Conditional Recurrence-Free Survival After Surgical Resection of Meningioma

BACKGROUND

Recurrence after meningioma resection warrants serial surveillance imaging, but little evidence guides the optimal time interval between imaging studies/surveillance duration.

OBJECTIVE

To describe recurrence-free survival (RFS) after meningioma resection, conditioned to short-term RFS.

METHODS

A retrospective cohort study for adults presenting for meningioma resection from 2000 to 2018 was conducted. The primary outcome was postoperative follow-up RFS. Conditional RFS Kaplan-Meier analysis was performed at 1, 2, 3, 5, and 10 years, conditioned to 6-month and 12-month RFS. RFS probabilities conditioned to 6-month RFS were estimated in subgroups, stratified by World Health Organization grade, extent of resection, and need for postoperative radiation.

RESULTS

In total, 723 patients were included. Median age at surgery was 57.4 years (IQR = 47.2-67.2). Median follow-up was 23.5 months (IQR = 12.3-47.8). Recurrence was observed in 90 patients (12%), with median time to recurrence of 14.4 months (IQR = 10.3-37.1). Conditioned to 6-month postoperative RFS, patients had 90.3% probability of remaining recurrence-free at 2 years and 69.4% at 10 years. Subgroup analysis conditioned to 6-month RFS demonstrated grade 1 meningiomas undergoing gross total resection (GTR) had 96.0% probability of RFS at 1 year and 82.8% at 5 years, whereas those undergoing non-GTR had 94.5% and 79.9% probability, respectively. RFS probability was 78.8% at 5 years for non-grade 1 meningiomas undergoing GTR, compared with 69.7% for non-grade 1 meningiomas undergoing non-GTR. Patients with non-grade 1 meningiomas undergoing upfront radiation had a 1-year RFS of 90.1% and 5-year RFS of 51.7%.

CONCLUSION

Recurrence risk after meningioma resection after an initial recurrence-free period is reported, with high-risk subgroups identified. These results can inform objective shared decision-making for optimal follow-up.

Association between preoperative hematologic markers and aggressive behavior in meningiomas

INTRODUCTION

Meningiomas have varying degrees of aggressive behavior. Some systemic hematologic makers are associated with malignancy, but their value in predicting aggressive meningioma behavior is not fully understood.

OBJECTIVE

To evaluate the association between preoperative markers such as neutrophil-lymphocyte ratio (NLR), neutrophil-monocyte ratio (NMR), monocyte-lymphocyte ratio (MLR), platelet-lymphocyte ratio (PLR), and prognostic nutritional index (PNI), and diagnostic and prognostic factors including WHO grade, proliferation index, presence of edema on preoperative MRI, and tumor recurrence.

METHODS

A retrospective review of patients treated between 2000 and 2019 with a preoperative complete blood count (CBC) differential lab draw before intracranial meningioma resection was conducted. All preoperative steroid dosages were converted to dexamethasone equivalents. Primary outcomes included presence/absence of perilesional edema, WHO grade, Ki-67/MIB-index, and recurrence. Univariate and multivariable regression analyses were conducted.

RESULTS

A total of 209 meningioma patients were included. Of these, 143 (68 %) were WHO grade I, 61 (29 %) grade II and 5 (2 %) were grade III. Recurrence was reported in 19 (9.1 %) tumors. No hematologic markers were associated with recurrence. In separate multivariable logistic analyses, no biomarkers were associated with perilesional edema or WHO grade. MLR was associated with higher MIB-index (p = 0.018, OR 6.57, 95 % CI 1.37-30.91).

CONCLUSION

Most hematologic markers were not associated with meningioma invasiveness, grade, proliferative index, or aggressiveness. Preoperative MLR was associated with high proliferation index in patients undergoing surgery for intracranial meningioma. Higher MLR could be a surrogate for meningioma proliferation and has potential to be used as an adjunct for risk-stratifying meningiomas.

Comparison of supratentorial meningioma resection outcomes by dural reconstruction technique

OBJECTIVE

Excision of intracranial meningiomas often requires resection or coagulation of the dura mater. The choice of dural closure technique is individualized and based on surgeon preference. The objective of this study was to determine outcomes following various dural closure techniques for supratentorial meningiomas.

METHODS

A retrospective, single-center cohort study was performed for patients who underwent excision of supratentorial meningiomas from 2000 to 2019. Outcomes including operative time, postoperative in-hospital complications, readmission, causes of readmission including surgical site infection, pseudomeningocele, need for shunt surgery, and imaging appearance of pseudomeningocele on long-term follow-up imaging were compared. Univariate and multivariable analyses were conducted.

RESULTS

A total of 353 patients who had complete clinical and operative data available for review were included. Of these patients, 227 (64.3%) had nonsutured dural graft reconstruction and 126 (35.7%) had sutured dural repair, including primary closure, artificial dura, or pericranial graft. There was significant variability in using nonsutured dural reconstruction compared with sutured dural repair technique among surgeons (p < 0.001). Tumors with sagittal sinus involvement were more likely to undergo nonsutured closure (n = 79, 34.8%) than dural repair (n = 26, 20.6%) (p = 0.003). There were no other differences in preoperative imaging findings or WHO grade. Frequency of surgical site infection and pseudomeningocele, need for shunt surgery, and recurrence were similar between those undergoing nonsutured and those undergoing sutured dural repair. The mean operative time for the study cohort was 234.9 (SD 106.6) minutes. The nonsutured dural reconstruction group had a significantly shorter mean operative time (223.9 [SD 99.7] minutes) than the sutured dural repair group (254.5 [SD 115.8] minutes) (p = 0.015). In a multivariable linear regression analysis, after controlling for tumor size and sinus involvement, nonsutured dural graft reconstruction was associated with a 36.8-minute reduction (95% CI -60.3 to -13.2 minutes; p = 0.002) in operative time.

