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Papillary glioneuronal tumor

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Overview

Papillary glioneuronal tumors (PGNTs) are rare, mixed neuronal-glial neoplasms characterized by their distinctive papillary architecture and glial differentiation. They were initially described as "pseudopapillary glioneurocytomas" and have since been classified under glioneuronal tumors in the WHO classification systems. PGNTs are typically benign but can exhibit invasive behavior in some cases, complicating their management. Primarily affecting children, adolescents, and young adults, these tumors are often associated with seizures and are frequently located in the temporal lobe near the third ventricle. Accurate diagnosis and management are crucial due to their potential for atypical behavior and the need for tailored treatment approaches to prevent recurrence and complications. 131123

Pathophysiology

The pathophysiology of PGNTs involves complex molecular alterations that drive both neuronal and glial differentiation. These tumors often harbor specific genetic fusions and mutations, although the exact mechanisms leading to their unique histological features remain under investigation. FGFR2 fusions, for instance, are frequently observed in glioneuronal tumors and contribute to the characteristic oligodendroglioma-like component seen in PGNTs. Additionally, alterations in the RAS-mitogen-activated protein kinase (RAS/MAPK) pathway, often due to mutations like BRAF V600E, play a significant role in tumor growth and differentiation. The presence of neuropil-like islands and papillary structures suggests a stem cell origin with biphenotypic differentiation, highlighting the complexity of these neoplasms at the cellular level. Despite these insights, the precise interplay between genetic alterations and the resulting histopathological features continues to be elucidated. 151323

Epidemiology

PGNTs are exceedingly rare, accounting for less than 0.02% of all intracranial tumors. They predominantly affect pediatric and young adult populations, with a slight male predominance observed in some studies. Geographic distribution does not appear to show significant variations, but specific incidence rates are not widely reported due to their rarity. Over time, advancements in molecular diagnostics have improved the identification and classification of these tumors, though large-scale epidemiological studies remain limited. The rarity of PGNTs poses challenges in establishing robust prevalence data, making clinical case series crucial for understanding their distribution and characteristics. 131123

Clinical Presentation

Patients with PGNTs typically present with seizures, often focal in nature, reflecting the tumor's common location in the temporal lobe. Headaches, cognitive decline, and focal neurological deficits may also occur, depending on the tumor's size and location. Atypical presentations can include increased intracranial pressure symptoms if there is significant mass effect or hydrocephalus. The rarity and variable imaging characteristics of PGNTs can lead to diagnostic delays, as these tumors may mimic other more common intracranial lesions. Early recognition is critical to avoid misdiagnosis and inappropriate management. 3112327

Diagnosis

The diagnosis of PGNTs involves a multifaceted approach combining clinical presentation, imaging studies, and histopathological analysis. Diagnostic Criteria and Tests:
  • Imaging: MRI is essential, often showing well-defined, cystic masses with solid papillary components, typically located in the temporal lobe near the third ventricle. Characteristic features include peritumoral edema and sometimes cystic changes. 327
  • Histopathology: Microscopic examination reveals the hallmark papillary structures composed of neoplastic cells with both neuronal and glial features. Immunohistochemistry typically shows markers for both neuronal (e.g., synaptophysin, NeuN) and glial (e.g., GFAP) differentiation. 132327
  • Molecular Testing: Genetic analysis, including fusion gene detection (e.g., FGFR2, BRAF V600E mutations), can confirm the diagnosis and differentiate PGNTs from other glioneuronal tumors. 1513
  • Differential Diagnosis:
    • - Gangliogliomas: Distinguished by more prominent neuronal elements and fewer glial features. - Dysembryoplastic Neuroepithelial Tumors (DNTs): Typically present with more distinct neuronal rosettes and are more commonly associated with long-standing epilepsy. - Pilocytic Astrocytomas: Characterized by a more uniform astrocytic appearance without the papillary architecture. 71423

    Management

    Surgical Resection

  • Objective: Gross total resection is the primary treatment goal to minimize recurrence risk.
  • Specifics:
    • - Procedure: Craniotomy with meticulous dissection to achieve maximal tumor removal while preserving eloquent cortex. - Indications: All patients with accessible tumors. - Contraindications: In cases where resection would cause significant neurological deficits. - Monitoring: Postoperative imaging to assess extent of resection and immediate complications. 2331

