Subependymal giant cell astrocytoma
Subependymal giant cell astrocytomas (SGCAs) are benign tumours (WHO grade I), seen almost exclusively in young patients with tuberous sclerosis. They can be either asymptomatic or symptomatic due obstructive hydrocephalus, surgery treatment is often curative.
On imaging, they classically appear as an intraventricular mass near the foramen of Monro, larger than 1 cm, showing calcifications, heterogenous MRI signal, and marked contrast enhancement.
Subependymal giant cell tumours are a well-known manifestation of tuberous sclerosis, affecting 5-15% of patients with the condition 8. They are principally diagnosed in patients under 20 years of age, only occasionally found in older individuals.
Subependymal giant cell tumours are often asymptomatic. When symptoms occur, they are usually a result of obstructive hydrocephalus because of mass effect around the ventricular system at the level of the interventricular foramen (of Monro).
Subependymal giant cell astrocytomas are considered WHO grade I lesions in the current (2016) WHO classification of CNS tumours 8.
These tumours are multilobulated well-circumscribed tumours arising from the wall of the lateral ventricles near the foramen of Monro. They frequently contain cysts and calcification 8.
Subependymal giant cell astrocytomas are believed to arise from a subependymal nodule present in the ventricular wall in a patient with tuberous sclerosis, although this has yet to be categorically established 4,8.
Histologically, subependymal nodules and subependymal giant cell tumours are essentially indistinguishable, and the distinction lies in the potential of a SEGA for growth and mass effect 5. The cells that appear astrocytic, usually resemble gemistocytes; large polygonal cells with prominent eosinophilic cytoplasm. A smaller number of ganglionic appearing giant pyramidal-like cells 8.
The ependymal lining over SGCAs remains intact making CSF seeding highly unlikely 7.
Current evidence suggests that they are of a mixed neuronal and glial lineage, although they continue to be classified as astrocytomas 5.
Immunohistochemical examination of these tumours demonstrates the following reactivity 8:
- S100: positive
- GFAP: variable
- synaptophysin: variable
- CD34: negative
- additional variable and focal reactivity: class III beta-tubulin, NeuN, SOX2
- typically appears as an intraventricular mass near the foramen of Monro
- they are usually larger than 1 cm
- lesions are iso- or slightly hypoattenuating to grey matter
- calcification is common and haemorrhage is possible
- accompanying hydrocephalus may be present
- often shows marked contrast enhancement (subependymal nodules also enhance)
- T1: heterogenous and hypo- to isointense to grey matter
- T2: heterogenous and hyperintense to grey matter; calcified components can be hypointense
- T1 C+ (Gd): can show marked enhancement
Treatment and prognosis
Young children who have tuberous sclerosis may be offered screening because of the increased risk of developing subependymal giant cell astrocytomas.
The main treatment is surgery, which is indicated if the tumour is symptomatic, or growth is demonstrated on MRI. Surgery is often curative. Oral Rapamycin™ (sirolimus) has also been trialled 3.
In the clinical context of known tuberous sclerosis, the appearance is virtually pathognomonic, and the main differential is between a subependymal nodule and SGCA. Serial imaging is most helpful here, as growth implies SCGA.
Other general considerations include:
- 1. Kaye AH, Laws ER. Brain tumors, an encyclopedic approach. Gulf Professional Publishing. (2001) ISBN:0443064261. Read it at Google Books - Find it at Amazon
- 2. Morantz RA, Walsh JW. Brain tumors, a comprehensive text. Informa HealthCare. (1994) ISBN:0824788265. Read it at Google Books - Find it at Amazon
- 3. Kalantari BN, Salamon N. Neuroimaging of tuberous sclerosis: spectrum of pathologic findings and frontiers in imaging. AJR Am J Roentgenol. 2008;190 (5): W304-9. doi:10.2214/AJR.07.2928 - Pubmed citation
- 4. Koeller KK, Sandberg GD. From the archives of the AFIP. Cerebral intraventricular neoplasms: radiologic-pathologic correlation. Radiographics. 22 (6): 1473-505. doi:10.1148/rg.226025118 - Pubmed citation
- 5. Goh S, Butler W, Thiele EA. Subependymal giant cell tumors in tuberous sclerosis complex. Neurology. 2004;63 (8): 1457-61. Neurology (citation) - Pubmed citation
- 6. Smith A, Smirniotopoulos J, Horkanyne-Szakaly I. From the Radiologic Pathology Archives: Intraventricular Neoplasms: Radiologic-Pathologic Correlation. Radiographics. 2013;33 (1): 21-43. Radiographics (full text) - doi:10.1148/rg.331125192
- 7. Textbook of Radiology and Imaging. Churchill Livingstone. (2003) ISBN:0443071098. Read it at Google Books - Find it at Amazon
- 8. Louis DN, Ohgaki H, Wiestler OD et-al. The 2007 WHO classification of tumours of the central nervous system. Acta Neuropathol. 2007;114 (2): 97-109. Acta Neuropathol. (full text) - doi:10.1007/s00401-007-0243-4 - Free text at pubmed - Pubmed citation
- WHO classification of CNS tumours
- WHO grading of CNS tumours
- VASARI MRI feature set
- diffuse astrocytoma grading
- grade I:
- grade II:
- grade III
- grade IV:
- glioblastoma vs cerebral metastasis
- radiation-induced gliomas
- gliomatosis cerebri (growth pattern)
- specific locations
- treatment response
- Stupp protocol
- glioma treatment response assessment in clinical trials
- multicentric glioblastoma
- multifocal glioblastoma
- prognostic genetic markers