we present two additional cases,
which are thought to belong to this novel entity.
Cases: The first case is from a 24-year-old female with long-standing
seizures refractory to multiple medications, since age 5. MRI revealed a
focus of T2/FLAIR cortical and subcortical hyperintense signal within the
left occipital lobe, with mild gyral expansion and minimal mass effect, for
which she elected surgical resection. The second case is from a 30-year-old
female with no known seizures. She underwent MRI for intermittent
episodes of vertigo, which revealed a cluster of well-delineated, variable
sized T2/FLAIR hyperintense cysts in the left frontal subcortical white
matter. Interval imaging was stable; however, she elected for surgical
resection. Histopathologic examination of both specimens revealed areas of
distinct to coalescent nodules within the subcortical white matter at the
cortical-white matter junction and focally extending into the cortex. The
nodules were composed of bland cells with round to ovoid nuclei, open
chromatin, variably prominent nucleoli and moderate amounts of eosinophilic
cytoplasm in a background of vacuolated neuropil. Immunohistochemical
stains demonstrate neuronal origin. Case 1 was also notable for a robust CD34-
positive nodular meshwork. The overlying cortex shows evidence of
architectural disarray, without significant mitotic activity, necrosis or micro-
vascular proliferation. Next-generation sequencing of 47 gene hot spots
(including BRAF) was negative for somatic mutations in Case 1.
Conclusions: We have identified two cases morphologically and clinically
consistent with the recently described ‘‘multinodular and vacuolating
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Page 53
neuronal tumors’’. We propose that these are low-grade neoplastic, or
possibly hamartomatous, lesions warranting further characterization.
194
Synaptophysin Positive Atypical Neuroepithelial Tumor With Diffuse
GFAP Expression at Recurrence: A Case Report.
Areli Cuevas-Ocampo1, Luis Moral1. 1Baystate Medical Center/Tufts
University School of Medicine
The overlap between oligodendroglioma and extraventricular neurocytoma is
rare and has been reported seldom in the medical literature. The biological
behavior is thought to be analogous to that of conventional oligodendroglioma.
We report a neuroepithelial neoplasm with neurocytic/oligodendrocytic differ-
entiation and atypical histologic features. The patient is a 30-year-old woman
who presented with sudden elevation of intracranial pressure. Imaging studies
revealed a 6.6 � 5.4 � 4.0 cm solid/cystic right parietal lobe mass which
recurred two years later. The patient underwent gross total tumor resection on
both occasions confirmed by imaging studies. Histologically, the initial and
recurrent tumors showed similar features; a high cellular density with oval to
spindle-shaped nuclei, mild- moderate pleomorphism, perinuclear spaces in
some cells, thick-walled vessels, focal calcifications and microvascular
proliferation. The first resection showed a focally well-demarcated brain/tumor
interface, strong reactivity for synaptophysin and variable staining for GFAP, 3
mitoses/10 HPF, Ki-67 of 7.6% and no necrosis. The recurrence displayed focal
necrosis, 6 mitoses/10 HPF, strong immunoreactivity for GFAP but no staining
for synaptophysin. Ki-67 appeared to be higher than in the initial resection.
Neither tumor was immunoreactive for IDH1 or neurofilament protein. 1p/19q
analysis by FISH failed to demonstrate co-deletion in both lesions. Although
this did not exclude oligodendroglioma, the lack of 1p/19q co-deletion, and
negative IDH1, favored the initial diagnosis of extraventricular neurocytoma.
Electron microscopy was attempted out of the paraffin blocks but the results
were inconclusive. The exact classification of this tumor is somewhat unclear
since they share similar morphologic features but a dissimilar immunopheno-
type. Whether this neoplasm represents an extraventricular neurocytoma with
oligodendrocytic differentiation or an oligodendroglioma with neurocytic
differentiation is open to discussion. Its atypical histologic features will likely
determine its clinical behavior. This case demonstrates the intriguing relation-
ship that exists between oligodendrocytic and neurocytic neoplasms.
