Efficacy of a Second Brain Biopsy for Intracranial Lesions after Initial Negativity

Abstract

Background and purpose: The rationale for performing a second brain biopsy after initial negativity is not well evaluated in the literature. This study was designed to 1) assess the efficacy of a second brain biopsy when the first biopsy was nondiagnostic, 2) identify possible factors associated with an increased diagnostic rate in the second biopsy, and 3) analyze additional morbidity induced by the second biopsy.

Methods: We performed a retrospective cohort study from 2009 to 2019, during which 1,919 patients underwent a brain biopsy, including 30 who were biopsied twice (1.6%). The specific histological diagnosis rate, diagnosis-associated factors, and complication rate were assessed for the 30 twice-biopsied patients.

Results: The second biopsy allowed a specific histological diagnosis in 86.7% of the patients who had initially undergone a nondiagnostic brain biopsy [odds ratio (OR)=7.5, 95% confidence interval (CI)=3.0-18.7, p<0.001]. The multivariate analysis showed that only prebiopsy corticosteroid administration (OR=2.6, 95% CI=1.1-6.0, p=0.01) was an important factor in predicting a nondiagnostic biopsy. None of the patients developed a symptomatic complication after the first biopsy, while two (6.0%) patients experienced a transient complication after the second biopsy (p=0.49).

Conclusions: Performing a second brain biopsy in patients who have an initial nondiagnostic biopsy is effective in most cases. We advocate that a second biopsy be systematically considered in the diagnosis algorithm of these patients after it has been verified that molecular testing cannot help to obtain a diagnosis. Corticosteroid administration can lead to nondiagnostic biopsies and should be avoided when possible during the prebiopsy period.

Keywords: brain tumor; corticosteroids; diagnosis; neoplasms; neuropathology; neurosurgery.

Fig. 1. Flow chart of patient inclusion in this study of the contribution to the diagnosis of a second brain biopsy after a nondiagnostic first biopsy.

Fig. 2. Four example cases illustrating the differences between the nondiagnostic first biopsy and the diagnostic second biopsy. The blue line indicates the biopsy target obtained by merging postoperative CT scan and preoperative MRI. Case #15. A 63-year-old female underwent a stereotactic brain biopsy for a left middle cerebellar peduncle lesion. The initial neuropathological examination found only normal cerebellar tissue. A postoperative CT scan showed a target error (A1). The neuropathological examination of the second stereotactic biopsy performed 19 days later was consistent with breast cancer metastasis (A2). The red arrowhead shows the target of the first biopsy (A2). Case #18. A 68-year-old male presented with left hemiparesis. Brain MRI showed a right frontal “flaky” contrast-enhanced lesion. Corticosteroids were introduced and then stopped 3 days before performing the stereotactic biopsy. The neuropathological analysis revealed inflammatory lesions with macrophage infiltration (B1). This noncontributory result led to a second biopsy being performed 25 days after withdrawing the corticosteroids, which led to a diagnosis of a B-cell primary lymphoma in the central nervous system (B2). Case #25. A 63-year-old male was admitted due to suspected left medial temporal tumor. The neuropathological examination of the stereotactic biopsy sample revealed nonspecific necrosis (C1). Corticosteroids were introduced after the biopsy, and tumor regression was found in brain MRI performed 20 days later (C2). Corticosteroid therapy was therefore stopped, and follow-up imaging revealed increases in the size and spread of the lesion (C3). A second brain biopsy performed 45 days after the first biopsy disclosed a grade IV glioma. Case #30. A 57-year-old female underwent a stereotactic brain biopsy due to suspected left medial temporal tumor (D1). The neuropathological examination revealed nonspecific necrosis. The second stereotactic biopsy performed 3 weeks later was consistent with a grade IV glioma (D2). The red arrowhead shows the particularly interesting finding of the trajectory of the first needle biopsy (D2).