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

OBJECTIVE: The course of malignant brain stem gliomas in childhood is rarely positive. Because of limited therapeutic options and potentially hazardous biopsies oncologist often relay on MRI diagnoses only for further therapy decisions. In this study we show that brain stem biopsies display a low morbidity rate and neuropathological assessment has a considerable impact on further treatment decision. METHODS: Within 18-months five children with brainstem symptoms and the radiological diagnosis of a malignant brainstem glioma, were identified. From this time point it was possible to analyze all samples with the 450K methylome analysis. Other neuropathological techniques included classical histology with immunohistochemistry. Surgery was performed as biopsy, either microsurgical, frame-guided (Leksell), robot-assisted (ROSA) or navigated (BrainLab, two children). RESULTS: Mean age of the children was 7.5years (range: newborn to 12years). There was no biopsy-related morbidity or mortality. The mean number of taken samples was 12 (range: 1-25). Histologic diagnosis could be established in all children, however, 450K methylome diagnosis was positive in only two out of five patients. CONCLUSION: Despite the technically difficult biopsies, all specimens were sufficient for immunohistochemical diagnosis, however, 450K methylome analysis could only be better established where multiple small samples were taken, instead of few larger ones. Based on the preoperative radiological diagnosis suggesting malignant brainstem glioma, all children would have been treated with combined radiation and temozolomid chemotherapy. Nevertheless, due to the availability of histology and molecular diagnostics, individualized therapy could be performed, preventing in two out of five children from unnecessary radiation and chemotherapy.

Stereotactic biopsy of brainstem lesions: 21 years experiences of a single center.

Stereotactic biopsies are procedures performed to obtain tumor tissue for diagnostic examinations. Cerebral lesions of unknown entities can safely be accessed and tissue can be examined, resulting in correct diagnosis and according treatment. Stereotactic procedures of lesions in highly eloquent regions such as the brainstem have been performed for more than two decades in our department. In this retrospective study we focus on results, approaches, modalities of anesthesia, and complications. We performed a retrospective analysis of our prospective database, including 26 patients who underwent stereotactic biopsy of the brainstem between April 1994 and June 2015. All of the patients underwent preoperative MRI. Riechert-Mundinger-frame was used before 2000, thereafter the Leksell stereotactic frame was used. After 2000 entry and target points were calculated by using BrainLab stereotactic system. We evaluated histopathological results as well as further treatment; additionally we compared complications of local versus general anesthesia and complications of a frontal versus a trans-cerebellar approach. Median age of all patients was 33 years, and median number of tissue samples taken was 12. In all patients a final histopathological diagnosis could be established. 5 patients underwent the procedure under local anesthesia, 21 patients in general anesthesia. In 19 patients a frontal approach was performed, while in 7 patients a trans-cerebellar approach was used. Complications occurred in five patients. Thereby no significant difference was found with regard to approach (frontal versus trans-cerebellar) or anesthesia (local versus general). Stereotactic biopsies even of lesions in the brainstem are a save way to obtain tumor tissue for final diagnosis, resulting in adequate treatment. Approach can be trans-cerebellar or frontal and procedure can be performed either under local or general anesthesia without significant differences concerning complication rate.