Current Trends for Improving Safety of Stereotactic Brain Biopsies: Advanced Optical Methods for Vessel Avoidance and Tumor Detection

Evaluation of feasibility accuracy and safety after 79 O-ARM based stereotactic brain biopsies

Frame-based Stereotactic Brain Biopsy (FSBB) is a minimally invasive procedure with a view to increasing the diagnostic yield. The aim of this study was to investigate the accuracy and safety of FSBB with the help of the intraoperative 3D O-ARM system. A preoperative MRI allowed for targeting the tissue to be sampled. A Leksell stereotactic frame was bolted to patient's skull in the operating room, and we proceeded to the intraoperative 3D O-ARM acquisition. A software platform was used to calculate stereotactic coordinates through combining both exams. A second 3D O-ARM acquisition was performed to control the final needle target point. A total of 79 patients were included in our study population, 68 biopsies (86.1%) yielded the diagnosis. Biopsy-related complications occurred in 11 patients (13.9%), of whom 8 were successfully diagnosed. Per and post-procedure complications occurred in 3 (3.8%) and 8 cases (10.1%) respectively. Mean operating time was 102 min. FSBB using the intraoperative 3D O-ARM system is a promising alternative. The rate of non-contributory biopsies is moderate given that this new procedure is conducted in the operating room from beginning to end. Complications were not directly linked to the procedure and does not compromise the diagnosis.

Intraoperative ex-vivo epifluorescent diagnostics of stereotactic brain biopsies using EndoScell scanner: diagnostic accuracy study

Brain biopsy is commonly employed for the histological diagnosis of complex intracranial diseases. To improve the positive diagnostic rate, the precision of intraoperative tissue sampling is critical. This study evaluated the accuracy of fluorescence imaging technology in rapidly distinguishing tumours from nontumour tissue during surgery, thus providing real-time feedback to surgeons and optimizing the surgical workflow. Biopsy samples from 65 patients were selected for this study. The lesion tissues were sequentially stained with sodium fluorescein and methylene blue, followed by fluorescence imaging via a handheld EndoScell scanner under an intraoperative cellular microscope. Frozen section examinations and haematoxylin-eosin (HE) staining were performed on the same lesion tissue by the pathology department. The time required for fluorescence imaging and pathology of frozen sections was recorded. The results of fluorescence imaging (whether the tissue was a tumour or nontumour tissue) and frozen pathology (whether the tissue was a tumour or nontumour tissue) were also recorded. The HE staining results were used as the final gold standard for diagnosis. The sensitivity, specificity, area under the curve (AUC), Kappa consistency test, and diagnostic efficiency of both methods were calculated. Lesion tissue and diagnostic results were successfully obtained from all 65 patients. When HE-stained histopathology was used as the gold standard, the sensitivity of fluorescence imaging was 100% (95% CI: 0.917-1.000), and the specificity was 63.6% (95% CI: 0.316-0.876). In comparison, the sensitivity of frozen section pathology was 88.9% (95% CI: 0.767-0.954), and the specificity was 100% (95% CI: 0.679-1.000). Both methods demonstrated high diagnostic accuracy. ROC curve analysis revealed that the AUCs for fluorescence imaging and frozen pathology were 0.818 and 0.944, respectively, with no significant difference observed in diagnostic performance (Z = 1.597, P > 0.05). Kappa consistency tests indicated that the Kappa value for frozen pathology compared with HE staining was 0.730 (P < 0.001); for fluorescence imaging compared with HE staining, the Kappa value was 0.744 (P < 0.001), thus demonstrating strong agreement with the HE staining results for both methods. In terms of time efficiency, fluorescence imaging was significantly faster than frozen section pathology [6 (4, 7) min vs. 48 (46, 55) min, Z=-9.856, P < 0.001], thus showing a clear advantage regarding time efficiency for fluorescence imaging. Intraoperative fluorescence imaging via an EndoScell scanner, which represents a novel method for histopathological diagnosis, has high diagnostic accuracy and efficiency. This method provides real-time guidance for tissue sampling strategies in brain biopsy, thereby improving the positive diagnostic rate and reducing surgical risk.

Robot-assisted stereotactic brain biopsy: A systematic review and meta-analysis

INTRODUCTION

Intracranial lesions often require tissue diagnosis through stereotactic biopsies. Originating in the 1970s, this technique has progressed, but limitations and risks persist. Recently, robot-assisted techniques have made strides, providing the potential for safer and more precise procedures. This study assesses the effectiveness and safety of robot-assisted brain biopsies.

