Stereotactic Biopsy Technique Research Articles

Diagnostic Accuracy of PET/CT-Guided Percutaneous Biopsies for Malignant Peripheral Nerve Sheath Tumors in Neurofibromatosis Type 1 Patients.

BackgroundMalignant peripheral nerve sheath tumors (MPNST) are one of the most frequent causes of death in patients with neurofibromatosis type 1 (NF1). Early detection is crucial because complete surgical resection is the only curative treatment. It has been previously reported that an 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) image with a T/L (Tumor/Liver) SUVmax ratio > 1.5 provides a high negative predictive value; however, it is not specific enough to make a NF1-related MPNST diagnosis. A formal proof of malignant transformation from a histological analysis is necessary before surgical excision because the procedure can cause mutilation. The objective of the present work was to investigate the effectiveness of and complications associated with PET/CT-guided percutaneous biopsies for an NF1-related MPNST diagnosis.MethodsPET/CT-guided percutaneous biopsy procedures performed on 26 NF1 patients with a clinical suspicion of MPNST and a suspect lesion from a PET/CT scan (T/L SUVmax ratio > 1.5) were retrospectively evaluated. The localization of the suspected malignant site was determined using PET/CT. A stereotactic (ultrasonic and CT control) core biopsy technique was used with a local anesthesia.ResultsThe first PET/CT-guided percutaneous biopsies enabled a pathological diagnosis for all of the patients (no "inconclusive " results were obtained), and no secondary procedures were needed. Among the 26 patients, the histopathological results from the biopsy were malignant in 17 cases and benign (BPNST with atypical cells) in nine cases. No complications from the diagnostic procedure were observed. A surgical resection was performed in 18 patients (seven benign and 11 malignant biopsies), removing the fine needle biopsy scar. In addition, six locally advanced/metastatic MPNST were treated with chemo/radiotherapy, and two BPNST had no progression after a follow-up of 14 and 39 months, respectively. The PET/CT-guided percutaneous biopsy gave 25 accurate diagnoses and one false negative (BPNST with atypical cells on the biopsy and MPNST on the operated tumor), resulting in a diagnostic accuracy rate of 96%. This false negative case may be explained by the high heterogeneity of the tumor: benign areas were contiguous with the malignant ones and associated with inflammation.ConclusionsPET/CT-guided percutaneous biopsies are an effective and relatively non-traumatic procedure for diagnosis of NF1-related MPNST. It is the most reliable approach for early detection of MPNST.

P04.25 * MOLECULAR ANALYSIS OF STEREOTACTIC BIOPSIES COMPARED TO TISSUE SAMPLES FROM OPEN TUMOR RESECTIONS IN GLIOMAS

Biomarkers, genetic alterations and epigenetic marks gain in importance as prognostic and predictive markers both, after primary diagnosis and in the recurrent disease situation. However, tissue samples are needed throughout the longitudinal course of the disease in order to adjust therapy to changing conditions. A remaining question is whether an open tumor resection is superior for pathological and molecular analysis compared to a small stereotactic biopsy. We compared the diagnostic potential of stereotactic biopsies to tissue samples from gross total resections. 16 stereotactic 1-mm tissue samples (2 diffuse astrocytomas, 2 anaplastic astrocytomas, 9 glioblastomas, 3 other tumors) were analyzed with an approach combining histopathologic diagnosis with small sample size-adjusted moleculargenetic analysis. Serial biopsies were taken throughout the tumor. Single probes were taken for single analysis (e.g. 1 probe for immunohistochemistry, 1 probe for genomic DNA extraction, 1 probe for RNA and protein extraction etc.). This procedure is eligible as the literature reports homogeneous distribution of biomarkers throughout tumors. We report that for each single patient a microscopic analysis, different immunhistochemical stainings (e.g. GFAP, S100, Vimentin, MAP2, EGFR, IDH1, p53, and MIB-1) as well as biochemical and molecular analysis could be performed with material obtained from a single stereotactic biopsy. The biochemical analysis was done by Western blot using various antibodies (e.g. ALDH1, AHR, GFAP, beta-actin). Furthermore, molecular techniques were applied including the methylation status of the MGMT promoter by bisulfit conversion of the DNA and following PCR and the IDH1/2 mutation status verification by pyro-sequencing. Genomic DNA could be extracted from all stereotactic probes. RNA extraction was also possible, but the amount of cDNA which could be obtained from the RNA of stereotactic samples was significant lower in 14 (out of the 16) samples than the amount of cDNA normally used for quantitative RT-PCR from open operations. There was no biopsy-related morbidity. We conclude that determination of many different immunohistochemical, biochemical, and molecular parameters are possible using the stereotactic biopsy technique. Moreover, the procedure is safe and reliable. The stereotactic biopsy enables decision making for optimizing the treatment of brain tumors without the necessity of an open resection. This finding has even more clinical impact in elderly patients or in patients with eloquent tumor localizations.

