Intraindividual comparison of histopathological diagnosis obtained by stereotactic serial biopsy to open surgical resection specimen in patients with intracranial tumours

Background

There are concerns in the literature about the accuracy of histopathological diagnosis obtained by stereotactic biopsy in patients with brain tumours. The aim of this study was to analyse intraindividually the histopathological accuracy of stereotactic biopsies of intracerebral lesions in comparison to open surgical resection.

Materials and methods

Between 2007 and 2011 a total of 635 patients underwent stereotactic serial biopsy in our department. Among these patients we identified 51 patients, who underwent magnetic resonance (MR) based stereotactic biopsy and subsequent open resection within 30 days. Mortality and morbidity data as well as final histopathological diagnoses of both procedures were compared with regard to tumour grade and tumour cell type. Patients with discrepancies between the histological diagnosis obtained by biopsy and open resection were classified into three subgroups (same cell type but different grading; same grading but different cell type and different grading as well as different cell type).

Results

The mean number of tissue samples taken by stereotactic serial biopsy from each patient was 12 (range 7–21). Minor morbidity was 6% and major morbidity was 14% after open surgery compared to no morbidity after stereotactic biopsy. Mortality was 2% after stereotactic biopsy (one patient died after stereotactic biopsy as a result of a fatal bleeding) compared to 0% in the resection group. Silent bleeding rate without any clinical symptoms was 8% in the biopsy group. A complete correlation of histopathological findings between the biopsy group and the resection group was achieved in 76% and was increased to 90% by analyzing clinical and neuroradiological information. In patients with recurrence the correlation was higher (94%) than for patients with primary brain lesions (67%). The discrepancies between the open resection group and biopsy group were analysed.

Conclusion

Stereotactic MR guided serial biopsy is a minimal invasive procedure with low morbidity and high diagnostic accuracy for diagnosis and grading of brain tumours. Diagnostic accuracy of stereotactic biopsy can be enhanced further by careful interpretation of neuroradiological and clinical information.     

Value of serial stereotactic biopsies and impedance monitoring in the treatment of deep brain tumours.

Thirty-five patients with deep brain tumours have been submitted to transtumoral stereotactic impedance monitoring and serial biopsy. The direct examination of the biopsy samples confirmed the presumptive clinical and neuroradiological diagnosis in 25 patients, but in 10 patients the histological diagnosis differed from the presumptive one. In this second group the treatment was changed as a result of the histological findings. Stereotactic biopsy avoided the risks of "blind" management. The technique, the indications and the diagnostic advantages of stereotactic biopsy are reported with two illustrative cases.     

Role of stereotactic biopsy in multifocal brain lesions: considerations on 100 consecutive cases.

One hundred patients affected by multifocal brain lesions were investigated by serial stereotactic biopsy. Systemic diseases and primary neoplasms elsewhere were previously ruled out. The histological diagnosis obtained in this series comprises malignant gliomas in 37% of patients; primary non-Hodgkin's brain lymphoma in 15%; metastatic brain tumours in 15% (no evidence of the primary tumour at the time of stereotactic surgery); low grade gliomas in 12%; infective diseases in 10% (including brain abscesses and multifocal viral encephalitis); and ischaemic lesions in 6%. In addition, two patients with germinomas, two with primitive neuroepithelial tumours, two with multiple telangiectases, and one with a teratoma were also included in this series. Histological findings obtained by stereotactic procedures guided the choice of treatment, avoiding the risks of blind treatments. Indications and future perspectives for stereotactic surgery in multifocal brain lesions are discussed with emphasis on advances in diagnostic and therapeutic tools.     

