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

Yıl 2010, Sayı: 1, 13 - 20, 01.03.2010

Aydın Sav

Öz

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.

Anahtar Kelimeler

intraoperative diagnosis frozen section neuropathology stereotactic biopsy intraoperative neurocytology

Kaynakça

  • Bigner DD, McLendon RE, Bruner JM (eds). Russell & Rubinstein’s Pathology of Tumors of the Nervous System. 6th ed, Edward Arnold, 1998.
  • Burger PC, Scheithauer BW: Tumors of the Nervous of the Central Nervous System. Atlas of Tumor Pathology, third series, fascicle 10. Washington, D.C., Armed Forces Institute of Pathology, 1994.
  • Burger PC, Scheithauer BW, Vogel FS: Surgical Pathology of the Nervous System and its Coverings, 4th ed. New York, Churchill Livingstone Inc, 2002.
  • Ellison D, Chimelli L, Harding B, Love S, Lowe J, Lowe J. Neuropathology: A reference text of CNS pathology, Mosby-Year Book, 1998.
  • Chandrasoma PT, Apuzzo MLJ. Stereotactic Brain Biopsy. New York, Igaku-Shoin,1989.
  • Brainard JA, Prayson RA, Barnett GH. Frozen section evaluation of stereotactic brain biopsies: diagnostic yield at the stereotactic target position in 188 cases. Arch Pathol Lab Med. 1997; 121(5):481-4.
  • Esiri MM, Oppenheimer DR. Diagnostic Neuropathology. Blackwell Science Inc, 1989.
  • Firlik KS, Martinez AJ, Lunsford LD. Use of cytological preparations for the intraoperative diagnosis of stereotactically obtained brain biopsies: a 19-year experience and survey of neuropathologists. J Neurosurg. 1999;91(3):454-8.
  • Folkerth RD. Smears and frozen sections in the intraoperative diagnosis of central nervous system lesions. Neurosurg Clin N Am. 1994;5(1):1-18.
  • Graham DI, Ironside JW, Bell JE. Color Atlas and Text of Neuropathology. 3rd ed, Britnell Book Wholesalers, 1996.
  • Eisenhardt L, Cushing H. Diagnosis of intracranial tumours by supravital technique. Am J Pathol 1930;6:541-552.
  • Russell D, Krayenbuhl H, Cairns H. The wet fi lm technique in the hisological diagnosis of intracranial tumours: A rapid method. J Pathol Bacteriol 1937;45:501-505.
  • Marshall LF, Adams H, Doyle D, Grahan HI. The histological accuracy of the smear technique for neurosurgical biopsies. J Neurosurg 1973;39:83-9.
  • Berkeley BB, Adams JH, Doyle D, Graham DI, Harper CG. The smear technique in the Diagnosis of neurosurgical biopsies. NZ Med J 1978;87:12-15.
  • Akpulat S, Kurtkaya Ö, Peker S, Sav A. Stereotaktik beyin biyopsilerinde intraoperatif tanı. XVII. Ulusal Patoloji Kongresi, 3-6 Ekim 2004, Gaziantep.
  • Arendt A. Intraoperative rapid frozen section diagnosis of brain biopsies (author’s transl)] Zentralbl Allg Pathol. 1982;126(1-2):16-8. German.
  • Bayındır C,Barlas O. Reliability of cytologic diagnosis of brain tumors in stereotactic biopsies. Med Bull İstanbul 1995;28;1:7-14.
  • Bülbül HD, Aksoy F, Sav A. Cerrahi Patolojide Frozen Section: 368 Frozen Section Olgusunun Retrospektif Analizi. Sekizinci Ulusal Patoloji Kongresi Kitabı, 21 24 Kasım 1988, Ankara, 1989; s. 59 63.
  • Cahill EM, Hidvegi DF. Crush preparations of lesions of the central nervous system. A useful adjunct to the frozen section. Acta Cytol. 1985;29(3):279-85.
  • Challis D.Broad sheet number 41:Frozen section and intra-operative diagnosis. Pathology 1997;29:165-174.
  • Martinez AJ, Pollack I, Hall WA, Lunsford LD. Touch preparations in the rapid intraoperative diagnosis of central nervous system lesions. A comparison with frozen sections and paraffi n-embedded sections. Mod Pathol. 1988;1(5):378-84.
  • Gürses İ, Sav A, Kurtkaya Ö. Cerrahi nöropatolojide intraoperatif tanının değerlendirilmesi: SSS lezyonlarının intraoperatif tanısında dokundurma ve ezme doku preparasyon tekniklerinin yeri. 15. Ulusal Patoloji Sempozyumu Türk Patoloji Dernegi, Cerrahi Patolojide Ayırıcı Tanı, 24-27 Mayıs 2000, Belek, Antalya.
  • Bigner SH, Johnston WW. Cytopathology of the Central Nervous System. ASCP Theory and Practice of Cytopathology. 3 Johnston WW, ed., Chicago: American Society of Clinical Pathologists,1994.
  • Burger PC. Use of cytological preparations in the frozen section diagnosis of central nervous system neoplasia. Am J Surg Pathol. 1985;9(5):344-54.