Molecular stereotactic biopsy technique improves diagnostic accuracy and enables personalized treatment strategies in glioma patients.

In gliomas molecular biomarkers are increasingly gaining diagnostic, prognostic and predictive significance. Determination of biomarker status after biopsy is important as not all patients are eligible for open tumor resection. We developed and validated prospectively (6/10-12/11) a protocol allowing for both reliable determination of multiple biomarkers and representative histological diagnoses from small-sized biopsies. All molecular stereotactic biopsies were performed according to a detailed workflow. The selection of specimens best suited for molecular analyses was intra-operatively guided by the attending neuropathologist. Postoperative screening was done by methylation specific PCR using two distinct cryopreserved specimens to test for reproducibility of the findings and to rule out contamination. The DNA of a single best-suited specimen (1 mm(3)) was subjected to detailed molecular analysis (MGMT promoter methylation, IDH1/2 mutational status, LOH 1p and/or 19q). 159 consecutively enrolled untreated gliomas were analyzed (94 glioblastomas, 2 gliosarcomas, 24 anaplastic astrocytomas, 10 oligo-tumors grade II/III, 20 grade II astrocytomas and 9 pilocytic astrocytomas). Transient morbidity was 2 %. Overall, the drop-out rate due to tissue contamination was 0.4 %. Median time from biopsy to histological and molecular genetic analyses was 3 and 5 days, respectively. Distributions of the respective biomarker status for tumor subgroups were consistent with the literature. The final histological diagnosis was changed/modified in 5/159 patients according to molecular findings. Treatment after molecular biopsy was highly personalized. Molecular stereotactic biopsy is feasible and safe, can be implemented in daily clinical practice, improves diagnostic precision and enables personalized treatment.

Therapeutic success in a case of anaerobic sepsis with multiple brain abscesses in the context of an efficient interdisciplinary cooperation

Background Brain abscess is one of the most serious complications of head infections, with significant case-fatality rates. Great progress was made after introduction of antimicrobial therapy with improved microbiologic culture techniques, particularly for anaerobes, and stereotactic brain biopsy and aspiration techniques. The incidence of neurological sequelae in patients who survive a brain abscess is high.

Досвід використання стереотаксичної техніки при хірургічному лікуванні кістозних вогнищевих утворень головного мозку

Вступ. Внутрішньомозкові кістозні вогнищеві утворення — ідеальна мішень для стереотаксичних втручань. Стереотаксична техніка при пункції та біопсії кістозних утворень головного мозку витісняє традиційні підходи до лікування цієї складної патології.Матеріали і методи. Матеріал дослідження — 24 хворі з кістозними вогнищевими утвореннями супратенторіальної локалізації, оперовані у клініці з 2009 по 2013 рік. Стереотаксичний супровід із використанням навігаційної системи Stealth Station® Treon® Plus фірми Medtroniс (США) та стереотаксичної системи Zamorano — Dujovny. Результати. Було проведено 20 втручань із використанням безрамної стереотаксичної техніки та 4 втручання з використанням рамного стереотаксису. Хворі були розподілені за діагнозами: абсцес головного мозку — 10, краніофарингеома — 5, анапластична астроцитома — 3, метастаз — 2, гематома — 2, анапластична епендимома — 1, астроцитома 2 ст. зл. — 1.Висновки. Лікування вогнищевих утворень головного мозку з використанням стереотаксичної техніки — сучасний, безпечний та ефективний вид хірургічного втручання.

