Influence of preoperative corticosteroid treatment on rate of diagnostic surgeries in primary central nervous system lymphoma: a multicenter retrospective study

Abstract

Background Corticosteroid therapy (CST) prior to biopsy may hinder histopathological diagnosis in primary central nervous system lymphoma (PCNSL). Therefore, preoperative CST in patients with suspected PCNSL should be avoided if clinically possible. The aim of this study was thus to analyze the difference in the rate of diagnostic surgeries in PCNSL patients with and without preoperative CST. Methods A multicenter retrospective study including all immunocompetent patients diagnosed with PCNSL between 1/2004 and 9/2018 at four neurosurgical centers in Austria was conducted and the results were compared to literature. Results A total of 143 patients were included in this study. All patients showed visible contrast enhancement on preoperative MRI. There was no statistically significant difference in the rate of diagnostic surgeries with and without preoperative CST with 97.1% (68/70) and 97.3% (71/73), respectively (p = 1.0). Tapering and pause of CST did not influence the diagnostic rate. Including our study, there are 788 PCNSL patients described in literature with an odds ratio for inconclusive surgeries after CST of 3.3 (CI 1.7–6.4). Conclusions Preoperative CST should be avoided as it seems to diminish the diagnostic rate of biopsy in PCNSL patients. Yet, if CST has been administered preoperatively and there is still a contrast enhancing lesion to target for biopsy, surgeons should try to keep the diagnostic delay to a minimum as the likelihood for acquiring diagnostic tissue seems sufficiently high.

An Update on Neurosurgical Management of Primary CNS Lymphoma in Immunocompetent Patients

“…A major clinical issue that may be responsible for distinct diagnostic delay is preoperative CST, especially if CST must be stopped before surgery due to regression ( 13 ). If clinically possible, CST should therefore strictly be avoided in potential PCNSL patients as it increases the rate of inconclusive biopsies ( 44 ). In patients with no history of malignancy or immunosuppression and periventricular tumors upon initial CT, we recommend withholding the patient from CST treatment until MRI provides further diagnostic information and subsequent steps of diagnosis should be executed shortly after.…”

“…Stereotactic or frameless biopsy is the standard neurosurgical procedure for acquiring tissue in PCNSL and achieves a diagnostic yield of more than 91% ( 13 , 44 ). Overall, stereotactic biopsy is accompanied a periprocedural morbidity of 8.5% and mortality of 0.9% ( 45 ).…”

“…This was formerly described as diagnostic for PCNSL, but is obsolete nowadays, as also other tumor entities were identified to show transient regression after CST ( 65 – 68 ). Retrospective studies showed an increased rate of inconclusive biopsies after CST of 11–22% ( 13 , 14 , 69 ), while recent retrospective studies showed that there is not necessarily a decrease in the diagnostic yield after preoperative CST ( 44 , 70 – 72 ). However, besides a potential selection bias, these studies lacked the statistical power to identify small differences in diagnostic rates.…”

“…However, besides a potential selection bias, these studies lacked the statistical power to identify small differences in diagnostic rates. A recent combined analysis of the available studies showed an odds ratio of 3.3 for inconclusive biopsy after CST ( 44 ). Although absolute numbers of inconclusive biopsies decreased, the odds ratio for inconclusive biopsy after preoperative CST remained the same.…”

“…The optimal management of PCNSL patients with preoperative CST remains controversial. The exact time of CST tapering that is necessary to overcome the influence of CST on diagnostic yield is not defined ( 13 , 44 ). In practice, if a contrast-enhanced lesion shows distinct regression, surgery is usually delayed until new progression is evident in serial MRI ( 9 , 73 ).…”