    Adjuvant Therapy

  • Objective: To address residual disease or high-risk features.
  • Specifics:
    • - Radiotherapy: Considered for cases with incomplete resection, high-grade features, or recurrent disease. - Dose: Typically 54-59.4 Gy in fractions. - Duration: Usually over 6-7 weeks. - Monitoring: Regular follow-up imaging and neurological assessments. - Chemotherapy: Generally not indicated for standard PGNTs but may be considered in refractory cases. - Drugs: Options include temozolomide or other targeted agents based on molecular profile. - Duration: Tailored to response and tolerance. - Monitoring: Regular blood counts, toxicity assessments, and tumor marker evaluations. 233122

    Follow-Up

  • Objective: To monitor for recurrence and manage long-term outcomes.
  • Specifics:
    • - Imaging: MRI every 6-12 months for the first 2-3 years, then annually if stable. - Neurological Assessments: Regular clinical evaluations focusing on seizure control and cognitive function. - Seizure Management: Continued antiepileptic therapy as needed, adjusting based on seizure control and side effects. 2331

    Complications

    Acute Complications

  • Postoperative Hemorrhage: Rare but requires immediate neurosurgical intervention.
  • Neurological Deficits: Potential for transient or permanent deficits depending on resection extent and location.

    • Long-Term Complications

  • Seizure Persistence: Despite resection, some patients may continue to experience seizures requiring ongoing management.
  • Tumor Recurrence: Risk varies; close follow-up imaging is crucial for early detection and management.
  • Referral Triggers: Persistent neurological deficits, new neurological symptoms, or imaging evidence of recurrence should prompt specialist referral. 2331

    • Prognosis & Follow-Up

    PGNTs are generally considered low-grade with favorable outcomes, especially when completely resected. Prognosis is typically good, but malignant transformation has been reported in rare cases, emphasizing the importance of vigilant follow-up. Key prognostic indicators include extent of resection, molecular profile (e.g., absence of high-risk mutations), and absence of invasive features on imaging. Recommended follow-up intervals include MRI every 6-12 months for the first few years, transitioning to annual scans if stable. Regular neurological assessments are essential to monitor for any signs of recurrence or new neurological deficits. 232231

    Special Populations

    Pediatric Patients

  • Considerations: Growth and development monitoring alongside seizure control and cognitive function.
  • Management: Emphasis on minimal invasive approaches to preserve neurological development.

    • Elderly Patients

  • Considerations: Increased risk of postoperative complications; careful risk-benefit analysis for surgical intervention.
  • Management: Tailored surgical strategies and close postoperative monitoring.

    • Molecular Subtypes

  • FGFR2 Fusion-Positive Tumors: May require more aggressive surveillance due to potential for atypical behavior.
  • BRAF V600E Mutated Tumors: Similar management principles apply, but molecular monitoring can guide tailored follow-up strategies. 232231

    • Key Recommendations

  • Surgical Resection: Aim for gross total resection to minimize recurrence risk. (Evidence: Strong)
  • Molecular Testing: Incorporate genetic analysis (e.g., FGFR2, BRAF V600E) for accurate diagnosis and subclassification. (Evidence: Strong)
  • Regular Follow-Up Imaging: Schedule MRI every 6-12 months for the first 2-3 years, then annually if stable. (Evidence: Moderate)
  • Neurological Assessments: Conduct regular clinical evaluations focusing on seizure control and cognitive function. (Evidence: Moderate)
  • Adjuvant Radiotherapy: Consider for incomplete resections or high-risk features, with dose typically 54-59.4 Gy. (Evidence: Moderate)
  • Seizure Management: Maintain and adjust antiepileptic therapy based on seizure control and side effects. (Evidence: Moderate)
  • Monitor for Recurrence: Be vigilant for imaging evidence of recurrence and neurological symptoms indicative of tumor progression. (Evidence: Moderate)
  • Tailored Management for Special Populations: Adjust surgical and follow-up strategies for pediatric and elderly patients. (Evidence: Expert opinion)
  • Consider Molecular Subtypes: Implement more frequent surveillance for tumors with high-risk molecular alterations. (Evidence: Expert opinion)
  • Multidisciplinary Approach: Involve neurosurgeons, oncologists, and neurologists for comprehensive patient care. (Evidence: Expert opinion)

