Primary management of atypical meningioma: treatment patterns and survival outcomes by patient age

Survival differences in malignant meningiomas: a latent class analysis using SEER data

BACKGROUND

Several studies have used demographic characteristics to examine differences in survival time for patients with malignant meningioma (MM). Latent class analysis (LCA), with its ability to identify mutually patterns of patients in a heterogeneous population. The aim of our study was to analyze the heterogeneity of sociodemographic characteristics in meningioma.

METHODS

The data of patients diagnosed with malignant meningioma (n = 1,562, age > 18 years old) were extracted from the Surveillance, Epidemiology, and End Result database. Data on sociodemographic characteristics such as age, sex, race, NHIA, marital status, household income, rural or urban residential area, and overall survival time were included. LCA was used to identify heterogeneous patterns of MM. each group was explored using Bayesian network analysis.

RESULTS

In total, 1562 patients with MM were processed by the LCA model; the 4-class latent class models were the best fit. LCA identified four survival groups: highest, intermediate-high, low-to-moderate, and lowest survival groups. Patients with the longest survival times-93.59 months-were 40-59 years old, female, Black, non-Hispanic, married, and had a family income of $60,000-$74,999 and lived in densely populated areas. Bayesian networks revealed correlations between patients with MM and sociodemographic characteristics in different latent class groups.

CONCLUSION

We identified and verified differences in clinical and sociodemographic characteristics between survival groups. A comprehensive understanding of the "people-oriented" subgroup characteristics will greatly benefit the diagnosis and treatment of MM.

Optimal treatment regimen for very elderly patients with atypical meningioma: an analysis of survival outcomes using the National Cancer Database (NCDB)

PURPOSE

We assess the efficacy of different surgical resection types, radiotherapy, systemic therapy on overall survival in very elderly patients (age > 80) with intracranial atypical meningioma in contrast with their elderly (65-80) counterparts.

METHODS

Patients > 65 years old with intracranial atypical meningiomas surgically resected and catalogued via the National Cancer Database were included. Cox proportional hazards models were developed to assess the association between surgical resection type, radiotherapy and systemic therapy with OS while controlling for sex, race, ethnicity, facility type, income, tumor size and CDCC score.

RESULTS

1747 elderly patients and 382 very elderly patients were included. 61.70% elderly patients and 58.90% very elderly patients received GTR. 26.50% elderly patients and 14.13% very elderly patients received radiotherapy. In multivariate analysis, subtotal resection is associated with worse survival (HR 1.28, p < 0.01) and radiotherapy is associated with improved survival (HR 0.76, p < 0.01). Systemic therapy was not associated with changes in survival outcomes (HR 1.17, p = 0.79). Using subgroup analysis, gross total resection is associated with better survival outcomes in both elderly and very elderly cohorts. Radiotherapy was not associated with improved survival (HR 0.85, p = 0.11) for patients between 65 and 80 years old, but was associated with improved survival (HR 0.51, p < 0.01) for patients > 80 years old.

CONCLUSION

GTR provides survival advantage in both elderly and very elderly cohorts. Radiotherapy provides survival benefits for very elderly patients even though very elderly patients are less likely to received radiotherapy. Very elderly patients may benefit from more aggressive management in the treatment of atypical meningiomas.

Predicting histological grade in symptomatic meningioma by an objective estimation of the tumoral surface irregularity

INTRODUCTION

Predicting the histopathologic grade of meningioma is relevant because local recurrence is significantly greater in WHO grade II-III compared to WHO grade I tumours, which would ideally benefit from a more aggressive surgical strategy. It has been suggested that higher WHO grade tumours are more irregularly-shaped. However, irregularity is a subjective and observer-dependent feature. In this study, the tumour surface irregularity of a large series of meningiomas, measured upon preoperative MRI, is quantified and correlated with the WHO grade.

METHODS

Unicentric retrospective observational study of a cohort of symptomatic meningiomas surgically removed in the time period between January 2015 and December 2022. Using specific segmentation software, the Surface Factor (SF) was calculated for each meningioma. SF is an objective parameter that compares the surface of a sphere (minimum surface area for a given volume) with the same volume of the tumour against the actual surface of the tumour. This ratio varies from 0 to 1, being 1 the maximum sphericity. Since irregularly-shaped meningiomas present proportionally greater surface area, the SF tends to decrease as irregularity increases. SF was correlated with WHO grade and its predictive power was estimated with ROC curve analysis.

RESULTS

A total of 176 patients (64.7% females) were included in the study; 120 WHO grade I (71.9%), 43 WHO grade II (25.7%) and 4 WHO grade III (2.4%). A statistically significant difference was found between the mean SF of WHO grade I and WHO grade II-III tumours (0.8651 ± 0.049 versus 0.7081 ± 0.105, p < 0.0001). Globally, the SF correctly classified more than 90% of cases (area under ROC curve 0.940) with 93.3% sensibility and 80.9% specificity. A cutoff value of 0.79 yielded the maximum precision, with positive and negative predictive powers of 82.6% and 92.6%, respectively. Multivariate analysis yielded SF as an independent prognostic factor of WHO grade.