195
An Intracranial Secondary Malignant Neoplasm after Wilms Tumor in
a Four- Year -Old Girl
Rong Li1, Dava Sue Cleveland1, Jeffrey Blount2, Alyssa Reddy3, James
Post1, David Kelly1. 1Department of Pathology and Laboratory Medicine,
Children’s of Alabama; 2Department of Neurosurgery, Children’s of
Alabama; 3Department of Neurology, Children’s of Alabama
Wilms tumor (WT) is the most common renal tumor in children with overall
survival rate of about 85%. However, the survivors of WT have substantial
risk of developing secondary malignant neoplasms, the most common tumor
type of which is carcinoma, followed by sarcoma and leukemia. Rare cases
of medulloblastoma and primitive neuroectodermal tumor have also been
documented in WT patients. However, to the best of our knowledge,
ependymoma has not been reported previously in patients after WT. Herein,
we present the case of a four-year-old female who initially presented with
left-sided abdominal asymmetry in September 2012. Imaging studies
revealed a large left-sided abdominal mass. A diagnosis of classic triphasic
WT with favorable histology was made by biopsy and a left nephrectomy
was performed after initial chemotherapy. The patient was treated with
abdominal radiation and additional chemotherapy. She subsequently
presented with chronic headache in November 2013. MRI scan demon-
strated a heterogeneously enhancing fourth ventricular mass. Suboccipital
craniotomy was performed and microscopic examination demonstrates an
anaplastic ependymoma characterized by numerous perivascular pseudoro-
settes and scattered true rosettes formed by relatively uniform cells. Portions
of this tumor displayed marked hypercellularity and increased nuclear
hyperchromasia. Microvascular proliferation, occasional mitotic figures, and
geographic tumor necrosis were also present. The tumor cells were diffusely
positive for glial fibrillary acidic protein and displayed dot-like positivity for
epithelial membrane antigen in scattered tumor cells. In summary, we
describe a case of fourth ventricular anaplastic ependymoma in a child who
has been treated successfully for WT. Clinicians, radiologists, and neuro-
pathologists should be aware of this rare association between ependymoma
and WT. Interestingly, the Wilms tumor gene (WT1) is expressed in nu-
merous neuroepithelial tumors, including ependymoma, and is increased
with the grade of malignancy. The important role of WT1 in tumorigenesis
and progression of brain tumor is worthy of further investigation.
196
Malignant Evolution of Desmoplastic Glioma with Anaplastic Features,
Including Postmortem Examination.
Catherine Stefaniuk1, Mohamed El Hag1, Duncan Stearns1, Michael
Coffey1, Mark Cohen1, Marta Couce1. 1Case Western Medical Center/
University Hospitals
Desmoplastic infantile gliomas (DIG) are WHO grade I supratentorial
neoplasms of voluminous size with divergent differentiation and intense
desmoplasia which typically follow a benign course following resection, even
when accompanied by anaplastic features. Here we report a girl diagnosed with
an anaplastic DIG at 3 months of age who died of disease two years later. We
describe the original histologic findings (Diagnostic Slide Session Case 2012-5)
and compare them with two subsequent surgeries and post-mortem evaluation.
MRI at presentation demonstrated a large hemispheric cystic mass with en-
hancing nodular components. Complete resection was accomplished in two
stages. Microscopic evaluation of the original tumor demonstrated ameningeal-
based desmoplastic astrocytic neoplasm with regionally high mitotic activity
and palisading necrosis. Three months later, MRI demonstrated increased
enhancement surrounding the resection cavity. A repeat resection showed
similar pathologic findings. The patient was given six months of vincristine,
cyclophosphamide, cisplatin and etoposide without radiation (POG protocol
#8633). One month later she had a third recurrence, which showed recurrent/
residual glioma, reactive astrocytosis with dystrophic calcifications, and focal
cortical dysplasia. The patient went under hospice care and died two years after
initial diagnosis. Autopsy showed a large necrotic mass affecting the entire right
cerebral hemisphere and crossing the corpus callosum, with extensive
subarachnoid and subependymal spread. Histological findings were similar to
those seen in her previous resections. As demonstrated by this case and others,
DIGs have the potential to behave aggressively. We suggest that ominous
histologic findings such as sarcomatoid architecture, palisading necrosis, and
increased mitotic figures be graded on their own merit and not be considered
within the spectrum of a WHO grade I tumor.
