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ORIGINAL ARTICLE
Year : 2019  |  Volume : 14  |  Issue : 1  |  Page : 175-180

Venture in 101 cranial punctures: A comparative study between frame-based versus frameless biopsy of 101 intracranial space occupying lesion


Department of Neurosurgery, National Institute of Neurological and Allied Sciences, Kathmandu, Nepal

Date of Web Publication21-Feb-2019

Correspondence Address:
Dr. Suresh Bishokarma
National Institute of Neurological and Allied Sciences, PO Box 3711, Bansbari, Kathmandu
Nepal
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajns.AJNS_137_18

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  Abstract 


Background: Presumptive diagnosis based solely on the clinical picture and imaging is not sufficient to provide appropriate treatment with certainty and hence histopathological confirmation of intracranial space occupying lesion (ICSOL) is essential. Needle biopsy via stereotactic frame-based or frameless neuronavigation technique is efficient procedure. The objective of this study is to compare their accuracy and efficacy and safety. Methods: This is a retrospective comparative study conducted among 101 biopsies of ICSOL. Patients data were retrieved from medical record. Data were analyzed in SPSS ver. 20. P value of <0.05 was considered significant. Results: Out of 101 patients, Frame-based stereotactic biopsy was done among 55 patients (54.4%) while 46 patients (45.6%) underwent frameless stealth neuronavigation guided biopsy. Male to female ration was 2.1:1. Age ranged from 5 to 82 years. 54.5% (55 patients) have deeper location of tumor while 45.5% (46 patients) have lobar location of tumor. Frontal (16.8%) and Thalamic (13.8%) were the common site. Mean size of tumor was 3.09±0.85cms. There was statistically significant difference in operative duration among study groups. Overall Diagnostic yield was 89.1%. Glioma was the most common (50.5%) diagnosis. Glioblastoma WHO Grade IV was 37.6% followed by lymphoma (12.8%). Conclusion: Needle biopsy via stereotactic frame-based or neuronavigation frameless technique is a safe and efficient procedure having high diagnostic yield. Reasons for negative biopsy could be missed target or retrieval of gliotic tissue.

Keywords: Biopsy, brain lesion, frame-based, frameless, neuronavigation, accuracy


How to cite this article:
Bishokarma S, Shrestha P, Koirala S, Raut M, Gongal DN. Venture in 101 cranial punctures: A comparative study between frame-based versus frameless biopsy of 101 intracranial space occupying lesion. Asian J Neurosurg 2019;14:175-80

How to cite this URL:
Bishokarma S, Shrestha P, Koirala S, Raut M, Gongal DN. Venture in 101 cranial punctures: A comparative study between frame-based versus frameless biopsy of 101 intracranial space occupying lesion. Asian J Neurosurg [serial online] 2019 [cited 2019 Sep 18];14:175-80. Available from: http://www.asianjns.org/text.asp?2019/14/1/175/245915




  Introduction Top


Presumptive diagnosis-based solely on the clinical picture and imaging is not sufficient to provide appropriate treatment with certainty. Histopathological confirmation of intracranial space occupying lesion (ICSOL) is essential to draw management plans and institute appropriate treatment. Biopsy through stereotactic technique (SB) is interesting choices. SB of brain lesion has been widely and safely performed procedure since it was first introduced in the late 1970s.[1] SB is indicated in every progressive, unverified intracranial lesion to obtain a histopathological diagnosis in cases where surgical resection is not preferred treatment. SB ascertains the histological diagnosis of brain lesions with low risk and high accuracy.[2] Reported series show various results of diagnostic yield. The present study was carried out to compare the diagnostic accuracy of frame-based and frameless technique and compare their effectiveness.


  Methods Top


This is a single-center retrospective analytical cross-sectional nonprobability purposive study conducted in our center among 101 patients during a period of 5 years from 2014 to 2018. All patients who underwent stereotactic biopsy of ICSOL through frame-based or frameless technique were included in the study. Those patients who denied consent for surgery were excluded from the study. Ethical clearance was approved by the Institutional Review Committee of our center.