  • Sav A, Ataizi Ç, Küllü S, Pamir N, Özer F. Santral sinir sistemi lezyonlarının peroperatuar tanısında uygulanan tekniklerin değerlendirilmesi (dokundurma, ezme ve frozen section tekniklerinin karşılaştırmalı sonuçları). X. Ulusal Patoloji Sempozyumu – Sitopatoloji, 30 Ekim 2 Kasım 1991.
  • Sav A, Dikeç D. Cerrahi Patolojide Frozen Section: 159 Frozen section olgusunun değerlendirilmesi. Ankara Numune Hastanesi Bülteni 1987;27(27) 1-2.
  • Shah AB, Muzumdar GA, Chitale AR, Bhagwati SN. Squash preparation and frozen section in intraoperative diagnosis of central nervous system tumors. Acta Cytol. 1998;Oct;42(5):1149-54.
  • Slowinski J,Harabin-Slowinska M.Smear technique in the intraoperative brain tumor diagnosis:its advantages and limitations. Neurol Res 1999;21(1):121-124.
  • Stefano DD,Scucchi LF,Cosentino L.Intraoperative diagnosis of nervous system lesions.Acta Cytol 1998;42:346-356.
  • Doğan T, Batırel H, Sav A. Frozen section material using distinctive preparation techniques (squash versus imprint). 8th International Medical Sciences Student Congress, İstanbul, May 13 15, 1992.
  • Kontozoglou TE,Cramer HM.The advantages of intraoperative cytology.Analysis of 215 smear and review of the literature.Acta Cytol 1991;35:154-164.
  • Luis FB Torres,Collaca LM.Smear technique in the intraoperative examination of nervous system lesions.Acta Cytol 1993;37:34-39.
  • Moss TM, Nicoll JAR, Ironside JW. Intraoperative Diagnosis of CNS tumors. London: Arnold, 1997.
  • Nguyen GK, Johnson ES, Mielke BW, Nguyen-Ho P. Cytology of intracranial tumors in crush preparations. Its contribution to frozen section diagnosis. Pathol Annu. 1994;29 ( Pt 2):233-57.
  • Sav A, Ataizi Ç, Küllü S, Pamir N, Özer F. Ultrasound guided beyin biopsilerinin değerlendirilmesi. dokundurma, ezme ve frozen section tekniklerinin karşılaştırmalı sonuçları). X. Ulusal Patoloji Sempozyumu, Sitopatoloji. 30 Ekim 2 Kasım 1991.
  • Ünüvar Atılmış Ü, Vardar Aker F., Güneş P, Peker Ö. Santral sinir sistemi tümörlerin intraoperatif acil tanısında sitolojisinin tanı değeri. Türk Patoloji Dergisi, 2001;17 (3-4):67-71.
  • Söylemezoğlu F, Sav A, Küllü S, Ersev A, Ataizi Ç. 264 Frozen Section Olgusunun Retrospektif Analizi. Kartal Eğitim ve Araştırma Klinikleri 191;1(3);2:133-137.
  • Reyes MG,Homsi F,Glick RP. Imprints, smears and frozen sections of brain tumors. Neurosurgery 191;29:575-579.
  • MacQueen CL. An improved mounting solution for frozen brain sections. Stain Technol. 1978;53(4):243-4.
  • Groves R, Hesslevik M. The diagnosis of frozen section examination in neurosurgery. Acta Neurol Scand 1966;42:268-74.
  • Hume Adams J, Graham DI, Doyle D. Brain biopsy. The smear technique for neurosurgical biopsies. London: Chapman & Hall, 1981.
  • Hayden R, Cajulis RS, Frias-Hidvegi D, Brody BA, Yu G, Levy R. Role of cytology in the intraoperative diagnosis of HIV-positive patients undergoing stereotactic brain biopsy. Acta Cytol. 1997;41(2):481-6.
  • Miller DC, Najjar S, Budzilovich GN. Neuropathology of AIDS in surgical biopsy specimens. Neurosurg Clin N Am. 1994;5(1):57-70.
  • Kleihues P, Cavenee W. Pathology and Genetics. Tumours of the Nervous System. WHO Classifi cation of Tumours. IARC, Lyon, 2000.
  • Kleihues P, Louis DN, Scheithauer BW, Rorke LB, Reifenberger G, Burger PC, Cavenee WK. The WHO classifi cation of tumors of the nervous system. J Neuropathol Exp Neurol 2002; 61, 3: 215-225.
  • McLendon RE, Bigner DD, Bigner S, Provenzale J. Pathology of Tumors of the Central Nervous System: A guide to Histologic Diagnosis. 1st ed., Edward Arnold, 2000.
  • Revesz T,Scaravilli F.Reliability of histological diagnosis including grading in gliomas biopsied by image-guided stereotactic technique. Brain;1993;16:781-793.
  • Robbins PD, Yu LL, Lee M, Stokes BA, Thomas GW, Watson P, Wong G. Stereotactic biopsy of 100 intracerebral lesions at Sir Charles Gairdner Hospital. Pathology. 1994;26(4):410-3.
  • Silverman JF. Cytopathology of fi ne-needle aspiration biopsy of the brain and spinal cord. Diagn Cytopathol. 1986;2(4):312-9.
  • Har-El G, Rao C, Swanson RM, Abdu AF, Milhorat TH. Frozen section in pituitary surgery. J Neurol Neurosurg Psychiatry. 1997;63(4):554.