METHODS

Following Cochrane and PRISMA guidelines, PubMed, Embase, and Web of Science were searched for publications up to July 2024. Outcomes assessed included neurological deficits, hemorrhage, mortality, target point error, operative time, and length of stay. Data extraction and bias assessment were conducted using standardized methods, and statistical analysis was performed using R software.

RESULTS

In this meta-analysis, 27 papers were included, involving 2605 patients. The gender distribution was 1448 males to 1141 females. The mean error in millimeters for the entry point error was 1.04 (95%CI: 0.72-1.37), while the target point error was 1.08 (95%CI: 0.49-1.66). The mean operative time was 52.45 min (95%CI: 37.83-67.07). Diagnostic yield had an estimated rate of 98% (95%CI: 97-98%; I²=31%). The length of hospital stay was 4.64 days (95%CI: 3.13, 6.14), from admission to discharge. The postoperative hemorrhage had an estimated risk of 6% (95%CI: 4-9%; I²=71%), while for transient neurological deficits, it was 4% (95%CI: 2-6%; I²=60%). Finally, the death related to the procedure was found to have an estimated risk of 0% (95%CI: 0-0%; I²=0%).

CONCLUSION

Our study found that the diagnostic yield of stereotactic brain biopsy, especially with robotic assistance, has proven to be highly effective. Robot-assisted biopsies also seems to reduce operative times and demonstrate high precision with low entry point error and target point error. Additionally, complication rates appear to be relatively low, and the average hospital stay is favorably short, underscoring the advantages of robotic assistance in stereotactic brain biopsy procedures.

Intraoperative glioblastoma surgery-current challenges and clinical trials: An update

Surgical excision is an important part of the multimodal therapy strategy for patients with glioblastoma, a very aggressive and invasive brain tumor. While major advances in surgical methods and technology have been accomplished, numerous hurdles remain in the field of glioblastoma surgery. The purpose of this literature review is to offer a thorough overview of the current challenges in glioblastoma surgery. We reviewed the difficulties associated with tumor identification and visualization, resection extent, neurological function preservation, tumor margin evaluation, and inclusion of sophisticated imaging and navigation technology. Understanding and resolving these challenges is critical in order to improve surgical results and, ultimately, patient survival.

Computed tomography-guided frame-based stereotactic brain biopsy of non-enhancing lesions using indirect evidence of target selection, technical consideration, and early clinical experience

Background

The objective was to study the effectiveness and diagnostic outcome of frame-based stereotactic brain biopsy (STB) done for contrast non-enhancing lesions using indirect evidence of target selection observed in a plain computed tomography (CT) scan of the head.

Methods

Data of patients with contrast non-enhancing brain lesions who underwent STB are collected retrospectively from NIMHANS Bangalore, hospital neurosurgery database from January 2021 to March 2023. Those cases subjected to plain CT scans after fixing the stereotactic frame to the head were included in the study. A final histopathological report analysis of these cases was done to assess the diagnostic accuracy.

Results

A total of 27 such cases were biopsied. The mean age of subjects was 44.04 ± 17.812 years. Most subjects were in the age group 31-40 years (29.6%). About 55.6% were male and 44.4% were female. The most common site of biopsy was the frontal lobe. The most common indirect evidence on CT was perilesional edema at 33.3% and periventricular location at 33.3%, followed by intralesional calcification at 11.1%. Our diagnostic accuracy was 92.59%. The asymptomatic hemorrhage rate was 2%, and an increase in perilesional edema was seen in 2% of cases.

Conclusion

Indirect targeting is a safe and intuitive method for biopsy of contrast non-enhancing lesions. Due consideration is to be given to various findings visible in non-contrast CT scans of the head as indirect evidence of target selection while performing frame-based STB of contrast non-enhancing lesions. This method will also be helpful in resource-limited centers, especially in low-income countries.

