- Division of Neurosurgery, University of California, San Diego, USA
- Center for Theoretic and Applied Neuro-Oncology, University of California, San Diego, USA
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston MA, USA
- Division of Neurosurgery, University of Chicago Medical Center, Chicago, IL, USA
Clark C. Chen
Division of Neurosurgery, University of California, San Diego, USA
Center for Theoretic and Applied Neuro-Oncology, University of California, San Diego, USA
DOI:10.4103/2152-7806.110677Copyright: © 2013 Waters JD This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Waters JD, Gonda DD, Reddy H, Kasper EM, Warnke PC, Chen CC. Diagnostic yield of stereotactic needle-biopsies of sub-cubic centimeter intracranial lesions. Surg Neurol Int 17-Apr-2013;4:
How to cite this URL: Waters JD, Gonda DD, Reddy H, Kasper EM, Warnke PC, Chen CC. Diagnostic yield of stereotactic needle-biopsies of sub-cubic centimeter intracranial lesions. Surg Neurol Int 17-Apr-2013;4:. Available from: http://sni.wpengine.com/surgicalint_articles/diagnostic-yield-of-stereotactic-needle-biopsies-of-sub-cubic-centimeter-intracranial-lesions/
Background:Stereotactic brain biopsies are widely used for establishing the diagnosis of intracranial lesions. Here we examine whether stereotactic biopsy of smaller brain lesions, defined for this study as being less than 1 cubic centimeter (1 cc) in volume, are associated with lowered diagnostic yield.
Methods:We conducted a retrospective analysis of 267 consecutive patients who underwent stereotactic brain biopsy between 2007 and 2011. Lesion volumes were calculated and were stratified by 1 cc.
Results:A total of 13 of 246 (5.2%) biopsies for lesions >1 cc resulted in nondiagnostic tissue or an incorrect diagnosis. In contrast, 5 of 21 (23.8%) biopsies for 1 cc biopsies (0% and 1%, respectively).
Conclusion:This study demonstrates that stereotactic cerebral biopsy of lesions less than a cubic centimeter in volume results in a lower diagnostic yield versus larger lesions (76.2% versus 94.8%). While auxiliary measures may be taken to improve diagnostic yield, these patients may be best managed in a specialized center with experienced stereotactic neurosurgeons and neuropathologists.
Keywords: Biopsy, diagnostic yield, size, stereotactic, tumor
Stereotactic-guided needle biopsy is a well-accepted method for obtaining tissue diagnosis for intracranial lesions that are not amenable to surgical resection. The accuracy, safety, and diagnostic yield of stereotactic needle-biopsies have been well established in the neurosurgical literature.[
Despite this extended literature, there has not been a study that looked specifically at how the size of the target influenced diagnostic yield. There are many reasons to expect lowered diagnostic yield for the smaller lesions. First, a smaller target will magnify the effect of any degree of mechanical deviation, however slight, within the stereotactic system. Second, tissues attained in the biopsy of smaller lesions are typically more limited in quantity, and the diagnostic yield directly correlates with the quantity of pathologic specimen secured and the expertise of the neuropathologist.[
Electronic records from 267 consecutive patients who underwent stereotactic needle-biopsy from 2007 to 2011 by PW and CC were retrospectively reviewed. Information was collected regarding final pathology, morbidity, and indications. Magnetic resonance (MR) images for each case were imported into the Inomed system (Stereoplan Plus, Germany) for volumetric calculation. Based on this calculation, lesions were stratified into <1 cm3 or >1 cm3. For each case, postoperative computed tomography (CT) was evaluated for evidence of new hyper-density at the biopsy site. For clinical follow-up, transient neurologic deficit was defined as an altered postoperative neurologic examination that resolved within a month of surgery. This study was approved by the institutional review boards under IRB#2010-P-000134.
After induction of anesthesia, a Riechert/Mundinger stereotactic head frame (Inomed GmbH, Emmendingen, Germany) was secured onto the patient's cranium. A 1.25 mm slice-thickness contrast-enhanced CT imaging of the head was subsequently acquired using either an intraoperative scanner (Ceretom, Neurologica, MA) or a conventional CT scanner. CT images were processed to yield three-dimensional reconstructions using software by Inomed (Stereoplan Plus, Germany). Using these reconstructions, an optimal trajectory through the lesion was planned to avoid intersection of vasculature or sulci. In select cases, a positron emission tomographic (PET) scan was performed to define the hyper-metabolic area as a target. Image fusion of the CT, MRI, and PET where available was then performed.
After mounting the aiming bow to the head frame, a scalp incision (approximately 3 cm in length) and burr hole were placed at the planned entry site. Biopsy forceps (1.0 or 1.4 mm) were then advanced to the lesion under the guidance of the aiming bow. Serial biopsy through the entire lesion was performed. Depending on the size of the lesion, 2 to >10 biopsies were taken in 1 mm intervals.
