Variations in attitudes towards stereotactic biopsy of adult diffuse midline glioma patients: a survey of members of the AANS/CNS Tumor Section

Abstract

Purpose Diffuse midline gliomas are rare midline CNS malignancies that primarily affect children but can also affect adults. While radiation is standard treatment, prognosis remains fatal. Furthermore, due to its sensitive anatomic location, many physicians have been reluctant to perform biopsies without potential for improved prognosis. However, recent advancements in molecular-targeted therapeutics have encouraged greater tissue sampling. While the literature reflects this progress, the landscape of how clinicians actually manage these patients remains unclear. Our goal was to assess the attitudes of current practicing neurosurgical oncologists towards management of adult diffuse midline gliomas, reasons behind their practices, and factors that might influence these practices. Methods We created and distributed a survey with 16 multiple choice and open-ended questions to members of the Tumor Section of the Congress of Neurological Surgeons. Results A total of 81 physicians responded to the survey. Although time since training and volume of glioma patients did not significantly affect the decision to consider clinical trials or to offer biopsy, those that operated on fewer gliomas (< 25/ year) were more likely to cite surgical morbidity as the primary reason not to biopsy these midline locations. Further, surgeons with access to more advanced molecular testing were significantly more likely to consider clinical trial eligibility when offering biopsies. Conclusion Factors that affect the management of diffuse midline gliomas and the role of biopsy are relatively uniform across the field, however, there were a few notable differences that reflect the changes within the neuro-oncology field in response to clinical trials.

Deep learning‐based prediction of H3K27M alteration in diffuse midline gliomas based on whole‐brain MRI

“…Different grades and molecular markers of gliomas have significant impacts on patient survival and treatment. The use of surgery or stereotaxic biopsy to clarify pathology is uncommon for gliomas that grow in midline locations that are surrounded by important functional tissues 18 . Although stereotaxic brain biopsy is the gold standard for histological and genetic classification, pathological diagnoses may remain uncertain in 7%–15% of patients 30 .…”

“…The use of surgery or stereotaxic biopsy to clarify pathology is uncommon for gliomas that grow in midline locations that are surrounded by important functional tissues. 18 Although stereotaxic brain biopsy is the gold standard for histological and genetic classification, pathological diagnoses may remain uncertain in 7%–15% of patients. 30 In recent years, owing to the increased capacity of computing power, the wider range of data, and the availability of better models and algorithms, deep learning has developed significantly.…”

“…At present, tissue biopsy is the main method to detect H3K27M alterations, but it often requires craniotomy, which is an invasive and high‐risk inspection method. A survey shows that more than half of surgeons (59%) will not consider routine biopsy for DMG 18 …”

“…A survey shows that more than half of surgeons (59%) will not consider routine biopsy for DMG. 18 Magnetic resonance imaging (MRI) is a noninvasive examination that can provide images of the whole tumor, offering advantages over stereotactic or open biopsy which provide only limited amounts of tumor tissue for molecular diagnoses and may be subject to sampling bias. However, the tumor appearance observed by the naked eye on MRI shows diversity, and its enhancement features, border features, infiltration appearance, and oedema are not enough to distinguish H3K27M alterations.…”