Safety and Efficacy of Frameless Stereotactic Brain Biopsy Techniques

To explore the safety and efficacy of frameless stereotactic brain biopsy. Diagnostic accuracy was calculated by comparing biopsy diagnosis with definitive pathology in 62 patients who underwent frameless stereotactic brain biopsy between January 2008 and December 2010 in Xiamen University Southeast Hospital. Preoperative characteristics and histological diagnosis were reviewed and then information was analysed to identify factors associated with the biopsy not yielding a diagnosis and complications. Diagnostic yield was 93.5%. No differences were found between pathological diagnosis and frozen pathological diagnosis. The most common lesions were astrocytic lesions, included 16 cases of low-grade glioma and 12 cases of malignant glioma. Remote hemorrhage, metastasis, and lymphoma were following in incidence. Multiple brain lesions were found in 17 cases (27.4%). Eleven cases were frontal lesions (17.7%), 8 were frontotemporal (12.9%), 6 were frontoparietal (9.7%), and 5 each were temporal, parietal, and parietotemporal lesions (8.1%). Postoperative complications occurred in 21.0% of the patients after biopsies, including 10 haemorrhages (16.1%) and 3 temporary neurological deficits (1 epilepsy, 1 headache, and 1 partial hemiparesis). No patient required operation for hematoma evacuation. Frameless stereotactic biopsy is an effective and safe technique for histologic diagnosis of brain lesions, particularly for multifocal and frontal lesions.

Personalized surgical therapy

Gliomas are more or less diffuse tumours with the ability to infiltrate surrounding functional brain tissue. Thus, curative surgical treatment generally cannot be achieved. Despite these limitations, open tumour resection represents one of the mainstays in glioma treatment settings. Beyond tissue sampling for accurate histological and molecular genetic evaluation, decompressive effects in the case of space occupying tumours and oncologically relevant cytoreductive effects of microsurgery have been reported in selected patients with glioma of different grades. This paper provides practical considerations in order to integrate the concept of a personalized surgical therapy into the prognostic network of low- and high-grade gliomas, covering both microsurgery and stereotactic biopsy techniques.

The safety and diagnostic value of frame-based and ct-guided stereotactic brain biopsy technique

The safety and diagnostic value of frame-based and ct-guided stereotactic brain biopsy technique

Predominant influence of MGMT methylation in non-resectable glioblastoma after radiotherapy plus temozolomide

BackgroundPatients with non-resectable glioblastoma generally exhibit a poor prognosis, even after radiotherapy plus concomitant and adjuvant temozolomide (XRT/TMZ→TMZ). Unfortunately, no data are available concerning the predictive value of O6-methylguanine-DNA methyltransferase...

Novel Molecular Stereotactic Biopsy Procedures Reveal Intratumoral Homogeneity of Loss of Heterozygosity of 1p/19q and TP53 Mutations in World Health Organization Grade II Gliomas

We report a molecular stereotactic biopsy technique that combines histopathologic diagnosis with small sample size-adjusted molecular genetic analysis of low-grade gliomas that are ineligible for tumor resection. Loss of heterozygosity (LOH) of 1p/19q and TP53 mutations were analyzed in 1-mm tissue samples from 42 World Health Organization grade II gliomas (30 astrocytomas, 8 oligoastrocytomas, 4 oligodendrogliomas) using polymerase chain reaction-based microsatellite and sequence analysis. Alternating histological and molecular genetic evaluation within 1-mm steps at different sites within each tumor was performed to determine reproducibility of the results and the intratumoral distribution of the biomarkers. Multiple serial biopsies (range, 2-5 per tumor) taken from distinct intratumoral areas revealed concordant molecular genetic findings and homogeneous distribution of both biomarkers throughout 41 tumors. Contamination by nonneoplastic tissue could be recognized by corresponding histological evaluation and resulted in discordant LOH findings in 1 tumor. The frequency of LOH 1p/19q and TP53 mutations was consistent with the literature; these genetic alterations were found to be mutually exclusive. There was no biopsy-related morbidity. We conclude that determination of the LOH 1p/19q and TP53 status using this molecular stereotactic biopsy technique is safe and reliable in cases of unresectable gliomas.

