Surgical outcomes after reoperation for recurrent non-skull base meningiomas

Single versus multiple reoperations for recurrent intracranial meningiomas

PURPOSE

To identify the risk factors and management of the multiple recurrences and reoperations for intracranial meningiomas.

METHODS

Data of a neurosurgical series of 35 patients reoperated on for recurrent intracranial meningiomas were reviewed. Analyzed factors include patient age and sex, tumor location, extent of resection, WHO grade, Ki67-MIB1 and PR expression at initial diagnosis, time to recurrence; pattern of regrowth, extent of resection, WHO grade and Ki67-MIB1 at first recurrence were also analyzed. All these factors were stratified into two groups based on single (Group A) and multiple reoperations (Group B).

RESULTS

Twenty-four patients (69%) belonged to group A and 11 (31%) to group B. The age < 65 years, male sex, incomplete resection at both initial surgery and first reoperation, and multicentric-diffuse pattern of regrowth at first recurrence are risk factors for multiple recurrences and reoperations. In group B, the WHO grade and Ki67-MIB1 increased in further recurrences in 54% and 64%, respectively. The time to recurrence was short in 7 cases (64%), whereas 4 patients (36%) further recurred after many years. Eight patients (73%) are still alive after 7 to 22 years and 2 to 4 reoperations.

CONCLUSION

The extent of resection and the multicentric-diffuse pattern of regrowth at first recurrence are the main risk factors for multiple recurrences and reoperations. Repeated reoperations might be considered even in patients with extensive recurrent tumors before the anaplastic transformation occurs. In such cases, even partial tumor resections followed by radiation therapy may allow long survival in good clinical conditions.

Grading meningioma resections: the Simpson classification and beyond

Technological (and also methodological) advances in neurosurgery and neuroimaging have prompted a reappraisal of Simpson's grading of the extent of meningioma resections. To the authors, the published evidence supports the tenets of this classification. Meningioma is an often surgically curable dura-based disease. An extent of meningioma resection classification needs to account for a clinically meaningful variation of the risk of recurrence depending on the aggressiveness of the management of the (dural) tumor origin.Nevertheless, the 1957 Simpson classification undoubtedly suffers from many limitations. Important issues include substantial problems with the applicability of the grading paradigm in different locations. Most notably, tumor location and growth pattern often determine the eventual extent of resection, i.e., the Simpson grading does not reflect what is surgically achievable. Another very significant problem is the inherent subjectivity of relying on individual intraoperative assessments. Neuroimaging advances such as the use of somatostatin receptor PET scanning may help to overcome this central problem. Tumor malignancy and biology in general certainly influence the role of the extent of resection but may not need to be incorporated in an actual extent of resection grading scheme as long as one does not aim at developing a prognostic score. Finally, all attempts at grading meningioma resections use tumor recurrence as the endpoint. However, especially in view of radiosurgery/radiotherapy options, the clinical significance of recurrent tumor growth varies greatly between cases.In summary, while the extent of resection certainly matters in meningioma surgery, grading resections remains controversial. Given the everyday clinical relevance of this issue, a multicenter prospective register or study effort is probably warranted (including a prominent focus on advanced neuroimaging).

Drug target therapy and emerging clinical relevance of exosomes in meningeal tumors

Meningioma is the most common central nervous system (CNS) tumor. In recent decades, several efforts have been made to eradicate this disease. Surgery and radiotherapy remain the standard treatment options for these tumors. Drug therapy comes to play its role when both surgery and radiotherapy fail to treat the tumor. This mostly happens when the tumors are close to vital brain structures and are nonbenign. Although a wide variety of chemotherapeutic drugs and molecular targeted drugs such as tyrosine kinase inhibitors, alkylating agents, endocrine drugs, interferon, and targeted molecular pathway inhibitors have been studied, the roles of numerous drugs remain unexplored. Recent interest is growing toward studying and engineering exosomes for the treatment of different types of cancer including meningioma. The latest studies have shown the involvement of exosomes in the theragnostic of various cancers such as the lung and pancreas in the form of biomarkers, drug delivery vehicles, and vaccines. Proper attention to this new emerging technology can be a boon in finding the consistent treatment of meningioma.

A nomogram for predicting the risk of major postoperative complications for patients with meningioma

PURPOSE

To identify risk factors for major postoperative complications in meningioma patients and to construct and validate a nomogram that identify patients at high risk of these complications.

METHODS

The medical records of meningioma patients who underwent surgical resection in our hospital from January 2018 to December 2020 were collected. The patients were divided into a training set (815 cases from the main campus in 2018 and 2019) and a validation set (300 cases from two other campuses in 2020). Major postoperative complications were defined as any new neurological deficits and complications classified as Clavien-Dindo Grading (CDG) II or higher. Univariate and multivariate analyses were conducted using the training set to identify independent risk factors. A nomogram was constructed based on these results. And then validated the nomogram through bootstrap re-sampling in both the training and validation sets. The concordance index (C-index) and the area under the curve (AUC) were used to assess the discriminative ability of the nomogram. The Hosmer-Lemeshow test was performed to evaluate the goodness-of-fit. The optimal cutoff point for the nomogram was calculated using Youden's index.

