14. Microscopical Examination, March 31, 1933
Dr. George M. Hass.
- Several sections are taken, the largest lock is removed so as to include the remnants of the pituitary gland, the infundibulum, the tuber and the major portion of the tumor which extended so as to obliterate a large part of the third ventricle. There were, also, blocks of tissue removed from along the aqueduct because in the gross specimen there was obvious tumor in the fourth ventricle. The attempt was made to follow the path of the tumor from the third ventricle to the region of the roof of the fourth ventricle. The sections are stained with eosin methylene blue, and P.T.A.H. The large block is composed almost entirely of solid tumor. This has, of course, largely obliterated any evidence of infundibulum or tuber of the pituitary. There are remnants of the pituitary gland at the periphery of the tumor, although a large portion of the anterior lobe, the pars intermedia and the posterior lobe have been entirely replaced and destroyed by the rapidly growing neoplasm. The essential histological features of this potion of the tumor as well as those block taken from the roof of the fourth ventricle are those of a rapidly growing glioma which can best be classified as a glioblastoma. The histology is somewhat atypical in that there are only a few necroses. Neither are there necrotic areas quite typical of those which are so commonly found in glioblastomas. The tumor is quite cellular and there is a great portion of cells with only a few glia fibrils. The cells vary a great deal in their morphology. Many are small, spherical and fusiform. Many have multiple processes. Others are polar spongioblasts. The tumor, on the whole, is somewhat edematous, which accounts for the separation of the cells and intercellular fibrils. In addition to the small types of cells and the fusiform cells, there are all gradations to huge multinucleated cells which are unquestionably multinucleated glioblasts. There are occasional multipolar mitoses and single mitoses in cells are quite common. The glia fibrils are often rather coarse, and the delicate neuroglia network is lacking. The blood vessels are rather scanty. There is no perivascular arrangement of cells such as is encountered in an oligodendroglioma. There are no large areas of hemorrhage or homogenous necrosis. The question arose in Dr. Wolbach's mind as to the possibility of this tumor representing a type of ependymoblastoma. The absence of blepharoplasten in cells served as one of the features which stood against such a diagnosis. The only other possibility seemed to be a rapidly growing glioma composed of many poorly differentiated cells and classifiable by the present terminology as a glioblastoma. The sections which pass across the aqueduct of Sylvius including both walls of the aqueduct in sagittal section show no evidence of extension of the neoplasm in the wall of the aqueduct. It must, therefore, be assumed from the degree of involvement of the fourth ventricle region by this tumor, that the tumor in the fourth ventricle arose from implants or by extension on one side or the other of the plane at which the single sagittal incision was made. Presumably the latter explanation is the more satisfactory.
- This 43 year old woman was first observed in August 1932. At this time she complained of headaches of 3 months duration. An x-ray diagnosis of suprasellar tumor was made. On Aug. 10, 1932, a right transfrontal exploration by Dr. Cushing removed no tumor. On Oct. 5, 1932, she returned to the hospital with essentially the same signs and symptoms as previously. On January 13, 1933 her symptoms had increased in severity and there were more prominent neurological findings. The subjective findings were headaches for two years, failing vision for 7 months, visual hallucinations for one year, weakness or right arm and right leg for 11 months, slowing of speech and mental faculties for 7 months, general lassitude for 11 months. Numbness and tingling sensation in the right lower leg of 5 months duration. Bilateral tinnitus, intermittent, for 5 months.
- P.E. showed bilateral diminution of visual acuity and bitemporal hemianopsia. The right upper lip was ptotic. There was a slight lower facial weakness and an anosmia on the right. There was slight hemiparesis on the right and a positive Romberg. Examination of optic discs showed a primary optic atrophy. There was some polyuria and polydipsia. On Jan. 24, 133, ad gray translucent tumor bulging down behind the chiasm was exposed by Dr. Cutler. A fragment of the tissue was taken for biopsy and histological examinations showed features most consistent with glioblastoma. She failed to improve and died on March 30.
- At autopsy the general physical features of the patient did not seem to be unusual in any respect. During removal of the brain, several small subarachnoid cysts were encountered. The convolutions of the brain were slightly flattened. The optic chiasm was thrust forward by a tumor in the region of the pituitary. This tumor seemed to extend downward from the third ventricle region where there was quite a firm mass, along with infundibulum and replacing a large amount of the pituitary gland. There was slight expansion of the sella tursica. After fixation in formalin a single sagittal incision was made so as to divide the brain and brain stem into two equal halves. The large tumor which measured 4 x 2 x 3 cm was located posterior to the optic chiasm and anterior to the corpora quadra geminae and posterior commissures. It had either filled the entire third ventricle or compressed it upward so that it seemed quite small. Anteriorly the tumor was fused with the optic chiasm and seemed to grow into the chiasm at the decussation. The aqueduct of Sylvius was not dilated but in the fourth ventricle there was a moss of tumor which largely filled the polyhedral space. The tumor in the third ventricle region extended downward as a broad projection along the general course of the infundibulum and replaced a large portion of the pituitary gland, so that roughly all of the pituitary except a small anteriorly displaced portion of the anterior lobe, consisted of tumor tissue. Dr. Richard Light, who was very much interested in this case, from the beginning of a patient who was under the care of both Dr. Cushing and Dr. Cutler, request one-half of the brain. This was submitted to him. He made a preparation of the specimen and has it in his charge. The other half of the specimen is to be submitted to the Warren Museum as a permanent specimen. Histological studies of the tumor showed that it was a somewhat atypical, very rapidly growing glioblastoma.
George Hass, M.D.