Navigation-guided endoscopic biopsy for intraparenchymal brain tumor

A preliminary study of the diagnostic efficacy and safety of the novel boring biopsy for brain lesions

Existing methods for biopsy of intraparenchymal brain lesions, including stereotactic biopsy and open block biopsy, have advantages and disadvantages. We propose a novel biopsy method, called “boring biopsy,” which aims to overcome the drawbacks of each conventional method. This method is less invasive and allows obtaining continuous specimens of sufficient volume. We aimed to assess the feasibility and efficacy of using boring biopsy for intraparenchymal brain lesions. We included 26 consecutive patients who underwent boring biopsy for intraparenchymal lesions. Columnar continuous specimens from the surface of the normal brain tissue to the tumor margin and the center of the lesion were obtained using the boring biopsy method. We used a catheter introducer with original modifications to create a cylindrical biopsy tool for surgery. Columnar continuous specimens were successfully obtained. Histopathological diagnosis was based on cellular changes and differentiation from normal tissues to the core of the lesion and established in all cases. No permanent deficits, major adverse outcomes, or deaths were observed. This novel technique may improve diagnostic accuracy and reduce invasiveness associated with brain biopsy. This method may become the next standard procedure, particularly in some cases where histological evaluation is paramount, and conventional biopsy methods are not suitable.

Hemorrhagic brain metastasis from small-cell carcinoma of the urinary bladder

Background:

Small-cell carcinoma of the urinary bladder (SCCB) accounts for 1% of all bladder tumors. We present a rare case of hemorrhagic metastatic brain tumor from SCCB diagnosed by navigation-guided endoscopic biopsy.

Case Description:

A 76-year-old man presented with sudden onset of aphasia and right hemiplegia from 3 weeks previously. He had a medical history of prostate cancer and SCCB. Computed tomography showed a mixed density mass in the left basal ganglia. On magnetic resonance imaging, the mass showed mixed intensity in both T1-weighted images and T2-weighted images, suggesting subacute hemorrhage. The mass was partially enhanced with gadolinium. The patient underwent endoscopic hematoma evacuation and partial removal of the tumor. Histopathological diagnosis was neuroendocrine carcinoma, which was consistent with SCCB metastasis. After surgery, the patient underwent whole-brain radiation therapy of 30 Gy. His general condition gradually deteriorated, however, and he died 4 months after surgery.

Conclusion:

Our patient had a rare case of brain metastasis derived from SCCB which presented with cerebral hemorrhage. Navigation-guided endoscopic biopsy was useful for the diagnostic sampling of deep localized brain tumors with hemorrhage.

Frameless Free-Hand Navigation-Guided Biopsy for Brain Tumors: A Simpler Method with an Endoscope Holder

Context/Aims:

Given the limitations of current navigation-guided brain biopsy methods, we aimed to introduce a novel method and validate its safety and accuracy.

Setting and Design:

This was a retrospective study of twenty consecutive patients who underwent brain biopsy at Shimane University Hospital, Japan.

Subjects and Methods:

Clinical records of 13 and 7 patients who underwent brain biopsy with the novel frameless free-hand navigation-guided biopsy (FFNB) method or a framed computed tomography-guided stereotactic biopsy (CTGB) method, respectively, were retrospectively reviewed. We compared age, sex, tumor location, histological diagnosis, maximum size of the tumor (target), depth from target to cortical surface on the same slice of CT or magnetic resonance imaging, operative position, anesthesia method, setup time for biopsy, incision-to-closure time, trial times for puncture, success rate, and complications in the two groups.

Statistical Analysis:

Fisher's exact test and the Wilcoxon rank-sum test were performed.

Results:

Clinical characteristics and lesion size did not differ significantly between the FFNB and CTGB groups. The depth of the target lesion was significantly greater in the CTGB group (P < 0.05). All FFNB and CTGB procedures reached and obtained the target tissue. The number of punctures and the average incision-to-closure time did not differ between the FFNB and CTGB groups. However, the preoperative setup time was significantly shorter using FFNB (P = 0.0003). No complications were observed in either group.

Conclusions:

FFNB was comparable with CTGB in terms of safety, accuracy, and operative duration. The preoperative setup time was shorter using FFNB. Therefore, FFNB is a feasible method for brain tumor biopsy.

Transtubular excisional biopsy as a rescue for a non-diagnostic stereotactic needle biopsy-case report and literature review

Stereotactic needle biopsy, a standard of care for acquiring deep-seated pathology, has limitations and risks in some situations. We present an uncommon case with basal ganglia dematiaceous mycetoma. Due to the firm consistency of the lesion, the initial stereotactic needle biopsy failed to provide a diagnosis. In a second operation, transtubular excisional biopsy was successfully performed to remove the entire mycetoma. We reviewed recent case series of transtubular approaches to deep-seated brain lesions and suggest this method could be a rescue for a non-diagnostic stereotactic needle biopsy and even may be the approach of choice in some cases.

