Elsevier

World Neurosurgery

Volume 96, December 2016, Pages 124-128
World Neurosurgery

Original Article
Stereotactic Biopsy of Pineal Lesions

https://doi.org/10.1016/j.wneu.2016.04.130Get rights and content

Background

Stereotactic biopsies are carried out to obtain tumor tissue of unknown entity from cerebral lesions. Thus, tumor tissue can be examined, resulting in correct diagnosis and treatment. These procedures go in hand with high accuracy, high diagnostic yield, and low complication rates.

Objectives

The aim of this study is to evaluate the results and complications of stereotactic biopsies carried out for lesions of the pineal region.

Methods

We performed a retrospective analysis of our prospective database and included 14 patients who underwent stereotactic biopsy of a pineal lesion between 2006 and February 2016. The Leksell stereotactic frame was used in all patients, and entry and target points were calculated using the BrainLab stereotactic system. We evaluated histopathologic results and postoperative complications such as hydrocephalus and hemorrhage.

Results

Histopathologic diagnosis was established in all patients. On postoperative computed tomography, 7 patients (50%) showed a circumscribed blood collection at the site of biopsy. Six patients (42.8%) required a cerebrospinal fluid drain preoperatively. Two patients needed external ventricular drain postoperatively (14.2%). One of these patients showed a small hemorrhage area that caused the hydrocephalus. The other patient showed only postoperative swelling. Preoperatively, 2 patients (14.2%) already had a ventriculoperitoneal (VP) shunt, whereas postoperatively, another 4 patients (28.5%) needed a VP shunt. Thus, of the 14 patients, 6 (42.8%) required a VP shunt.

Conclusions

Because of their localization, pineal lesions may result in emergence of a hydrocephalus. Stereotactic biopsies in this area may increase this effect and, thus, even VP shunts are necessary in some patients.

Introduction

In various neurosurgical departments, stereotactic biopsies are performed as standard procedures to obtain tissue of unknown entity for histopathologic diagnosis.

Stereotactic biopsies can be performed under various modalities. Different departments use local or general anesthesia,1 frame-based and frameless systems, or intraoperative magnetic resonance imaging (MRI) and robotic-assisted systems.2, 3 Even lesions in highly eloquent areas can be safely reached; also, children can undergo the procedure.4, 5

The aim of this study is to evaluate the results and complications of stereotactic biopsies carried out for lesions of the pineal region.

The region of the pineal gland is dorsally bound to the corpus callosum, ventrally to the quadrigeminal plate, and rostrally to the midbrain and third ventricle. Caudally, the pineal area is restricted by the vermis.6 Because of the variety of different tissues, wide-ranging lesions can arise not only in pediatric patients (3%–8% of pediatric brain tumors) but also in adults (<1%).7 In young patients (<40 years), tumors are most likely to be germinomas, whereas in patients older than 40 years, gliomas are the most common entitiy.8 Because of their localization and possible compression of the aqueduct, pineal lesions can lead to hydrocephalus.

Furthermore, the pineal region has various vessels (vein of Galen, basal vein of Rosenthal, internal cerebral veins, and choroidal arteries) that might be harmed during stereotactic surgery, causing hemorrhage.9, 10

Section snippets

Methods

We performed a retrospective analysis of our prospective database and included 14 patients who had undergone stereotactic biopsy of a pineal lesion between 2006 and February 2016.

Indication to biopsy the pineal lesion was based on interdisciplinary tumor board decision. Lesions that showed contrast enhancement or progression in size were biopsied.

We included 8 male (57.1%) and 6 (42.9%) female patients; the median age was 39.5 years. In all cases, thin-slice MRI was performed before surgery. On

Results

Initial symptoms were headache in 4 patients (28.6%), vision impairment in 3 patients (21.4%), and hydrocephalus in 2 patients (14.3%). Three patients described diffuse symptoms with nausea and headache (21.4%), 1 patient showed hemiparesis (7.1%), and in 1 patient the lesion was an incidental finding (7.1%).

