NeoplasmStereotactic biopsy of brain stem masses: decision analysis and literature review
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
References (37)
- et al.
Magnetic resonance spectroscopy in childhood brainstem tumors
Pediatr Neurol
(2002) - et al.
Results and expectations with image-integrated brainstem stereotactic biopsy
Surg Neurol
(1995) - et al.
Transcerebellar biopsy in the posterior fossa: 12 years experience
Surg Neurol
(1987) - et al.
Stereotaxic suboccipital transcerebellar biopsy of pontine mass lesions
J Neurosurg
(1989) - et al.
Computed tomographic guidance stereotaxis in the management of intracranial mass lesions
Neurosurgery
(1983) A new instrument for stereotaxic brain tumour biopsy. Technical note
Acta Chir Scand
(1971)- et al.
Diffusion weighted imaging in radiation necrosis
J Neurol Neurosurg Psychiatry
(2003) - et al.
The stereotactic approach to brain stem lesions: a follow-up of 29 cases
Acta Neurochir Suppl (Wien)
(1991) - et al.
Stereotactic biopsy of brain stem lesions
Minim Invasive Neurosurg
(2001) - et al.
Stereotactic surgery for mass lesions of the midbrain and pons
Neurosurgery
(1985)
Can patients be anticoagulated after intracerebral hemorrhage? A decision analysis
Stroke
Central nervous system tumors in children
Cancer
Magnetic resonance-guided stereotactic biopsies: results in 100 consecutive cases
Acta Neurochir
Stereotactic biopsy and treatment of brain stem lesions: combined study of 33 cases (Bologna-Marseille)
Acta Neurochir Suppl
Serial stereotactic biopsy of brain stem expanding lesions. Considerations on 45 consecutive cases
Acta Neurochir Suppl
The incidence of unexpected pathological findings in an image-guided biopsy series: a review of 100 consecutive cases
Neurosurgery
Stereotactic biopsies of focal brainstem lesions
Surg Neurol
Brainstem gliomas in adults: prognostic factors and classification
Brain
Cited by (36)
The stereotactic suboccipitaltranscerebellar approach to lesions of the brainstem and the cerebellum
2018, Clinical Neurology and NeurosurgeryCitation Excerpt :The technical challenge of the suboccipital approach results in various alternative stereotactic routes particularly to the brainstem. The transfrontal trajectory is the most common frame-based approach [7–9], but alternative approaches were also described [10,12]. There are few studies comparing the transfrontal and the suboccipital-transcerebellar route depicting either approach comparable concerning the obtainment of a histopathological diagnosis and the complication rate [13,14].
IDH1 mutation analysis in low cellularity specimen: A limitation of diagnostic accuracy and a proposal for the diagnostic procedure
2013, Pathology Research and PracticeCitation Excerpt :One study stated that at least 50% of the specimen must be composed of neoplastic cells to ensure reliable detection of mutant alleles in conventional IDH1 PCR-sequencing [12], and it seems that a greater than 30% tumor fraction is required for correct mutation detection [25,26]. This is a critical issue in the practice of neuropathology since the number of stereotactic biopsies is being increased, and specimens with variable cellularities will be present since many biopsies may be done in a peripheral area of an infiltrative glioma, where the relative tumor fraction is decreased [27,28]. A similar situation may be encountered with biopsies where instrument access is not feasible.
Minimized doses for linear accelerator radiosurgery of brainstem metastasis
2011, International Journal of Radiation Oncology Biology PhysicsStereotactic robot-guided biopsies of brain stem lesions: Experience with 15 cases
2010, NeurochirurgieCitation Excerpt :For the two patients (cases 1 and 14), postoperative CT scan revealed a correct biopsy location with no haemorrhage. Data in the literature described two types of stereotactic approach to the brain stem: the frame-based (Abernathey et al., 1989; Boviatsis et al., 2003; Dorward et al., 2002; Guthrie et al., 1989; Guy et al., 1989; Rajshekhar and Chandy, 1995; Samadani and Judy, 2003; Samadani et al., 2006; Steck and Friedman, 1995; St George et al., 2004) and the frameless (Barnett et al., 1999; Benabid et al., 1997; Benabid et al., 1998; Dorward et al., 2002) procedures. In the majority of studies, stereotactic frames were used, and included the CRW (Dorward et al., 2002), the BRW (Guthrie et al., 1989) and the Leksell G systems (St George et al., 2004).