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

Yıl 2010, Sayı: 1, 13 - 20, 01.03.2010

Aydın Sav

Öz

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.

Anahtar Kelimeler

intraoperatif tanı frozen section nöropatoloji stereotaktik biyopsi intraoperatif nörositoloji

Kaynakça

  • Bigner DD, McLendon RE, Bruner JM (eds). Russell & Rubinstein’s Pathology of Tumors of the Nervous System. 6th ed, Edward Arnold, 1998.
  • Burger PC, Scheithauer BW: Tumors of the Nervous of the Central Nervous System. Atlas of Tumor Pathology, third series, fascicle 10. Washington, D.C., Armed Forces Institute of Pathology, 1994.
  • Burger PC, Scheithauer BW, Vogel FS: Surgical Pathology of the Nervous System and its Coverings, 4th ed. New York, Churchill Livingstone Inc, 2002.
  • Ellison D, Chimelli L, Harding B, Love S, Lowe J, Lowe J. Neuropathology: A reference text of CNS pathology, Mosby-Year Book, 1998.
  • Chandrasoma PT, Apuzzo MLJ. Stereotactic Brain Biopsy. New York, Igaku-Shoin,1989.
  • Brainard JA, Prayson RA, Barnett GH. Frozen section evaluation of stereotactic brain biopsies: diagnostic yield at the stereotactic target position in 188 cases. Arch Pathol Lab Med. 1997; 121(5):481-4.
  • Esiri MM, Oppenheimer DR. Diagnostic Neuropathology. Blackwell Science Inc, 1989.
  • Firlik KS, Martinez AJ, Lunsford LD. Use of cytological preparations for the intraoperative diagnosis of stereotactically obtained brain biopsies: a 19-year experience and survey of neuropathologists. J Neurosurg. 1999;91(3):454-8.
  • Folkerth RD. Smears and frozen sections in the intraoperative diagnosis of central nervous system lesions. Neurosurg Clin N Am. 1994;5(1):1-18.
  • Graham DI, Ironside JW, Bell JE. Color Atlas and Text of Neuropathology. 3rd ed, Britnell Book Wholesalers, 1996.
  • Eisenhardt L, Cushing H. Diagnosis of intracranial tumours by supravital technique. Am J Pathol 1930;6:541-552.
  • Russell D, Krayenbuhl H, Cairns H. The wet fi lm technique in the hisological diagnosis of intracranial tumours: A rapid method. J Pathol Bacteriol 1937;45:501-505.
  • Marshall LF, Adams H, Doyle D, Grahan HI. The histological accuracy of the smear technique for neurosurgical biopsies. J Neurosurg 1973;39:83-9.
  • Berkeley BB, Adams JH, Doyle D, Graham DI, Harper CG. The smear technique in the Diagnosis of neurosurgical biopsies. NZ Med J 1978;87:12-15.
  • Akpulat S, Kurtkaya Ö, Peker S, Sav A. Stereotaktik beyin biyopsilerinde intraoperatif tanı. XVII. Ulusal Patoloji Kongresi, 3-6 Ekim 2004, Gaziantep.
  • Arendt A. Intraoperative rapid frozen section diagnosis of brain biopsies (author’s transl)] Zentralbl Allg Pathol. 1982;126(1-2):16-8. German.
  • Bayındır C,Barlas O. Reliability of cytologic diagnosis of brain tumors in stereotactic biopsies. Med Bull İstanbul 1995;28;1:7-14.
  • Bülbül HD, Aksoy F, Sav A. Cerrahi Patolojide Frozen Section: 368 Frozen Section Olgusunun Retrospektif Analizi. Sekizinci Ulusal Patoloji Kongresi Kitabı, 21 24 Kasım 1988, Ankara, 1989; s. 59 63.
