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A case of brain stem Epidermoid (mimicking low grade glioma on MRI image) in 16 year female, transcerebellar awake biopsy with aspiration of cyst done in semi sitting position
Source publication
Brain stem lesions are pathologically heterogeneous. Pre-operative radiological diagnoses prove to be wrong in 10 to 20% of cases. It is therefore imperative to have a tissue diagnosis for appropriate therapeutic measures. We report a series of 24 patients (14 males, ten females, age range: 6-17 years) CT guided stereotactic biopsy for brain stem l...
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Citations
... Furthermore, clear discrimination between the three most common diagnoses of posterior fossa lesions (brain tumor, lymphoma, inflammatory process) is not possible with radiologic diagnostic tools alone [17]. Especially in pediatric patients, the gap between radiological and histopathological diagnosis is well-described [7,19,27]. Considering the fulminant differences in treatment and outcome, it is on the one hand risky to rely on radiological diagnostics alone, and on the other hand, the benefits of a modern molecular pathological analysis cannot be used [21,22,24]. ...
Objective
Lesions of the posterior fossa (brainstem and cerebellum) are challenging in diagnosis and treatment due to the fact that they are often located eloquently and total resection is rarely possible. Therefore, frame-based stereotactic biopsies are commonly used to asservate tissue for neuropathological diagnosis and further treatment determination. The aim of our study was to assess the safety and diagnostic success rate of frame-based stereotactic biopsies for lesions in the posterior fossa via the suboccipital-transcerebellar approach.
Methods
We performed a retrospective database analysis of all frame-based stereotactic biopsy cases at our institution since 2007. The aim was to identify all surgical cases for infratentorial lesion biopsies via the suboccipital-transcerebellar approach. We collected clinical data regarding outcomes, complications, diagnostic success, radiological appearances, and stereotactic trajectories.
Results
A total of n = 79 cases of stereotactic biopsies for posterior fossa lesions via the suboccipital-transcerebellar approach (41 female and 38 male) utilizing the Zamorano-Duchovny stereotactic system were identified. The mean age at the time of surgery was 42.5 years (± 23.3; range, 1–87 years). All patients were operated with intraoperative stereotactic imaging (n = 62 MRI, n = 17 CT). The absolute diagnostic success rate was 87.3%. The most common diagnoses were glioma, lymphoma, and inflammatory disease. The overall complication rate was 8.7% (seven cases). All patients with complications showed new neurological deficits; of those, three were permanent. Hemorrhage was detected in five of the cases having complications. The 30-day mortality rate was 7.6%, and 1-year survival rate was 70%.
Conclusions
Our data suggests that frame-based stereotactic biopsies with the Zamorano-Duchovny stereotactic system via the suboccipital-transcerebellar approach are safe and reliable for infratentorial lesions bearing a high diagnostic yield and an acceptable complication rate. Further research should focus on the planning of safe trajectories and a careful case selection with the goal of minimizing complications and maximizing diagnostic success.
... In previous reports, the diagnostic rate of brainstem tumor biopsy varied from 84% to 97% [7][8][9][10][11][12][13][14][15], which are comparable to our results. Regarding the approach, the transfrontal and transcerebellar routes are the two major surgical routes [11,[15][16][17]; however, there is a paucity of evidence as to which approach is more suitable [13,14,18]. ...
... In previous reports, the diagnostic rate of brainstem tumor biopsy varied from 84% to 97% [7][8][9][10][11][12][13][14][15], which are comparable to our results. Regarding the approach, the transfrontal and transcerebellar routes are the two major surgical routes [11,[15][16][17]; however, there is a paucity of evidence as to which approach is more suitable [13,14,18]. Dellaretti et al. [12] reported that the transfrontal approach achieved a higher diagnostic rate (95%) than the transcerebellar approach (84%), but the difference was not statistically significant, similar to the observation in other studies [19,20]. ...
... Dellaretti et al. [12] reported that the transfrontal approach achieved a higher diagnostic rate (95%) than the transcerebellar approach (84%), but the difference was not statistically significant, similar to the observation in other studies [19,20]. For pediatric brainstem tumors, the diagnostic rate via the transcerebellar approach was 96% [13]. In our cohort, a high diagnostic rate and a low complication rate were both achieved, indicating that the transcerebellar approach is safe, though it requires ingenuity to target the accessible lesions such as those in the cerebellar peduncle. ...
