Imaging Conundrum of Granular Cell Astrocytoma: A Case Report

Abstract
Introduction: Granular cell astrocytoma (GCA) does not have defined radiological criteria/appearance for diagnosis. Here we present a case of GCA that was initially diagnosed as primary CNS lymphoma before pathologic diagnosis was available.
Case Description: We report a 73 year old male patient who presented to our ED with tonic-clonic seizures with additional seizures at ED. Initial CT showed no intracranial hemorrhages and MRI brain showed T2 intense lesions in the left inferior basal ganglia, left temporal stem and left amygdala. CT abdomen and pelvis showed thickened rectosigmoid junction, enlarged prostate and no lymphadenopathy in the chest, abdomen or pelvis. MRI brain spectroscopy showed increased choline peak, decrease of NAA peak and no appreciable lactate peak and it also showed that the lesion was homogeneously enhancing with rapid growth rate. Considering all these appearances, a diagnosis of primary CNS lymphoma was considered. Patient then had a left temporal stereotactic craniotomy and microsurgical subtotal resection of the left temporal mass. A gross total resection was not possible due to the location of the lesion. Pathology showed cells with abundant granular cytoplasm, perivascular lymphocytic and histiocytic infiltrates with strong nuclear activity for Olig2 and nonreactivity for CD 163 or MNDA. A final pathological diagnosis of granular cell astrocytoma was made. Patient was treated with 60Gy radiation to his post-surgical area with concurrent temozolomide. Patient received 2 cycles of temozolomide, which was stopped due to transaminitis. Patient’s mental status and neurological status further declined after the treatment and was placed on hospice.
Conclusion: Granular cell astrocytoma can show unusual radiological appearances that can mimic primary CNS lymphoma. Pathological verification of the diagnosis is important. It should be treated as high grade glioma.

Keywords
case report, granular cell astrocytoma, MRI spectroscopy, MRI brain, radiation

Cite this paper
Fan Zhu, Sonal Paul, Eric Miller, Chathula Kumarasinghe, Bahaa Mokhtar, Madhumathi Kalavar, Imaging Conundrum of Granular Cell Astrocytoma: A Case Report , SCIREA Journal of Clinical Medicine. Volume 6, Issue 1, February 2021 | PP. 61-75. 10.54647/cm32391

References

[ 1 ]	Vizcaino M.A., Palsgrove D.N., Yuan M., et. al.: Granular cell astrocytoma: an aggressive IDH-wildtype diffuse glioma with molecular genetic features of primary glioblastoma. Brain Pathol 2019; 29: pp. 193-204
[ 2 ]	Case Reports , World Neurosurg. 2020 Feb;134:164-169. doi:10.1016/j.wneu.2019.10.169. Epub 2019 Nov 4. Imaging and Radiologic-Pathologic Correlation in Granular Cell Astrocytomas: Report of 2 Cases Antonio Montalvo Afonso , Juan Vicente Darriba Alles , Ángela Moreno Gutiérrez , Lain Hermes González Quarante , Roberto García Leal , Juan Adan Guzmán de Villoria Lebiedziejewski , Emma Sola Vendrell
[ 3 ]	Brat D.J., Scheithauer B.W., Medina-Flores R., Rosenblum M.K., Burger P.C.: Infiltrative astrocytomas with granular cell features (granular cell astrocytomas): a study of histopathologic features, grading, and outcome. Am J Surg Pathol 2002; 26: pp. 750-757
[ 4 ]	Voellger B., Tapia-Perez J.H., Rupa R., et. al.: Survival in granular cell astrocytomas. J Neurol Surg A Cent Eur Neurosurg 2015; 76: pp. 30-38.
[ 5 ]	Imitola J., Wagoner J., Khurana J.S.: Rapid dissemination of granular cell astrocytoma arising from periventricular stem cell regions in chronic multiple sclerosis. J Neurooncol 2015; 124: pp. 147-149.
[ 6 ]	Calli C., Kitis O., Yunten N., Yurtseven T., Islekel S., Akalin T.: Perfusion and diffusion MR imaging in enhancing malignant cerebral tumors. Eur J Radiol 2006; 58: pp. 394-403.
[ 7 ]	Mader I, Rauer S, Gall P, Klose U. (1)H MR spectroscopy of inflammation, infection and ischemia of the brain. (2008) European journal of radiology. 67 (2): 250-7. doi:10.1016/j.ejrad.2008.02.033
[ 8 ]	Clark JB. N-acetyl aspartate: a marker for neuronal loss or mitochondrial dysfunction. (1998) Developmental neuroscience. 20 (4-5): 271-6. doi:10.1159/000017321 - Pubmed
[ 9 ]	Hesselink, JR. Fundamentals of MR Spectroscopy. Available online: http://spinwarp.ucsd.edu/NeuroWeb/Text/mrs-TXT.htm
[ 10 ]	Ishimaru H, Morikawa M, Iwanaga S et-al. Differentiation between high-grade glioma and metastatic brain tumor using single-voxel proton MR spectroscopy. Eur Radiol. 2001;11 (9): 1784-91.
[ 11 ]	Shi Y, Morgenstern N. Granular cell astrocytoma. Arch Pathol Lab Med. 2008 Dec;132(12):1946-50. doi: 10.1043/1543-2165-132.12.1946. PMID: 19061297.
[ 12 ]	Brat DJ, Scheithauer BW, Medina-Flores R, Rosenblum MK, Burger PC. Infiltrative astrocytomas with granular cell features (granular cell astrocytomas): a study of histopathologic features, grading, and outcome. Am J Surg Pathol. 2002; 26:750–757.
[ 13 ]	Liao W., Liu Y., Wang X., et. al.: Differentiation of primary central nervous system lymphoma and high-grade glioma with dynamic susceptibility contrast-enhanced perfusion magnetic resonance imaging. Acta Radiol 2009; 50: pp. 217-225.
[ 14 ]	Han S., Zhang C., Li Q., et. al.: Tumour-infiltrating CD4(+) and CD8(+) lymphocytes as predictors of clinical outcome in glioma. Br J Cancer 2014; 110: pp. 2560-2568.
[ 15 ]	Sayour E.J., McLendon P., McLendon R., et. al.: Increased proportion of FoxP3+ regulatory T cells in tumor infiltrating lymphocytes is associated with tumor recurrence and reduced survival in patients with glioblastoma. Cancer Immunol Immunother 2015; 64: pp. 419-427.
[ 16 ]	Brat DJ, Scheithauer BW, Medina-Flores R, Rosenblum MK, Burger PC. Infiltrative astrocytomas with granular cell features (granular cell astrocytomas): a study of histopathologic features, grading, and outcome. Am J Surg Pathol. 2002; 26:750–757.
[ 17 ]	Castellano-Sanchez AA, Ohgaki H, Yokoo H, et al. Granular cell astrocytomas show a high frequency of allelic loss but are not a genetically defined subset. Brain Pathol. 2003;13:185–194.