  • Cahill EM, Hidvegi DF. Crush preparations of lesions of the central nervous system. A useful adjunct to the frozen section. Acta Cytol. 1985;29(3):279-85.
  • Challis D.Broad sheet number 41:Frozen section and intra-operative diagnosis. Pathology 1997;29:165-174.
  • Martinez AJ, Pollack I, Hall WA, Lunsford LD. Touch preparations in the rapid intraoperative diagnosis of central nervous system lesions. A comparison with frozen sections and paraffi n-embedded sections. Mod Pathol. 1988;1(5):378-84.
  • Gürses İ, Sav A, Kurtkaya Ö. Cerrahi nöropatolojide intraoperatif tanının değerlendirilmesi: SSS lezyonlarının intraoperatif tanısında dokundurma ve ezme doku preparasyon tekniklerinin yeri. 15. Ulusal Patoloji Sempozyumu Türk Patoloji Dernegi, Cerrahi Patolojide Ayırıcı Tanı, 24-27 Mayıs 2000, Belek, Antalya.
  • Bigner SH, Johnston WW. Cytopathology of the Central Nervous System. ASCP Theory and Practice of Cytopathology. 3 Johnston WW, ed., Chicago: American Society of Clinical Pathologists,1994.
  • Burger PC. Use of cytological preparations in the frozen section diagnosis of central nervous system neoplasia. Am J Surg Pathol. 1985;9(5):344-54.
  • Sav A, Ataizi Ç, Küllü S, Pamir N, Özer F. Santral sinir sistemi lezyonlarının peroperatuar tanısında uygulanan tekniklerin değerlendirilmesi (dokundurma, ezme ve frozen section tekniklerinin karşılaştırmalı sonuçları). X. Ulusal Patoloji Sempozyumu – Sitopatoloji, 30 Ekim 2 Kasım 1991.
  • Sav A, Dikeç D. Cerrahi Patolojide Frozen Section: 159 Frozen section olgusunun değerlendirilmesi. Ankara Numune Hastanesi Bülteni 1987;27(27) 1-2.
  • Shah AB, Muzumdar GA, Chitale AR, Bhagwati SN. Squash preparation and frozen section in intraoperative diagnosis of central nervous system tumors. Acta Cytol. 1998;Oct;42(5):1149-54.
  • Slowinski J,Harabin-Slowinska M.Smear technique in the intraoperative brain tumor diagnosis:its advantages and limitations. Neurol Res 1999;21(1):121-124.
  • Stefano DD,Scucchi LF,Cosentino L.Intraoperative diagnosis of nervous system lesions.Acta Cytol 1998;42:346-356.
  • Doğan T, Batırel H, Sav A. Frozen section material using distinctive preparation techniques (squash versus imprint). 8th International Medical Sciences Student Congress, İstanbul, May 13 15, 1992.
  • Kontozoglou TE,Cramer HM.The advantages of intraoperative cytology.Analysis of 215 smear and review of the literature.Acta Cytol 1991;35:154-164.
  • Luis FB Torres,Collaca LM.Smear technique in the intraoperative examination of nervous system lesions.Acta Cytol 1993;37:34-39.
  • Moss TM, Nicoll JAR, Ironside JW. Intraoperative Diagnosis of CNS tumors. London: Arnold, 1997.
  • Nguyen GK, Johnson ES, Mielke BW, Nguyen-Ho P. Cytology of intracranial tumors in crush preparations. Its contribution to frozen section diagnosis. Pathol Annu. 1994;29 ( Pt 2):233-57.