Fluorescence-Guided Surgical Techniques in Adult Diffuse Low-Grade Gliomas: State-of-the-Art and Emerging Techniques: A Systematic Review

Diffuse low-grade gliomas are infiltrative tumors whose margins are not distinguishable from the adjacent healthy brain parenchyma. The aim was to precisely examine the results provided by the intraoperative use of macroscopic fluorescence in diffuse low-grade gliomas and to describe the new fluorescence-based techniques capable of guiding the resection of low-grade gliomas. Only about 20% and 50% of low-grade gliomas are macroscopically fluorescent after 5-amino-levulinic acid (5-ALA) or fluorescein sodium intake, respectively. However, 5-ALA is helpful for detecting anaplastic foci, and thus choosing the best biopsy targets in diffuse gliomas. Spectroscopic detection of 5-ALA-induced fluorescence can detect very low and non-macroscopically visible concentrations of protoporphyrin IX, a 5-ALA metabolite, and, consequently, has excellent performances for the detection of low-grade gliomas. Moreover, these tumors have a specific spectroscopic signature with two fluorescence emission peaks, which is useful for distinguishing them not only from healthy brain but also from high-grade gliomas. Confocal laser endomicroscopy can generate intraoperative optic biopsies, but its sensitivity remains limited. In the future, the coupled measurement of autofluorescence and induced fluorescence, and the introduction of fluorescence detection technologies providing a wider field of view could result in the development of operator-friendly tools implementable in the operative routine.

The ClearPoint Array Frame: An MRI Compatible System that Supports Non-craniotomy, Multi-trajectory (NCMT) Stereotactic Procedures

BACKGROUND

With continued evolution in stereotactic techniques and an expanding armamentarium of surgical therapeutic options, non-craniotomy stereotactic procedures in neuro-oncology are becoming increasingly complex, often requiring multi-trajectory approaches. Here we demonstrate that the ClearPoint SmartFrame Array (Solana Beach, California, USA), a second-generation magnetic resonance imaging-compatible stereotactic frame, supports such non-craniotomy, multi-trajectory (NCMT) stereotactic procedures.

METHODS

We previously published case reports demonstrating the feasibility of NCMT through the ClearPoint SmartFrame Array. Here we prospectively followed the next 10 consecutive patients who underwent such multi-trajectory procedures to further establish procedural safety and clinical utility.

RESULTS

Ten patients underwent complex, multi-trajectory stereotactic procedures, including combinations of needle biopsy ± cyst drainage and laser interstitial thermal therapy targeting geographically distinct regions of neoplastic lesions under the same anesthetic event. The median maximal radial error of stereotaxis was 1.0 mm. In all cases, definitive diagnosis was achieved, and >90% of the intended targets were ablated. The average stereotaxis time for the multi-trajectory procedure was 119 ± 22.2 minutes, comparing favorably to our previously published results of single-trajectory procedures (80 ± 9.59 minutes, P = 0.125). There were no procedural complications. Post-procedure, the neurologic condition of 1 patient improved, while the remaining 9 patients remained stable. All patients were discharged home, with a median hospital stay of 1 day (range: 1-12 days). With a median follow-up of 376 days (range: 155-1438 days), there were no 30-day readmissions or wound complications.

CONCLUSIONS

Geographically distinct regions of brain cancer can be safely and accurately accessed through the ClearPoint Array frame in NCMT stereotactic procedures.

Comparison meta-analysis of intraoperative MRI-guided needle biopsy versus conventional stereotactic needle biopsies

Background

MRI-guided needle biopsy (INB) is an emerging alternative to conventional frame-based or frameless stereotactic needle biopsy (SNB). Studies of INB have been limited to select case series, and comparative studies between INB and SNB remain a missing gap in the literature. We performed a meta-analysis to compare INB and SNB literature in terms of diagnostic yield, surgical morbidity and mortality, tumor size, and procedural time.

Methods

We identified 36 separate cohorts in 26 studies of SNB (including both frameless and frame-based biopsies, 3374 patients) and 27 studies of INB (977 patients). Meta-regression and meta-analysis by proportions were performed.

Results

Relative to publications that studied SNB, publications studying INB more likely involved brain tumors located in the eloquent cerebrum (79.4% versus 62.6%, P = 0.004) or are smaller in maximal diameter (2.7 cm in INB group versus 3.6 cm in the SNB group, P = .032). Despite these differences, the pooled estimate of diagnostic yield for INB was higher than SNB (95.4% versus 92.3%, P = .026). The pooled estimate of surgical morbidity was higher in the SNB group (12.0%) relative to the INB group (6.1%) (P = .004). Mortality after the procedure was comparable between INB and SNB (1.7% versus 2.3%, P = .288). Procedural time was statistically comparable at 90.3 min (INB) and 103.7 min (SNB), respectively (P = .526).