CONCLUSION

The Surface Factor is an objective and quantitative parameter that helps to identify aggressive meningiomas preoperatively. A cutoff value of 0.79 allowed differentiation between WHO grade I and WHO grade II-III with high precision.

Risk factors on surgical compliance and its impact on survival outcomes in meningioma patients: a SEER-based retrospective propensity-score matched analysis

BACKGROUND

This study aimed to analyze the effect of surgical compliance on the survival outcome of patients with meningioma and explore the factors affecting surgical compliance.

METHODS

We selected data from the Surveillance, Epidemiology, and End Results database for 122,632 meningioma patients diagnosed between 2004 and 2018. The effect of surgical compliance on patients' overall survival (OS) was analyzed through Cox regression and Kaplan-Meier curves. Independent risk factors for surgical compliance were identified through multifactorial logistic regression analyses to construct diagnostic nomograms, further assessed by receiver operating characteristic curves. Furthermore, we used univariate and multivariate logistic regression analyses to evaluate relevant variables linked to adherence with meningioma surgery. Moreover, 1:1 propensity score matching was applied to assess the validity of the results in patients with favorable and poor surgical compliance.

RESULTS

A total of 48,735 were eligible from the initial cohort of 122,632 patients with meningioma. Among them, 45,038 (92.40%) exhibited good surgical compliance, while 3697 (7.60%) had poor surgical compliance. The rate of patients with good surgical compliance was significantly higher than that of patients with inadequate surgical compliance (p < 0.001). Moreover, surgical compliance is an independent prognostic factor for OS in meningioma patients. Univariate Cox regression analysis indicated that individuals with poor surgical compliance demonstrated lower OS rates than those with good surgical compliance (hazard ratio [HR 2.404; 95% confidence interval [CI] 2.276-2.54, p < 0.001], consistent with the observation in the multivariate analysis (HR 1.564; 95% CI 1.471-1.663, p < 0.001). We developed a prediction model using seven variables: age, sex, race, tumor behavior recode, tumor size, family income, and residential setting (p < 0.05). Surgical compliance was associated with patient age, sex, race, tumor behavior recode, tumor size, family income, and residential setting by logistic regression analysis.

CONCLUSIONS

Surgical compliance emerged as an independent prognostic factor for survival in patients with meningioma. Poor surgical compliance was associated with older age, black and other races, females, advanced-stage tumors, larger tumor size, lower household income, and rural residence. When patients experienced these conditions, OS was shorter, requiring more aggressive treatment.

Advancing personalized prognosis in atypical and anaplastic meningiomas through interpretable machine learning models

PURPOSE

The primary purpose of this study was to utilize machine learning (ML) models to create a web application that can predict survival outcomes for patients diagnosed with atypical and anaplastic meningiomas.

METHODS

In this retrospective cohort study, patients diagnosed with WHO grade II and III meningiomas were selected from the National Cancer Database (NCDB) to analyze survival outcomes at 12, 36, and 60 months. Five machine learning algorithms - TabPFN, TabNet, XGBoost, LightGBM, and Random Forest were employed and optimized using the Optuna library for hyperparameter tuning. The top-performing models were then deployed into our web-based application.

RESULTS

From the NCDB, 12,197 adult patients diagnosed with histologically confirmed WHO grade II and III meningiomas were retrieved. The mean age was 61 (± 20), and 6,847 (56.1%) of these were females. Performance evaluation indicated that the top-performing models for each outcome were the models built with the TabPFN algorithm. The TabPFN models yielded area under the receiver operating characteristic (AUROC) values of 0.805, 0.781, and 0.815 in predicting 12-, 36-, and 60-month mortality, respectively.

CONCLUSION

With the continuous growth of neuro-oncology data, ML algorithms act as key tools in predicting survival outcomes for WHO grade II and III meningioma patients. By incorporating these interpretable models into a web application, we can practically utilize them to improve risk evaluation and prognosis for meningioma patients.

Long-Term Follow-Up, Treatment Strategies, Functional Outcome, and Health-Related Quality of Life after Surgery for WHO Grade 2 and 3 Intracranial Meningiomas

Simple Summary

Meningiomas are the most common group of primary intracranial tumors. While the majority are classified as WHO grade 1, WHO grade 2 and 3 meningiomas have poorer outcomes, even after gross total resection, and often require supplementary treatment. Long-term follow-up data regarding the progression-free survival (PFS) and overall survival (OS) for grade 2 and 3 tumors are scarce, and data evaluating the routine use of supplementary radiotherapy and radiosurgery have been inconclusive. Furthermore, few studies have reported data on the health-related quality of life (HRQoL), anxiety, and depression for these patients. In this population-based cohort study, we reviewed 51 cases of WHO grade 2 and 3 meningiomas. We found that the median OS was 13 years for grade 2 and 1.4 years for grade 3 meningiomas. Meningioma was the cause of death in 93% of the patients who passed away. The surviving patients showed HRQoL measures comparable to that of the general population, with the exception of significantly more anxiety and depression. All patients who worked preoperatively returned to work after their treatment.