805例立体定向脑活检报告

目的　探讨立体定向脑活检方法的可靠性和安全性 ,研究手术方法及技术要点。方法　回顾性分析80 5例立体定向手术对脑深部病灶活检病理学检查。其中用CT引导活检 6 0 5例 ,MR引导活检 2 0 0例 ;幕上脑深部活检 6 4 5例 ,幕下病灶活检 16 0例 ;单道入路活检取材 5 30例 ,多道入路活检取材 2 0 5例 ,多发病灶活检取材 70例。结果　 710例 (88 2 0 % )获取各类脑肿瘤的病理学诊断 ,5 0例 (6 2 1% )为炎性病理 ,2 5例 (3 11% )为寄生虫或囊肿类病理 ,其余 2 0例 (2 4 8% )所取得的病理组织未能提供正确的病理定性诊断。病理阳性诊断率为 97 5 2 % ,肿瘤发现率为 88 2 0 % ,死亡 3例 ,死亡率 0 37% ,并发症发生 19例 (2 36 % )。结论　现代立体定向脑深部病灶活检技术安全、可靠。     

Incidental stereotactic diagnosis of cerebral insults

Abstract

Among the patients (6854 patients 1990–1999) who underwent computer-assisted stereotactic biopsy most were referred with the presumptive diagnosis of a brain mass lesion. Forty-three cases (0.63%) were found in which the final histopathological diagnosis excluded a neoplastic, infectious or inflammatory lesion but disclosed a cerebral insult. Histologically these could be subdivided into ischemic insults in 38 cases (88%) and hemorrhagic insults in five cases (12%). On the basis of clinical and radiological findings in this group, 35 patients (81%) were sent to our department because of suspected neoplasmatic lesions, two patients (5%) because of multiple sclerosis, two patients (5%) because of inflammatory disease and one patient (2%) because of a suspected infectious parasitic disease. All patients underwent initial CT examinations which showed hypodense lesions of the brain in 38 patients (88%) and hyperdense lesions in five cases (12%). Constant enhancement on CT scans of the mass lesion was found in 12 patients (28%) only. Fourteen lesions (33%) were located in the right hemisphere, five lesions (12%) in the left hemisphere, nine lesions (21%) in the basal ganglia, four lesions (9%) in the midbrain, two lesions (4.5%) in the corpus callosum and one lesion (2%) in a thalamus. Multiple lesions were present in eight cases (19%). The most common initial neurological symptoms upon clinical presentation were hemiparesis (18 patients, 42%), epilepsy (eight patients, 18%), a change in mental status (six patients, 14%). There was no mortality and no operative morbidity associated with the stereotactic biopsy in this group of patients. The most common neurological disorder, cerebrovascular insult, rarely poses diagnostic problems. If there are doubts a serial stereotactic biopsy can safely clarify the situation.     

Incidental stereotactic diagnosis of cerebral insults

Among the patients (6854 patients 1990-1999) who underwent computer-assisted stereotactic biopsy most were referred with the presumptive diagnosis of a brain mass lesion. Forty-three cases (0.63%) were found in which the final histopathological diagnosis excluded a neoplastic, infectious or inflammatory lesion but disclosed a cerebral insult. Histologically these could be subdivided into ischemic insults in 38 cases (88%) and hemorrhagic insults in five cases (12%). On the basis of clinical and radiological findings in this group, 35 patients (81%) were sent to our department because of suspected neoplasmatic lesions, two patients (5%) because of multiple sclerosis, two patients (5%) because of inflammatory disease and one patient (2%) because of a suspected infectious parasitic disease. All patients underwent initial CT examinations which showed hypodense lesions of the brain in 38 patients (88%) and hyperdense lesions in five cases (12%). Constant enhancement on CT scans of the mass lesion was found in 12 patients (28%) only. Fourteen lesions (33%) were located in the right hemisphere, five lesions (12%) in the left hemisphere, nine lesions (21%) in the basal ganglia, four lesions (9%) in the midbrain, two lesions (4.5%) in the corpus callosum and one lesion (2%) in a thalamus. Multiple lesions were present in eight cases (19%). The most common initial neurological symptoms upon clinical presentation were hemiparesis (18 patients, 42%), epilepsy (eight patients, 18%), a change in mental status (six patients, 14%). There was no mortality and no operative morbidity associated with the stereotactic biopsy in this group of patients. The most common neurological disorder, cerebrovascular insult, rarely poses diagnostic problems. If there are doubts a serial stereotactic biopsy can safely clarify the situation.     