Conclusions

Our meta-analysis indicates that, relative to SNB, INB is more often performed for the challenging, smaller-sized brain tumors located in the eloquent cerebrum. INB is associated with lower surgical morbidity and improved diagnostic yield.

How to handle brain tumors after esophagectomy with curative intent: A single center 20-year experience

BACKGROUND

Brain metastases after esophagectomy are rare. Moreover, a diagnostic uncertainty remains as pathology is rarely obtained and radiological features can show similarities to primary brain tumors. Our aim was to demonstrate the diagnostic uncertainty and identify risk factors associated with brain tumors (BT) after esophagectomy with curative intent.

METHODS

All patients who underwent an esophagectomy with curative intent from 2000 to 2019 were reviewed. Diagnostics and characteristics of BT were analyzed. Multivariable logistic and cox regression were performed to determine factors associated with development of BT and survival, respectively.

RESULTS

In total, 2131 patients underwent esophagectomy with curative intent, of which 72 patients (3.4%) developed BT. Pathological diagnosis was obtained in 26 patients (1.2%), of which 2 patients were diagnosed with glioblastoma. On multivariate analysis, radiotherapy (OR, 7.71; 95%CI: 2.66-22.34, p < 0.001) was associated with an increased risk of BT and early-stage tumors (OR, 0.29; 95%CI: 0.10-0.90, p = 0.004) with a decreased risk of BT. Median overall survival was 7.4 months (95%CI: 4.80-9.96). BT treated with curative intent (surgery or stereotactic radiation) had a significantly better median overall survival (16 months; 95%CI: 11.3-20.7) compared to those without (3.7 months; 95%CI: 0.9-6.6, p < 0.001) CONCLUSIONS: Advanced stage tumors and radiotherapy seem related to the development of brain tumors after esophagectomy with curative intent. However, an important diagnostic uncertainty remains in these patients as pathological diagnosis is only obtained in a minority of cases. Tissue confirmation can be useful to inform a patient-tailored multimodality treatment strategy in select patient.

Core Needle Biopsy Guidance Based on Tissue Morphology Assessment with AI-OCT Imaging

This paper presents a combined optical imaging/artificial intelligence (OI/AI) technique for the real-time analysis of tissue morphology at the tip of the biopsy needle, prior to collecting a biopsy specimen. This is an important clinical problem as up to 40% of collected biopsy cores provide low diagnostic value due to high adipose or necrotic content. Micron-scale-resolution optical coherence tomography (OCT) images can be collected with a minimally invasive needle probe and automatically analyzed using a computer neural network (CNN)-based AI software. The results can be conveyed to the clinician in real time and used to select the biopsy location more adequately. This technology was evaluated on a rabbit model of cancer. OCT images were collected with a hand-held custom-made OCT probe. Annotated OCT images were used as ground truth for AI algorithm training. The overall performance of the AI model was very close to that of the humans performing the same classification tasks. Specifically, tissue segmentation was excellent (~99% accuracy) and provided segmentation that closely mimicked the ground truth provided by the human annotations, while over 84% correlation accuracy was obtained for tumor and non-tumor classification.

Two-photon microendoscope for label-free imaging in stereotactic neurosurgery

We demonstrate a gradient refractive index (GRIN) microendoscope with an outer diameter of ∼1.2 mm and a length of ∼186 mm that can fit into a stereotactic surgical cannula. Two photon imaging at an excitation wavelength of 900 nm showed a field of view of ∼180 microns and a lateral and axial resolution of 0.86 microns and 9.6 microns respectively. The microendoscope was tested by imaging autofluorescence and second harmonic generation (SHG) in label-free human brain tissue. Furthermore, preliminary image analysis indicates that image classification models can predict if an image is from the subthalamic nucleus or the surrounding tissue using conventional, bench-top two-photon autofluorescence.

Intraoperative Fluorescein Sodium in Pediatric Neurosurgery: A Preliminary Case Series from a Singapore Children's Hospital