    • References

    1 Métais A, Dangouloff-Ros V, Garcia J, Vannod-Michel Q, Csanyi M, Tauziède-Espariat A et al.. Phenotypic and epigenetic heterogeneity in FGFR2-fused glial and glioneuronal tumours. Neuropathology and applied neurobiology 2024. link 2 Chapman N, Greenwald J, Suddock J, Xu D, Markowitz A, Humphrey M et al.. Clinical, pathologic, and genomic characteristics of two pediatric glioneuronal tumors with a CLIP2::MET fusion. Acta neuropathologica communications 2024. link 3 Du X, He Y, Li F, Wang X, Kong X, Ye M et al.. Imaging manifestations of papillary glioneuronal tumors. Neurosurgical review 2024. link 4 Liu J, Lin F, Sun Y, Liu X. Clinicopathological analysis of rosette-forming glioneuronal tumors. Diagnostic pathology 2024. link 5 Stone TJ, Mankad K, Tan AP, Jan W, Pickles JC, Gogou M et al.. DNA methylation-based classification of glioneuronal tumours synergises with histology and radiology to refine accurate molecular stratification. Neuropathology and applied neurobiology 2023. link 6 Barresi V, Gianno F, Marucci G. Newly recognised Tumour Types in Glioneuronal tumours according to the 5th edition of the CNS WHO Classification. Pathologica 2022. link 7 Vaz A, Cavalcanti MS, da Silva Junior EB, Ramina R, de Almeida Teixeira BC. Uncommon Glioneuronal Tumors: A Radiologic and Pathologic Synopsis. AJNR. American journal of neuroradiology 2022. link 8 Ho CY, Bornhorst M, Almira-Suarez MI, Donev K, Grafe M, Gordish-Dressman H et al.. Clinicopathologic Features of Diencephalic Neuronal and Glioneuronal Tumors. Journal of neuropathology and experimental neurology 2020. link 9 Lamszus K, Makrigeorgi-Butera M, Laas R, Westphal M, Stavrou D. September 2002: 24-year-old female with a 6-month history of seizures. Brain pathology (Zurich, Switzerland) 2003. link 10 Pai V, Laughlin S, Ertl-Wagner B. Imaging of pediatric glioneuronal and neuronal tumors. Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery 2024. link 11 Farooqi HA, Nabi R, Zahid T, Hayder Z. Breaking new ground: can artificial intelligence and machine learning transform papillary glioneuronal tumor diagnosis?. Neurosurgical review 2024. link 12 Rai V, Jaiswal S, Nangarwal B, Bhargav M. Intraventricular papillary glioneuronal tumor with high proliferation index and CD117 positivity: Report of an atypical case and review of literature. Journal of cancer research and therapeutics 2023. link 13 Tsuboi N, Ishida J, Shimazu Y, Edaki H, Uneda A, Otani Y et al.. Genomic Profiling of a Case of Glioneuronal Tumor with Neuropil-like Islands. Acta medica Okayama 2022. link 14 Uchiyama T, Gomi A, Nobusawa S, Fukushima N, Matsubara D, Kawai K. A case of a rosette-forming glioneuronal tumor with clinicopathological features of a dysembryoplastic neuroepithelial tumor and fibroblast growth factor receptor 1 internal tandem duplication. Brain tumor pathology 2021. link 15 Hockman JT, El Tecle NE, Urquiaga JF, Alexopoulos G, Guzman MA, Coppens J. Dissemination Patterns and Short-Term Management of Multifocal Rosette-Forming Glioneuronal Tumors. World neurosurgery 2021. link 16 Wu T, Miller A, Jager M, Southard T. Glioneuronal Hamartomas in the Central Nervous System of Two Goats. Journal of comparative pathology 2020. link 17 Matsumura N, Natsume A, Maeda S, Aoki K, Yamazaki T, Nobusawa S et al.. Malignant transformation of a dysembryoplastic neuroepithelial tumor verified by a shared copy number gain of the tyrosine kinase domain of FGFR1. Brain tumor pathology 2020. link 18 Al Krinawe Y, Esmaeilzadeh M, Hartmann C, Krauss JK, Hermann EJ. Pediatric rosette-forming glioneuronal tumor of the septum pellucidum. Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery 2020. link 19 Harrison W, Elsamadicy AA, McMahon JT, Chagoya G, Sobel RA, McLendon RE et al.. Glioneuronal Tumor With Features of Ganglioglioma and Neurocytoma Arising in the Fourth Ventricle: A Report of 2 Unusual Cases and a Review of Infratentorial Gangliogliomas. Journal of neuropathology and experimental neurology 2019. link 20 Kurozumi K, Nakano Y, Ishida J, Tanaka T, Doi M, Hirato J et al.. High-grade glioneuronal tumor with an ARHGEF2-NTRK1 fusion gene. Brain tumor pathology 2019. link 21 Yadav N, Rao S, Saini J, Prasad C, Mahadevan A, Sadashiva N. Papillary glioneuronal tumors: A radiopathologic correlation. European journal of radiology 2017. link 22 Ahmed AK, Dawood HY, Gerard J, Smith TR. Surgical Resection and Cellular Proliferation Index Predict Prognosis for Patients with Papillary Glioneuronal Tumor: Systematic Review and Pooled Analysis. World neurosurgery 2017. link 23 Tomita T, Volk JM, Shen W, Pundy T. Glioneuronal tumors of cerebral hemisphere in children: correlation of surgical resection with seizure outcomes and tumor recurrences. Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery 2016. link 24 Dodgshun AJ, SantaCruz N, Hwang J, Ramkissoon SH, Malkin H, Bergthold G et al.. Disseminated glioneuronal tumors occurring in childhood: treatment outcomes and BRAF alterations including V600E mutation. Journal of neuro-oncology 2016. link 25 Prabowo AS, van Thuijl HF, Scheinin I, Sie D, van Essen HF, Iyer AM et al.. Landscape of chromosomal copy number aberrations in gangliogliomas and dysembryoplastic neuroepithelial tumours. Neuropathology and applied neurobiology 2015. link 26 Allinson KS, O'Donovan DG, Jena R, Cross JJ, Santarius TS. Rosette-forming glioneuronal tumor with dissemination throughout the ventricular system: a case report. Clinical neuropathology 2015. link 27 Tan W, Huang W, Xiong J, Pan J, Geng D, Jun Z. Neuroradiological features of papillary glioneuronal tumor: a study of 8 cases. Journal of computer assisted tomography 2014. link 28 El Demellawy D, Sur M, Ahmed AD, Provias J. Hemispheric extra-ventricular glioneurocytoma: a clinicopathological review with detailed immunohistochemical profile. Pathology, research and practice 2012. link 29 Buccoliero AM, Castiglione F, Degl'innocenti DR, Moncini D, Paglierani M, Sardi I et al.. Glioneuronal tumor with neuropil-like islands: clinical, morphologic, immunohistochemical, and molecular features of three pediatric cases. Pediatric and developmental pathology : the official journal of the Society for Pediatric Pathology and the Paediatric Pathology Society 2012. link 30 Flannery T, Purce A, Harney J, McKinstry S, Ironside JW, Herron B. Bilateral