CT或MRI引导立体定向活检方法的研究

目的：探讨用CT或MRI引导立体定向对脑深部病变进行活检手术的可行性和准确性。方法：用CT或MRI引导的脑立体定向地605例脑深部病变进行活检以期获得病变的组织学诊断，其中男357例，女248例，年龄：2．5－78岁，平均37．7岁，用CT引导立体定向活检515例，用MRI引导的定向活检90例。结果：522例（86．28％）获得脑肿瘤的病理组织，39例（6．44％）为炎性病理组织，其他病理组织23例（2．4％），16例（2．65％）未能提供病理学诊断，阳性诊断率97．35％，并发症发生13例（2．47％），死亡2例，死亡率为0．33％，结论：采用CT或MRI引导的立体定向脑深部病变活检是一种诊断准确率高，安全可靠，并发症少，创伤轻微，死亡率极低的手术方法，值得推广应用。     

立体定向脑病变活检术28例临床分析

目的分析研究MRI引导下的立体定向技术对脑部病灶行立体定向活检术病理诊断结果,探讨手术方法与技巧。方法使用Leksell立体定向定位头架,在MRI引导下行立体定向穿刺活检。结果活检术后病理胶质瘤13例,淋巴瘤5例,脑转移癌3例,炎性病变4例,寄生虫2例,胶质增生1例。活检总阳性率96.43%。并发颅内出血1例(3.57%),癫痫发作1例(3.57%),无死亡病例。结论脑立体定向活检术安全、高效为下一步治疗提供可靠的病理学证据。     

Accuracy of frameless and frame-based image-guided stereotactic brain biopsy in the diagnosis of glioma: comparison of biopsy and open resection specimen

OBJECTIVES: Tissue heterogeneity and rapid tumor progression may decrease the accuracy a prognostic value of stereotactic brain biopsy in the diagnosis of gliomas. Correct tumor grading is therefore dependent on the accuracy of biopsy needle placement. There has been a dramatic increase in the utilization of frameless image-guided stereotactic brain biopsy; however, its accuracy in the diagnosis of glioma remains unstudied. METHODS: The diagnoses of 21 astrocytic brain tumors were derived using image-guided stereotactic biopsy (12 frame-based, nine frameless) and followed by open resection of the lesion 1.5 (0.5-4) months later. The histologic diagnoses yielded by the biopsy were compared with subsequent histologic diagnosis from open tumor resection. RESULTS: Histology of 21 stereotactic biopsies accurately represented the greater lesion at open resection a median of 45 days later in 16 (76%) cases and correctly guided therapy in 19 (91%) cases. Biopsy accuracy of frameless versus frame-based stereotaxis was similar (89 versus 66%, p=0.21). In three (14%) cases, biopsy specimens were adequate to diagnose glioma; however, histology was insufficient for definitive tumor grading. Anaplastic oligodendroglioma (ODG) was under-graded as low-grade ODG in one (5%) case. Biopsy of new onset glioblastoma multiforme (GBM) yielded necrosis/gliosis and was termed non-diagnostic in one patient. Tumors <50 cm(3) were 8-fold less likely to accurately represent the grade of the entire lesion at resection compared with lesions <50 cm(3) (OR, 8.8; 95% CI, 0.9-100, p=0.05). DISCUSSION: Both frameless and frame-based MRI-guided stereotactic brain biopsy are safe and accurately represent the larger glioma mass sufficiently to guide subsequent therapy. Large tumor volume had a higher incidence of non-concordance. Increasing the number of specimens taken through the long dimension of large tumors may improve diagnostic accuracy.     