197
Disseminated Choroid Plexus Papillomas in Adults. A Review of the
Literature
Marwah Abdulkader1, Gregory Bosh1, Edward Dropcho1, Aaron Cohen-
Gadol1, Jose Bonnin1. 1Indiana University School of Medicine
Choroid plexus papillomas (CPPs) are uncommon, usually intraventricular,
low-grade tumors accounting for less than 1% of all intracranial neoplasms
and 1-3% of brain tumors in children. Dissemination of CPPs to multiple
levels of the neuraxis has been observed. A 21-year-old female had a
craniotomy with resection of a CPP involving the right lateral ventricle. She
had multifocal disease and not all areas of the tumor were resected. No
postoperative radiation or chemotherapy was given but no progression was
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observed over the ensuing years. Seventeen years later, she developed epi-
sodes of dizziness, some short-term memory impairment and episodes of
confusion. At a visit to her primary care physician, because of a gingival
abscess, a follow-up MRI was obtained. This revealed hydrocephalus and
multiple intraventricular and subarachnoid lesions compatible with dissemi-
nated CPPs. The tumors masses involved both lateral ventricles as well as
the third and fourth ventricles. The largest one was in the third ventricle,
extended into the suprasellar compartment and compressed the optic chiasm.
This lesion was resected via an endoscopic craniofacial approach. The
surgical procedure has been reported elsewhere. Histopathologically, the
tumor revealed the characteristic architectural and cytologic features of
CPPs, with very low mitotic and Ki-67 labeling indices. Multifocal CPPs at
the time of initial presentation is an extremely rare occurrence and only
twenty-two cases of disseminated CPPs after the original surgical resection
have been reported in the literature. With some exceptions, disseminated
CPPs have been observed in adults and they involved multiple sites along
the CSF pathways. Occasionally, intraparenchymal extension has been
documented and secondary involvement in the suprasellar cistern was
previously reported in only five cases. There is no consensus on the
postoperative treatment of disseminated CPPs. Generally, the metastatic
lesions maintain the low-grade features of the primary tumor.
198
Recurrent Subependymoma of Fourth Ventricle with Unusual
Histological Features: A Case Report
Nishant Tiwari1, Suzanne Powell2, Hidehiro Takei2. 1Baylor College of
Medicine, Houston, TX; 2The Methodist Hospital, Houston, TX
Subependymoma is a rare variant of ependymal neoplasm with distinct
histological features. It is a slow-growing and well-circumscribed tumor,
corresponding to WHO grade I. Many cases are incidentally found at
autopsy, while surgically resected cases are usually those arising from the
4th ventricle. Subependymoma is characterized histologically by clusters of
ependymal tumor cells arranged in a gliofibrillary matrix with no high grade
features. We present here a very unusual case of recurrent subependymoma
with high grade histological features.
The patient was a 62-year-old female who previously underwent a gross total
resection of a 4th ventricular subependymoma 6 years ago. No recurrence had
been found by follow-up MRI until 4 years ago. Recently, she presented with
symptoms related to increased intracranial pressure and was found to have an
enhancing mass in the 4th ventricle by MRI. She subsequently underwent
resection of the recurrent tumor.
Histologically, the resected tumor showed a characteristic histologic pattern of
subependymoma with small clusters and nests of ependymal cells with an
interspersed gliofibrillary matrix. No true ependymal rosettes or perivascular
pseudorosettes were present. In addition, there were very unusual histological
features, including focal areas of necrosis, microvascular proliferation,
thrombosed blood vessels, and scattered mitotic figures. Immunohistochemi-
cally, scattered p53 positive tumor cells were noted, and a Ki-67 labeling index
was approximately 5% (15% in the highest areas).