Biopsy technique

In our unit, we use two techniques: frame-based stereotactic and frameless neuronavigation-guided biopsy. A biopsy is done by dedicated neurosurgeons. The selection of technique was based on the surgeon preference.

Technique of frame-based biopsy

For frame-based biopsy, Cosman-Robert-Wells (CRW) frame was used. The patient was assessed clinically and available records such as computed tomography (CT) scan and chest X-ray evaluated. Coagulation profile is checked. Head of the patient was shaved or washed with antiseptics, and base ring of Brown-Roberts-Wells system was secured into the outer table of the skull with four screws after infiltrating the required points with 2% lignocaine [Figure 1]a. The patient was shifted to CT scanner [Figure 1]b. The localizing ring was attached to the base ring before CT scanning.
Figure 1: (a) Localizer ring secured in the outer table of the skull, (b) Patient in CT console with frame fixed on the head, (c) Rectilinear phantom pointer (RLPP) with CRW stereotactic frame calibrated to phantom target, (d) CRW frame is mounted on patient head for biopsy of target lesion

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Contrast-enhanced CT was done in each patient. Areas with contrast enhancement were selected while areas of most suspicion were selected for nonenhancing lesion. Pixel coordinates of nine localizer rods were derived and recorded. Patient was shifted to the operation room.

X and Y coordinates were calculated with Radionic Sterocalc, and three scales (anteroposterior, lateral, and vertical) were calculated. Calculation was calibrated to phantom target [Figure 1]c. Patient head is prepped and draped. Entry point was infiltrated with 2% lignocaine, incised, and small burr hole made with Hudson perforator or Manman perforator. Durotomy was made with electrocautery. CRW frame was mounted on the head. A side cutting biopsy needle was used, and an average of four specimens was obtained through single trajectory and sent for histopathological analysis [Figure 1]d. Wound closed with one or two stitches and base ring removed and patients sent back to the Intensive Care Unit for monitoring.

Duration of procedure recorded from starting of frame fixation till closure of the wound was retrieved from anesthesia chart.

Technique of stealth neuronavigation frameless biopsy

Image acquisition was done from magnetic resonance imaging image loaded compact disc and patient registered in stealth, neuronavigation system, an infrared led-based system. Head of patient was shaved after general anesthesia and head fixed with three pins clamp on Mayfield [Figure 2]a. Taylor–Haughton line drawn and tumor marked on the scalp with the neuronavigation guidance. Technique was similar to Dorward technique of neuronavigation-guided biopsy.[3] Entry point selection was done to achieve the shortest safe path toward target lesion [Figure 2]b. All calculation was done to avoid vascular structure along the trajectory. Skin incision was done and burr hole was created with Manman air-driven drill. Durostomy was done [Figure 2]c and four specimens were retrieved with the help of 14-gauge navigation cannula [Figure 2]d. Biopsy specimens sent for histopathological analysis. Wound closed with one or two stitches and observed in the Intensive Care Unit for monitoring. The duration of procedure recorded from starting of Mayfield three pin fixations to closure of the wound was retrieved from anesthesia chart.
Figure 2: (a) Head fixed with three pins clamp on Mayfield, (b) Target lesion is navigated and locked for biopsy from shortest safe route, (c) Burr hole and durostomy before biopsy, (d) Delivering Biopsy specimen for Histopathological examination

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  Results Top


Of 101 patients, most of them were male 68.3% (69 patients). Age ranged from 5 years to 82 years with the mean age of 46.12 ± 18.56 years. Most ICSOL were supratentorial while only one was infratentorial tumor. About 54.5% (55 patients) have deeper location of tumor while 45.5% (46 patients) have lobar location of tumor. Frontal (16.8%) and thalamic (13.8%) were the common sites. Right side was 54.4% (55 patients) while left was 44.6% (45 patients). The mean size of tumor was 3.089 ± 0.8497 cm with a range from 2 cm to 7 cm while 78.2% of tumor were of size <2 cm and 21.7% of tumor were ≤2 cm size [Table 1].
Table 1: Result in 101 brain biopsies of intracranial space occupying lesion