Before biopsy, tumor progression was observed in 4 patients (28.5%) in the course of a scheduled follow-up examination after initial diagnosis.

Thirteen of the 14 included patients received

Discussion

Pineal tumors are rare lesions accounting for less than 5% of all intracranial tumors.11, 12 As with all tumors, adequate therapy is based on correct diagnosis. Even although imaging techniques have much improved recently in as much that most pineal lesions show individual intensity in MRI diffusion-weighted imaging and MRI spectroscopy,13 the gold standard is still histopathologic diagnosis.

In the pineal area, biopsies can be performed stereotactically or endoscopically. However, comparing a

Conclusions

Stereotactic biopsy of pineal lesions can be performed with high diagnostic yield and is still the standard procedure to obtain tumor tissue on which to base further therapy. In many patients, the postoperative course is complicated by hemorrhage or hydrocephalus, necessitating close surveillance.

References (17)

There are more references available in the full text version of this article.

Cited by (18)

  • Management of Obstructive Hydrocephalus Associated with Pineal Region Cysts and Tumors and Its Implication in Long-Term Outcome

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    Direct removal of the lesions, endoscopic third ventriculostomy (ETV) plus biopsy, and shunt procedures are the most frequently carried out. However, standard protocols are still not well established.3-10 We present and discuss obstructive hydrocephalus management associated with pineal region tumors and cysts in HUH.

  • Lateral Temporal Approach for Image-Guided Stereotactic Biopsy of Pineal Region Tumors

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    It should also avoid transgression of the ventricle, which could lead to a shift in anatomic structures with egress of CSF or even choroid plexus injury and bleeding. Previously described stereotactic biopsy approaches (Table 1) include frontal oblique,2,12,13,18-22 lateral temporal orthogonal,12,13,18-22 high posterior parietal,2 and parieto-occipital20,21 routes. The most commonly reported approach is the frontal oblique route, which is fairly long and traverses the internal capsule.

  • Prognostic risk factors for postoperative hemorrhage in stereotactic biopsies of lesions in the basal ganglia

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    Nevertheless, our clinical experience also showed that the location of the stereotactic biopsy is important. We were able to provide evidence that for example stereotactic biopsy of pineal lesions show a higher risk of bleeding and consecutive hydrocephalus [20]. Grossmann et al. have shown that also lesions located in the brainstem showed a significantly higher occurrence of hemorrhagic complications [12].

  • “Two is not enough” – Impact of the number of tissue samples obtained from stereotactic brain biopsies in suspected glioblastoma

    2018, Journal of Clinical Neuroscience
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    The procedure is generally performed with high safety and precision resulting in high diagnostic yield. Also deep seated tumors and lesions in eloquent areas can be reached safely and in most of the case series published, a final diagnosis could be established [13,15]. In our already published studies we have shown, that the procedure can be performed safely not only in adults but also in children, HIV patients, and patients with brainstem lesion as well as pineal lesions.

  • Biopsies of pediatric brainstem lesions display low morbidity but strong impact on further treatment decisions

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    However, these improved diagnostic and therapeutic approaches may be associated with an increased risk of biopsy-related complications thereby potentially abolishing the effect of longer survival, in particular, if the best result of an individualized therapy is only a slightly prolonged live expectancy. In former studies we have shown, that stereotactic procedures, even in eloquent brain areas, can be carried out with a low morbidity and mortality in adults [15,16] and children [14]. In this study we will show that brainstem biopsies in children can be performed safely and have a high impact on the individual therapy.

  • Benefit and Complications of Frame-Based Stereotactic Biopsy in Old and Very Old Patients

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    To obtain tumor tissue, stereotactic biopsy of cerebral lesions is often performed. Studies have shown that it is a safe procedure in children and adults with brain lesions in various locations.4,8,11-15 Even eloquent locations such as the brainstem can be accessed and tissue samples can be taken with maximum safety and high precision.13,16

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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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