(1) Background: Fluorescein sodium (Na-Fl) has been described as a safe and useful neurosurgical adjunct in adult neurooncology. However, its use has yet to be fully established in children. We designed a study to investigate the use of intraoperative Na-Fl in pediatric brain tumor surgery. (2) Methods: This is a single-institution study for pediatric brain tumor patients managed by the Neurosurgical Service, KK Women's and Children's Hospital. Inclusion criteria consists of patients undergoing surgery for suspected brain tumors from 3 to 19 years old. A predefined intravenous dose of 2 mg/kg of 10% Na-Fl is administered per patient. Following craniotomy, surgery is performed under alternating white light and YELLOW-560 nm filter illumination. (3) Results: A total of 21 patients with suspected brain tumours were included. Median age was 12.1 years old. For three patients (14.3%), there was no significant Na-Fl fluorescence detected and their final histologies reported a cavernoma and two radiation-induced high grade gliomas. The remaining patients (85.7%) had adequate intraoperative fluorescence for their lesions. No adverse side effects were encountered with the use of Na-Fl. (4) Conclusions: Preliminary findings demonstrate the safe and efficacious use of intraoperative Na-Fl for brain tumors as a neurosurgical adjunct in our pediatric patients.

Imaging Recommendations for the Diagnosis, Staging, and Management of Adult Brain Tumors

Neuroimaging plays a pivotal role in the clinical practice of brain tumors aiding in the diagnosis, genotype prediction, preoperative planning, and prognostication. The brain tumors most commonly seen in adults are extra-axial lesions like meningioma, intra-axial lesions like gliomas and lesions of the pituitary gland. Clinical features may be localizing like partial seizures, weakness, and sensory disturbances or nonspecific like a headache. On clinical suspicion of a brain tumor, the primary investigative workup should focus on imaging. Other investigations like fundoscopy and electroencephalography may be performed depending on the clinical presentation. Obtaining a tissue sample after identifying a brain tumor on imaging is crucial for confirming the diagnosis and planning further treatment. Tissue sample may be obtained by techniques such as stereotactic biopsy or upfront surgery. The magnetic resonance (MR) imaging protocol needs to be standardized and includes conventional sequences like T1-weighted (T1W) imaging with and without contrast, T2w imaging, fluid-attenuated axial inversion recovery, diffusion-weighted imaging (DWI), susceptibility-weighted imaging, and advanced imaging sequences like MR perfusion and MR spectroscopy. Various tumor characteristics in each of these sequences can help us narrow down the differential diagnosis and also predict the grade of the tumor. Multidisciplinary co-ordination is needed for proper management and care of brain tumor patients. Treatment protocols need to be adapted and individualized for each patient depending on the age, general condition of the patient, histopathological characteristics, and genotype of the tumor. Treatment options include surgery, radiotherapy, and chemotherapy. Imaging also plays a vital role in post-treatment follow-up. Sequences like DWI, MR perfusion, and MR spectroscopy are useful to distinguish post-treatment effects like radiation necrosis and pseudoprogression from true recurrence. Radiological reporting of brain tumor images should follow a structured format to include all the elements that could have an impact on the treatment decisions in patients.

Advances, technological innovations, and future prospects in stereotactic brain biopsies

Stereotactic brain biopsy is one of the most frequently performed brain surgeries. This review aimed to expose the latest cutting-edge and updated technologies and innovations available to neurosurgeons to safely perform stereotactic brain biopsy by minimizing the risks of complications and ensuring that the procedure is successful, leading to a histological diagnosis. We also examined methods for improving preoperative, intraoperative, and postoperative workflows. We performed a comprehensive state-of-the-art literature review. Intraoperative histology, fluorescence, and imaging techniques appear as smart tools to improve the diagnostic yield of biopsy. Constant innovations such as optical methods and augmented reality are also being made to increase patient safety. Robotics and integrated imaging techniques provide an enhanced intraoperative workflow. Patients' management algorithms based on early discharge after biopsy optimize the patient's personal experience and make the most efficient possible use of the available hospital resources. Many new trends are emerging, constantly improving patient care and safety, as well as surgical workflow. A parameter that must be considered is the cost-effectiveness of these devices and the possibility of using them on a daily basis. The decision to implement a new instrument in the surgical workflow should also be dependent on the number of procedures per year, the existing stereotactic equipment, and the experience of each center. Research on patients' postbiopsy management is another mandatory approach to enhance the safety profile of stereotactic brain biopsy and patient satisfaction, as well as to reduce healthcare costs.

5-Aminolevulinic acid-enhanced fluorescence-guided treatment of high-grade glioma using angled endoscopic blue light visualization: technical case series with preliminary follow-up

OBJECTIVE

5-Aminolevulinic acid (5-ALA)-enhanced fluorescence-guided resection of high-grade glioma (HGG) using microscopic blue light visualization offers the ability to improve extent of resection (EOR); however, few descriptions of HGG resection performed using endoscopic blue light visualization are currently available. In this report, the authors sought to describe their surgical experience and patient outcomes of 5-ALA-enhanced fluorescence-guided resection of HGG using primary or adjunctive endoscopic blue light visualization.

