PMC8769385_01
(A) Plain cervical MRI scan performed at the previous hospital showing no abnormal findings. (B-D) Initial contrast-enhanced head MRI scan showing a homogeneously enhanced 7-cm left frontal mass lesion (A), and dissemination into the left lateral ventricular wall (B) and the basal cistern (C). MRI: magnetic resonance imaging.
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F1
A cervical magnetic resonance imaging (MRI) examination did not reveal any significant changes (Fig. 1A). She then had a head MRI examination, which showed a left frontal mass that was 7 cm in diameter with dissemination into the left lateral ventricular wall and the basal cistern (Figs. 1B-1D).
Gadolinium-enhanced spinal MRI scan showing new disseminations (arrow) after the first tumor resection in the cervical (A) and lumbar (B) regions. MRI: magnetic resonance imaging.
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F2
Instead, the hydrocephalus worsened, and the dissemination was newly detected in the spinal region (Fig. 2) and cerebellopontine angle.
(A) Hematoxylin-eosin staining of the first surgical specimens showing giant cells mainly consisting of a mega nucleus and a bizarre polynucleus, which was sometimes located eccentrically, and cells with a wide range of eosinophilic, vacuolated, and foamy cytoplasm. (B) Hematoxylin-eosin staining showing clusters of small oval cells. (C-K) Immunohistochemical staining for the first surgical specimens. (C) Diffuse positivity in the nuclei for p53. (D) Diffuse positivity in the nuclei for INI1. (E) Diffuse positivity in the cytoplasm for vimentin. (F) Negative staining for IDH1R132H. (G) Negative staining for H3K27M. (H) Negative staining for GFAP. (I) Positive staining for MIB-1 in 30% of giant cells. (J) Positive staining for PTEN in the cytoplasm of giant cells. (K) Positive staining for CD133 in both giant (arrowheads) and small cells (arrows), contrast negative findings in endothelial cells and inflammatory cells. (L) Papanicolaou staining for the ascites collected by peritoneal puncture at the time of death showing some atypical oval cells with intense hematoxylin staining (arrows); these cells resemble small cells shown in B and K. Scale bar indicates 100 microm. GFAP: glial fibrillary acidic protein.
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F3
Hematoxylin-eosin staining of the first surgical specimens showed giant cells consisting mainly of a mega nucleus and a bizarre polynucleus, which was sometimes located eccentrically, as well as cells with a wide range of eosinophilic, vacuolated, and foamy cytoplasm (Fig. 3A). Tumors consisted of small to medium spindle-shaped or multi-ridged cells, cells with multipolar processes, and small cells with a high nuclear-to-cytoplasm ratio (Fig. 3B). Immunohistochemistry showed diffuse positive nuclear staining for p53 (1:200, Dako, Fig. 3C) and INI-1 (1:500, Becton Dickinson, Fig. 3D), and cytoplasmatic staining for vimentin (1:200, Leica, Fig. 3E). No immunostaining was detected for IDH1R132H (1:100, Dianova, Fig. 3F), H3K27M (1:200, Abcam, Fig. 3G), and glial fibrillary acidic protein (GFAP) (1:100, Dako, Fig. 3H). MIB-1 immunostaining (1:200; Dako, Fig. 3I) was positive in 30% of giant cells and 60% of small cells. As a result, PTEN (1:10000; proteintech, Fig. 3J) was strongly positive in the cytoplasm of the tumor cells; therefore, PTEN mutation was denied. In contrast, moderate CD133 expression (1:1500; proteintech, Fig. 3K) was observed in not only giant cells but also small cells. Papanicolaou staining for the ascites collected by peritoneal puncture revealed a lot of small oval atypical cells rather than giant cells (Fig. 3L).