RESULTS

In the training set, 135 cases (16.56%) experienced major postoperative complications. The independent risk factors identified were male sex, recurrent tumors, American Society of Anesthesiologists (ASA) class III-IV, preoperative Karnofsky Performance Scale (KPS) score < 80, preoperative serum albumin < 35 g/L, tumor in the skull base or central sulcus area, subtotal tumor resection (STR), allogeneic blood transfusion, and larger tumor size. A nomogram was constructed based on these risk factors. It demonstrated good predictive performance, with a C-index of 0.919 for the training set and 0.872 for the validation set. The area under the curve (AUC) > 0.7 indicated satisfactory discriminative ability. The Hosmer-Lemeshow test showed no significant deviation from the predicted probabilities. And the cutoff for nomogram total points was about 200 (specificity 0.881 and sensitivity 0.834).

CONCLUSIONS

The constructed nomogram demonstrated robust predictive performance for major postoperative complications in meningioma patients. This model can be used by surgeons as a reference in clinical decision-making.

Interdisciplinary Therapeutic Approaches to Atypical and Malignant Meningiomas

Meningiomas have the highest incidence among brain tumors. In contrast to benign tumors that constitute the majority of this tumor entity, the treatment of aggressive meningiomas (WHO Grade 2 and 3) is more challenging, requiring gross total removal of the tumor and the affected dura and adjuvant radiotherapy. Sometimes the location and/or the configuration of the tumor do not favor radical surgical resection without endangering the patient's clinical condition after surgery and pharmacological therapy has, until now, not been proven to be a reliable alternative. Discussion: In this narrative review, we discuss the current literature with respect to the management of meningiomas, discussing the importance of the grade of resection in the overall prognosis of the patient and in the planning of adjuvant therapy. Conclusions: According to the location and size of the tumor, radical resection should be taken into consideration. In patients with aggressive meningiomas, adjuvant radiotherapy should be performed after surgery. In cases of skull base meningiomas, a maximal, though safe, resection should take place before adjuvant therapy. An interdisciplinary approach is beneficial for patients with primary or recurrent meningioma.

Cost-Effectiveness Analysis of 68Ga-DOTATATE PET/MRI in Radiotherapy Planning in Patients with Intermediate-Risk Meningioma

BACKGROUND AND PURPOSE

While contrast-enhanced MR imaging is the criterion standard in meningioma diagnosis and treatment response assessment, gallium 68Ga-DOTATATE PET/MR imaging has increasingly demonstrated utility in meningioma diagnosis and management. Integrating 68Ga-DOTATATE PET/MR imaging in postsurgical radiation planning reduces the planning target volume and organ-at-risk dose. However, 68Ga-DOTATATE PET/MR imaging is not widely implemented in clinical practice due to higher perceived costs. Our study analyzes the cost-effectiveness of 68Ga-DOTATATE PET/MR imaging for postresection radiation therapy planning in patients with intermediate-risk meningioma.

MATERIALS AND METHODS

We developed a decision-analytical model based on both recommended guidelines on meningioma management and our institutional experience. Markov models were implemented to estimate quality-adjusted life-years (QALY). Cost-effectiveness analyses with willingness-to-pay thresholds of $50,000/QALY and $100,000/QALY were performed from a societal perspective. Sensitivity analyses were conducted to validate the results. Model input values were based on published literature.

RESULTS

The cost-effectiveness results demonstrated that 68Ga-DOTATATE PET/MR imaging yields higher QALY (5.47 versus 5.05) at a higher cost ($404,260 versus $395,535) compared with MR imaging alone. The incremental cost-effectiveness ratio analysis determined that 68Ga-DOTATATE PET/MR imaging is cost-effective at a willingness to pay of $50,000/QALY and $100,000/QALY. Furthermore, sensitivity analyses showed that 68Ga-DOTATATE PET/MR imaging is cost-effective at $50,000/QALY ($100,000/QALY) for specificity and sensitivity values above 76% (58%) and 53% (44%), respectively.

CONCLUSIONS

68Ga-DOTATATE PET/MR imaging as an adjunct imaging technique is cost-effective in postoperative treatment planning in patients with meningiomas. Most important, the model results show that the sensitivity and specificity cost-effective thresholds of 68Ga-DOTATATE PET/MR imaging could be attained in clinical practice.

