Abstract
Stereotactic biopsy has been validated for tissue sampling of deep-seated lesions that cannot be easily resected via open craniotomy. However, some inherent problems including the inability to directly observe the lesion and difficulty in confirming hemostasis limit its usefulness. To overcome these issues, we used the endoscope in brain tumor biopsy, for not only intraventricular tumors but also intraparenchymal tumors. The rigid scope was used in association with a surgical navigation system for intraparenchymal lesions via a transcortical route. There were no useful anatomical landmarks when the trajectory to the lesions was decided; therefore, surgical navigation system was required for the transcortical procedures. The endoscopic procedure described here was attempted in 21 cases of intraparenchymal lesions between January 2007 and February 2012. A definitive diagnosis was obtained in all cases, and genetic analysis was performed when required. Serious postsurgical hemorrhage or neurological deficits were not observed in any cases. Endoscopic surgery provides a clear view of the target and makes it easier to differentiate tumor tissue from normal brain tissue. Moreover, the endoscope helped to confirm hemostasis during the procedure. Thus, endoscopic biopsy has the potential to contribute toward safe and reliable diagnosis of brain tumors.
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Yavor Enchev, Varna, Bulgaria
Nagahisa et al. reported their experience with endoscopic biopsy in a series of 21 cases with intraparenchymal brain lesions which were highly suspected to be neoplastic. The patients underwent endoscopic biopsy because they were not indicated for direct resection due to their multiple lesions or to their deep-seated or eloquent area’s lesions. The intraparenchymal lesions were treated by transcortical route with navigation assistance. The authors achieved excellent results—100 % verification of the lesions, with 0 % procedure-related morbidity or mortality. The unavoidable comparison of the technique and results of the navigation-assisted endoscopic biopsy with stereotactic biopsy was analyzed by the authors. Undoubtedly, the endoscopic biopsy provided a direct visualization of the target and facilitated the differentiation of tumor tissue from normal brain parenchyma. A supplementary advantage of the analyzed technique was the secure hemostasis during the procedure. Thus, the authors’ series suggested that the navigation-assisted endoscopic biopsy being a versatile procedure has the potential to be reasonable alternative to stereotaxy for safe and reliable histopathological diagnosis. However, further larger series are required to validate the value of this technique.
Henry W. S. Schroeder, Greifswald, Germany
The authors present their experience with navigation-assisted endoscopic biopsy of 21 cases of intraparenchymal lesions. A definitive diagnosis was obtained in all patients. Neurological deficits were not observed. The authors concluded that endoscopic biopsy has the potential to contribute toward a safe and reliable diagnosis of brain tumors.
Endoscopic biopsy of intra- and paraventricular tumors has been well established in many centers. However, endoscopic biopsy of intraparenchymal tumors has only rarely been reported. I have done a few endoscopic biopsies of intraparenchymal lesions. I used the LOTTA ventriculoscope and inserted the endoscopic sheath under navigational guidance directly into the tumor. The advantage of direct visualization and active hemostasis is obvious. However, in most cases, we still prefer a stereotactic frame-based (in small lesions) or frameless biopsy (in larger lesions). The symptomatic hemorrhage rate (approx 2 %) is low and the histological yield high.
I was surprised about the large diameter of the sheath which the authors used for the transparenchymal approach. Eight millimeters is quite thick, especially when using the OI endoscope which has a small outer diameter. This is much thicker and therefore more invasive than that of needles used for stereotactic biopsy.
Conclusions that endoscopic biopsy is more effective than stereotactic biopsy in terms of reliability and safety cannot be drawn from this small series. Only a prospective randomized trial comparing stereotactic with stereotactic endoscopic biopsy could tell which technique is truly less risky and has a better histological yield.
Lennart H. Stieglitz, Bern, Switzerland
Combinations of well-established techniques sometimes open the door to new approaches for diagnosis and treatment. There are three commonly used procedures for sampling tumor material for histopathologic examinations. In superficial lesions, the tissue can often be taken in an open biopsy. In periventricular lesions, endoscopy is often helpful, and in deep-seated tumors, frame-based and frameless stereotaxy provides minimally invasive and effective tissue sampling.
In the field of neurosurgery, constant improvements occur through experience and applications of new technology. Because the field of neurosurgery is relatively young, in this field—perhaps more than in other fields—it is important to remain open-minded to the possible benefits of applying new approaches to old problems. Biopsy of intraparenchymatous deep-seated lesions is normally performed using only stereotaxy.
Shinya Nagahisa et al. present their experience with a combination of frameless stereotaxy and endoscopy to sample deep-seated lesions. Their results were comparable to those of pure stereotactic approaches in terms of successful asservation of tumor material, hemorrhage, and neurological deficits. Of course, disadvantages of this technique must also be considered; while frame-based stereotaxy allows approach to lesions only a few millimeters in size, navigated endoscopy may provide less precision. Furthermore, an endoscope is far larger than a biopsy needle and can theoretically cause more tissue damage. Advantages include the possibility to inspect the tissue before taking biopsies and to treat hemorrhage immediately. A superiority of this combination method will be difficult to show because of the already small risk of hemorrhage after stereotactic biopsy, thus requiring a very large number of patients to gain sufficient power. I imagine that this technique might be useful in highly vascularized lesions that a neurosurgeon is reluctant to access stereotactically.
Although I do not think that endoscopy will be the technique of choice for biopsies of most deep-seated lesions, this is a useful contribution to the surgical armamentarium that might prove helpful in selected cases.
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Nagahisa, S., Watabe, T., Sasaki, H. et al. Surgical navigation-assisted endoscopic biopsy is feasible for safe and reliable diagnosis of unresectable solid brain tumors. Neurosurg Rev 36, 595–601 (2013). https://doi.org/10.1007/s10143-013-0467-9
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DOI: https://doi.org/10.1007/s10143-013-0467-9