non-contiguous atypical papillary glioneuronal tumor: case report. Clinical neuropathology 2012. link 31 Pimentel J, Barroso C, Miguéns J, Firmo C, Antunes JL. Papillary glioneuronal tumor--prognostic value of the extension of surgical resection. Clinical neuropathology 2009. link 32 Lu JQ, Scheithauer BW, Sharma P, Scott JN, Parney IF, Hader W et al.. Multifocal complex glioneuronal tumor in an elderly man: an autopsy study: case report. Neurosurgery 2009. link 33 Govindan A, Mahadevan A, Bhat DI, Arivazhagan A, Chakraborti S, Suja MS et al.. Papillary glioneuronal tumor-evidence of stem cell origin with biphenotypic differentiation. Journal of neuro-oncology 2009. link 34 Allende DS, Prayson RA. The expanding family of glioneuronal tumors. Advances in anatomic pathology 2009. link 35 Tan CC, Gonzales M, Veitch A. Clinical implications of the infratentorial rosette-forming glioneuronal tumor: case report. Neurosurgery 2008. link 36 Barbashina V, Salazar P, Ladanyi M, Rosenblum MK, Edgar MA. Glioneuronal tumor with neuropil-like islands (GTNI): a report of 8 cases with chromosome 1p/19q deletion analysis. The American journal of surgical pathology 2007. link 37 Vaquero J, Coca S. Atypical papillary glioneuronal tumor. Journal of neuro-oncology 2007. link 38 Edgar MA, Rosenblum MK. Mixed glioneuronal tumors: recently described entities. Archives of pathology & laboratory medicine 2007. link 39 Chen L, Piao YS, Xu QZ, Yang XP, Yang H, Lu DH. Papillary glioneuronal tumor: a clinicopathological and immunohistochemical study of two cases. Neuropathology : official journal of the Japanese Society of Neuropathology 2006. link 40 Epelbaum S, Kujas M, Van Effenterre R, Poirier J. Two cases of papillary glioneuronal tumours. British journal of neurosurgery 2006. link 41 Ishizawa T, Komori T, Shibahara J, Ishizawa K, Adachi J, Nishikawa R et al.. Papillary glioneuronal tumor with minigemistocytic components and increased proliferative activity. Human pathology 2006. link 42 Jacques TS, Eldridge C, Patel A, Saleem NM, Powell M, Kitchen ND et al.. Mixed glioneuronal tumour of the fourth ventricle with prominent rosette formation. Neuropathology and applied neurobiology 2006. link 43 Vajtai I, Kappeler A, Lukes A, Arnold M, Lüthy AR, Leibundgut K. Papillary glioneuronal tumor. Pathology, research and practice 2006. link 44 Tanaka Y, Yokoo H, Komori T, Makita Y, Ishizawa T, Hirose T et al.. A distinct pattern of Olig2-positive cellular distribution in papillary glioneuronal tumors: a manifestation of the oligodendroglial phenotype?. Acta neuropathologica 2005. link 45 Tsukayama C, Arakawa Y. A papillary glioneuronal tumor arising in an elderly woman: a case report. Brain tumor pathology 2002. link 46 Teo JG, Gultekin SH, Bilsky M, Gutin P, Rosenblum MK. A distinctive glioneuronal tumor of the adult cerebrum with neuropil-like (including "rosetted") islands: report of 4 cases. The American journal of surgical pathology 1999. link 47 Shimbo Y, Takahashi H, Hayano M, Kumagai T, Kameyama S. Temporal lobe lesion demonstrating features of dysembryoplastic neuroepithelial tumor and ganglioglioma: a transitional form?. Clinical neuropathology 1997. link