Role of risk factors, scoring systems, and prognostic models in predicting the functional outcome in meningioma surgery: multicentric study of 552 skull base meningiomas

Despite the importance of functional outcome, only a few scoring systems exist to predict neurologic outcome in meningioma surgery. Therefore, our study aims to identify preoperative risk factors and develop the receiver operating characteristics (ROC) models estimating the risk of a new postoperative neurologic deficit and a decrease in Karnofsky performance status (KPS). A multicentric study was conducted in a cohort of 552 consecutive patients with skull base meningiomas who underwent surgical resection from 2014 to 2019. Data were gathered from clinical, surgical, and pathology records as well as radiological diagnostics. The preoperative predictive factors of functional outcome (neurologic deficit, decrease in KPS) were analyzed in univariate and multivariate stepwise selection analyses. Permanent neurologic deficits were present in 73 (13.2%) patients and a postoperative decrease in KPS in 84 (15.2%). Surgery-related mortality was 1.3%. A ROC model was developed to estimate the probability of a new neurologic deficit (area 0.74; SE 0.0284; 95% Wald confidence limits (0.69; 0.80)) based on meningioma location and diameter. Consequently, a ROC model was developed to predict the probability of a postoperative decrease in KPS (area 0.80; SE 0.0289; 95% Wald confidence limits (0.74; 0.85)) based on the patient's age, meningioma location, diameter, presence of hyperostosis, and dural tail. To ensure an evidence-based therapeutic approach, treatment should be founded on known risk factors, scoring systems, and predictive models. We propose ROC models predicting the functional outcome of skull base meningioma resection based on the age of the patient, meningioma size, and location and the presence of hyperostosis and dural tail.

Loss of H3K27me3 expression enriches in recurrent grade 1&2 meningiomas and maintains as a biomarker stratifying progression risk

PURPOSE

To determine if loss of H3K27me3 could predict higher risk of re-recurrence in recurrent meningiomas.

METHODS

A retrospective, single-center cohort study was performed for patients who underwent resection of recurrent grade 1 (N = 132) &2 (N = 32) meningiomas from 2009 to 2013. Association of H3K27me3 staining and clinical parameters was analyzed. Additionally, H3K27me3 staining was performed from 45 patients whose tumors recurred and were resected during the follow-up, to evaluate H3K27me3 change during tumor progression. Survival analysis was performed as well.

RESULTS

Loss of H3K27me3 expression was observed in 83 patients, comprising 63 grade 1 (47.7%) and 20 grade 2 patients (62.5%). Both grade 1 (p < 0.001) and grade 2 recurrent meningiomas (p < 0.001) had a higher frequency of H3K27me3 loss, compared to de novo meningiomas. 8 of 27 tumors with retained H3K27me3 lost H3K27me3 during re-recurrence (29.6%), while no gain of H3K27me3 was observed in progressive disease from 18 tumors with H3K27me3 loss. Loss of H3K27me3 expression was associated with an earlier re-recurrence in recurrent meningiomas grade 1 and 2 (p < 0.001), and was an independent prognostic factor for PFS in recurrent grade 1 meningiomas (p = 0.005).

CONCLUSION

Compared to primary meningiomas, recurrent meningiomas more predominantly had loss of H3K27me3 expression, and further loss can occur during the progression of recurrent tumors. Our results further demonstrated that loss of H3K27me3 predicted shorter PFS in recurrent grade 1 and grade 2 meningiomas. Our work thus supports clinical testing of H3K27me3 in recurrent meningiomas WHO grade 1 and 2.

Clinical Management of Supratentorial Non-Skull Base Meningiomas

Supratentorial non-skull base meningiomas are the most common primary central nervous system tumor subtype. An understanding of their pathophysiology, imaging characteristics, and clinical management options will prove of substantial value to the multi-disciplinary team which may be involved in their care. Extensive review of the broad literature on the topic is conducted. Narrowing the scope to meningiomas located in the supratentorial non-skull base anatomic location highlights nuances specific to this tumor subtype. Advances in our understanding of the natural history of the disease and how findings from both molecular pathology and neuroimaging have impacted our understanding are discussed. Clinical management and the rationale underlying specific approaches including observation, surgery, radiation, and investigational systemic therapies is covered in detail. Future directions for probable advances in the near and intermediate term are reviewed.

Microscope-Based Augmented Reality with Intraoperative Computed Tomography-Based Navigation for Resection of Skull Base Meningiomas in Consecutive Series of 39 Patients