Abstract

Progression-free survival (PFS) and overall survival (OS) for WHO grade 2 and 3 intracranial meningiomas are poorly described, and long-term results and data evaluating the routine use of supplementary fractionated radiotherapy (RT) or stereotactic radiosurgery (SRS) has been inconclusive. The aim of this study was to determine the long-term PFS and OS at a center that does not employ routine adjuvant RT. For this purpose, a retrospective population-based cohort study was conducted of all WHO grade 2 and 3 meningiomas surgically treated between 2005 and 2013. The cohort was uniformly defined according to the WHO 2007 criteria to allow comparisons to previously published reports. Patient records were reviewed, and patients were then prospectively contacted for structured quality-of-life assessments. In total, 51 consecutive patients were included, of whom 43 were WHO grade 2 and 8 were grade 3. A Simpson grade 1–2 resection was achieved in 62%. The median PFS was 31 months for grade 2 tumors, and 3.4 months for grade 3. The median OS was 13 years for grade 2, and 1.4 years for grade 3. The MIB-1-index was significantly associated with an increased risk for recurrence (p = 0.018, OR 1.12). The median PFS was significantly shorter for high-risk tumors compared to the low-risk group (10 vs. 46 months; p = 0.018). The surviving meningioma patients showed HRQoL measures comparable to that of the general population, with the exception of significantly more anxiety and depression. All patients who worked before surgery returned to work after their treatment. In conclusion, we confirm dismal prognoses in patients with grade 2 and 3 meningiomas, with tumor-related deaths resulting in severely reduced OS. However, the cohort was heterogenous, and a large subgroup of both grade 2 and 3 meningiomas was alive at 10 years follow-up, suggesting that a cure is possible. In addition, fractionated radiotherapy and chemotherapy had little benefit when introduced for recurrent and progressive diseases.

Incidence and Survival of Benign, Borderline, and Malignant Meningioma Patients in the United States from 2004 to 2018

Meningioma is the most common primary central nervous system tumor, and its incidence is increasing. A systematic epidemiological and clinical analysis is required to better estimate its public health impact and understand its prognostic factors. Data were obtained from the Surveillance, Epidemiology, and End Results (SEER) database from 2004 to 2018 for all types of meningiomas without an age restriction. Age-adjusted incidence rates (IRs) and 95% confidence intervals were estimated according to sex, age, race, ethnicity, and tumor location. Kaplan-Meier analysis and multivariate Cox proportional hazard models were used to analyze the overall survival (OS). The competing risk regression model of Fine-Gray was used to analyze cause-specific survival. Data from a total of 109,660 meningioma patients were analyzed. A majority of patients were older than 60 years, and only 0.41% of patients were 0-19 years. The meningioma IRs were higher in females, Black, and non-Hispanic patients than in males, White, and Hispanic patients, respectively, and IRs increased with age. The ratio of IRs for females to males was 2.1 and also increased with age, peaking at 3.6 in the 45-49-year-old group. Older and male patients with all types of meningiomas, Black patients with benign and borderline meningiomas, and patients with larger borderline and malignant meningiomas showed poorer prognosis. For all meningioma types, surgical resection improved survival. The reported incidence rates and survival trends covered all demographics and subtypes of meningiomas. Older age, male sex, Black race, and tumor size may be important prognostic factors for meningioma cases, and tumor resection can substantially improve survival among meningioma patients.

Development of an Image-Based Methodology for the Evaluation of Histopathological Features in Human Meningioma

Meningioma is the most common intracranial tumor in adulthood. With a clear female predominance and a recurrence rate that reaches 20%, it is, despite being considered a benign tumor, a pathology that greatly compromises post-diagnosis quality of life. Its prone to recur or progress to a higher degree is difficult to predict in the absence of obvious histological criteria. This project aims to develop an automatic methodology to aid in the diagnosis of meningiomas that is objective and easily reproducible. The methodology is based on histopathological image analysis using artificial intelligence and machine learning algorithms. It includes a semi-automatic process of identification and cleaning of the scanned samples, an automatic detection of the nuclei of each image and, finally, the parameterization of the samples. The obtained data together with the clinical information will be analyzed using statistical methods in order to provide a methodology to support clinical diagnosis and decision-making in patient management. The result is the development of an effective methodology that generates a set of data associated with morphological parameters with different trends according to the pathological groups studied. A tool has been developed that allows an effective semiautomatic analysis of the images to evaluate these parameters in an objective and reproducible way, helping in clinical decision-making and facilitating to undertake projects with large sample series. Clinical Relevance- The main contribution of this project is in the field of neuropathology, for the diagnosis of meningiomas, the most common brain tumor. The present project provides an objective and quantifiable prognosis methodology for the meningiomas, offering a more precise monitoring of the treatment applied to the patient, resulting in a better prognosis and better quality of life.

