Monday, December 10, 2018

A Pattern-Based Approach to the Interpretation of Skeletal Muscle Biopsies

Chunyu (Hunter) Cai, MD, PhD
Chunyu (Hunter) Cai, Douglas Anthony, and Peter Pytel have authored a wonderfully useful review article in Modern Pathology entitled A Pattern-Based Approach to the Interpretation of Skeletal Muscle Biopsies. Dr. Cai wrote the following to me: "In this review, we take a pathology-friendly approach and categorize muscle biopsies into 6  morphologic groups, and discuss common differential diagnoses for each group. I think this review fills a void that there is not a good quick guide for NP fellows, residents and even neuropathologists who don’t sign out muscle cases on a routine base." Thanks, Drs. Cai, Anthony, and Pytel for a review article that will be a fixture on the desks of many neuropathologists in the coming years!

Tuesday, December 4, 2018

Giant cell GBM masquerading as an anaplastic PXA

At first glance, this tumor with pleomorphic cells and prominent perivascular lymphocytic cuffing strikes one as a pleomorphic xanthoastrocytoma (PXA).

The relative circumscription, as demonstrated by the stark difference in tumor burden in adjacent gyri depicted above also suggests the possibility of  PXA.

The presence of mitotic figures (center of picture above) and a small amount of necrosis and microvascular proliferation (not pictured) suggests the possibility of anaplastic PXA.

However, perivascular lymphocytes and relative circumscription can be seen in giant cell glioblastoma (GC-GBM). Pointing away from anaplastic PXA is the fact that there was no evidence of Rosenthal fibers and eosinophilic granular bodies. Additionally, there was strong p53 immunohistochemical positivity. The final diagnosis was Glioblastoma, IDH-wildtype, WHO grade IV, giant cell variant.

Wednesday, November 28, 2018

A middle-aged patient with panhypopituitarism

The clinicoradiological suspicion in this case of a middle-aged patient with panhypopituitarism was hypophysitis.

T1 sagittal post-contrast
Transphenoidal hypohysectomy yielded the following specimen:

Two populations of cells predominate: small monomorphic cells and larger pleomorphic cells
Immunohistochemistry identified the larger pleomorphic cells as representing a large B-cell lymphoma, while the small cells were intermixed non-neoplastic T-cells.

This ACTH immunostain demonstrates the progressive obliteration of the pituitary gland by the invading lymphoma

Diffuse large B-cell lymphoma presenting as a pituitary mass is rare. A few case reports exist in the literature.

Friday, November 23, 2018

Unexpected Neuropathology Fellowship opening at Mount Sinai starting July 2019

John F. Crary, MD, PhD
Dr. John Crary just informed me that his institution, Mount Sinai, has an unexpected opening for a neuropathology fellowship starting in July 2019.  Interested candidates can contact him at

Wednesday, November 21, 2018

Tuesday, November 20, 2018

Monday, November 19, 2018

Perforating injury of globe

Ocular perforation caused by BB gun is a through-and-through injury with entrance and exit wounds in limbus and sclera, respectively. The track of the BB is marked by fresh blood. Posteriorly detached vitreous also contains ochre-colored degenerated blood.

(Source: Eagle R. Eye Pathology: An Atlas and Text. Second Edition. 2011)

Wednesday, November 14, 2018

Q&A with Dr Peter Cummings, co-author of “Brainwashed: The Bad Science Behind CTE and the Plot to Destroy Football”

Peter Cummings, MD

1.   Chronic traumatic encephalopathy has been considered by many to be a distinct nosologic entity since 1928, when Dr. Harrison Martland published the article Punch Drunk” in JAMA. Do you believe that CTE is a distinct entity? If so, what, in your opinion, defines CTE?