MRI 导向立体定向活检术在颅内病变诊断中的应用简

目的探讨MR／引导下立体定向活检手术在颅内病灶诊断的准确性、安全性及其临床应用价值。方法回顾性分析52例病变性质不明的颅内病变病人的临床资料,在MRI导向下行立体定向活检术。结果52例病人均取得病理诊断．活检成功率100％。星形细胞瘤20例（38．5％）,脑转移瘤13例（25．0％）,脑非化脓性感染10例（19．2％）,非霍奇金淋巴瘤4例（7．7％）,胶质细胞增生2例（3．8％）,脑真菌病、脑囊尾蚴病及结核性病变各1例（1．9％）。术后无一例出现严重并发症。除l例放弃治疗,其余病人转相应专科治疗。结论对于难以行开颅手术的颅内疑难病变,MRI导向立体定向活检手术可提供一种可靠的诊断手段,为临床进一步诊疗提供理论依据。     

Influence of the type of surgery on the histologic diagnosis in patients with anaplastic gliomas.

Stereotactic biopsy of CNS tumors provides a small amount of tissue for pathologic diagnosis. This potentially leads to inaccurate grading of gliomas because of their histologic heterogeneity. We compared histologic diagnoses in a consecutive series of 329 patients with newly diagnosed anaplastic gliomas whose diagnoses were established by either stereotactic biopsy or open resection. Of 262 patients undergoing resection, 214 (82%) had glioblastomas and 48 (18%) had anaplastic astrocytomas (AAs). Of 67 patients undergoing stereotactic biopsy, 33 (49%) had glioblastomas and 34 (51%) had AAs. This difference suggests that some AAs diagnosed by stereotactic biopsy are actually glioblastomas and has important implications for the design and interpretation of clinical trials.     

Comparative analysis of diagnostic accuracy of different brain biopsy procedures

BACKGROUND: Image-guided procedures such as computed tomography (CT) guided, neuronavigator-guided and ultrasound-guided methods can assist neurosurgeons in localizing the intraparenchymal lesion of the brain. However, despite improvements in the imaging techniques, an accurate diagnosis of intrinsic lesion requires tissue sampling and histological verification. AIMS: The present study was carried out to examine the reliability of the diagnoses made on tumor sample obtained via different stereotactic and ultrasound-guided brain biopsy procedures. MATERIALS AND METHODS: A retrospective analysis was conducted of all brain biopsies (frame-based and frameless stereotactic and ultrasound-guided) performed in a single tertiary care neurosciences center between 1995 and 2005. The overall diagnostic accuracy achieved on histopathology and correlation with type of biopsy technique was evaluated. RESULTS: A total of 130 cases were included, which consisted of 82 males and 48 females. Age ranged from 4 to 75 years (mean age 39.5 years). Twenty per cent (27 patients) were in the pediatric age group, while 12% (16 patients) were >or= 60-years of age. A definitive histological diagnosis was established in 109 cases (diagnostic yield 80.2%), which encompassed 101 neoplastic and eight nonneoplastic lesions. Frame-based, frameless stereotactic and ultrasound-guided biopsies were done in 95, 15 and 20 patients respectively. Although the numbers of cases were small there was trend for better yield with frameless image-guided stereotactic biopsy and maximum diagnostic yield was obtained i.e, 87% (13/15) in comparison to conventional frame-based CT-guided stereotactic biopsy and ultrasound-guided biopsy. CONCLUSIONS: Overall, a trend of higher diagnostic yield was seen in cases with frameless image-guided stereotactic biopsy. Thus, this small series confirms that frameless neuronavigator-guided stereotactic procedures represent the lesion sufficiently in order to make histopathologic diagnosis.     

颅内多发病灶的立体定向活检术后病理学结果与MRS结果的比较分析

目的探讨立体定向活检术及磁共振波谱成像（MRS）在颅内多发病灶定性诊断中的临床价值。方法回顾性分析37例经MRI、MRS和立体定向活检术后病理学检查确诊的颅内多发病灶患者的临床资料,其中行有框架定向活检术22例,无框架神经导航定向活检术15例。结果 37例均获得明确病理学诊断,其中低级别胶质瘤19例,高级别胶质瘤8例,淋巴瘤3例,多发脱髓鞘3例,炎性病灶2例,转移癌2例。术后出现癫痫发作1例,活检靶点少量出血1例。病理学诊断与MRS诊断符合率为83.8%（31/37）,误诊率为16.2%（6/37）。结论 MRS在颅内多发病灶的诊断中具有较高的准确性,但仍有一定的误诊率;立体定向活检术微创、安全,在颅内多发病灶的诊断中具有决定性的意义;MRS的代谢变化在活检术靶点选择上具有一定的指导价值。     