  • Sav A, Ataizi Ç, Küllü S, Pamir N, Özer F. Ultrasound guided beyin biopsilerinin değerlendirilmesi. dokundurma, ezme ve frozen section tekniklerinin karşılaştırmalı sonuçları). X. Ulusal Patoloji Sempozyumu, Sitopatoloji. 30 Ekim 2 Kasım 1991.
  • Ünüvar Atılmış Ü, Vardar Aker F., Güneş P, Peker Ö. Santral sinir sistemi tümörlerin intraoperatif acil tanısında sitolojisinin tanı değeri. Türk Patoloji Dergisi, 2001;17 (3-4):67-71.
  • Söylemezoğlu F, Sav A, Küllü S, Ersev A, Ataizi Ç. 264 Frozen Section Olgusunun Retrospektif Analizi. Kartal Eğitim ve Araştırma Klinikleri 191;1(3);2:133-137.
  • Reyes MG,Homsi F,Glick RP. Imprints, smears and frozen sections of brain tumors. Neurosurgery 191;29:575-579.
  • MacQueen CL. An improved mounting solution for frozen brain sections. Stain Technol. 1978;53(4):243-4.
  • Groves R, Hesslevik M. The diagnosis of frozen section examination in neurosurgery. Acta Neurol Scand 1966;42:268-74.
  • Hume Adams J, Graham DI, Doyle D. Brain biopsy. The smear technique for neurosurgical biopsies. London: Chapman & Hall, 1981.
  • Hayden R, Cajulis RS, Frias-Hidvegi D, Brody BA, Yu G, Levy R. Role of cytology in the intraoperative diagnosis of HIV-positive patients undergoing stereotactic brain biopsy. Acta Cytol. 1997;41(2):481-6.
  • Miller DC, Najjar S, Budzilovich GN. Neuropathology of AIDS in surgical biopsy specimens. Neurosurg Clin N Am. 1994;5(1):57-70.
  • Kleihues P, Cavenee W. Pathology and Genetics. Tumours of the Nervous System. WHO Classifi cation of Tumours. IARC, Lyon, 2000.
  • Kleihues P, Louis DN, Scheithauer BW, Rorke LB, Reifenberger G, Burger PC, Cavenee WK. The WHO classifi cation of tumors of the nervous system. J Neuropathol Exp Neurol 2002; 61, 3: 215-225.
  • McLendon RE, Bigner DD, Bigner S, Provenzale J. Pathology of Tumors of the Central Nervous System: A guide to Histologic Diagnosis. 1st ed., Edward Arnold, 2000.
  • Revesz T,Scaravilli F.Reliability of histological diagnosis including grading in gliomas biopsied by image-guided stereotactic technique. Brain;1993;16:781-793.
  • Robbins PD, Yu LL, Lee M, Stokes BA, Thomas GW, Watson P, Wong G. Stereotactic biopsy of 100 intracerebral lesions at Sir Charles Gairdner Hospital. Pathology. 1994;26(4):410-3.
  • Silverman JF. Cytopathology of fi ne-needle aspiration biopsy of the brain and spinal cord. Diagn Cytopathol. 1986;2(4):312-9.
  • Har-El G, Rao C, Swanson RM, Abdu AF, Milhorat TH. Frozen section in pituitary surgery. J Neurol Neurosurg Psychiatry. 1997;63(4):554.
Toplam 50 adet kaynakça vardır.

Ayrıntılar

Birincil Dil Türkçe
Bölüm Research Article
Yazarlar

Aydın Sav

Yayımlanma Tarihi 1 Mart 2010
Yayımlandığı Sayı Yıl 2010Sayı: 1

Kaynak Göster

EndNote Sav A (01 Mart 2010) Nöroşirürjide Rezeksiyon Cerrahisi ile Stereotaktik Beyin Biyopsilerinde İntraoperatif Tanı - Başarı ve Başarısızlık Ölçütleri. Acıbadem Üniversitesi Sağlık Bilimleri Dergisi 1 13–20.