Background: The aim of surgery for skull base meningiomas is maximal resection with minimal damage to the involved cranial nerves and cerebral vessels; thus, implementation of technologies for improved orientation in the surgical field, such as neuronavigation and augmented reality (AR), is of interest. Methods: Included in the study were 39 consecutive patients (13 male, 26 female, mean age 64.08 ± 13.5 years) who underwent surgery for skull base meningiomas using microscope-based AR and automatic patient registration using intraoperative computed tomography (iCT). Results: Most common were olfactory meningiomas (6), cavernous sinus (6) and clinoidal (6) meningiomas, meningiomas of the medial (5) and lateral (5) sphenoid wing and meningiomas of the sphenoidal plane (5), followed by suprasellar (4), falcine (1) and middle fossa (1) meningiomas. There were 26 patients (66.6%) who underwent gross total resection (GTR) of the meningioma. Automatic registration applying iCT resulted in high accuracy (target registration error, 0.82 ± 0.37 mm). The effective radiation dose of the registration iCT scans was 0.58 ± 1.05 mSv. AR facilitated orientation in the resection of skull base meningiomas with encasement of cerebral vessels and compression of the optic chiasm, as well as in reoperations, increasing surgeon comfort. No injuries to critical neurovascular structures occurred. Out of 35 patients who lived to follow-up, 33 could ambulate at their last presentation. Conclusion: A microscope-based AR facilitates surgical orientation for resection of skull base meningiomas. Registration accuracy is very high using automatic registration with intraoperative imaging.

Clinical Outcomes Following Re-Operations for Intracranial Meningioma

Simple Summary

This study investigated patients who underwent more than one operation for a meningioma, a type of brain tumor. Currently, there is little evidence available for this specific patient group. The purpose of this study was to determine if patients had an improvement or deterioration following a second operation for a recurrent meningioma, and to identify any factors that may influence this change. The results demonstrated that following a second operation for meningioma, patients have poorer outcomes. The findings of this study provide supporting information for surgeons and patients, thereby informing decisions related to patient care and re-operation.

Abstract

The outcomes following re-operation for meningioma are poorly described. The aim of this study was to identify risk factors for a performance status outcome following a second operation for a recurrent meningioma. A retrospective, comparative cohort study was conducted. The primary outcome measure was World Health Organization performance. Secondary outcomes were complications, and overall and progression free survival (OS and PFS respectively). Baseline clinical characteristics, tumor details, and operation details were collected. Multivariable binary logistic regression was used to identify risk factors for performance status outcome following a second operation. Between 1988 and 2018, 712 patients had surgery for intracranial meningiomas, 56 (7.9%) of which underwent a second operation for recurrence. Fifteen patients (26.8%) had worsened performance status after the second operation compared to three (5.4%) after the primary procedure (p = 0.002). An increased number of post-operative complications following the second operation was associated with a poorer performance status following that procedure (odds ratio 2.2 [95% CI 1.1–4.6]). The second operation complication rates were higher than after the first surgery (46.4%, n = 26 versus 32.1%, n = 18, p = 0.069). The median OS was 312.0 months (95% CI 257.8–366.2). The median PFS following the first operation was 35.0 months (95% CI 28.9–41.1). Following the second operation, the median PFS was 68.0 months (95% CI 49.1–86.9). The patients undergoing a second operation for meningioma had higher rates of post-operative complications, which is associated with poorer clinical outcomes. The decisions surrounding second operations must be balanced against the surgical risks and should take patient goals into consideration.

Effect of adjuvant radiotherapy after subtotal resection for WHO grade I meningioma: a propensity score matching analysis of the Brain Tumor Registry of Japan

PURPOSE

This study aimed to improve the understanding of the role of adjuvant radiotherapy (AR) after subtotal resection (STR) of World Health Organization (WHO) grade I meningiomas.

METHODS

We retrospectively reviewed the Brain Tumor Registry of Japan database. Among 7341 patients diagnosed with intracranial meningioma during 2001-2008, we identified 406 patients with WHO grade I meningioma treated with STR as initial treatment. Data on progression-free survival (PFS) were assessed for their relevance to clinical factors including age, sex, tumor location and size, presence of preoperative symptoms, and AR.

RESULTS

AR was administered for 73 patients (18.0%). Regrowth occurred in 90 cases (22.2%) during the median follow-up period of 6.0 years (interquartile range, 2.7-7.7 years). Multivariate Cox regression analysis of the entire cohort showed that no AR was associated with significantly shorter PFS (hazard ratio [HR] 2.52, 95% confidence interval [CI] 1.33-5.42, p = 0.004). The therapeutic effect of AR was confirmed for skull base, but not non-skull base, meningiomas (p = 0.003 and 0.69, respectively). Propensity score matching analysis balanced the influence of confounding factors to generate AR+ and AR- cohorts of 73 patients each. PFS was significantly longer in the AR+ cohort than in the AR- cohort (HR 3.46, 95% CI 1.53-8.59, p = 0.003). Subgroup analysis demonstrated the favorable effect of AR only for skull base meningiomas.

CONCLUSIONS

Our study revealed that AR improves tumor control after STR in WHO grade I meningiomas. However, this beneficial effect might be limited to skull base meningiomas.

Meningioma surgical outcomes and complications in patients aged 75 years and older

OBJECTIVE

Meningioma incidence increases with age, yet limited data exist on how comorbidities impact complication rates in elderly patients undergoing meningioma resection. The objective of this study was to report surgical outcomes and identify risk factors for perioperative complications.