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Frame-based stereotactic biopsy was done among 55 patients (54.4%) while 46 patients (45.6%) underwent frameless neuronavigation-guided biopsy. Overall, mean operative duration was 155.89 ± 46.12 min; moreover, there was statistically significant in operative duration among study groups (186.36 ± 26.4 min vs. 119.45 ± 37.26 min in frame-based vs. frameless group with P < 0.05) Overall, diagnostic yield was 89.1%. There was no statistically significant difference in diagnostic yield of both technique (P = 0.995) [Table 2].
Table 2: Diagnostic yield of frame-based versus frameless biopsy procedure

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Histopathological examination (HPE) revealed diverse pathology with glioma being the most common (50.5%) [Table 3]. Of 101 biopsies, histopathology revealed glioblastoma WHO Grade IV among 37.6% (38 patients), lymphoma (12.8%), diffuse astrocytoma (7%), metastasis (6%), and few cases of anaplastic astrocytoma, oligodendroglioma, metaplastic meningioma, and angiomatous meningioma. Similarly, among infective pathology, abscess was most common histological findings accounting (8.9%) while tuberculosis (3.9%), cryptococcal (0.9%), and neurocysticercosis (0.9%) were sparsely diagnosed. Preoperative diagnosis was revised with a new diagnosis in 18.8% of cases (19 patients) while similar pathological type is revealed in 70.3% of cases (71 patients) while histopathology was reported negative in 10.9% (11 patients). There was no statistical significant difference in diagnostic yield of both technique [Table 2]. Among those with inconclusive HPE report, six were gliosis (5.9%), one (0.9%) was chronic inflammatory neuroparenchyma (no evidence of tuberculosis), and four were normal brain (3.9%) [Table 4]. Overall, postoperative morbidity was 4.9%. Two patients developed seizure among frame-based stereotactic group while tract hematoma was present in one case of each study group which were managed conservatively. One patient in frameless neuronavigation group developed neurological deficit. The mean duration of hospital stay was 11.83 ± 10.13 days (range: 4–42 days). There was no statistical significant difference in hospital stay among two groups (mean ± standard deviation 10.63 ± 9.6 vs. 13.26 ± 10.63 days in frame-based vs. frameless group; P = 0.20) [Table 1]. There was no mortality in any groups.
Table 3: Histopathology conclusion of biopsy specimens

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Table 4: Inconclusive diagnosis (n=11)

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  Discussion Top


SB is a safe and efficient procedure, particularly in cases with lesions in which a craniotomy and resective surgery are not indicated primarily. The principle of stereotactic biopsy of ICSOL had evolved over years ever since Horsly and Clarke [4] performed the first stereotactic brain biopsy on the cerebellum of a rat and Spiegel and Wycis, later in 1947, displayed their first human SB using three-dimensional coordinate system using intracranial landmark defined by pneumoencephalography.[5] Maroon et al. first reported CT-guided stereotactic system in 1977.[6] In most such cases, conclusive diagnosis can be established by SBs alone.[7],[8] In reported series, accuracy of stereotactic biopsy has shown a great variation ranging from 60% to 98%.[9]

Demographics

Most of our patients were male (68.3%) which were similar to the study done by Tsermoulas et al.[10] Our series did not show any difference in the diagnostic accuracy with the gender of the patients similar to various study.[11],[12] The mean age of our patients was 46.119 ± 18.55 years. Age factor did not have statistically significant association with the diagnostic yield in this study, though a study done by Tsermoulas et al.[10] showed more likelihood of diagnostic yield in older patient compared to younger patient.