Serial stereotactic biopsy of brainstem lesions in adults improves diagnostic accuracy compared with MRI only

Objective:The aim of the current prospective study was to analyse the validity of MRI based diagnosis of brainstem gliomas which was verified by stereotactic biopsy and follow-up evaluation as well...

Stereotactic Transperineal Prostate Biopsy

This study investigates the detection rate of nonpalpable, isoechoic occult prostate malignancy using a stereotactic transperineal prostate biopsy (STPB) technique in patients with a previously negative transrectal ultrasound-guided prostate biopsy.

Identification of occult prostate malignancy using a stereotactic transperineal prostate biopsy technique

15520 Background: This study investigates the detection rate of non-palpable, isoechoic occult prostate malignancy using a stereotactic transperineal prostate biopsy (STPB) technique in patients with previously negative transrectal ultrasound-guided prostate biopsy. Methods: 327 consecutive patients with continued rising total prostate specific antigen (PSA) with a minimum of 1 prior benign transrectal prostate biopsy (range 1–8), underwent STPB at a single out-patient institution between 05/2004 and 11/2006. Median patient age, total PSA and prostate volume and number of specimens obtained were 62 years, 8.3 ng/ml, 46.1 cm3 and 40 specimens, respectively. Similar to a prostate brachytherapy procedure, the prostate was positioned on the implant grid. Specimens were obtained according to x, y, and z coordinates from eight equal octants with pathology reported accordingly. A greater number of specimens were obtained from the apical half than the basilar half of the prostate; this was attributed to smaller glands in which the apical specimens sufficiently sampled the anterior curvature of the gland. Results: STPB yielded adenocarcinoma in 125/327 (38%) patients. The number of biopsy cores obtained per patient approximated the prostate gland volume in cm3. Multivariate analysis (paired samples t-tests) demonstrated there was a significant difference in detection rates with the apex having a higher incidence of malignancy than the base of the prostate gland (p=.000). Furthermore, the anterior apex harbored significantly more adenocarcinoma when compared to the posterior apex (p=.026) ( Table 1 ). Conclusions: STPB is efficacious for diagnosis of non-palpable, isoechoic occult prostate malignancy. A possible explanation for the significant finding in this study that occult malignancies occupy a higher percentage of apical biopsies using STPB may be related to difficulty and limitations of apical sampling using a standard transrectal biopsy approach. [Table: see text] No significant financial relationships to disclose.

An unusual case of intracerebral Non-Langerhans cell histiocytosis with review of the literature

Conclusion This case shows the unusual manifestation of a primary intracerebral Non-Langerhans cell histiocytosis, which begins as a solid mass around the sellar region and shows a remarkable extension as a flat lining of inner and outer liquor spaces. Stereotactic brain biopsy technique today is a valuable high tech tool to clarify intracerebral tumorous lesions with a minimum of risk for the patient and with the possibility to perform all necessary tissue investigations. from 35te Tagung der Pathologen am Oberrhein/35th Meeting of Pathologists of the Upper Rhine Region (PATOR) The Institute of Pathology, University Hospital Freiburg, Germany. 1 July 2006

The Use of Stereotactic Excisional Biopsy in the Management of Invasive Breast Cancer