Stereotactic frame-based brain tumor biopsy (SFB) is a potent diagnostic tool considering its minimal invasiveness, though its diagnostic power and safety for brainstem lesions remain to be discussed. Here, we aimed to examine the usefulness of SFB for brainstem tumors. Twenty-two patients with brainstem tumors underwent 23 SFBs at our institution during 2002–2021. We retrospectively analyzed patient characteristics, tumor pathology, surgical procedures, and outcomes, including surgery-related complications and the diagnostic value. Seven (32%) tumors were located from the midbrain to the pons, eleven (50%) in the pons only, and four (18%) from the pons to the medulla oblongata. The target lesions were in the middle cerebellar peduncles in sixteen procedures (70%), the cerebellum in four (17%), the inferior cerebellar peduncles in two (9%), and the superior cerebellar peduncles in one (4%). A definitive diagnosis was made in 21 patients (95%) at the first SFB. The diagnoses were glioma in seventeen (77%) cases, primary central nervous system lymphoma in four (18%), and a metastatic brain tumor in one (5%). The postoperative complications (cranial nerve palsy in three [13%] cases, ataxia in one [4%]) were all transient. SFB for brainstem tumors yields a high diagnostic rate with a low risk of morbidity.
... Thus, including our own institutional series, a total of 18 studies were included in the present meta-analysis. 2,5,6,8,9,11,16,17,[19][20][21][22][23]25,29,32,33 ...
... The studies comprised a sample of 735 patients. 2,5,6,8,9,11,16,17,[19][20][21][22][23]25,29,32,33 The cohorts varied between 10 and 130 patients, with a median of 24 patients per study. Annually, a median of 3.1 patients received stereotactic biopsy for BSTs in the individual institutions (range 1.4-10.0 ...
OBJECTIVE
Recent studies have shed light on the molecular makeup of diffuse intrinsic pontine gliomas and led to the identification of potential treatment targets for these lesions, which account for the majority of pediatric brainstem tumors (pedBSTs). Therefore, stereotactic biopsy–driven molecular characterization of pedBSTs may become an important prerequisite for the management of these fatal brain tumors. The authors conducted a systemic review and meta-analysis to precisely determine the safety and diagnostic success of stereotactic biopsy of pedBSTs.
METHODS
A systematic search of PubMed, EMBASE, and the Web of Science yielded 944 potentially eligible abstracts. Meta-analysis was conducted on 18 studies (including the authors’ own institutional series), describing a total of 735 biopsy procedures for pedBSTs. The primary outcome measures were diagnostic success and procedure-related complications. Pooled estimates were calculated based on the Freeman-Tukey double-arcsine transformation and DerSimonian-Laird random-effects model. Heterogeneity, sensitivity, and meta-regression analyses were also conducted.
RESULTS
The weighted average proportions across the analyzed studies were 96.1% (95% CI 93.5%–98.1%) for diagnostic success, 6.7% (95% CI 4.2%–9.6%) for overall morbidity, 0.6% (95% CI 0.2%–1.4%) for permanent morbidity, and 0.6% (95% CI 0.2%–1.3%) for mortality. Subgroup analyses at the study level identified no significant correlation between the outcome measures and the distribution of the chosen biopsy trajectories (transfrontal vs transcerebellar), age, year of publication, or the number of biopsy procedures annually performed in each center.
CONCLUSION
Stereotactic biopsy of pedBSTs is safe and allows successful tissue sampling as a prerequisite for the molecular characterization and the identification of potentially druggable targets toward more individualized treatment concepts to improve the outcome for children harboring such lesions.
... A total of 44 children with diffuse brain stem lesions on MRI scans underwent biopsy, which showed 10% having a pathological diagnosis different from glioma [14]. Cumulative experience from over 300 children who underwent biopsy for pontine tumors showed that postoperative symptoms and signs are relatively infrequent and majority of these consisted of transient cranial neuropathies or mild motor weakness [15,16]. Increasing use of DTI, tractography and PET 'hotspots' to locate the corticospinal tracts during surgical evaluation, have resulted in lowering of morbidity and re-defining safety of biopsy [17,18]. ...
SUMMARY Diffuse intrinsic pontine glioma (DIPG) is an aggressive tumor that is universally fatal, and to-date we are at a virtual standstill in improving its grim prognosis. Dearth of tissue due to rarity of biopsy has precluded understanding the elusive biology and frustration continues in reproducing faithful animal models for translational research. Furthermore the intricate anatomy of the pons has forestalled locoregional therapy and drug penetration. Over the last few years, biopsy-driven targeted therapy, development of vitro and xenograft animal models for therapeutic testing, profiling immunotherapeutic strategies and locoregional infusion of drugs in brain stem tumors, now provide a sense of hope in the years ahead. This review aims to discuss current status and advances in the management of these tumors.