Diagnostic yield

In this study, the overall diagnostic yield was 89.1% with similar yield in both the group (89.1%). There was no statistically significant difference in accuracy of frameless or frame-based technique in this study. In most cases, conclusive diagnosis can be established by stereotactic biopsy alone.[7] Our study did not show any difference in diagnostic yield with respect to the side and location of tumor. Some studies showed anatomical site to be significant in diagnostic yield while few other did not show any difference.[13]

In a meta-analysis done by Hall.[14] among 7471 patients diagnostic yield of frame-based biopsy was 91%, similarly Jain et al.[15] showed overall accuracy of 80.2% (84.2% in frame based and 87% in frameless biopsy technique) while Livermore and Woodworth et al.[16] had diagnostic yield of 94.9% and 90%, respectively [Table 5]. In this study, HPE revealed diverse pathology with glioma is the most common (50.5%), glioblastoma WHO Grade IV among 37.6% (38 patients), lymphoma (12.8%), diffuse astrocytoma (7%), metastasis (6%), and few cases of anaplastic astrocytoma, oligodendroglioma, metaplastic meningioma, and angiomatous meningioma. In a study done by Jain et al.,[15] of 130 biopsies, 70% were gliomas, 5.4% were lymphomas, and 4% were infective while a study done by Joshi et al.[17] among 40 patients revealed gliomas in 72.5% of patients and lymphomas in 5% patients. In this study, histopathology was reported negative in 10.9% (11 patients). Reason for negative report was due to missed target acquiring normal brain for histology or retrieval of glial tissue/nonspecific chronic inflammatory tissue from target. A study done by Jain et al.[15] had overall negative result in 16% (21 patients of 130). Histology was normal brain in 8.5% of 130 patients, gliosis in 3%, and inadequate tissue in 3% of cases in their study.
Table 5: Comparison of diagnostic yield with other studies

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Morbidity

Needle biopsy through frame-based or frameless technique is a safe and efficient procedure. However, it has a morbidity rate ranging from 0.9% to 15% and mortality rate between 0% and 4.2% in reported series.[2],[18] Hemorrhage at the biopsy site is reported as most common complication following needle biopsy.[9] In a study done by Kreth et al.,[18] 0.9% developed hemorrhage-related complication. In this study, overall postoperative morbidity was 4.9%. Two patients (1.97%) developed seizure among frame-based stereotactic group while tract hematoma was present in one case of each study group which were managed conservatively. One patient in neuronavigation developed neurological deficit. As reported by Krieger et al.,[9] of 3500 stereotactic biopsies, they had one procedure-related death, seven significant hemorrhages including subdural and epidural hematomas, five seizures (1.4%), and two infections.


  Conclusion Top


Needle biopsy through frameless or frame-based technique is a safe and efficient procedure. Both techniques have a high diagnostic yield. Reasons for negative biopsy were missed target or retrieval of gliotic tissue from the target lesion. High-volume prospective study is recommended to attest these inferences.[19]

Limitations

This study inherent the limitation of retrospective study. There is also the issue of sample bias with regard to the decision as to which biopsy technique to use is not allocated randomly.

Acknowledgment

We would like to acknowledge late senior neurosurgeon Prof. UP Devkota, neurosurgery consultants and residents who were involved in needle biopsy during the study period.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Conway LW. Stereotaxic diagnosis and treatment of intracranial tumors including an initial experience with cryosurgery for pinealomas. J Neurosurg 1973;38:453-60.  Back to cited text no. 1
    
2.
Bernstein M, Parrent AG. Complications of CT-guided stereotactic biopsy of intra-axial brain lesions. J Neurosurg 1994;81:165-8.  Back to cited text no. 2
    
3.
Dorward NL, Paleologos TS, Alberti O, Thomas DG. The advantages of frameless stereotactic biopsy over frame-based biopsy. Br J Neurosurg 2002;16:110-8.  Back to cited text no. 3
    
4.
Horsly V, Clarke RH. The structure and function of cerebellum examined by a new method. Brain 1908;31:45-124.  Back to cited text no. 4
    