Subependymomas are known to be low-grade lesions and are usually cured
if completely excised. The tumor presented here is very unique in that
several high grade pathological features were found in an otherwise typical
subependymoma. Although subependymomas can have higher grade tumor
components (most commonly with ependymoma; hybrid tumor), high grade
pathologic features are usually not seen. Our case may represent anaplastic
transformation of subependymoma, although no such examples have been
reported to date, and close clinical follow-up has been recommended.
199
Ependymal Tumor of the Pituitary
Derick Aranda1, Joseph Parisi1, John Atkinson1, Mark Jentoft1. 1Mayo Clinic
Although a wide range of histologic entities may occur in the sella, only rare
cases of ependymal lesions have been described in this region. We report a
60-year-old man who presented with a mass lesion within the sella turcica
clinically thought to represent a pituitary adenoma that demonstrated histo-
morphologic, immunohistochemical, and ultrastructural features of an ependy-
moma. The lesion showed immunoreactivity to GFAP, EMA, and S100; but
none to pituitary hormones or chromogranin. It is important to separate this
entity from pituitary adenoma since the clinical behavior of sellar lesions with
ependymal differentiation is not known. The tumor also stained positively for
TTF 1, which is of interest since the origin of these lesions is not certain. A
hypothesis is that these ependymal tumors of the pituitary represent a variant of
pituicytoma, which originate from ‘‘ependymal pituicytes.’’ TTF 1 is expressed
in the ventral forebrain and pituitary during development. Although TTF 1
positivity supports a variant of pituicytoma, it rarely has been reported in cases
of 3rd ventricular ependymoma. Consequently, the origin of this lesion remains
speculative, although recognition of this entity will stimulate future studies and
follow-up.
200
Combining Whole Slide Imaging with Telepathology for Neuropathology
Intraoperative Consultation
Jo Elle Peterson1, Andreana Rivera1, J Goodman2, Michael Thrall1, Suzanne
Powell1. 1Houston Methodist Hospital; 2Baylor College of Medicine
Whole slide imaging (WSI) is a technology employed at the HoustonMethodist
Hospital system to create digital reconstructions of pathology glass slides. This
methodology facilitates rapid long-distance transmission of images for viewing
by branch hospital pathologists and remote consultations for diagnostic prob-
lems. For a standard tissue section, WSI creates a two-dimensional image at
20� magnification. Cytology slides, where cellular detail is of critical im-
portance, however, require three-dimensional evaluation. While it is possible to
create a more three-dimensional image withWSI, it takes longer, requires more
memory, and is slow to load and manipulate. For our routine neuropathology
intraoperative consultation, both cytologic preparations and frozen tissue
sections are utilized for diagnostic purposes. WSI for cytologic preparations
in the intraoperative setting is not possible, given the requirement of a 20minute
turn-around-time. Intranet-connected microscope-mounted cameras (netcams)
make remote evaluation of cytologic preparations possible by live streaming of
images. We examined the combined use of these technologies in the remote
diagnosis of intraoperative consultation neuropathology specimens. Board
certified neuropathologists remotely evaluated twenty-five neuropathology
cases in a simulated intraoperative consultation setting. All cases had two
cytologic preparations. Twenty-three cases had a single frozen section slide,
while two cases had two frozen section slides. The following times were
recorded: time to perform WSI and make imaging available to the neuro-
pathologist; time reviewing cytologic preparations via netcam; time reviewing
WSI reconstruction(s); and total time to diagnosis (turn-around-time). A turn-
around-time of less than 20 minutes was possible in all cases, including those
containing multiple frozen section slides and those requiring rescanning due to
WSI system malfunctions. The turn-around-times ranged from 5:10 (minutes:-
seconds) to 19:13 amongst the neuropathologists. We conclude that the
combined use of netcams and WSI is feasible in the intraoperative setting for
remote neuropathology specimens.
Abstracts J Neuropathol Exp Neurol � Volume 73, Number 6, June 2014
� 2014 American Association of Neuropathologists, Inc.638
Copyright © 2014 by the American Association of Neuropathologists, Inc. Unauthorized reproduction of this article is prohibited.