... A similar pattern was observed in other Indian studies also, in contrary to Western studies. [17,30,31] We noted that all the biopsies in diffuse nonenhancing lesions were gliomas. The histopathology of the lesions in children were pilocytic astrocytoma (n = 1), anaplastic astrocytoma (n = 2), GBM or high grade glioma (n = 1), malignant glioma with further classification not possible (n = 2). ...
... Various approaches and techniques have been used to perform STB in brainstem lesions. While some authors have used a transfrontal access to the brainstem lesions, [17,23] Patel et al. [31] and Abernathey et al. [3] exclusively used transcerebellar approach in all of their patients. Both the approaches have advantages and limitations. ...
... Some authors reported the transcerebellar approach for brainstem lesions, which reflect the different institutional practice. [3,31] In the present series, a twist drill craniostomy has been utilized in most of the cases for performing STB. Many authors utilize a burr hole for performing a STB for a brainstem lesion, [31,34] while some series describe the use of twist drill cranisotomy for STB. ...
Stereotactic biopsy of brainstem lesions have been performed with varying indications, with most of the literature reporting on children.
The present study retrospectively analyzed all cases that underwent stereotactic biopsy for brainstem lesion in both adult and pediatric population between 1994 and 2009 in a single tertiary neurosurgical center. The clinical and radiological features, technique of the procedure, morbidity, diagnostic accuracy, spectrum of diagnosis, and variations in adult and pediatric population were analyzed.
Eighty-two patients were included in the study. Computed tomography (CT) was used as guidance in 73 (38 children and 35 adults) patients and magnetic resonance imaging (MRI) in 9 (3 children and 6 adults). The biopsy was performed in a procedure room under local anesthesia in most adults, while children required sedation. Glioblastoma comprised 29.3% of all pathologies in children, compared with only 4.9% of the pathologies in adult population (P = 0.007). Tuberculosis was the next major diagnosis (9.8%). In 12 patients, initial biopsy was inconclusive. Following a repeat biopsy in 5 of these patients, a diagnosis was possible for 75/82 (91.5%) patients by STB. The location of the target, the choice of entry, the radiological characteristic of the lesion, enhancement pattern, and age group did not significantly correlate with the occurrence of inconclusive biopsy. Permanent complications occurred in two patients (2.4%). There was no mortality in this series.
Stereotactic biopsy has an important role in brainstem lesions, more significantly in adults, due to wider pathological spectrum. It can be performed safely under local anesthesia through a twist drill craniostomy in most of the adults.
... The majority of studies are related to adult patients who received the procedure in a semi-sitting position under a local anesthesia. The experience of applying this procedure to children is limited to several institutions worldwide [15][16][17]. In children, the majority of pontine mass lesions in children are DPG, for which no tissue biopsy has been recommended for decades [3]. ...
Introduction:
The need for a surgical biopsy for diffuse pontine glioma (DPG) is increasing, and a safer and less invasive procedure is required.
Methods:
We describe a transcerebellar stereotactic biopsy procedure that can be safely performed in young children. Four pediatric patients with DPG underwent transcerebellar stereotactic biopsies.
Results:
All of the patients were diagnosed with gliomas, and one patient had a transient numbness of the lip margin after the procedure.
Discussion:
Transcerebellar stereotactic biopsy is a relatively safe way to obtain a tissue diagnosis for children with DPG.
... The role of stereotactic biopsy (SB) of brain stem lesions has been debated. [36][37][38]41,42] It is now clear that SB done by an experienced team with modern imaging equipment can be as safe as in any other location in the brain. The procedure is offered when unresectable lesions do not exhibit the classical characteristics of a diffuse glioma on clinical and radiological examination. ...
Brain tumours form the most common type of solid tumour in children and more that 50% of these are infratentorial. Cerebellar astrocytomas and brain stem gliomas are the commonest posterior fossa glial tumours in children. Cerebellar astrocytomas represent up to 10% of all primary brain tumours and up to 25% of posterior fossa tumors in children, with Low grade gliomas forming the commonest of the cerebellar gliomas. They commonly present with symptoms and signs of raised intracranial pressure due to obstructive hydrocephalus. Radiologically they may be solid or cystic with or without a mural nodule. Surgical excision is the mainstay of treatment and forms the most consistent factor influencing progression free and long term survival. While majority of the tumours are pilocytic astrocytomas, they may also be fibrillary astrocytomas or even high grade tumours. Tumour histology does not appear to be an independent factor in the prognosis of these children, and therefore no palliative treatment after surgery is advocated. Brain stem gliomas account for approximately 10% of all pediatric brain tumours. Cranial nerve signs, ataxia and cerebellar signs with or without symptoms and signs of raised intracranial pressure are classically described symptoms and signs. Radiographic findings and clinical correlates can be used to categorize brain stem tumours into four types: diffuse, focal, exophytic and cervicomedullary. Histologically most brain stem gliomas are fibrillary astrocytomas. Diffuse brain stem gliomas are the most commonly seen tumour in the brain stem. These lesions are malignant high grade fibrillary astrocytomas. Focal tumours of the brain stem are demarcated lesions generally less than 2 cms in size, without associated edema. Most commonly seen in the midbrain or medulla, they form a heterogeneous pathological group, showing indolent growth except when the lesion is a PNET. Dorsally exophytic tumours lie in the fourth ventricle, while cervicomedullary lesions are similar to spinal intramedullary tumours. Expanding lesions are the only lesions amenable for excision while infiltrative and ventral lesions are not.