Stereotactic breast biopsy techniques minimize the surgical trauma associated with conventional wire-guided open breast biopsy for non-palpable breast lesions (NPBLs). Advanced breast biopsy instrumentation (ABBI) allows for a 2-cm core of breast tissue to be excised under stereotactic guidance in an outpatient setting. We report our initial experience with ABBI. Hospital charts from 89 ABBI procedures between 10/1996 and 07/2002 were retrospectively reviewed for patient characteristics, ABBI parameters, radiographic appearance, pathology, complications, and clinical follow-up. Data are presented as percentage/median (range). Median age was 59 years (range: 39-80 years), mammographic lesions were classified as calcifications 49% (44/89), soft tissue 39% (35/89), or mixed 11% (10/89). Median radiographic size was 7 mm (1-60 mm). Final pathology revealed ductal carcinoma in situ (DCIS) in 7% (6/89) and invasive cancer in 22% (20/89). Microscopically clear margins were obtained in 55% (11/20) of patients with invasive cancer. Of these, 82% (9/11) chose not to undergo further local surgical therapy. Eight patients remain disease free at 56 months (range: 41-95 months) follow-up. The ninth patient was deceased at 6 months from an unrelated cause. The overall complication rate was 3% (3/89). A definitive diagnosis was obtained in 100% of malignant and 87% of benign cases. Median waiting time was 19 days (range: 0-90 days). Our experience demonstrates that ABBI is an effective diagnostic tool for NPBLs. It is associated with minimal complications, and provides negative margins in over half of malignant cases. In selected patients with invasive cancer and negative margins, ABBI may obviate the need for further local surgical treatment. ABBI merits additional investigation as a therapeutic modality for early breast cancer.

A contralateral, transfrontal, extraventricular approach to stereotactic brainstem biopsy procedures

The authors report on the technique and results of stereotactic biopsy for intrinsic lateral pontine and medial cerebellar lesions via a contralateral, transfrontal, extraventricular approach. Multiplanar stereotactic magnetic resonance imaging was used to plan an intraparenchymal approach, thus limiting the number of crossed pial surfaces to one and eliminating the need to cross ependymal surfaces. After the administration of a local anesthetic agent with light intravenous sedation, six patients harboring intrinsic lateral pontine lesions underwent biopsies via this intraparenchymal approach with 100% diagnostic yield and no operative morbidity. In comparison to the ipsilateral transfrontal approach, the contralateral approach laterally expands the infratentorial area accessible during biopsy to include the lateral pons and middle cerebellar peduncle. The contralateral, transfrontal, extraventricular approach is a useful, straightforward and safe alternative to the suboccipital transcerebellar and ipsilateral, transfrontal, transtentorial routes for reaching lesions of the lateral pons and middle cerebellar peduncle.

Interdisciplinary consensus on the use and technique of vacuum-assisted stereotactic breast biopsy

Purpose: Quality assurance of stereotactic vacuum-assisted breast biopsy (VB). Method: A consensus was achieved based on the existing literature and the experience of VB users (Ethicon Endosurgery, Norderstedt). Results: The imaging work-up must be completed according to existing standards before an indication for stereotactic VB is established. Indications include microcalcifications and small non-palpable masses; for the time being lesions very close to the skin and architectural distortions (radial scar) are considered less suitable. Acquisition of >20 cores (11 Gauge) should be routinely attempted (goals: as complete a removal of small lesions as possible, thereby increasing diagnostic confidence and reducing so-called ‘underestimates’). The pre/post-fire and post-biopsy stereotactic images and a post-biopsy orthogonal mammogram must be documented. All cases with no or uncertain histopathological correlation require discussion in a regular interdisciplinary conference and a documented consensus concerning further work-up or therapy. Standardised documentation of the primary findings and follow-up mammography after approximately 6 months is requested. Conclusion: This consensus includes protocols for the establishment of an indication, performance indicators, interdisciplinary interpretation and therapeutic recommendation, documentation and follow-up. It does not replace official recommendations for percutaneous biopsy.