MRI立体定向活检术在颅内病变诊断中的应用

目的 探讨MRI引导下立体定向活检术在颅内病变诊断中的作用价值。方法 自2009年1月至2015年3月应用立体定向系统与手术计划软件对25例颅内病变诊断不明确的患者行MRI定位下立体定向活检术。结果 除1例活检阴性外,病理诊断与最后诊断（结合临床和其他检查结果）一致20例,不一致4例;最后诊断与术前MRI诊断相符合8例,不符合9例,影像未诊断6例;切除术后病理与影像相符合1例,无明确关系1例。术后6例病变内少量出血,保守治疗;1例左额叶出血30 ml,行开颅血肿清除+去骨瓣减压术。结论 MRI立体定向活检术对颅内多发、深部病变的诊断具有重要价值,其安全性较高,但仍需进一步避免脑出血的风险。     

立体定向活检术结合伽玛刀治疗脑深部胶质瘤

目的探讨立体定向活检术结合伽玛刀治疗脑深部胶质瘤的效果。方法利用立体定向活检术明确病灶性质后,伽玛刀治疗脑深部病灶26例,伽玛刀治疗剂量18-25Cy。结果26例脑深部病灶立体定向活检术后病理学诊断为胶质瘤;伽玛刀治疗后半年实体肿瘤控制有效率达88．5％（23／26）。结论对无明显颅内压增高的脑深部胶质瘤患者,立体定向活检术明确肿瘤性质后,减少手术带来的并发症;对体积稍大者采用剂量分割方法以提高肿瘤的处方剂量,从而使肿瘤控制率达到较好的水平。     

The stereotactic biopsy diagnosis of focal intracerebral lesions in AIDS patients

Focal intracerebral lesions were biopsied stereotactically in 23 adult HIV-infected patients, the main indication for which was the failure to respond to anti-toxoplasma treatment. A cerebral disease was the initial or main complaint in 19 of them. In 22 of 25 stereotactic approaches, a clear-cut morphological diagnosis could be established (9 primary brain lymphoma, 7 necrotizing toxoplasma encephalitis, 5 progressive multifocal leukoencephalopathy, 1 HIV encephalitis, 3 unspecific tissue changes). In 7 of 8 deceased patients, autopsy confirmed the bioptical diagnosis. The high diagnostic yield was related to the strategy of the stereotactic method and the sample size (3 to 4 consecutive samples along the stereotactic track including the marginal zones, 1 cm long tissue cylinders). Formalin fixation and paraffin embedding of the samples provide the possibility of serial sections and special stainings (immunohistochemistry, in-situ hybridization) and kill the HIV. Stereotactic brain biopsy is a highly accurate diagnostic tool to ascertain the nature of focal intracerebral lesions in selected AIDS patients.     

Der Stellenwert der stereotaktischen Hirnbiopsie für das Management von Patienten mit supratentoriellen Gliomen WHO-Grad-II