Background and Importance Brainstem lesions may be unresectable or unapproachable. Regardless, the histopathological diagnosis is fundamental to determine the most appropriate treatment. We present our experience with transfrontal stereotactic biopsy technique for brainstem lesions as a safe and effective surgical route even when contralateral transhemispheric approach is required for preservation of eloquent tissue.
Clinical Presentation Twenty-five patients underwent surgery by transfrontal approach. Medical records were reviewed for establishing the number of patients who had postoperative histopathological diagnosis and postoperative complications. Twenty-four patients (18 adults and 7 children) had histopathological diagnosis. There were 18 astrocytomas documented, of which 12 were high grade and 6 low grade. The other diagnoses included viral encephalitis, post–renal transplant lymphoproliferative disorder, nonspecific chronic inflammation, Langerhans cell histiocytosis, and two metastases. No case was hindered by cerebrospinal fluid loss or ventricular entry. Complications included a case of mesencephalic hemorrhage with upper limb monoparesis and a case of a partially compromised third cranial nerve in another patient without associated bleeding.
Conclusion Stereotactic biopsy of brainstem lesions by transfrontal ipsilateral or transfrontal transhemispheric contralateral approaches is a safe and effective surgical approach in achieving a histopathological diagnosis in both pediatric and adult populations.
Introduction and objectives
This study aims at presenting our experience of the MRI-guided frame-based stereotactic brainstem biopsy method, and evaluating the outcomes of the procedure.
Patients and methods
The current study involved 18 cases that underwent MRI-guided frame-based stereotactic biopsy for brainstem lesions between 2011 and 2018 in our clinic. The relevant data regarding the technique of the biopsy procedure, morbidity, histopathological diagnosis it yields and diagnostic accuracy was retrospectively analyzed.
Results
Stereotactic biopsy procedure was performed on 18 patients, including 16 adults and two children. MRI was used as guidance for the biopsy procedure in all patients. The adult patients had the biopsy under local anesthesia; as for the pediatric patients local anesthesia plus sedation was used. All patients received diagnosis based on the histopathological examination of their biopsy samples. No equivocal or negative results, and no major morbidity or mortality was seen in the patients after the procedure.
Conclusions
MRI-guided frame-based stereotactic biopsy can be considered as a safe and efficient diagnostic method for brainstem lesions when its diagnostic yield and its morbidity and/or mortality rates are evaluated. Choosing the best trajectory for each lesion, using MRI as guidance for targeting, taking a limited number of biopsy samples are valuable criteria for the decreased morbidity rates in stereotactic brainstem biopsy procedures.
Introduction and objectives:
This study aims at presenting our experience of the MRI-guided frame-based stereotactic brainstem biopsy method, and evaluating the outcomes of the procedure.
Patients and methods:
The current study involved 18 cases that underwent MRI-guided frame-based stereotactic biopsy for brainstem lesions between 2011 and 2018 in our clinic. The relevant data regarding the technique of the biopsy procedure, morbidity, histopathological diagnosis it yields and diagnostic accuracy was retrospectively analyzed.
Results:
Stereotactic biopsy procedure was performed on 18 patients, including 16 adults and two children. MRI was used as guidance for the biopsy procedure in all patients. The adult patients had the biopsy under local anesthesia; as for the pediatric patients local anesthesia plus sedation was used. All patients received diagnosis based on the histopathological examination of their biopsy samples. No equivocal or negative results, and no major morbidity or mortality was seen in the patients after the procedure.
Conclusions:
MRI-guided frame-based stereotactic biopsy can be considered as a safe and efficient diagnostic method for brainstem lesions when its diagnostic yield and its morbidity and/or mortality rates are evaluated. Choosing the best trajectory for each lesion, using MRI as guidance for targeting, taking a limited number of biopsy samples are valuable criteria for the decreased morbidity rates in stereotactic brainstem biopsy procedures.
