Nöroşirürjide Rezeksiyon Cerrahisi ile Stereotaktik Beyin Biyopsilerinde İntraoperatif Tanı - Başarı ve Başarısızlık Ölçütleri

Amaç: Sinir sisteminin hastalıklarının cerrahi ve medikal tanı/tedavilerinde kullanılan bir yöntem olan intraoperatif tanı cerrahi rezeksiyon ve stereotaktik girişimlerde kullanılır. İntraoperatif tanı yöntemlerinin özgüllüğü, duyarlığı ve genel doğruluk derecesi tanı / tedaviye katkıda bulunan intraoperatif tanı ölçütlerinin çözümlemesidir. Materyal: Marmara Üniversitesi Nörolojik Bilimler Enstitüsü Patoloji Laboratuarına 1995-2003 yılları arasında gelen cerrahi rezeksiyon materyali n=529 ve stereotaktik beyin biyopsilerine n=368 [toplam=897] İOT’larda kullanılan dokundurma ve ezme preparatlar tekrar değerlendirilmiştir ve İOT’lerle parafi n blok tanıları karşılaştırılmıştır. Bulgular: Rezeksiyon cerrahisi ve stereotaktik biyopsilerde sırasıyla özgüllük %98 / 91, duyarlık %99.2 / 97 ve genel doğruluk derecesi %97.2 / 96.8 dir. Rezeksiyonlarda duyarlığı etkileyen lezyonlar infl amatuar lezyonlar, normal hipofi z, nöronal-glial tümörler, abse iken, stereotaktiklerde reaktif nörosellüler ve nöropil proliferasyonları, abse / serebrit ile infeksiyonlardır. Buna karşılık, özgüllüğü etkileyen lezyonlar ise, rezeksiyon materyalinde metastazlar, ensefalomalasi, lemfoma/lösemi, pilositik astrositoma ile normal nöral dokudur. Ortalama tanı süresi 20.2 dakikadır. Tartışma: I. Başarısızlıkların çözümlenmesinde neler ile karşılaşılır? 1. tümörün derecesini belirleyen tüm kriterlerin yapılan örneklemede izlenmemesi; 2. tümörün tüm bileşenlerinin örneklenmemiş olması; 3. yüksek dereceli tümörlerde hücre tipinin belirlenmesindeki zorluk; 4. glial tümörlerde vasküler proliferasyonun VEP olarak yorumlanması; 5. klinik ve radyolojik bulguların bildirilmemesi; 6 “radyasyona bağlı atipi”nin tümör olarak yorumlanması; 7. nekroz ve “reaktif atipi” ile seyreden infl amatuar lezyonların tümör olarak yorumlanması; 8. düşük dereceli tümörlerin “reaktif atipi” olarak yorumlanması; 9. Stromadan zengin tümörlerin neoplastik hücrelerinin yaymalara düşmemesidir. II. Başarısızlıklar nasıl önlenir? 1. Nöroşirurjiyen ve nöroradyolog ile birlikte çalışmalıdır. 2. İyi donanımlı doku hazırlama teknikleri, ameliyathane-patoloji fi zik mekanlarının koordinasyonu 3. Deneyimli nöroradyoloji, nöropatoloji bilgi birikimine sahip bir ekip çalışmasıyla sağlanabilir.

Intraoperative Diagnosis In Neurosurgical Resection Material and Stereotactic Brain Biopsies: Criteria For Success and Failure

Purpose: As a diagnostic and therapeutic tool intraoperative diagnosis IOD is widely used both in surgical resection SR and stereotactic biopsy STX approaches to nervous system. In this study sensitivity, specifi city and overall accuracy of IOD’s were analyzed. Material: Techniques known as imprint and squash preparation diagnoses were reevaluated and results were compared with that of paraffi n section diagnoses in a cohort formed by neurosurgical SR n=529 and STX n=368 [total=897] those were retrieved form archival material of Marmara University Neurological Sciences Institute, pathology laboratory in a period of 1995-2003. Findings: Specifi city values were found to be 98% and 91% in SR and STX biopsies respectively. Sensitivity rates were 99.2% and 97 and overall accuracy rates were 97.2/ and 97%. It was also clearly demonstrated factors eff ecting sensitivity in resected material were mainly infl ammatory lesions, normal pituitary tissue, neuronal- glial tumors and abscess whereas reactive changes and proliferations and infectious conditions, i.e., abscess and cerebritis in STX. However it was found factors aff ecting specifi city were consisted of metastasis, encephalomalasia, lymphoma/leukemia, pilocytic astrocytoma and normal neural tissue in SR. Mean time for intraoperative diagnosis was found to be 20.2 minutes. Discussion: I. What are the main diagnostic pitfalls? Unavoidable sampling errors, lack of relevant criteria in tumor grading; improper sampling of tumor components; inability of identifi cation of cell types in high grade tumors; misinterpretation of vascular proliferation as endothelial proliferation; insuffi cient clinical and radiological data; misinterpretation of radiation induced reactive changes as neoplastic alterations; misinterpretation of infl ammation induced necrosis and reactive atypia as neoplastic features; misinterpretation of low grade neoplastic lesions as reactive changes; lack of exfoliation of neoplastic cells in matrix rich lesions. II. How to avoid failures? Close cooperation with neurosurgeon and neuroradiologist; well equipped pathology laboratory in or around operating room; experienced neurosurgery, neuroradiology and neuropathology teamwork.

Keywords:

intraoperative diagnosis, frozen section, neuropathology, stereotactic biopsy intraoperative neurocytology,

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