The impact of multiple lesions on progression-free survival of meningiomas: a 10-year multicenter experience

OBJECTIVE

Multiple meningiomas (MMs) occur in as many as 18% of patients with meningioma, and data on progression-free survival (PFS) are scarce. The objective of this study was to explore the influence of the number of lesions and clinical characteristics on PFS in patients with WHO grade I meningiomas.

METHODS

The authors retrospectively reviewed the records of all adults diagnosed with a meningioma at their three main sites from January 2009 to May 2020. Progression was considered the time from diagnosis until radiographic growth of the originally resected meningioma. A secondary analysis was performed to evaluate the time of diagnosis until the time to second intervention (TTSI). Univariable and multivariable analyses were conducted to assess whether the number of lesions or any associated variables (age, sex, race, radiation treatment, tumor location, and extent of resection) had a significant impact on PFS and TTSI.

RESULTS

Eight hundred thirty-eight patients were included. Use of a log-rank test to evaluate PFS and TTSI between a single and multiple lesions showed a significantly shorter progression for MM (p < 0.001 and p < 0.001, respectively). Multivariable Cox regression analysis showed significantly inferior PFS on MM compared to a single lesion (hazard ratio [HR] 2.262, 95% confidence interval [CI] 1.392-3.677, p = 0.001) and a significantly inferior TTSI for patients with MM when compared to patients with a single meningioma (HR 2.377, 95% CI 1.617-3.494, p = 0.001). By testing the number of meningiomas as a continuous variable, PFS was significantly inferior for each additional meningioma (HR 1.350, 95% CI 1.074-1.698, p = 0.010) and TTSI was significantly inferior as well (HR 1.428, 95% CI 1.189-1.716, p < 0.001). African American patients had an inferior PFS when compared to non-Hispanic White patients (HR 3.472, 95% CI 1.083-11.129, p = 0.036).

CONCLUSIONS

The PFS of meningiomas appears to be influenced by the number of lesions present. Patients with MM also appear to be more prone to undergoing a second intervention for progressive disease. Hence, a closer follow-up may be warranted in patients who present with multiple lesions. These results show a decreased PFS for each additional lesion present, as well as a shorter PFS for MM compared to a single lesion. When assessing associated risk factors, African American patients showed an inferior PFS, whereas older age and adjuvant therapy with radiation showed an improved PFS.

Clinicopathologic Characteristics of Grade 2/3 Meningiomas: A Perspective on the Role of Next-Generation Sequencing

Background

Grade 2/3 meningiomas have locally aggressive behaviors often requiring additional treatment plans after surgical resection. Herein, we explored the clinical significance of next-generation sequencing (NGS) in characterizing the molecular profiles of high-grade meningiomas.

Methods

Patients with intracranial meningioma who underwent surgical resection in a single institution were retrospectively reviewed. Clinicopathologic relevance was evaluated using recurrence-free survival (RFS) as an outcome measure. NGS for the targeted gene regions was performed in 40 participants.

Results

Among the 713 individuals in the study population, 143 cases (20.1%) were identified as having grade 2 or 3 meningiomas with a significantly lower female predominance. While the difference in RFS between grade 2 and 3 meningiomas was insignificant, a few conventional grade 2 cases, but with TERT promoter hotspot mutation, were highly progressive and refractory to the treatment. From the NGS study, recurrent mutations in TRAF and AKT1 were identified with a higher prevalence (17.5% and 12.5%, respectively) compared with grade 2/3 meningiomas reported in previous literature. However, their relations to other histopathologic properties or clinical factors were rarely observed.

Conclusions

Grade 2/3 meningiomas show a broad spectrum of molecular profiles, as they have heterogeneous histologic characteristics.

Prognostic Factors and Treatment Strategies for Elderly Patients with Malignant Meningioma: A SEER Population-Based Study

OBJECTIVE

Malignant meningioma (MM) is a relatively rare disease with poor survival. Few studies had focused on MM in the elderly population. This study aims to explore the prognostic factors and optimal therapeutic strategy in elderly patients with MM.

METHODS

We took advantage of the Surveillance, Epidemiology, and End Results (SEER) database to include 275 adult patients with histologically confirmed MM between 2011 and 2018. The Kaplan-Meier curves were plotted by different covariates to reveal the survival probability. Univariate and multivariable Cox proportional hazard regression analyses were applied to identify prognostic factors for cancer-specific survival (CSS).

RESULTS

The multivariable analysis in the elderly group revealed that when compared with patients receiving gross total resection (GTR), patients receiving biopsy had significantly worse CSS (HR = 3.72; 95% CI: 1.35-10.21; P = 0.011), whereas patients receiving subtotal resection (STR) had nearly the same CSS (HR = 0.83; 95% CI: 0.37-1.86; P = 0.653). Meanwhile, postoperative radiotherapy (PORT) showed no significant association with CSS in the elderly patient group (HR = 0.94; 95% CI: 0.42-2.12; P = 0.888).

CONCLUSION

Surgical resection is recommended for elderly patients with MM in the absence of surgical contraindications, but GTR does not present survival benefit in the elderly patients compared with STR. Additional large-scale clinical studies are needed to explore the survival benefit of PORT applied in patients with MM.