METHODS

The authors performed a retrospective review of prospectively collected data from 30 consecutive patients who underwent 5-ALA-enhanced fluorescence-guided biopsy or resection of newly diagnosed HGG was performed. Patient demographic data, tumor characteristics, surgical technique, EOR, tumor fluorescence patterns, and progression-free survival were recorded.

RESULTS

In total, 30 newly diagnosed HGG patients were included for analysis. The endoscope was utilized for direct 5-ALA-guided port-based biopsy (n = 9), microscopic to endoscopic (M2E; n = 18) resection, or exoscopic to endoscopic (E2E; n = 3) resection. All endoscopic biopsies of fluorescent tissue were diagnostic. 5-ALA-enhanced tumor fluorescence was visible in all glioblastoma cases, but only in 50% of anaplastic astrocytoma cases and no anaplastic oligodendroglioma cases. Gross-total resection (GTR) was achieved in 10 patients in whom complete resection was considered safe, with 11 patients undergoing subtotal resection. In all cases, endoscopic fluorescence was more avid than microscopic fluorescence. The endoscope offered the ability to diagnose and resect additional tumor not visualized by the microscope in 83.3% (n = 10/12) of glioblastoma cases, driven by angled lenses and increased fluorescence facilitated by light source delivery within the cavity. Mean volumetric EOR was 90.7% in all resection patients and 98.8% in patients undergoing planned GTR. No complications were attributable to 5-ALA or blue light endoscopy.

CONCLUSIONS

The blue light endoscope is a viable primary or adjunctive visualization platform for optimization of 5-ALA-enhanced HGG fluorescence. Implementation of the blue light endoscope to guide resection of HGG glioma is feasible and ergonomically favorable, with a potential advantage of enabling increased detection of tumor fluorescence in deep surgical cavities compared to the microscope.

Surgical Neuro-Oncology

Gliomas are the most common intrinsic brain tumor in adults. Although maximal tumor resection improves survival, this must be balanced with preservation of neurologic function. Technological advancements have greatly expanded our ability to safely maximize tumor resection and design innovative therapeutic trials that take advantage of intracavitary delivery of therapeutic agents after resection. In this article, we review the role of surgical intervention for both low-grade and high-grade gliomas and the innovations that are driving and expanding the role of surgery in this therapeutically challenging group of malignancies.

Sonobiopsy for minimally invasive, spatiotemporally-controlled, and sensitive detection of glioblastoma-derived circulating tumor DNA

Though surgical biopsies provide direct access to tissue for genomic characterization of brain cancer, they are invasive and pose significant clinical risks. Brain cancer management via blood-based liquid biopsies is a minimally invasive alternative; however, the blood-brain barrier (BBB) restricts the release of brain tumor-derived molecular biomarkers necessary for sensitive diagnosis.

Methods: A mouse glioblastoma multiforme (GBM) model was used to demonstrate the capability of focused ultrasound (FUS)-enabled liquid biopsy (sonobiopsy) to improve the diagnostic sensitivity of brain tumor-specific genetic mutations compared with conventional blood-based liquid biopsy. Furthermore, a pig GBM model was developed to characterize the translational implications of sonobiopsy in humans. Magnetic resonance imaging (MRI)-guided FUS sonication was performed in mice and pigs to locally enhance the BBB permeability of the GBM tumor. Contrast-enhanced T₁-weighted MR images were acquired to evaluate the BBB permeability change. Blood was collected immediately after FUS sonication. Droplet digital PCR was used to quantify the levels of brain tumor-specific genetic mutations in the circulating tumor DNA (ctDNA). Histological staining was performed to evaluate the potential for off-target tissue damage by sonobiopsy.

Results: Sonobiopsy improved the detection sensitivity of EGFRvIII from 7.14% to 64.71% and TERT C228T from 14.29% to 45.83% in the mouse GBM model. It also improved the diagnostic sensitivity of EGFRvIII from 28.57% to 100% and TERT C228T from 42.86% to 71.43% in the porcine GBM model.

Conclusion: Sonobiopsy disrupts the BBB at the spatially-targeted brain location, releases tumor-derived DNA into the blood circulation, and enables timely collection of ctDNA. Converging evidence from both mouse and pig GBM models strongly supports the clinical translation of sonobiopsy for the minimally invasive, spatiotemporally-controlled, and sensitive molecular characterization of brain cancer.