Three-Dimensional, computer simulated navigation in endoscopic neurosurgery

BACKGROUND

In order to address the pre- and perioperative need for visualization and prediction of patient-specific anatomy for surgical planning, endoscopic neurosurgeons have increasingly relied on computerized navigation devices to guide their surgical approaches.

OBJECTIVE

This manuscript aims to review: 1) the use of neuronavigation in endoscopic neurosurgery for pre-operative planning, 2) the intraoperative advantages of neuronavigation in endoscopic neurosurgery, and 3) the effects of navigation guidance on operative time, registration accuracy, brain shift, and avoidance of complications. Limitations of the current neuroendoscopic navigation literature will be discussed.

METHODS

We conducted a search using PubMed-MEDLINE; the keywords "stereotactic navigation AND endoscopic surgery" and "simulation AND endoscopic neurosurgery". 36 studies were identified that addressed the use of neuronavigation in endoscopic neurosurgery. These studies were then further analyzed for topics relevant to computerized neuroendoscopy and reviewed for the purposes of this article.

CONCLUSION

Three-dimensional, frameless neuronavigation systems are useful in endoscopic neurosurgery to assist in the pre-operative planning of potential trajectories and to help localize the pathology of interest. Neuronavigation appears to be accurate to < 1-2 mm without issues related to brain shift. Further work is necessary in the investigation of the effect of neuronavigation on operative time, cost, and patient-centered outcomes.

5-Aminolaevulinic Acid-Induced Fluorescence in Primary Central Nervous System Lymphoma

OBJECTIVE

Diagnosis of primary central nervous system lymphoma (PCNSL) is usually confirmed by brain biopsy and subsequent neuropathologic workup. 5-Aminolevulinic acid (5-ALA)-induced fluorescence has been established for diagnostic and therapeutic purposes in glioma treatment during the last few years and is discussed for use in other cranial tumors. Its role in diagnosis and treatment of PCNSL is still elusive.

METHODS

This retrospective study includes clinical, magnetic resonance imaging, pathologic and surgical data of selected 11 patients with PCNSL at two university hospitals within the last 4 years undergoing surgical treatment for resection because of imminent mass effect or suspected cerebral glioma. Patients received 5-ALA for fluorescence-guided resection preoperatively.

RESULTS

The 11 subjects age ranged from 59 to 81 years. Postsurgical pathologic workup revealed malignant B cell lymphoma with morphologic features of diffuse large B cell lymphoma. Eight of these 11 patients with PCNSL showed a clear fluorescence induced by 5-ALA. After surgical resection, patients were treated with combination chemotherapy regimens.

CONCLUSION

In patients with glioma, the use of 5-ALA is known to be associated with increased extent of resection and survival benefit. Our data and retrospective analysis of a larger patient cohort suggest that the use of 5-ALA in PCNSL should be included in a surgical approach, if this is reconsidered for select patients within a clinical study. In addition, even photodynamic therapy in combination with 5-ALA might be studied.

Intraparenchymal brain lesion biopsy guided by a rigid endoscope and navigation system

Background:

The authors report a continuous case series of navigation-guided rigid endoscopic biopsy via the transcortical route for intraparenchymal brain lesions to assess the feasibility and efficacy of the method.

Methods:

Thirty-four patients with intraparenchymal brain lesions found on neurovisualization underwent navigation-guided rigid endoscopic biopsy. Most of the preoperative diagnoses were glioma WHO Grade II–IV (16 cases) or malignant lymphoma (15 cases). Intraoperative photodynamic diagnosis and intraoperative pathological diagnosis were used in 28 and 29 cases, respectively. In 2 cases with small and deep lesions, intraoperative magnetic resonance imaging was used for confirming the accuracy of the biopsy point.

Results:

The sampling accuracy determined by postoperative imaging and the definitive diagnosis ratio were 94% (32 out of 34 cases) and 97% (33 out of 34 cases), respectively. There was no postoperative mortality. In 2 patients, mild postoperative permanent morbidity (5.9%), presumably related to this technique, was observed in the early cases in the current group (34 case series).

Conclusion:

The method was estimated as safe and feasible for diagnostic tissue sampling of intraparenchymal brain lesions.