A Magnetic Resonance Imaging-Based Radiomic Model for the Noninvasive Preoperative Differentiation Between Transitional and Atypical Meningiomas

Preoperative distinction between transitional meningioma and atypical meningioma would aid the selection of appropriate surgical techniques, as well as the prognosis prediction. Here, we aimed to differentiate between these two tumors using radiomic signatures based on preoperative, contrast-enhanced T1-weighted and T2-weighted magnetic resonance imaging. A total of 141 transitional meningioma and 101 atypical meningioma cases between January 2014 and December 2018 with a histopathologically confirmed diagnosis were retrospectively reviewed. All patients underwent magnetic resonance imaging before surgery. For each patient, 1227 radiomic features were extracted from contrast-enhanced T1-weighted and T2-weighted images each. Least absolute shrinkage and selection operator regression analysis was performed to select the most informative features of different modalities. Subsequently, stepwise multivariate logistic regression was chosen to further select strongly correlated features and build classification models that can distinguish transitional from atypical meningioma. The diagnostic abilities were evaluated by receiver operating characteristic analysis. Furthermore, a nomogram was built by incorporating clinical characteristics, radiological features, and radiomic signatures, and decision curve analysis was used to validate the clinical usefulness of the nomogram. Sex, tumor shape, brain invasion, and four radiomic features differed significantly between transitional meningioma and atypical meningioma. The clinicoradiomic model derived by fusing the above features resulted in the best discrimination ability, with areas under the curves of 0.809 (95% confidence interval, 0.743-0.874) and 0.795 (95% confidence interval, 0.692-0.899) and sensitivity values of 74.0% and 71.4% in the training and validation cohorts, respectively. The clinicoradiomic model demonstrated good performance for the differentiation between transitional and atypical meningioma. It is a quantitative tool that can potentially aid the selection of surgical techniques and the prognosis prediction and can thus be applied in patients with these two meningioma subtypes.

A Clinical Prognostic Model Based on Preoperative Hematological and Clinical Parameters Predicts the Progression of Primary WHO Grade II Meningioma

Purpose

The purpose was to explore the correlation between hematological parameters and the progression of WHO grade II meningioma, and establish a clinical prognostic model based on hematological parameters and clinical prognostic factors to predict the progression-free survival (PFS) of patients.

Methods

A total of 274 patients with WHO grade II meningiomas were included. Patients were randomly divided into a training cohort (192, 70%) and a test cohort (82, 30%). In the training cohort, the least absolute shrinkage and selection operator Cox regression analysis were used to screen for hematological parameters with prognostic value, and the hematological risk model (HRM) was constructed based on these parameters; univariate and multivariate Cox regression analyses were utilized to screen for clinical prognostic factors, and a clinical prognostic model was constructed based on clinical prognostic factors and HRM. The prognostic stability and accuracy of the HRM and clinical prognostic model were verified in the test cohort. Subgroup analysis was performed according to the patients' different clinical characteristics.

Results

Preoperative neutrophil-to-lymphocyte ratio, lymphocyte-to-monocyte ratio, platelet-to-lymphocyte ratio, albumin-to-globulin ratio, D-dimer, fibrinogen, and lactate dehydrogenase were associated with the PFS of patients. The areas under curve of the HRM were 0.773 (95% confidence interval [CI] 0.707-0.839) and 0.745 (95% CI 0.637-0.852) in the training cohort and test cohort, respectively. The progression risk was higher in the high-risk group than that in the low-risk group categorized by the optimal cutoff value (2.05) of hematological risk scores. The HRM, age, tumor location, tumor size, peritumoral edema, extent of resection, Ki-67 index, and postoperative radiotherapy were the prognostic factors for the progression of meningiomas. The corrected C-index of the clinical prognosis model was 0.79 in the training cohort. Clinical decision analysis showed that the clinical prognostic model could be used to obtain favorable clinical benefits. In the subgroup analysis, the HRM displayed excellent prognostic stability and general applicability in different subgroups.

Conclusions

Preoperative hematological parameters are associated with the postoperative progression of WHO grade II meningiomas. The clinical prognosis model constructed based on hematological parameters and clinical prognostic factors has favorable predictive accuracy and clinical benefits.

The meningioma surface factor: a novel approach to quantify shape irregularity on preoperative imaging and its correlation with WHO grade

OBJECTIVE

Atypical and anaplastic meningiomas account for 20% of all meningiomas. An irregular tumor shape on preoperative MRI has been associated with WHO grade II-III histology. However, this subjective allocation does not allow quantification or comparison. An objective parameter of irregularity could substantially influence resection strategy toward a more aggressive approach. Therefore, the aim of this study was to objectively quantify the level of irregularity on preoperative MRI and predict histology based on WHO grade using this novel approach.