Posthoc pathology review
For the <1 cm3 lesions that were biopsied and yielded nondiagnostic tissue or misdiagnosis, we retrieved the original slides as well as slides from the repeat biopsy or resection. The slides were reviewed with an independent neuropathologist (HR) who was not involved in the initial diagnosis. “Limited tissue” was used to designate situations where the pathologist felt that the tissue obtained during the first biopsy was lesional but definitive diagnosis was not possible due to tissue limitation.
Of the 267 patients, 21 (7.9%) had lesions that were <1 cm3. A summary of the final pathologic diagnosis for the 267 biopsied cases as stratified by <1 cm3 and >1 cm3 volume is presented in
Of the >1 cm3 biopsies, 5.2% (13/246) resulted in nondiagnostic tissue or incorrect diagnosis [
All 21 lesions <1 cm3 were also contrast enhancing. Figure
Cases of misdiagnosis (a) Misdiagnosed subependymoma (initial biopsy showed anaplastic astrocytoma, subsequent resection showed subependymoma. (b) Initial biopsy nondiagnostic. Repeat biopsy showed lymphoma (c) Radiation necrosis (d) Nondiagnostic (resection showed pilocytic astrocytoma) (e) Nondiagnostic
In terms of achieving a definitive diagnosis, the gross diagnostic yield was 94.8% and 76.2% for the >1 cm3 and the <1 cm3 lesions, respectively. The difference in diagnostic yield was statistically significant (P = 0.0081, Fisher's Exact Test).
Posthoc analysis of the tissue specimens from these lesions suggests that the primary cause for diagnostic failure was due to the limited amount of tissue [
Morbidities associated with the biopsies did not significantly differ based on the lesion size [
Postoperative CT demonstrated hyper-density at the site of biopsy in 15% (37/246) of the patients with >1 cm3 lesion and 9.5% (2/21) of the patients with <1 cm3 lesion (P = 0.7485, Fisher's Exact test). With the exception of the above noted cases, the hyper-density did not contribute to clinically detectable changes in neurologic examination.
This study represents the first to our knowledge to evaluate the diagnostic yield of stereotactic brain biopsy of small lesions (<1 cm3) relative to larger lesions. In our series, diagnostic yield from biopsies of lesions >1 cm3 (94.8%) was comparable to previously published rates of 90-96% for stereotactic brain biopsies without size stratification.[
Our study contributes to the field of neurosurgical oncology in two ways. First, our study suggest that the risk of a nondiagnostic biopsy for <1 cm3 lesions are significantly higher than most biopsies in general.[
Posthoc review of the tissue specimen for the mis-diagnostic or nondiagnostic cases offered an opportunity to investigate the underlying cause. The observations that lesional tissue was obtained during the first biopsy and that the differential diagnosis generated using these specimens included the final diagnosis support the accuracy of the frame-based stereotactic biopsy. In this context, the major determinant of diagnosis for the <1 cm3 lesion appeared to be the familiarity of the pathologist in the handling and analysis of limited specimens. A smaller lesion necessarily translated into less tissue for examination, and the published literature suggested that diagnostic yield is a function of the amount of available specimen.[
There are several limitations to this study. First and foremost, this study included patients treated by two surgeons (CC and PW) at a single institution. As such, the results presented here may not be broadly applicable. Second, the size criteria for small versus large lesions using a 1 cm3 volumetric cut off was somewhat arbitrary. Third, the number of <1 cm3 biopsies performed are fairly limited, constituting only 7.9% of all biopsies performed. Realizing the small sample size, we nevertheless performed this analysis of the patients accumulated over the 3-year interval with the goal of assessing the diagnostic yield in a timely manner. Finally, the retrospective design means that patient selection bias cannot be entirely excluded as the cause of the differential diagnostic yield. Despite these limitations, the implications of our findings contribute to the management of patients with a small intracranial lesion.
Many adjuncts to the biopsy technique and recent advances in technology may improve diagnostic yield in the biopsy of small lesions.[
This study demonstrates that stereotactic cerebral biopsy of < 1 cm3 intracranial lesions is associated with a lower diagnostic yield relative to the >1 cm3 lesions (76.2% versus 94.8%, respectively). Morbidities associated with biopsy in both groups are comparable at approximately 1%. Our findings identify the neuropathologist's expertise in the handling and analysis of limited specimen as a critical determinant of tissue diagnosis. Our findings also support the accuracy of frame-based stereotactic biopsy in tissue acquisition. Given the technical challenges associated with these biopsies, consideration should be given for referral of patients with such lesions to centers where experienced stereotactic neurosurgeons and neuropathologists are available.
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