That's a good question! If you look at the totality of the literature in a historical context, you see the 'classic' boxers neuropathological changes followed by the Omalu cases and then the McKee cases. Looking at all of these cases you can see that there is a wide spectrum of changes considered to be "CTE". Right now I think all we can say is CTE is a pattern; we don't know what causes it and we don't know what it causes. There are cases of CTE-like pathology in people who have never been exposed to repetitive head trauma and never had a head injury. The answer is probably more complex than we're able to say right now. There are extremist views (such as that expressed in a 2015 BMJ editorial) that suggest CTE doesn't exist outside of boxing and CTE as described in football players is an American social phenomenon. There is a lot more work to do in this area and we discuss that in the book.

2.   Whats your opinion of the work of Bennet Omalu as it pertains to CTE?

It's certainly historically important. After all, it's what really launched this whole conversation. We talk a little bit about it in the book. I do think there is some debate on whether or not some of his cases are CTE, but that might be a factor related to the wide spectrum of patterns said to be present in these individuals. I've always been curious as to why none of his football player cases were examined in the process to develop a consensus diagnosis. Again, that is something we discuss in the book.

3.   What conclusions drawn by Dr. Ann McKee regarding CTE do you have issue with?

I take issue with a number of things. First, I think the way the cases are portrayed in the media is disingenuous. In the CTE Center’s scientific papers, they assert that one cannot imply or conclude prevalence but then will go on to state in the media that they think every player has this. The CTE Center has also clearly stated in their papers that findings of a study should not  be used to inform safety and/or policy decisions in youth football but then proposes publicly in the media and in testimony before state legislatures that tackle football should be banned for kids under 14. It also bothers me when they put up a photo of an atrophic brain and claim it's severe CTE without any other qualifier. Over half of the 'severe' cases of CTE have another primary neurodegenerative disease, so when you look at those nice photos of atrophic brains, you have to wonder what other disease is lurking in there. Is it also Alzheimer’s disease? As stated by their very own consensus recommendations, if another neurodegnerative disease is present, it excludes CTE as the sole diagnosis. So, when the photos are shown in the media and they don't tell you it's Alzheimer's disease with CTE, it's disingenuous at best. Science doesn't stop at the paper, it continues into the public arena where it is used to educate the public. Here, it's not educating, it's fear mongering. I also have great concerns over the lack of transparency with information coming from the CTE Center. I described some of this in great detail in the book. For example, not turning over documents when presented with a signed release from a family; requiring a subpoena and then failing to turn over all the records; when I demand the missing records I am asked 'why am I drilling so hard? The NHL didn't drill this hard,'; and when I finally get the records, the names of the clinicians who reached the diagnoses are blacked out. Why? Additionally, the public should know that there exists cases where neuropathologists have looked at brains prior to the CTE Center and failed to find CTE, but when the brain arrive at the CTE Center, they all have CTE. This diagnostic discrepancy is alarming. There are many other examples in the book.

4.   The title of your book is rather sensational (the plot to destroy football”). Are there actually people plotting a plan? If so, who are these conspirators?

I think we paint a pretty clear picture in the book of what is going on and how football has been targeted. For example, with the recent proposed legislation to ban youth tackle football in California, I found it outrageous that if the bill would have passed, an 8 year old in California wouldn't be able to play football, but could box or fight in MMA--sports designed to target the head. If this bill was really about brain health in kids, the coverage would encompass all areas of potential brain injury in all sports—not just football. The PR campaign accompanying the public release of the various CTE studies intentionally generate undue fear in parents and in the general public. The PR has intentionally tried to definitively link youth football to subsequent CTE-- and there is no scientific evidence of that. And for scientists involved in CTE research, who mind you, have no training, certification, or experience in youth football, to call out the sport for not responding is deceptive-- it's one of the reasons why I did become certified and I started to coach both flag and tackle and I would argue that no other youth sport has made a more radical transformation than youth football in response to safety concerns; I know this because I coach! Another example from the book is how some at BU have tried to silence me and discredit my opinions. 

In the end "Brainwashed" is a very optimistic book full of hope and information which we hope will empower people. We wrote it as two dads asking the same questions a lot of other parents are asking and I think people who read the book will see that and realize it’s our journey for the truth for our own kids. In the end, we really hope people will have more information and be in a better position to make an informed decision as to whether or not a particular sport is right for their family.