Clinical outcomes as a function of the number of samples taken during stereotactic needle biopsies: a meta-analysis

BACKGROUND

Stereotactic needle biopsy remains the cornerstone for tissue diagnosis for tumors located in regions of the brain that are difficult to access through open surgery.

OBJECTIVE

We perform a meta-analysis of the literature to examine the relation between number of samples taken during biopsy and diagnostic yield, morbidity and mortality.

METHODS

We identified 2416 patients from 28 cohorts in studies published in PubMed database that studied stereotactic needle biopsies for tumor indications. Meta-analysis by proportions and meta-regression analyses were performed.

RESULTS

On meta-analysis, the morbidity profile of the published needle biopsy studies clustered into three groups: studies that performed < 3 samples (n = 8), 3-6 samples (n = 13), and > 6 samples during biopsy (n = 7). Pooled estimates for biopsy related morbidity were 4.3%, 16.3%, and 17% for studies reporting < 3, 3-6, and > 6 biopsy samples, respectively. While these morbidity estimates significantly differed (p < 0.001), the diagnostic yields reported for studies performing < 3 biopsies, 3-6 samples, and > 6 samples were comparable. Pooled estimates of diagnostic yield for these three groups were 90.4%, 93.8%, and 88.1%, respectively. Mortality did not significantly differ between studies reporting differing number of samples taken during biopsy.

CONCLUSIONS

Our meta-analysis suggests that morbidity risk in needle biopsy is non-linearly associated with the number of samples taken. There was no association between the number of biopsies taken, and diagnostic yield or mortality.

Optical Brain Biopsy with a Fluorescence and Vessel Tracing Probe

BACKGROUND

Accurate stereotactic biopsies of brain tumors are imperative for diagnosis and tailoring of the therapy. Repetitive needle insertions enhance risks of brain lesioning, hemorrhage, and complications due to prolonged procedure.

OBJECTIVE

To investigate clinical benefits of a combined 5-aminolaevulinic acid (5-ALA) fluorescence and laser Doppler flowmetry system for the detection of malignant brain tumor and blood vessels in stereotactic biopsies.

METHODS

Planning of targets and trajectories was followed by optical measurements in 20 patients, using the Leksell Stereotactic System and a manual insertion device. Fluorescence spectra, microvascular blood flow, and tissue grayness were recorded each millimeter along the paths. Biopsies were taken at preplanned positions. The diagnoses were compared with the fluorescence signals. The recordings were plotted against measurement positions and compared. Sites indicating a risk of hemorrhage were counted as well as the time for the procedures.

RESULTS

Signals were recorded along 28 trajectories, and 78 biopsies were collected. The final diagnosis showed 17 glioblastomas, 2 lymphomas, and 1 astrocytoma grade III. Fluorescence was seen along 23 of the paths with 4 having the peak of 5-ALA fluorescence 3 mm or more from the precalculated target. There was increased microcirculation in 40 of 905 measured positions. The measurement time for each trajectory was 5 to 10 min.

CONCLUSION

The probe provided direct feedback of increased blood flow along the trajectory and of malignant tissue in the vicinity of the target. The method can increase the precision and the safety of the biopsy procedure and reduce time.

Fluorescence-Guided Surgery: A Review on Timing and Use in Brain Tumor Surgery

Fluorescence-guided surgery (FGS) allows surgeons to have improved visualization of tumor tissue in the operating room, enabling maximal safe resection of malignant brain tumors. Over the past two decades, multiple fluorescent agents have been studied for FGS, including 5-aminolevulinic acid (5-ALA), fluorescein sodium, and indocyanine green (ICG). Both non-targeted and targeted fluorescent agents are currently being used in clinical practice, as well as under investigation, for glioma visualization and resection. While the efficacy of intraoperative fluorescence in studied fluorophores has been well established in the literature, the effect of timing on fluorophore administration in glioma surgery has not been as well depicted. In the past year, recent studies of 5-ALA use have shown that intraoperative fluorescence may persist beyond the previously studied window used in prior multicenter trials. Additionally, the use of fluorophores for different brain tumor types is discussed in detail, including a discussion of choosing the right fluorophore based on tumor etiology. In the following review, the authors will describe the temporal nature of the various fluorophores used in glioma surgery, what remains uncertain in FGS, and provide a guide for using fluorescence as a surgical adjunct in brain tumor surgery.