METHODS

A retrospective study on meningiomas resected between January 2010 and December 2018 was conducted at two neurosurgical centers. This novel approach relies on the theory that a regularly shaped tumor has a smaller surface area than an irregularly shaped tumor with the same volume. A factor was generated using the surface area of a corresponding sphere as a reference, because for a given volume a sphere represents the shape with the smallest surface area possible. Consequently, the surface factor (SF) was calculated by dividing the surface area of a sphere with the same volume as the tumor with the surface area of the tumor. The resulting value of the SF ranges from > 0 to 1. Finally, the SF of each meningioma was then correlated with the corresponding histopathological grading.

RESULTS

A total of 126 patients were included in this study; 60.3% had a WHO grade I, 34.9% a WHO grade II, and 4.8% a WHO grade III meningioma. Calculation of the SF demonstrated a significant difference in SFs between WHO grade I (SF 0.851) and WHO grade II-III meningiomas (SF 0.788) (p < 0.001). Multivariate analysis identified SF as an independent prognostic factor for WHO grade (OR 0.000009, 95% CI 0.000-0.159; p = 0.020).

CONCLUSIONS

The SF is a proposed mathematical model for a quantitative and objective measurement of meningioma shape, instead of the present subjective assessment. This study revealed significant differences between the SFs of WHO grade I and WHO grade II-III meningiomas and demonstrated that SF is an independent prognostic factor for WHO grade.

Treatment and follow-up results of WHO grade II meningiomas

Meningiomas are the most common primary intracranial tumors. They have three pathologic grades. Surgical resection aiming Simpson I resection is the standard treatment for meningiomas. Radiotherapy and Gamma Knife radiosurgery are the main adjuvant and salvage treatments. Chemotherapy has limited use. Grade II, and III meningiomas have a higher recurrence rate, and adjuvant radiotherapy is usually the standard treatment for grade III meningiomas but there is not a consensus regarding grade II meningiomas. In this paper, we analyzed our meningioma series of 1401 patients and presented the treatment and follow-up results of 170 grade II meningioma cases. The median follow-up of grade II meningiomas was 61 (range = 1-231) months. The mean age of patients was 52.5 ± 15.0 years, 102 of them were female and 68 were male (female/male ratio = 1.5). The median progression-free survival (PFS) of them was 109 months, and the cumulative overall survival (OS) rate was 85% at 10 years. Meningiomas with gross total resection, non-skull base meningiomas, and primary grade II meningiomas had longer PFS with statistical significance, while non-skull base meningiomas, younger group of patients, and primary grade II meningiomas had longer OS with a statistical significance.

Clinical Factors and Outcomes of Atypical Meningioma: A Population-Based Study

Objective

Atypical meningioma is a non-benign tumor, and its prognostic factors and treatment strategies are unclear.

Methods

Patients with atypical meningioma, between 2004 and 2016, were collected from the Surveillance, Epidemiology, and End Results database. Then, we randomly divided patients into a training set and a validation set at a ratio of 8:2. The nomogram was constructed based on the multivariate Cox regression analyses. And the concordance index, calibration curves, and receiver operating character were used to assess the predictive ability of the nomogram. We divided the patient scores into three groups and constructed a survival curve using Kaplan–Meier analysis.

Results

After our inclusion and exclusion criteria, 2358 patients were histologically diagnosed of atypical meningioma. The prognostic nomogram comprised factors of overall survival, including age, tumor size and surgery. The concordance index was 0.715 (95%CI=0.688-0.742) for overall survival in the training set and 0.688 (95%CI=0.629-0.747) for overall survival in the validation set. The calibration curves and receiver operating character also indicated the good predictability of the nomogram. Risk stratification revealed a statistically significant difference among the three groups of patients according to quartiles of risk score.

Conclusion

Gross total resection is an independent factor for survival, and radiation after non-gross total resection potentially confers a survival advantage for patients with atypical meningioma.

Adjuvant radiation for WHO grade II and III intracranial meningiomas: insights on survival and practice patterns from a National Cancer Registry

INTRODUCTION

WHO grades II (atypical) and III (malignant) meningiomas are associated with significant morbidity and mortality. The role of adjuvant radiotherapy (RT) in management remains controversial. The goal of this study was to evaluate the impact of adjuvant RT on 5-year survival in patients with atypical and malignant meningiomas. We secondarily aimed to assess contemporary practice patterns and the impact of sociodemographic factors on outcome.

METHODS

We queried the National Cancer Database for patients ≥ 18 years of age with cranial atypical or malignant meningiomas from 2010 through 2015 who underwent surgical resection with or without adjuvant radiotherapy. Subjects with unknown WHO grade or radiation status and those not receiving any surgical procedure were excluded from analysis.