The advantages of frameless stereotactic biopsy over frame-based biopsy

A comparison study is presented, which examines the outcome, complications and cost of stereotactic brain biopsy performed with a frameless versus a frame-based method. The technique of frameless stereotactic biopsy has been shown previously, in both laboratory and in vivo studies, to achieve a level of accuracy at least equal to frame-based biopsy. The investigators have validated the technique in a large clinical series. The frameless and frame-based series were concurrent, comprising 76 and 79 cases, respectively. The frameless stereotactic technique involved standard needle biopsy, targeted by an image-guidance system and directed by a novel rigid adjustable instrument-holder. Frame-based biopsies were performed with the CRW and Leksell systems. There were no significant differences in the demographics, lesion site, size and pathologies between the groups. Operating theatre occupancy and anaesthetic time were both significantly shorter for the frameless series than the frame-based series ( p < 0.0001). In addition, the complication rate in the frameless biopsy series was significantly lower than in the frame-based series ( p = 0.018). This resulted in lower ITU bed occupancy ( p = 0.02), shorter mean hospital stay ( p = 0.0013) and significant cost savings ( p = 0.0022) for the frameless stereotactic biopsy group, despite the greater use of more expensive MRI in these cases. This comparison study demonstrates that the superior imaging, target visualization and flexibility of the technique of frameless stereotactic biopsy translates into tangible advantages for safety, time and cost when compared with the current gold-standard of frame-based biopsy. The principles are discussed and the authors propose a definition for the term 'frameless stereotaxy'.

Stereotactic localization of breast lesions: how it works and methods to improve accuracy.

A computer simulation of stereotactic breast biopsy was developed that paralleled the geometric configuration of a currently available breast biopsy system. This model was developed to define and improve the targeting of breast lesions with stereotactic biopsy techniques. Lesions must be clearly identified and accurately targeted on both views for successful localization. Nonvisualization of a lesion may result from overlying tissue or from the geometric configuration of the imaging system. Familiarity with the geometric configuration of the biopsy unit, especially the location of the reference point and center of rotation, facilitates understanding of apparent changes in lesion position (parallax shift). Inaccuracy in lesion targeting on one or both views will manifest predominantly as an error in the calculated z value (depth). The magnitude and direction of this error are largely determined by the direction of the targeting error. Compensatory strategies include use of a long-throw core biopsy gun or directional vacuum-assisted biopsy device and additional sampling along the z axis and should be accompanied by critical evaluation of both pre- and postfire images. Understanding geometric considerations as well as how targeting accuracy affects accuracy in lesion localization should lead to greater success in sampling even challenging breast lesions at stereotactic biopsy.

Use of advanced breast biopsy instrumentation while performing stereotactic breast biopsies: review of 150 consecutive biopsies

Background: Stereotactic breast biopsies are being performed in the United States with increasing frequency. Advanced breast biopsy instrumentation (ABBI) is a recent addition to the list of available stereotactic breast biopsy devices (eg, fine-needle aspiration, automated needle cores, and vacuum-assisted devices). Indications for the ABBI procedure in the management of patients with nonpalpaple mammographic lesions have not been established. Study Design: Prospectively collected data on 150 patients biopsied with the ABBI procedure were reviewed. Results: From April 1996 to May 1997, 150 patients with indeterminate or suspicious nonpalpable mammographic lesions were biopsied using the ABBI technique. Complications were minor. One patient (0.6%) required a repeat biopsy because of insufficient tissue and one patient had repeat excision to confirm the diagnosis of atypical ductal hyperplasia. Cancer was diagnosed in 26%. Followup mammograms were obtained in 94% of the patients. Lesions were missed in three patients (2%), none of whom were later found to have cancer. One patient (0.6%) required a repeat ABBI biopsy for postbiopsy architectural distortion. Postprocedure mammographic scarring was otherwise minimal and was noted in only 16% of the patients. Of the 111 patients with benign diagnoses, 67 were seen for clinical followup; 98% had good cosmetic outcomes and were satisfied with the ABBI technique. Conclusions: The ABBI technique is a safe, reliable stereotactic breast biopsy technique that is well accepted by patients. The sensitivity and specificity of ABBI biopsy for the diagnosis of carcinoma in this series were each 100% for the 142 patients returning for followup. Indications for the technique are similar to those for traditional needle localization excisional breast biopsies.