Deep Learning-Based Studies on Pediatric Brain Tumors Imaging: Narrative Review of Techniques and Challenges

Brain tumors diagnosis in children is a scientific concern due to rapid anatomical, metabolic, and functional changes arising in the brain and non-specific or conflicting imaging results. Pediatric brain tumors diagnosis is typically centralized in clinical practice on the basis of diagnostic clues such as, child age, tumor location and incidence, clinical history, and imaging (Magnetic resonance imaging MRI / computed tomography CT) findings. The implementation of deep learning has rapidly propagated in almost every field in recent years, particularly in the medical images’ evaluation. This review would only address critical deep learning issues specific to pediatric brain tumor imaging research in view of the vast spectrum of other applications of deep learning. The purpose of this review paper is to include a detailed summary by first providing a succinct guide to the types of pediatric brain tumors and pediatric brain tumor imaging techniques. Then, we will present the research carried out by summarizing the scientific contributions to the field of pediatric brain tumor imaging processing and analysis. Finally, to establish open research issues and guidance for potential study in this emerging area, the medical and technical limitations of the deep learning-based approach were included.

Droplet digital PCR-based detection of circulating tumor DNA from pediatric high grade and diffuse midline glioma patients

BACKGROUND

The use of liquid biopsy is of potential high importance for children with high grade (HGG) and diffuse midline gliomas (DMG), particularly where surgical procedures are limited, and invasive biopsy sampling not without risk. To date, however, the evidence that detection of cell-free DNA (cfDNA) or circulating tumor DNA (ctDNA) could provide useful information for these patients has been limited, or contradictory.

METHODS

We optimized droplet digital PCR (ddPCR) assays for the detection of common somatic mutations observed in pediatric HGG/DMG, and applied them to liquid biopsies from plasma, serum, cerebrospinal fluid (CSF), and cystic fluid collected from 32 patients.

RESULTS

Although detectable in all biomaterial types, ctDNA presented at significantly higher levels in CSF compared to plasma and/or serum. When applied to a cohort of 127 plasma specimens from 41 patients collected from 2011 to 2018 as part of a randomized clinical trial in pediatric non-brainstem HGG/DMG, ctDNA profiling by ddPCR was of limited use due to the small volumes (mean = 0.49 mL) available. In anecdotal cases where sufficient material was available, cfDNA concentration correlated with disease progression in two examples each of poor response in H3F3A_K27M-mutant DMG, and longer survival times in hemispheric BRAF_V600E-mutant cases.

CONCLUSION

Tumor-specific DNA alterations are more readily detected in CSF than plasma. Although we demonstrate the potential of the approach to assessing tumor burden, our results highlight the necessity for adequate sample collection and approach to improve detection if plasma samples are to be used.

Efficacy of a Second Brain Biopsy for Intracranial Lesions after Initial Negativity

Background and Purpose

The rationale for performing a second brain biopsy after initial negativity is not well evaluated in the literature. This study was designed to 1) assess the efficacy of a second brain biopsy when the first biopsy was nondiagnostic, 2) identify possible factors associated with an increased diagnostic rate in the second biopsy, and 3) analyze additional morbidity induced by the second biopsy.

Methods

We performed a retrospective cohort study from 2009 to 2019, during which 1,919 patients underwent a brain biopsy, including 30 who were biopsied twice (1.6%). The specific histological diagnosis rate, diagnosis-associated factors, and complication rate were assessed for the 30 twice-biopsied patients.

Results

The second biopsy allowed a specific histological diagnosis in 86.7% of the patients who had initially undergone a nondiagnostic brain biopsy [odds ratio (OR)=7.5, 95% confidence interval (CI)=3.0–18.7, p<0.001]. The multivariate analysis showed that only prebiopsy corticosteroid administration (OR=2.6, 95% CI=1.1–6.0, p=0.01) was an important factor in predicting a nondiagnostic biopsy. None of the patients developed a symptomatic complication after the first biopsy, while two (6.0%) patients experienced a transient complication after the second biopsy (p=0.49).

Conclusions

Performing a second brain biopsy in patients who have an initial nondiagnostic biopsy is effective in most cases. We advocate that a second biopsy be systematically considered in the diagnosis algorithm of these patients after it has been verified that molecular testing cannot help to obtain a diagnosis. Corticosteroid administration can lead to nondiagnostic biopsies and should be avoided when possible during the prebiopsy period.