RESULTS

The study includes 7486 patients, 6788 with atypical and 698 with malignant meningiomas. Overall 5-year survival was 76.9% (95% CI 75.5-78.3%) and 43.3% (95% CI 38.8-48.2%) among patients with WHO grades II and III meningiomas, respectively. Adjuvant RT correlated with improved survival in a multivariable model in patients with grade II tumors (HR 0.78; p = 0.029) regardless of the extent of resection. Age (HR 2.33; p < 0.001), male sex (HR 1.27; p < 0.001), Black race (HR 1.27; p = 0.011) and Charlson-Deyo Score ≥ 2 (1.35; p = 0.001) correlated with poorer survival whereas private insurance (HR 0.71; p < 0.001) correlated with improved survival. Adjuvant RT was also associated with improved 5-year survival among those with grade III tumors on univariate analysis (log-rank p = 0.006) but was underpowered for multivariable modeling. Utilization of adjuvant radiotherapy was only 28.4% and correlated with private insurance status. Academic institutions (25.3%) and comprehensive community cancer programs (21.4%) had lower radiotherapy utilization rates compared with integrated network cancer programs (30.5%) and community cancer programs (29.7%).

CONCLUSIONS

Adjuvant RT may correlate with improved overall survival in patients with grades II and III intracranial meningiomas regardless of the extent of resection. There is poor utilization of adjuvant RT for patients with grades II and III meningiomas likely due to a paucity of quality data on the subject. These findings will be strengthened with prospective data evaluating the role of adjuvant RT.

Determining the role of adjuvant radiotherapy in the management of meningioma: a Surveillance, Epidemiology, and End Results analysis

OBJECTIVEThe aim of this study was to illustrate the demographic characteristics of meningioma patients and observe the effect of adjuvant radiation therapy on survival by using the Surveillance, Epidemiology, and End Results (SEER) database. More specifically, the authors aimed to answer the question of whether adjuvant radiotherapy following resection of atypical meningioma confers a cause-specific survival benefit. Additionally, they attempted to add to previous characterizations of the epidemiology of primary meningiomas and assess the effectiveness of the standard of care for benign and anaplastic meningiomas. They also sought to characterize the efficacy of various treatment options in atypical and anaplastic meningiomas separately since nearly all other analyses have grouped these two together despite varying treatment regimens for these behavior categories.METHODSSEER data from 1973 to 2015 were queried using appropriate ICD-O-3 codes for benign, atypical, and anaplastic meningiomas. Patient demographics, tumor characteristics, and treatment choices were analyzed. The effects of treatment were examined using a multivariate Cox proportional hazards model and Kaplan-Meier survival analysis.RESULTSA total of 57,998 patients were included in the analysis of demographic, meningioma, and treatment characteristics. Among this population, cases of unspecified WHO tumor grade were excluded in the multivariate analysis, leaving a total of 12,931 patients to examine outcomes among treatment paradigms. In benign meningiomas, gross-total resection (HR 0.289, p = 0.013) imparted a significant cause-specific survival benefit over no treatment. In anaplastic meningioma cases, adjuvant radiotherapy imparted a significant survival benefit following both subtotal (HR 0.089, p = 0.018) and gross-total (HR 0.162, p = 0.002) resection as compared to gross-total resection alone. In atypical tumors, gross-total resection plus radiotherapy did not significantly change the hazard risk (HR 1.353, p = 0.628) compared to gross-total resection alone. Similarly, it was found that adjuvant radiation did not significantly benefit survival after a subtotal resection (HR 1.440, p = 0.644).CONCLUSIONSThe results of this study demonstrate that the role of adjuvant radiotherapy, especially after the resection of atypical meningioma, remains somewhat unclear. Thus, given these results, prospective randomized clinical studies are warranted to provide clear information on the effects of adjuvant radiation in meningioma treatment.

Risk factors associated with postoperative recurrence in atypical intracranial meningioma: analysis of 263 cases at a single neurosurgical centre

OBJECTIVE

Atypical meningioma (AM) has a high rate of local recurrence after surgery, and the role of adjuvant radiotherapy in AM remains controversial. We analysed progression-free survival (PFS) and identified the factors associated with postoperative recurrence in AM patients.

METHODS

Data were obtained from 263 AM patients who underwent surgery at our institution between October 2009 and September 2018. Analyses included factors such as the extent of surgical resection, MIB-1 labelling index, brain invasion and therapy modality. Univariate and multivariate analyses were used to assess recurrence-related prognostic factors.

RESULT

The median follow-up duration was 41 months, and the median PFS was 28 months. Gross total resection (GTR) was achieved in 213 (81.0%) patients, and 86 (32.7%) patients received postoperative radiation therapy (RT). During follow-up, there were 61 (23.2%) tumour recurrences. In a Cox multivariate analysis, MIB-1 labelling index (hazard ratio = 2.637; p < 0.001), secondary tumour (hazard ratio = 3.541; p < 0.001), tumour size (hazard ratio = 1.818; p = 0.032) and extent of resection (hazard ratio = 2.861; p < 0.001) were independent significant predictors of tumour recurrence. RT was associated with reduced tumour recurrence in subtotal resection (STR) (p = 0.023) but not GTR (p = 0.923). An analysis of 6 meningioma patients who underwent more than 3 operations suggested that the recurrence time became shorter and the MIB-1 labelling index increased as the number of recurrences increased.

CONCLUSIONS

MIB-1 labelling index, secondary tumour, tumour size and extent of resection were powerful predictors of recurrence in AM patients. Postoperative RT did not decrease the risk of recurrence in GTR patients.