5.
Quiñones-Molina R, Alaminos A, Molina H, Muñoz J, López G, Alvarez L, et al. Computer-assisted CT-guided stereotactic biopsy and brachytherapy of brain tumors. Stereotact Funct Neurosurg 1994;63:52-5.  Back to cited text no. 5
    
6.
Maroon JC, Bank WO, Drayer BP, Rosenbaum AE. Intracranial biopsy assisted by computerized tomography. J Neurosurg 1977;46:740-4.  Back to cited text no. 6
    
7.
Apuzzo ML, Chandrasoma PT, Cohen D, Zee CS, Zelman V. Computed imaging stereotaxy: Experience and perspective related to 500 procedures applied to brain masses. Neurosurgery 1987;20:930-7.  Back to cited text no. 7
    
8.
Chandrasoma PT, Smith MM, Apuzzo ML. Stereotactic biopsy in the diagnosis of brain masses: Comparison of results of biopsy and resected surgical specimen. Neurosurgery 1989;24:160-5.  Back to cited text no. 8
    
9.
Krieger MD, Chandrasoma PT, Zee CS, Apuzzo ML. Role of stereotactic biopsy in the diagnosis and management of brain tumors. Semin Surg Oncol 1998;14:13-25.  Back to cited text no. 9
    
10.
Tsermoulas G, Mukerji N, Borah AJ, Mitchell P, Ross N. Factors affecting diagnostic yield in needle biopsy for brain lesions. Br J Neurosurg 2013;27:207-11.  Back to cited text no. 10
    
11.
Dammers R, Haitsma IK, Schouten JW, Kros JM, Avezaat CJ, Vincent AJ, et al. Safety and efficacy of frameless and frame-based intracranial biopsy techniques. Acta Neurochir (Wien) 2008;150:23-9.  Back to cited text no. 11
    
12.
Kim JE, Kim DG, Paek SH, Jung HW. Stereotactic biopsy for intracranial lesions: Reliability and its impact on the planning of treatment. Acta Neurochir (Wien) 2003;145:547-54.  Back to cited text no. 12
    
13.
Gaudin PB, Sherman ME, Brat DJ, Zahurak M, Erozan YS. Accuracy of grading gliomas on CT-guided stereotactic biopsies: A survival analysis. Diagn Cytopathol 1997;17:461-6.  Back to cited text no. 13
    
14.
Hall WA. The safety and efficacy of stereotactic biopsy for intracranial lesions. Cancer 1998;82:1749-55.  Back to cited text no. 14
    
15.
Jain D, Sharma MC, Sarkar C, Deb P, Gupta D, Mahapatra AK, et al. Correlation of diagnostic yield of stereotactic brain biopsy with number of biopsy bits and site of the lesion. Brain Tumor Pathol 2006;23:71-5.  Back to cited text no. 15
    
16.
Woodworth GF, McGirt MJ, Samdani A, Garonzik I, Olivi A, Weingart JD, et al. Frameless image-guided stereotactic brain biopsy procedure: Diagnostic yield, surgical morbidity, and comparison with the frame-based technique. J Neurosurg 2006;104:233-7.  Back to cited text no. 16
    
17.
Joshi RM, Lohani S, Devkota UP. Computed tomography guided stereotactic biopsy of cerebral lesion: A safe diagnostic procedure. Nepal J Neurosci 2015;12;14-9.  Back to cited text no. 17
    
18.
Kreth FW, Muacevic A, Medele R, Bise K, Meyer T, Reulen HJ, et al. The risk of haemorrhage after image guided stereotactic biopsy of intra-axial brain tumours – A prospective study. Acta Neurochir (Wien) 2001;143:539-45.  Back to cited text no. 18
    
19.
Livermore LJ, Ruichong Ma, Bojanic S, Erlick AC. Pereira. Yield and complications of frame-based and frameless stereotactic brain biopsy – The value of intra-operative histological analysis. British Journal of Neurosurgery 2014;28:5:637-44.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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