ForumComparative Effectiveness of Frame-Based, Frameless, and Intraoperative Magnetic Resonance Imaging–Guided Brain Biopsy Techniques
Introduction
The continued evolution of image-guided surgical techniques over the past 20 years has led to tremendous advances in neurosurgery. Frame-based techniques have long been considered the “gold standard” for sampling intracranial lesions, with the rigid frame providing excellent targeting precision 2, 3, 6, 12, 13, 18, 20. However, use of a frame-based technique is limited by the frame’s bulkiness, the patient’s discomfort, the calculations involved in defining stereotactic entry points, the possible prolonged surgical time, and the risk of postoperative infection at the frame’s fixture points (17). Frameless stereotactic techniques have become a popular choice among neurosurgeons because they are easy to use and provide comparable diagnostic yield 1, 6.
Because both frame-based and frameless stereotactic biopsy techniques use preoperative images with a registered probe to access target tissue, they both have a similar drawback: there is no real-time radiographic feedback confirming that the biopsy needle is in the target tissue. Intraoperative brain shifting and cerebrospinal fluid loss or technical issues can lead to a potential misalignment between the image guide and the actual brain configuration during the operation 5, 7, 11, 14, 15, 16, 20. The development of intraoperative magnetic resonance imaging (MRI) systems has made real-time radiographic feedback a possibility for brain biopsy. In the intraoperative MRI system used, a frameless three-dimensional optical stereotactic system is combined with intraoperative acquisition of MRI images to provide surgeons with near real-time navigation (15). Using a combination of light-emitting diode–based optical tracking of biopsy probes with intraoperative manipulation of MRI planes, surgeons are able to modify the preplanned trajectory based on the real-time intraoperative MRI image (4). Intralesional biopsy could be confirmed with the real-time MRI image.
Several reports have been published comparing the effectiveness of the frame-based and frameless stereotactic brain biopsy methods 6, 8, 19, 21. These reports found similar diagnostic yield between the 2 methods 6, 8, 19, 21. However, results comparing the complications and length of hospitalization vary among different studies 8, 19. We previously demonstrated the feasibility and accuracy of an intraoperative MRI brain biopsy technique in a case series of an earlier cohort of 68 patients (15). A separate group from the University of Minnesota also demonstrated in a case series that interventional MRI–guided biopsy is a safe and effective method (9). However, there have not been any studies comparing the safety and effectiveness of intraoperative MRI brain biopsy with the traditional stereotactic biopsy methods. In the present study, we evaluate a series of 288 consecutive brain biopsies performed over 8 years at the Brigham and Women’s Hospital in Boston, Massachusetts. We report our analysis of diagnostic yield, complications, and length of postoperative hospital stay between frame-based, frameless, and intraoperative MRI–guided brain biopsy procedures.
Section snippets
Materials and Methods
We reviewed a consecutive series of patients who underwent needle-based brain biopsy at Brigham & Women’s Hospital from 2000–2008. Open biopsy cases were excluded from the study. The attending neurosurgeons had a choice of 1 of 3 biopsy methods (frame-based, frameless, and intraoperative MRI–guided stereotactic). There were 288 biopsies performed in 277 patients. Age, gender, image characteristics, history of prior treatments, duration of hospital stay, and postoperative complications were
Factors Affecting Needle Biopsy Yields
The overall diagnostic yield was 87.8%, with a definitive histologic diagnosis in 253 of 288 cases. In 35 cases (12.2%), the biopsy yielded nondefinitive diagnoses, such as atypical cells, inflammation cells, or gliosis. We first analyzed possible factors that might affect needle biopsy yields, including age, gender, image characteristics, and history of previous treatments. Table 1 shows a univariate analysis of factors thought to play a role in affecting the diagnostic yield regardless of the
Comparable Diagnostic Yield Among 3 Needle Biopsy Methods
The present study describes our experience of a large series of consecutive needle brain lesion biopsies using frame-based, frameless, or intraoperative MRI–guided neuronavigational techniques. When we consider all patients in the series including patients with a history of previous treatments, frame-based needle biopsies were associated with the highest diagnostic yield, and intraoperative MRI–guided needle biopsies were associated with the lowest diagnostic yield. However, examination of
Conclusions
Frame-based, frameless, and intraoperative MRI–guided brain biopsy techniques are approximately equivalent in their ability to obtain a histopathologic diagnosis reliably after lesion sampling in patients with no prior radiation or surgical treatments. Frame-based brain biopsy has better diagnostic yield than intraoperative MRI–guided biopsy when all patients are included in the analysis. The intraoperative MRI–guided technique may prove to be safer and more cost-efficient in the future, as
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