    Original source

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      Phenotypic and epigenetic heterogeneity in FGFR2-fused glial and glioneuronal tumours. — Métais A, Dangouloff-Ros V, Garcia J, Vannod-Michel Q, Csanyi M, Tauziède-Espariat A et al. Neuropathology and applied neurobiology (2024)
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      Clinical, pathologic, and genomic characteristics of two pediatric glioneuronal tumors with a CLIP2::MET fusion. — Chapman N, Greenwald J, Suddock J, Xu D, Markowitz A, Humphrey M et al. Acta neuropathologica communications (2024)
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      Imaging manifestations of papillary glioneuronal tumors. — Du X, He Y, Li F, Wang X, Kong X, Ye M et al. Neurosurgical review (2024)
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      Clinicopathological analysis of rosette-forming glioneuronal tumors. — Liu J, Lin F, Sun Y, Liu X Diagnostic pathology (2024)
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      DNA methylation-based classification of glioneuronal tumours synergises with histology and radiology to refine accurate molecular stratification. — Stone TJ, Mankad K, Tan AP, Jan W, Pickles JC, Gogou M et al. Neuropathology and applied neurobiology (2023)
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      Newly recognised Tumour Types in Glioneuronal tumours according to the 5th edition of the CNS WHO Classification. — Barresi V, Gianno F, Marucci G Pathologica (2022)
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      Uncommon Glioneuronal Tumors: A Radiologic and Pathologic Synopsis. — Vaz A, Cavalcanti MS, da Silva Junior EB, Ramina R, de Almeida Teixeira BC AJNR. American journal of neuroradiology (2022)
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      Clinicopathologic Features of Diencephalic Neuronal and Glioneuronal Tumors. — Ho CY, Bornhorst M, Almira-Suarez MI, Donev K, Grafe M, Gordish-Dressman H et al. Journal of neuropathology and experimental neurology (2020)
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      Intraventricular papillary glioneuronal tumor with high proliferation index and CD117 positivity: Report of an atypical case and review of literature. — Rai V, Jaiswal S, Nangarwal B, Bhargav M Journal of cancer research and therapeutics (2023)
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      A case of a rosette-forming glioneuronal tumor with clinicopathological features of a dysembryoplastic neuroepithelial tumor and fibroblast growth factor receptor 1 internal tandem duplication. — Uchiyama T, Gomi A, Nobusawa S, Fukushima N, Matsubara D, Kawai K Brain tumor pathology (2021)
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      Dissemination Patterns and Short-Term Management of Multifocal Rosette-Forming Glioneuronal Tumors. — Hockman JT, El Tecle NE, Urquiaga JF, Alexopoulos G, Guzman MA, Coppens J World neurosurgery (2021)
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      Malignant transformation of a dysembryoplastic neuroepithelial tumor verified by a shared copy number gain of the tyrosine kinase domain of FGFR1. — Matsumura N, Natsume A, Maeda S, Aoki K, Yamazaki T, Nobusawa S et al. Brain tumor pathology (2020)
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      High-grade glioneuronal tumor with an ARHGEF2-NTRK1 fusion gene. — Kurozumi K, Nakano Y, Ishida J, Tanaka T, Doi M, Hirato J et al. Brain tumor pathology (2019)
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      Surgical Resection and Cellular Proliferation Index Predict Prognosis for Patients with Papillary Glioneuronal Tumor: Systematic Review and Pooled Analysis. — Ahmed AK, Dawood HY, Gerard J, Smith TR World neurosurgery (2017)
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      Glioneuronal tumors of cerebral hemisphere in children: correlation of surgical resection with seizure outcomes and tumor recurrences. — Tomita T, Volk JM, Shen W, Pundy T Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery (2016)
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      Disseminated glioneuronal tumors occurring in childhood: treatment outcomes and BRAF alterations including V600E mutation. — Dodgshun AJ, SantaCruz N, Hwang J, Ramkissoon SH, Malkin H, Bergthold G et al. Journal of neuro-oncology (2016)
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      Landscape of chromosomal copy number aberrations in gangliogliomas and dysembryoplastic neuroepithelial tumours. — Prabowo AS, van Thuijl HF, Scheinin I, Sie D, van Essen HF, Iyer AM et al. Neuropathology and applied neurobiology (2015)
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      Neuroradiological features of papillary glioneuronal tumor: a study of 8 cases. — Tan W, Huang W, Xiong J, Pan J, Geng D, Jun Z Journal of computer assisted tomography (2014)
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      Hemispheric extra-ventricular glioneurocytoma: a clinicopathological review with detailed immunohistochemical profile. — El Demellawy D, Sur M, Ahmed AD, Provias J Pathology, research and practice (2012)
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      Glioneuronal tumor with neuropil-like islands: clinical, morphologic, immunohistochemical, and molecular features of three pediatric cases. — Buccoliero AM, Castiglione F, Degl'innocenti DR, Moncini D, Paglierani M, Sardi I et al. Pediatric and developmental pathology : the official journal of the Society for Pediatric Pathology and the Paediatric Pathology Society (2012)
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      Bilateral non-contiguous atypical papillary glioneuronal tumor: case report. — Flannery T, Purce A, Harney J, McKinstry S, Ironside JW, Herron B Clinical neuropathology (2012)
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      Atypical papillary glioneuronal tumor. — Vaquero J, Coca S Journal of neuro-oncology (2007)
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      Papillary glioneuronal tumor. — Vajtai I, Kappeler A, Lukes A, Arnold M, Lüthy AR, Leibundgut K Pathology, research and practice (2006)
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      A distinct pattern of Olig2-positive cellular distribution in papillary glioneuronal tumors: a manifestation of the oligodendroglial phenotype? — Tanaka Y, Yokoo H, Komori T, Makita Y, Ishizawa T, Hirose T et al. Acta neuropathologica (2005)
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      A papillary glioneuronal tumor arising in an elderly woman: a case report. — Tsukayama C, Arakawa Y Brain tumor pathology (2002)
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      A distinctive glioneuronal tumor of the adult cerebrum with neuropil-like (including "rosetted") islands: report of 4 cases. — Teo JG, Gultekin SH, Bilsky M, Gutin P, Rosenblum MK The American journal of surgical pathology (1999)
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      Temporal lobe lesion demonstrating features of dysembryoplastic neuroepithelial tumor and ganglioglioma: a transitional form? — Shimbo Y, Takahashi H, Hayano M, Kumagai T, Kameyama S Clinical neuropathology (1997)
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