Elsevier

Surgical Neurology

Volume 66, Issue 5, November 2006, Pages 484-490
Surgical Neurology

Neoplasm
Stereotactic biopsy of brain stem masses: decision analysis and literature review

https://doi.org/10.1016/j.surneu.2006.05.056Get rights and content

Abstract

Background

Adult brain stem tumors are rare, and diverse pathology can be found in this location. Stereotactic biopsy of lesions in the brain stem has been performed since the 1960s with high diagnostic and low complication rates. Advances in imaging technology have raised questions regarding the utility of biopsy. We perform decision analysis to aid clinicians in their approach to management of adult brain stem lesions.

Methods

A structured literature search revealed 20 publications with 457 patients who had undergone brain stem lesion biopsy. These publications were reviewed to determine diagnostic rates and the incidence of complications. Standard decision analytic techniques were applied to the case of a virtual adult patient with a lesion in the brain stem.

Results

A 1-way sensitivity analysis revealed the likelihood that the preoperative diagnosis was correct and the rate at which incorrect treatment was based on faulty empirical diagnosis as the 2 factors with the greatest effects on patient outcome. The diagnostic rate and complication rate of biopsy, within the ranges reported in the literature, had lesser effects. A threshold analysis was constructed to compare outcomes from stereotactic biopsy vs empiric therapy for a brain stem lesion. The probability that the preoperative diagnosis is correct is plotted vs the probability that empirical treatment based on an incorrect diagnosis will have adverse effect.

Conclusions

Management of lesions in the adult brain stem requires careful consideration of multiple preoperative factors including clinical and radiographic diagnostic certainty, consequences of empiric therapy, and the surgeon's complication rate.

Introduction

Tumors of the brain stem comprise 10% to 15% of all intracranial tumors in the pediatric population [10]. Most of these lesions are brain stem gliomas that are evaluated with MRI, from which most diagnoses may be obtained directly. In the adult population however, brain stem tumors are rarer, comprising only about 2% of all brain tumors [37]. Furthermore, there appears to be a wider diversity of pathology in brain stem tumors of adults as compared with children. Image-guided stereotactic biopsy of brain stem lesions has been performed since 1975 [24]. High diagnostic and low complication rates for biopsy of brain stem lesions [7], [12], [13], [18], [19], [20], [29], [30], [35] rival those of biopsy for supratentorial intracranial mass lesions [2], [11]. Furthermore, as with supratentorial lesions [14], findings upon biopsy are not always suggested by preoperative assessment.

We supplement a structured literature review with our recent series of patients with brain stem lesions to define the overall rates of morbidity, mortality, and diagnosis for biopsy of lesions in the brain stem. We also perform a threshold analysis to determine when biopsy is indicated for management of lesions in the brain stem.

Section snippets

Materials and methods

We performed a structured literature search using MEDLINE to identify all English-language publications related to stereotactic brain stem biopsy between 1975 and 2004. This was supplemented with selected references from the bibliographies of the articles retrieved and the “Related Articles” feature of PubMed. Individual case reports and reviews not introducing original data were excluded. As our goal was to address brain stem masses in adults, we excluded series that were exclusively or

Analysis of case series

In addition to our 12 patients, 20 case series with brain stem lesion biopsies have been reported in the literature since 1985 (Table 2). The diversity of adult intrinsic lesion pathology is summarized in Table 3. Predominantly 4 different types of stereotactic frames have been used. The Leksell (Elekta, Stockholm, Sweden) for 25% of biopsies (n = 93), the Riechert (Fischer-Leibinger, Freiburg, Germany) for 21% (n = 78), Todd-Weills (Compass, Rochester, MN)/Kelly Goerss for 7% (n = 26), and the

Discussion

Threshold analysis reveals that as long as an individual surgeon's diagnostic accuracy and complication rates are relatively comparable to those in the literature, one factor impacting whether a biopsy should be performed is the probability that the correct diagnosis can be obtained clinicoradiographically.

Preoperative radiologic assessment of brain stem masses can include CT, MRI, and metabolic imaging such as PET or SPECT scanning. Most of the literature published to date regarding brain stem

Conclusions

In children, the incidence of brain stem gliomas and the accuracy of clinical and radiographic criteria in predicting diagnosis are such that biopsy is unnecessary in many cases. In adults, however, the greater incidence of brain stem lesions other than gliomas, and the relative safety of biopsy favor its use when the preoperative diagnosis, is not obvious and the risks of incorrect empirical therapy are high. We provide a decision analysis model to assist in determining when stereotactic

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