METHODS

We performed a retrospective study of patients 75 years and older undergoing meningioma resection. Outcomes included survival and complications. Major complications were those requiring surgical intervention or causing permanent neurological deficit. Recursive partitioning, Kaplan-Meier survival, univariate and multi-variate (MVA) analyses were performed.

RESULTS

From 1996 to 2014, 103 patients with a median age of 79 years (IQR 77-83 years) underwent cranial meningioma resection. Median follow-up was 5.8 years (IQR 1.7-8.7 years). Median actuarial survival was 10.5 years. Complications occurred in 32 patients (31.1%), and 13 patients (12.6%) had multiple complications. Major complications occurred in 16 patients (15.5%). Increasing age was not a significant predictor of any (p = 0.6408) or major complication (p = 0.8081). On univariate analysis, male sex, Charlson Comorbidity Index greater than 8, and cardiovascular comorbidities were significantly associated with major complications. On MVA only cardiovascular comorbidities (OR 3.94, 95% CI 1.05-14.76, p = 0.0238) were significantly associated with any complication. All patients with major complications had cardiovascular comorbidities, and on MVA male gender (OR 3.78, 95%CI 1.20-11.93, p = 0.0212) was associated with major complications.

CONCLUSIONS

Cardiovascular comorbidities and male gender are significant risk factors for complications after meningioma resection in patients aged 75 years and older. While there is morbidity associated with meningioma resection in this cohort, there is also excellent long-term survival.

Is Falcine Meningioma a Diffuse Disease of the Falx? Case Series and Analysis of a "Grade Zero" Resection

BACKGROUND

Falcine meningiomas have unique characteristics including their high rates of recurrence, association with high grade pathology, increased male prevalence, and potential for diffuse involvement of the falx.

OBJECTIVE

To address these issues in a substantial series of falcine meningiomas and report on the impact of extent of resection for this distinct meningioma entity.

METHODS

Retrospective analysis of characteristics and outcomes of 59 falcine meningioma patients who underwent surgery with the senior author. A "Grade Zero" category was used when an additional resection margin of 2 to 3 cm from the tumor insertion was achieved.

RESULTS

For de novo falcine meningiomas, gross total resection (GTR) was associated with significantly decreased recurrence incidence compared with subtotal resection (P ≤ .0001). For recurrent falcine meningiomas, median progression-free survival (PFS) was significantly improved for GTR cases (37 mo vs 12 mo; P = .017, hazard ratio (HR) .243 (.077-.774)). "Grade Zero" resection demonstrated excellent durability for both de novo and recurrent cases, and PFS was significantly improved with "Grade Zero" resection for recurrent cases (P = .003, HR 1.544 (1.156-2.062)). The PFS benefit of "Grade Zero" resection did not achieve statistical significance over Simpson grade 1 during the limited follow-up period (mean 2.8 yr) for these groups.

CONCLUSION

The recurrence of falcine meningiomas is related to the diffuse presence of tumor between the leaflets of the falx. Increased extent of resection including, when possible, a clear margin of falx surrounding the tumor base was associated with the best long-term outcomes in our series, particularly for recurrent tumors.

Postoperative diffusion-weighted imaging and neurological outcome after convexity meningioma resection

OBJECTIVE

Convexity meningiomas are commonly managed with resection. Motor outcomes and predictors of new deficits after surgery are poorly studied. The objective of this study was to determine whether postoperative diffusion-weighted imaging (DWI) was associated with neurological deficits after convexity meningioma resection and to identify the risk factors for postoperative DWI restriction.

METHODS

A retrospective review of patients who had undergone convexity meningioma resection from 2014 to 2018 was performed. Univariate and multivariate logistic regressions were performed to identify variables associated with postoperative neurological deficits and a DWI signal. The amount of postoperative DWI signal was measured and was correlated with low apparent diffusion coefficient maps to confirm ischemic injury.

RESULTS

The authors identified 122 patients who had undergone a total of 125 operations for convexity meningiomas. The median age at surgery was 57 years, and 70% of the patients were female. The median follow-up was 26 months. The WHO grade was I in 62% of cases, II in 36%, and III in 2%. The most common preoperative deficits were seizures (24%), extremity weakness/paralysis (16%), cognitive/language/memory impairment (16%), and focal neurological deficit (16%). Following resection, 89% of cases had no residual deficit. Postoperative DWI showed punctate or no diffusion restriction in 78% of cases and restriction > 1 cm in 22% of cases. An immediate postoperative neurological deficit was present in 14 patients (11%), but only 8 patients (7%) had a deficit at 3 months postoperatively. Univariate analysis identified DWI signal > 1 cm (p < 0.0001), tumor diameter (p < 0.0001), preoperative motor deficit (p = 0.0043), older age (p = 0.0113), and preoperative embolization (p = 0.0171) as risk factors for an immediate postoperative deficit, whereas DWI signal > 1 cm (p < 0.0001), tumor size (p < 0.0001), and older age (p = 0.0181) were risk factors for deficits lasting more than 3 months postoperatively. Multivariate analysis revealed a DWI signal > 1 cm to be the only significant risk factor for deficits at 3 months postoperatively (OR 32.42, 95% CI 3.3-320.1, p = 0.0002). Further, estimated blood loss (OR 1.4 per 100 ml increase, 95% CI 1.1-1.7, p < 0.0001), older age (OR 1.1 per year older, 95% CI 1.0-1.1, p = 0.0009), middle third location in the sagittal plane (OR 16.9, 95% CI 1.3-216.9, p = 0.0026), and preoperative peritumoral edema (OR 4.6, 95% CI 1.2-17.7, p = 0.0249) were significantly associated with a postoperative DWI signal > 1 cm.