Immortal Time Bias in National Cancer Database Studies

PURPOSE

In studies evaluating the benefit of adjuvant therapies, immortal time bias (ITB) can affect the results by incorrectly reporting a survival advantage. It does so by including all deceased patients who may have been planned to receive adjuvant therapy within the observation cohort. Given the increase in National Cancer Database (NCDB) analyses evaluating postoperative radiation therapy (PORT) as an adjuvant therapy, we sought to examine how often such studies accounted and adjusted for ITB.

METHODS AND MATERIALS

A systematic review was undertaken to search MEDLINE and EMBASE from January 2014 until May 2019 for NCDB studies evaluating PORT. After appropriate exclusion criteria were applied, 60 peer-reviewed manuscripts in which PORT was compared with postoperative observation or maintenance therapy were reviewed. The manuscripts were reviewed to evaluate whether ITB was accounted for, the method with which it was adjusted for, impact factor, year of publication, and whether PORT was beneficial.

RESULTS

Of the 60 publications reviewed, 23 studies (38.3%) did not include an adjustment for ITB. Most studies that did adjust for ITB employed a single landmark (LM) time (n = 31), 4 used a sequential landmark analyses, and 2 used a time-dependent Cox model. In 23 of 31 studies (74.2%) that did adjust for ITB via a single LM time, the rationale behind why the specified LM time was chosen was not clearly explained. There was no relationship between adjusting for ITB and year of publication (P = .074) or whether the study was published in a high-impact journal (P = .55).

CONCLUSIONS

Studies assessing adjuvant radiation therapy by analyzing the NCDB are susceptible to ITB, which overestimates the effect size of adjuvant therapies and can provide misleading results. Adjusting for this bias is essential for accurate data representation and to better quantify the impact of adjuvant therapies such as PORT.

Initial management of meningiomas: Analysis of the National Cancer Database

BACKGROUND

Meningiomas are the most common central nervous system tumor. We describe current trends in treatment and survival using the largest cancer dataset in the United States.

METHODS

We analyzed the National Cancer Database from 2004 to 2014, for all patients with diagnosis of meningioma.

RESULTS

201,765 cases were analyzed. Patients were most commonly White (81.9%) females (73.2%) with a median age of 64 years. Fifty percent of patients were diagnosed by imaging. Patients were reported as grade I (24.9%), grade II (5.0%), grade III (0.7%), or unknown WHO grade (69.4%). Patients diagnosed by imaging were older, received treatment in community facilities, had higher Charlson-Deyo score, and a lower rate of private insurance. Watchful waiting was the most common treatment modality (46.7%), followed by surgery only (40%). Grade II and III patients were more likely to receive therapy. Watchful waiting increased from 35.2% in 2004 to 51.4% in 2014. Younger age, male gender, private insurance, and treatment in academic facilities were determinants for receipt of surgery and/or radiation. Median survival was 12.6 years, higher in histologically confirmed cases (13.1 years). Older patients, Blacks, males, those that received radiation plus surgery, and were treated in community facilities had an increased risk of mortality.

CONCLUSIONS

Over half of patients were diagnosed by imaging, suggesting a higher role of clinical determinants over histological confirmation in treatment decisions. Watchful waiting as initial management is increasing. Our survival analysis favored histological confirmation. Patients receiving radiation and surgery had an increased risk of mortality.

Nonmalignant and malignant meningioma incidence and survival in the elderly, 2005-2015, using the Central Brain Tumor Registry of the United States

BACKGROUND

Meningioma incidence increases significantly with age. In the expanding elderly population, we lack complete understanding of population-based trends in meningioma incidence/survival. We provide an updated, comprehensive analysis of meningioma incidence and survival for individuals aged over 65.

METHODS

Data were obtained from the Central Brain Tumor Registry of the United States (CBTRUS) from 2005-2015 for nonmalignant and malignant meningioma. Age-adjusted incidence rates per 100000 person-years were analyzed by age, sex, race, ethnicity, location, and treatment modalities. Survival was analyzed using Kaplan-Meier and multivariable Cox proportional hazards models for a subset of CBTRUS data.

RESULTS

Nonmalignant meningioma incidence doubled from adults age 65-69 years to adults over age 85 years and was significantly greater in females than males for all ages. Malignant meningioma incidence did not differ by sex for any age grouping. Nonmalignant and malignant meningioma incidence was significantly greater in black populations versus others. Nonmalignant meningioma survival was worse with age, in black populations, and in males, including when analyzed by 5-year age groups. Surgical resection and radiation did not improve survival compared with resection alone in nonmalignant meningioma.

CONCLUSIONS

This study reports increasing nonmalignant meningioma incidence in the elderly, increased incidence in black populations, and in females. In contrast, malignant meningioma incidence did not differ between sexes. Risk of death was higher for black individuals and males. Additionally, radiation did not confer a survival advantage when combined with resection for nonmalignant meningioma. Thus, we identify clinically relevant discrepancies in meningioma incidence/survival that require further study.