Department of Neurosurgery, Wessex Neurological Centre, Southampton General Hospital, Southampton, Hampshire, UK.
J Neurosurg. 2010 Aug;113(2):170-8. doi: 10.3171/2009.12.JNS09573.
Stereotactic biopsy is a safe and effective technique for the diagnosis of brain tumors. The use of intraoperative neuropathological examination has been routinely advocated to increase diagnostic yield, but the procedure lengthens surgical time, may produce false-negative and -positive results, and current biopsy techniques have a very low nondiagnostic rate. Therefore, the authors questioned the need for intraoperative histological evaluation.
The authors prospectively studied all patients undergoing image-guided biopsy under the care of a single surgeon (P.L.G.) between July 2005 and October 2007. A Stryker neuronavigation system with a trajectory guide was used to plan a single trajectory, and, using a side-cutting biopsy cannula, multiple biopsy samples were taken from between 1 and 4 sites within the tumor. Tissue was inspected macroscopically by the surgeon and was only submitted for neuropathological assessment postoperatively.
One hundred thirty-four biopsies were performed during the study. A positive diagnosis was established in 133 cases (99.3%). One biopsy was negative (0.7%) and postoperative imaging (performed because the tissue was macroscopically normal) demonstrated inaccurate targeting of the lesion. Significant complications were seen in 3 patients (2.2%) who all had preoperative WHO performance scores of III or IV. Two patients suffered delayed deterioration and died due to probable surgical complications--one with thalamic glioblastoma multiforme (GBM) and one with gliomatosis cerebri. One patient with GBM suffered an intracerebral hematoma that was managed conservatively. Postoperative seizures were seen in 4 patients (3%), and 2 patients (1.5%) experienced a transient neurological deficit. Histological diagnosis showed a GBM in 64 cases, Grade III glioma in 19, Grade I or II in 23, metastasis in 10, lymphoma in 13, and other disease in 4. There were 32 patients discharged to home on the same day as surgery. Compared with the authors' previous retrospective audit into 127 biopsies, this technique showed improved diagnostic yield (99.3 vs 94.5%, p = 0.032) with fewer complications (2.2 vs 4.7% [not statistically significant]).
This technique of image-guided biopsy has high diagnostic yield with acceptably low morbidity and may be performed as a day case. Intraoperative neuropathological examination would not have increased the diagnostic yield further in this study, and its routine use may not be necessary. In the authors' department pounds sterling 70,350 (UK)/$114,522 (US) would have been saved by not using intraoperative neuropathology in this series. Therefore, intraoperative neuropathology should no longer be routinely recommended.
立体定向活检是一种安全有效的脑肿瘤诊断方法。术中神经病理检查的应用已被常规提倡以提高诊断率，但该过程延长了手术时间，可能产生假阴性和假阳性结果，且当前的活检技术具有非常低的非诊断率。因此，作者对术中组织学评估的必要性提出了质疑。
作者前瞻性研究了 2005 年 7 月至 2007 年 10 月期间由一位外科医生（P.L.G.）护理的所有接受影像引导活检的患者。使用 Stryker 神经导航系统和轨迹引导器规划一条单一的轨迹，并使用侧切活检套管，从肿瘤内的 1 至 4 个部位采集多个活检样本。外科医生对组织进行了宏观检查，仅在术后将其送检神经病理评估。
在研究期间进行了 134 次活检。133 例（99.3%）建立了阳性诊断。1 例活检为阴性（0.7%），术后影像学检查（因组织宏观上正常而行）显示病变的定位不准确。3 例（2.2%）患者出现显著并发症，他们术前的世界卫生组织（WHO）表现评分均为 III 或 IV 级。2 例患者出现延迟恶化并因可能的手术并发症死亡，其中 1 例为丘脑多形性胶质母细胞瘤（GBM），1 例为脑胶质细胞瘤病。1 例 GBM 患者发生颅内血肿，采用保守治疗。4 例（3%）患者术后出现癫痫发作，2 例（1.5%）患者出现短暂性神经功能缺损。组织学诊断显示 64 例为 GBM、19 例为 3 级胶质瘤、23 例为 1 级或 2 级、10 例为转移瘤、13 例为淋巴瘤和 4 例为其他疾病。32 例患者在手术当天出院回家。与作者之前回顾性审核的 127 例活检相比，该技术显示出更高的诊断率（99.3%比 94.5%，p=0.032）和更低的并发症发生率（2.2%比 4.7%[无统计学意义]）。
这种影像引导活检技术具有较高的诊断率，发病率可接受，并且可以作为日间手术进行。在本研究中，术中神经病理学检查不会进一步提高诊断率，因此其常规应用可能并非必要。在作者所在的部门，本系列病例中不使用术中神经病理学检查可节省 70350 英镑（英国）或 114522 美元（美国）。因此，术中神经病理学检查不应再常规推荐。