Photodynamic Diagnosis Using 5-Aminolevulinic Acid in 41 Biopsies for Primary Central Nervous System Lymphoma

We evaluated the feasibility of 5-aminolevulinic acid (5-ALA)-mediated photodynamic diagnosis (PDD) in the biopsy for primary central nervous system lymphoma (PCNSL). 5-ALA (20 mg kg(-1) ) was administered orally 4 hours preoperatively. Forty-one biopsies obtained under PDD in 47 consecutive biopsies (46 patients) that were finally pathologically diagnosed as PCNSL were evaluated. Positive fluorescence was observed in 34 of those 41 biopsies (82.9%). An intraoperative pathological diagnosis (IOD) of suspected PCNSL was made in 21 of the biopsies with positive fluorescence (61.8%). However, the eight IODs in the remaining 13 biopsies (23.5%) were not correct (atypical cell, 4; high-grade glioma, 1; gliosis, 1; unremarkable, 2). In those 8 biopsies, PCNSL was confirmed by the final pathological diagnosis. There was no difference in the mean Mib-1 labeling index between the biopsies with positive fluorescence (86.5%) and those without positive fluorescence (90.0%). IOD was not performed in 6 biopsies; however, 5 of those biopsies (83.3%) showed positive fluorescence and were finally pathologically diagnosed as PCNSL. Use of PDD in biopsies for patients with suspected PCNSL is a reliable way of obtaining specimens of adequate quality for the final pathological diagnosis and may lead to improved diagnostic yield in the biopsy of PCNSL.

Endoscopic biopsy of brain tumors: Does the technique matter?

Background:

Endoscopic biopsy of brain tumors is an important part of the armamentarium of management of intra- and periventricular tumors that is generally considered an acceptable and, in some situations, a preferred method for tissue sampling. The diagnostic yield of the procedure has been variably reported. Technical aspects of the procedure should undoubtedly reflect on its success rate and accuracy. Such impact on diagnostic yield of endoscopic brain biopsy is infrequently discussed in the literature.

Methods:

A search of the medical literature was conducted for publications on endoscopic brain biopsy. These reports were analyzed regarding the various technical aspects.

Results:

In the 43 publications analyzed, lenscopes were exclusively used in 22 reports and a tissue diagnosis was possible in 362 out of 387 endoscopic biopsies with a diagnostic yield of 93.54%. Only fiberscopes were used in 8 reports and a tissue diagnosis was possible in 100 out of 132 endoscopic biopsies with a diagnostic yield of 75.76%. The diagnostic yield in the mixed and unspecified groups was 88.95 and 88.04%, respectively. Very few details on the histopathological methods and tumor molecular genetics could be found.

Conclusion:

Endoscopic biopsy of brain tumors has a higher diagnostic yield when lenscopes are used. Neuronavigation seems to add to the diagnostic accuracy of the procedure. Studies detailing molecular genetic features of biopsied tumors are necessary in the future.

Dual-port technique in navigation-guided endoscopic resection for intraparenchymal brain tumor

BACKGROUND

In navigation-guided endoscopic surgery performed via a single port, the interference of surgical instruments often disturbs the resection and hemostasis.

CASE DESCRIPTION

With regard to this, we designed a dual-port technique for navigation-guided endoscopic surgery in a 62-year-old man, with intraparenchymal anaplastic astrocytoma. Two transparent sheaths with Nelaton tubes were inserted in the front of the target lesion via an infinity-shaped burr hole, under the control of the navigation system. The lesion was removed partially using a rigid endoscope and several surgical tools through the bilateral ports. Using the new method, it was convenient to perform hemostasis with bipolar coagulation and aspiration, without any interference from the surgical instruments during the surgery.

CONCLUSION

The offered dual-port technique may be included in surgery planning for elderly patients or patients in particular conditions, with intraparenchymal brain tumors.

Navigation-guided endoscopic biopsy for pathological diagnosis for intraparenchymal pure germinoma near the ventricular trigone

BACKGROUND

The authors report a case of intraparenchymal germinoma pathologically diagnosed using navigation-guided endoscopic biopsy.

CASE DESCRIPTION

A 27-year-old man had mild left hemiparesis, transcortical motor aphasia, and amnesia. Magnetic resonance (MR) imaging revealed an intraparenchymal mass lesion near the left ventricular trigone. Navigation-guided endoscopic biopsy was performed, and histopathology revealed large neoplastic cells immunohistochemically positive for germinoma-specific antigens, which were diagnosed as pure germinoma. Chemotherapy with whole-brain radiotherapy was performed, and the neurological symptoms did not change during the treatment. Follow-up MR imaging 1 year after the surgery showed no evidence of recurrence or dissemination.

CONCLUSIONS

Navigation-guided endoscopic biopsy can be a useful technique in such intraparenchymal germinoma cases.