CONCLUSIONS

A DWI signal > 1 cm is significantly associated with postoperative neurological deficits, both immediate and long-lasting. Greater estimated blood loss, older age, tumor location over the motor strip, and preoperative peritumoral edema increase the risk of having a postoperative DWI signal > 1 cm, reflective of perilesional ischemia. Most immediate postoperative deficits will improve over time. These data are valuable when preoperatively communicating with patients about the risks of surgery and when postoperatively discussing prognosis after a deficit occurs.

A Prognostic Gene-Expression Signature and Risk Score for Meningioma Recurrence After Resection

BACKGROUND

Prognostic markers for meningioma are needed to risk-stratify patients and guide postoperative surveillance and adjuvant therapy.

OBJECTIVE

To identify a prognostic gene signature for meningioma recurrence and mortality after resection using targeted gene-expression analysis.

METHODS

Targeted gene-expression analysis was used to interrogate a discovery cohort of 96 meningiomas and an independent validation cohort of 56 meningiomas with comprehensive clinical follow-up data from separate institutions. Bioinformatic analysis was used to identify prognostic genes and generate a gene-signature risk score between 0 and 1 for local recurrence.

RESULTS

We identified a 36-gene signature of meningioma recurrence after resection that achieved an area under the curve of 0.86 in identifying tumors at risk for adverse clinical outcomes. The gene-signature risk score compared favorably to World Health Organization (WHO) grade in stratifying cases by local freedom from recurrence (LFFR, P < .001 vs .09, log-rank test), shorter time to failure (TTF, F-test, P < .0001), and overall survival (OS, P < .0001 vs .07) and was independently associated with worse LFFR (relative risk [RR] 1.56, 95% CI 1.30-1.90) and OS (RR 1.32, 95% CI 1.07-1.64), after adjusting for clinical covariates. When tested on an independent validation cohort, the gene-signature risk score remained associated with shorter TTF (F-test, P = .002), compared favorably to WHO grade in stratifying cases by OS (P = .003 vs P = .10), and was significantly associated with worse OS (RR 1.86, 95% CI 1.19-2.88) on multivariate analysis.

CONCLUSION

The prognostic meningioma gene-expression signature and risk score presented may be useful for identifying patients at risk for recurrence.

Small Cerebellopontine Angle Meningioma-Surgical Experience of 162 Patients and Literature Review

Objective

To retrospective analyze the clinical data of 162 patients with small cerebellopontine angle meningiomas. To compare with the nature of tumors, symptoms pre- and post-treatments, neurological deficit, and prognosis in literatures. To explore the surgical outcomes of small cerebellopontine angle meningiomas and summarize the surgical experience.

Methods

All of 162 patients with small cerebellopontine angle meningiomas underwent surgery between January 2010 and December 2019 in the neurosurgery department of the First Affiliated Hospital of Soochow University. This cohort of eight literatures reported about stereotactic radiotherapy of small cerebellopontine angle meningiomas between January 2010 and December 2019. All clinical data were obtained for analysis.

Results

Compared with stereotactic radiotherapy, surgical treatment for small cerebellopontine angle meningiomas lead to the better results in relieving symptoms and inhibiting tumor progression. Surgical treatment can obtain the exact pathological examination results to guide the further treatment.

Conclusions

Surgical treatment should be the first choice for small cerebellopontine angle meningiomas.

Multiplatform genomic profiling and magnetic resonance imaging identify mechanisms underlying intratumor heterogeneity in meningioma

Meningiomas are the most common primary intracranial tumors, but the molecular drivers of meningioma tumorigenesis are poorly understood. We hypothesized that investigating intratumor heterogeneity in meningiomas would elucidate biologic drivers and reveal new targets for molecular therapy. To test this hypothesis, here we perform multiplatform molecular profiling of 86 spatially-distinct samples from 13 human meningiomas. Our data reveal that regional alterations in chromosome structure underlie clonal transcriptomic, epigenomic, and histopathologic signatures in meningioma. Stereotactic co-registration of sample coordinates to preoperative magnetic resonance images further suggest that high apparent diffusion coefficient (ADC) distinguishes meningioma regions with proliferating cells enriched for developmental gene expression programs. To understand the function of these genes in meningioma, we develop a human cerebral organoid model of meningioma and validate the high ADC marker genes CDH2 and PTPRZ1 as potential targets for meningioma therapy using live imaging, single cell RNA sequencing, CRISPR interference, and pharmacology.