OBJECTIVE: The aim of this prospective study was to compare the diagnostic value of magnetic resonance imaging (MRI) and stereotactic biopsy in patients harboring WHO grade II gliomas. METHODS: Stereotactic biopsy was performed in 62 adult patients with low-signal, nonenhancing, space-occupying lesions on T1 MR imaging between 1998 and 2001. The results of histological analysis were compared to the preoperative imaging diagnoses. Any adverse perioperative sequel was considered as morbidity. Applied treatment strategies are described. RESULTS: Transient perioperative morbidity for the stereotactic approach was 4.8% (three patients), and there was no mortality or permanent morbidity. In four patients, neoplastic lesions could be excluded (gliosis: three patients, encephalitis: one), and WHO grade III gliomas were seen in five patients (14.8.% false positive rate of neurodiagnostic imaging). The diagnostic reliability of stereotactic biopsy was 96.8%. The following treatment strategies were initiated: microsurgery (17 patients), interstitial radiosurgery (12 patients), combination of microsurgery and interstitial radiosurgery (21 patients), external beam irradiation (six patients),and chemotherapy (two patients). Four patients were initially not treated. CONCLUSIONS: Diagnostic neuroimaging is not sufficient for the planning of rational treatment strategies in patients harboring WHO grade II gliomas. Frame-based stereotactic biopsy is a prerequisite for individualized treatment strategies.     

立体定向活检术在颅内无强化效应病变中的诊断价值

目的 探讨立体定向活检术在颅内无强化效应病变中的定性诊断价值.方法 对47例在MRI增强扫描中未见明显强化的颅内病变行立体定向活检,其中MRI引导有框架立体定向活检38例,无框架神经导航定向活检9例.结果 获得明确病理诊断42例,未获得阳性病理结果5例,活检病理诊断阳性率89.4％.对颅内非肿瘤性病变,MRI诊断与病理诊断相符合9例;对肿瘤性病变,MRI诊断与病理诊断相符合14例;MRI诊断与病理诊断的符合率为48.9％.活检术后穿刺道少量出血1例,无颅内感染和死亡病例.结论 对颅内无强化效应的病变,立体定向活检是获得定性诊断安全、可靠的方法.     

影像学引导的立体定向脑活检手术

目的探讨现代神经成像技术(CT、MRI)引导的立体定向脑病变活检术对组织病理学诊断的可靠性和正确性,总结手术操作方法和技术要点。方法采用CT、MRI与立体定向技术相结合,进行脑部病变的活检手术共605例,其中450例用CT或MRI片目测靶点坐标定位,155例采用计算机辅助的立体定向手术(CAPN)工作站,自动计算靶点和规划活检入路。结果522例确诊为各种脑肿瘤,39例为炎性病理,23例为寄生虫或先天性囊肿,16例未能提供可供确诊的病理,阳性诊断率为97.36%。并发症15例,其中2例死亡。结论先进影像技术引导下的立体定向脑病变活检术是神经内、外科脑部病变获得定性诊断安全、可靠的手术方法。术中应注意改进操作方法,以提高病理诊断的阳性率,并达到微侵袭性手术的要求。     

Accuracy and diagnostic yield of stereotactic biopsy in the diagnosis of brain masses: Comparison of results of biopsy and resected surgical specimens

The aim of this retrospective study was to investigate the diagnostic yield and accuracy of stereotactic biopsy in patients harboring brain mass. Stereotactic biopsy was performed in 130 patients between 1995 and 2000 in an educational and research hospital in Turkey. The results of histological analysis were compared to the resected specimens in 23 patients. The lesions were lobar in 62% of cases and deep‐seated in 38% of cases. During the biopsy procedures, the pathologist was in the operating theatre and a very small fragment was used for cytological examination. No frozen section was used in any of the cases. Samples were diagnostic in 122 cases. The overall diagnostic yield of the procedure was 94%. A definitive histological diagnosis was not made in eight patients. The histological diagnoses of the two procedures were identical (complete agreement) in 16 cases. In three cases, the histological diagnoses between the two procedures were slightly different without impact on patient care (minor disagreement). The diagnosis of the stereotactic biopsy was completely changed after craniotomy in four cases (major disagreement). The accuracy of the histological diagnosis was 83%. There was only one major complication, which involved intracerebral hemorrhage. Despite the limited number of patients who underwent resection, our data suggest that stereotactic biopsy of brain masses is a safe and accurate technique that can obtain adequate tissue for histological diagnosis, thus providing the best avaible treatment for patients. Cytological evaluation of the streotactic biopsy also is a highly effective tool for obtaining sufficient material during the procedure in many cases.