Expert: Claes-Gustaf Nordquist, M.D. - 9/8/2010

Question
I just had an MRI spectroscopy done and met with my doctor
who interpreted the report. He said that there are elevated
levels of choline present in my brain, in the
frontal/parietal regions, which indicate that there are
malignant and infiltrative tumor cells in these areas. The
spectroscopy report said, "high choline peak in the central
and posterior aspect of the lesion. This is worrisome for an
infiltrative tumor." Does this mean with absolute certainty
that I have a malignant tumor in my brain?

In January of 2010, I had a craniotomy done to remove a
benign tumor (at that time, my neurosurgeon stated that it
was benign but did not know what type of tumor it was). The
tumor sample was sent to John Hopkins University Pathology
Dept. and the report came back with an inconclusive
diagnosis. The report stated, "slight hypercellularity.
Several areas are suspicious for infiltrating, these are
focal, small, and a reactive process cannot be excluded. If
it is a tumor, it is low grade (grade II). The MIB-1 rate is
low."  I don't understand what this means. Could you help me
to understand this?

And, also, in your opinion, why would a university as
reputable as John Hopkins not be able to provide a clear
diagnosis of the tissue samples that were sent by my
neurosurgeon? Is this to be expected or could this have  
been due to the pathology department's own errors?

I appreciate your time and assistance in responding to my
questions. Thank you very much.  

Answer
Actually your question is such a difficult one that it should have been directed to an expert of pathology - even better if to an expert of tumor pathology or neuropathology. However regardless of if your tumor has been sent to John Hopkins, Harvard, Stanford, Yale, MD Anderson or the Armed Forces' Institute of Pathology etc. brain tumor pathology is DIFFICULT! It is so hard that it is normally not done by one pathologist but by a number of very experienced and gifted neuro- and tumor pathologists on a concensus basis. So there is ALWAYS an uncertainty factor!  What John Hopkins is saying in the report is that you have probably had (maybe still have) a brain tumor. That tumor was/is probably malignant. But it seems that its level of malignancy (if malignant and a tumor) is low - grade II (2). Malignancy is estimated by grade from I (1) to IV (4). Where I (1) is lowest and IV (4) is the highest grade of malignancy. Obviously a grade IV (4) is worst. Grades I (1) and II (2) can be called relatively well behaved while III (3) and IV (4) are bad. Though of course also the lower 2 grades are bad in the long run.  Now with regards to your MRI spectroscopy. Yes it is a very interesting and useful tool but just as there are uncertainties with the pathology picture here it is the same with this method. I'm not even prepared to compare them. This is the situation at present. I'm sorry it is not possible at present to be sure of anything or more precise! You can always ask for a second opinion on the pathology and your MRI test. Good luck!




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