The Preferred Locations of Meningioma According to Different Biological Characteristics Based on Voxel-Wise Analysis

Objective: Meningiomas presented preferred intracranial distribution, which may reflect potential biological natures. This study aimed to analyze the preferred locations of meningioma according to different biological characteristics. Method: A total of 1,107 patients pathologically diagnosed with meningiomas between January 2012 and December 2016 were retrospectively analyzed. Preoperative MRI were normalized, and lesions were semiautomatically segmented. The stereospecific frequency and p value heatmaps were constructed to compare two biological phenotypes using two-tailed Fisher's exact test. Age, sex, WHO grades, extent of resection (EOR), recurrence, and immunohistochemical markers including p53, Ki67, epithelial membrane antigen (EMA), progesterone receptor (PR), and CD34 were statistically analyzed. Recurrence-free survival (RFS) were analyzed by Kaplan-Meier method. Result: Of 1,107 cases, convexity (20.8%), parasagittal (16.1%), and falx (11.4%) were the most predominant loci of meningiomas. The p-value heatmap suggested lesion predominance in the left frontal and occipital convexity among older patients while in the left sphenoid wing, and right falx, parasellar/cavernous sinus, and middle fossa among younger patients. Lesions located at anterior fossa and frontal structures were more frequently seen in the male while left parietal falx and tentorial regions, and right cerebellopontine angle in the female. Grades II and III lesions presented predominance in the frontal structures compared with grade I ones. Meningiomas at the left parasagittal sinus and falx, tentorium, intraventricular regions, and skull-base structures were significantly to receive subtotal resection. Lesions with p53 positivity were statistically located at the left frontal regions and parasellar/cavernous sinus, higher Ki67 index at the left frontal and bilateral parietal convexity and right parasellar/cavernous sinus, EMA negativity at the right olfactory groove and left middle fossa, and CD34 positivity at the sellar regions and right sphenoid wing. Tumor recurrence rates for grades I, II, and III were 2.8, 7.9, and 53.8%, respectively. Inferior RFS, higher Ki67 index, grades II and III, and a larger preoperative volume were observed in older patients. Recurrent meningiomas were more frequently found at the occipital convexity, tentorium, sellar regions, parasagittal sinus, and left sphenoid wing. Conclusion: The preferred locations of meningioma could be observed according to different biological characteristics, which might be helpful for clinical decisions.

The effect of household income on outcomes following supratentorial meningioma resection

OBJECTIVE

This study assesses the impact of Median Household Income (MHI) on short- and long-term morbidity and mortality following supratentorial meningioma resection.

PATIENTS AND METHODS

351 consecutive patients undergoing supratentorial meningioma tumor resection, at a single health system over a six-year period (June 09, 2013 to April 26, 2019) were analyzed retrospectively. Outcomes assessed included readmission, emergency department (ED) evaluation, and mortality within 90 days of surgery. Univariate regression analysis was conducted amongst the entire population. The population was then divided into quartiles based on median household income and univariate analysis was conducted between the lowest (Q1) and highest (Q4) quartiles. Significance was set at a P-value < 0.05. Stepwise regression was performed to identify confounding variables in the logistic model.

RESULTS

In the whole population, lower Median Household Income correlated to a significant increase in ED evaluation within 90-days of supratentorial meningioma resection. No significant difference was noted between median household income and 90-day readmission, 90-day unplanned re-operation, return to surgery after index admission within 90-days, return to surgery during the duration of the follow-up period, mortality within 90-days, and mortality during the duration of the follow-up period. In addition, when comparing Q1 (MHI ≤ $51,780) and Q4 (MHI ≥ $87,958), similar results were noted with increased ED evaluation for patients with lower MHI, but no significant difference in other factors of morbidity or mortality.

CONCLUSION

Following supratentorial meningioma resection, a lower median household income was significantly associated with increased emergency department visits within 90 post-operative days.

Brachytherapy with surgical resection as salvage treatment for recurrent high-grade meningiomas: a matched cohort study

PURPOSE

To evaluate surgical resection with brachytherapy placement as a salvage treatment in patients with recurrent high-grade meningioma who exhausted prior external beam treatment options.

METHODS

Single-center retrospective review of our institutional experience of brachytherapy implantation from 2012 to 2018. The primary outcome of the study was progression free survival (PFS). Secondary outcomes included overall survival (OS) and complications. A matched cohort of patients not treated with brachytherapy over the same time period was evaluated as a control group. All patients had received prior radiation treatment and underwent planned gross total resection (GTR) surgery.

RESULTS

A total of 27 cases were evaluated. Compared with prior treatment, brachytherapy implantation demonstrated a statistically significant improvement in tumor control [HR 0.316 (0.101 - 0.991), p = 0.034]. PFS-6 and PFS-12 were 92.3% and 84.6%, respectively. Compared with the matched control cohort, brachytherapy treatment demonstrated improved PFS [HR 0.310 (0.103 - 0.933), p = 0.030]. Overall survival was not statistically significantly different between groups [HR 0.381 (0.073 - 1.982), p = 0.227]. Overall postoperative complications were comparable between groups, although there was a higher incidence of radiation necrosis in the brachytherapy cohort.

CONCLUSION

Brachytherapy with planned GTR improved PFS in recurrent high-grade meningioma patients who exhausted prior external beam radiation treatment options. Future improvement of brachytherapy dose delivery methods and techniques may continue to prolong control rates and improve outcomes for this challenging group of patients.

The Role of Surgery in Meningiomas

PURPOSE OF REVIEW

This review presents the most recent evidences and recommendations in the pre-, intra-, and post-surgical management of patients harboring meningiomas. Due to the increasing relevance of multimodal approaches, in order to preserve patients' neurological function and quality of life (QoL), the role of observation and radiation treatments (as either primary or adjuvant therapy) has also been discussed.

RECENT FINDINGS

Multiple advances in neurosurgery, including the use of the microscope and endoscope, improved preoperative neuroimaging, intraoperative image-guided approaches, and intraoperative neurophysiological monitoring, have extended the neurosurgeon's ability to remove lesions that were previously considered only partially resectable or unresectable, while minimizing morbidity. On the other hand, the preservation of patients' neurological integrity and QoL are increasingly important issues, more than complete tumor resection, for both patients and neurosurgeons. In this setting, stereotactic radiosurgery (SRS) and radiotherapy (RT) may be considered safe and effective alternatives for asymptomatic small- to moderate-sized tumors that demonstrate growth on serial imaging, or in combination with planned subtotal resection (STR) for tumors in critical locations. Data supporting the use of pharmacotherapy in meningiomas are, to date, weak, but the strength of the evidence might improve in the next future with the identification of targetable mutations. Complete microsurgical resection remains the standard of care if it can be achieved with minimal or no morbidity. However, many studies have reported SRS/RT as safe and effective treatments, either as primary approach or as complementary to surgery, especially when dealing with critically located meningiomas (e.g., cranial base) or in patients with comorbidity or wishing to avoid invasive treatments. The management of meningiomas is a field of complementary disciplines: neurosurgeon needs to work closely with radiation oncologists while tailoring the optimal treatment for these patients in order to achieve the best results.

Second Free Flap Surgery for Skull Base Tumors: Case Report and Literature Review

Tumors of the skull base, such as meningiomas, tend to recur. With progress in free vascularized flap surgery, an increasing number of studies are investigating skull base reconstruction with free flaps after tumor removal. In this report, we discuss the results of second free flap surgery after skull base reconstructive surgery. We retrospectively analyzed data from patients treated at our center during the period from 2013 through 2017. All four patients identified had skull base anaplastic meningioma and had undergone radiotherapy. In all cases, the flap and donor blood vessel were sourced from sites that differed from those used in the previous surgeries. No complications developed, such as cerebrospinal fluid leakage, meningitis, wound infection, wound hemorrhage, or flap necrosis. Because the first flap was found to be unviable, it was difficult to preserve and was removed. Essential points in preventing complications are anchoring at the appropriate site, pinprick testing of the created flap, and use of multilayered countermeasures to prevent cerebrospinal fluid leakage.

Radiotherapy for recurrent intracranial epidermoid cysts without malignant transformation: a single-institution case series

INTRODUCTION

Recurrent intracranial epidermoid cysts may be difficult to address surgically given their proximity to critical neurovascular structures of the skull base. There are emerging reports of using radiotherapy (RT) for the treatment of recurrent epidermoid cysts. Here, we report a case series of adjuvant fractionated external beam RT for recurrent intracranial epidermoid cysts.

METHODS

A single-institution review of all recurrent epidermoid cysts treated with adjuvant therapy between 2000 and 2017 was performed.

RESULTS

Eight patients with recurrent epidermoid cysts who underwent adjuvant external beam RT were identified. Average age at initial diagnosis was 42.2 years, and median clinical follow-up after initial diagnosis and RT was 16.4 and 2.9 years, respectively. The median number of surgical resections prior to RT was 3 (range 2-5). Rationale for RT included multiple recurrent disease, rapid recurrence following prior resection, increased risk of further surgical morbidity, and patient preference. Median dose was 50.4 delivered in 1.8 Gy fractions (median 28 fractions). By the date of last follow-up, no patient has demonstrated progression, and there have been no cases of malignant degeneration.

CONCLUSION

Adjuvant RT should be considered in the context of recurrent epidermoid cysts to decrease the likelihood of further recurrences.