CONCLUSIONS

Dural reconstruction using a nonsutured graft and sutured dural repair exhibit similar postoperative outcomes for patients undergoing resection for supratentorial meningiomas. Although sutured grafts may sometimes be necessary, nonsutured graft reconstruction for most supratentorial meningioma resections may suffice. The decreased operative time associated with nonsutured grafts may ultimately result in cost savings. These findings should be taken into consideration when selecting a dural reconstruction technique for supratentorial meningioma.

Outcomes following surgical resection of cystic intracranial meningiomas

INTRODUCTION

Cystic meningiomas are rare, accounting for 2-7% of all intracranial meningiomas. Little is known regarding whether these meningiomas behave differently compared to solid meningiomas. We sought to study this relatively uncommon imaging appearance of meningioma and to evaluate its clinical significance.

METHODS

A single-institution retrospective cohort study of surgically-treated meningioma patients between 2000 and 2019 was conducted. Cystic meningioma was defined as a tumor with an intratumoral or peritumoral cyst present on preoperative imaging. Demographics, preoperative imaging, histopathology characteristics, operative data, and surgical outcomes were reviewed. Imaging variables, histopathology and outcomes were reported for cystic meningiomas and compared with non-cystic meningiomas. Univariate/multivariable analyses were conducted.

RESULTS

Of 737 total meningiomas treated surgically, 38 (5.2%) were cystic. Gross total resection (GTR) was achieved in 84.2% of cystic meningioma patients. Eighty-two percent of cystic meningiomas were WHO grade I (n = 31), 15.7% were grade II and 2.6% were grade III. Most cystic meningiomas had low Ki-67/MIB-1 proliferation index (n = 24, 63.2%). A total of 18.4% (n = 7) patients with cystic meningioma had recurrence compared to 12.2% (n = 80) of patients with non-cystic meningioma (p = 0.228). No significant difference in median time to recurrence was observed between cystic and non-cystic meningiomas (25.4, Q1:13.9, Q3:46.9 months vs. 13.4, Q1:8.6, Q3:35.5 months, p = 0.080).

CONCLUSIONS

A small portion of intracranial meningiomas have cystic characteristics on imaging. Cystic meningiomas are frequently WHO grade I, have low proliferation index, and had similar outcomes compared to non-cystic meningioma. Cysts in meningioma may not be a surrogate to determine aggressive meningioma behavior.

The behavioral, psychological, and social impacts of team sports: a systematic review and meta-analysis

Objectives: To assess the association between team sport participation and behavioral, psychological, and social health outcomes in young athletes.Methods: A systematic review and meta-analysis were undertaken to identify studies published between 01/01/1950-05/01/2020 investigating the association between team sport participation and health outcomes in young athletes (<25 years). Included studies compared team sport participants to controls or themselves, assessed health outcomes, and had a sample size >50. Prospective and retrospective studies were included; non-primary literature was excluded. Health outcomes were categorized as: 1) behavioral, 2) psychological, or 3) social. Data were extracted to form 2 × 2 tables for each study to calculate odds ratios (OR) and 95% confidence intervals (CI).Results: Of 371 queried articles, 34 studies from 10 countries across 4 continents were included, with 9 reporting homogenous outcomes for meta-analysis.Behavioral: Fifteen studies evaluated behavioral health outcomes of alcohol and/or drug use, fitness, and diet. Quantitatively, team sport participation was found to decrease rates of cigarette/tobacco use across 5 studies (OR 0.72, 95% CI 0.69-0.76) and alcohol/drug use across 7 studies (OR 0.73, 95% CI 0.69-0.77). Qualitatively, 12/15 (80%) of studies confirmed improved behavioral health outcomes with team sport participation.Psychological: Nineteen studies evaluated psychological health outcomes including anorexia, anxiety, depression, self-esteem, and suicidal ideation. Quantitatively, team sport participation was associated with decreased depression/anxiety rates across 5 studies (OR 0.59, 95%CI 0.54-0.64). Qualitatively, 14/19 (74%) of studies confirmed improved psychological health.Social: Ten studies evaluated social health outcomes including academic performance, commitment, psychosocial health, social behavior/identity, and delinquency/high-risk activity. Qualitatively, 7/10 (70%) of studies confirmed improved social health outcomes with team sport participation.Conclusion: Team sport participation was associated with decreased odds of smoking/tobacco use, alcohol/drug use, and depression/anxiety. Though few studies mentioned potential negative effects of team sport participation, the majority reported improved behavioral, psychological, and social health outcomes in youth athletes worldwide.

The cost of a single concussion in American high school football: a retrospective cohort study

Aim:

The potential financial burden of American football-related concussions (FRC) is unknown. Our objective was to describe the healthcare costs associated with an FRC and determine factors associated with increased costs.

Methodology/results:

A retrospective cohort study of concussed high school football players presenting between November 2017 and March 2020 was undertaken; 144 male high school football players were included. Total costs were about $115,000, for an average direct healthcare cost of $800.10/concussion. Visiting the emergency department (β = 502.29, 95% CI: 105.79–898.61; p = 0.01), the initial post-concussion symptom scale score (β = 0.39, 95% CI: 0.11–0.66; p = 0.01) and a post-concussion syndrome diagnosis (β = 670.37, 95% CI: 98.96–1241.79; p = 0.02) were each independently associated with total costs.

Conclusion:

A granular understanding of cost-driving factors associated with FRC is the first step in understanding the cost–effectiveness of prevention and treatment methods.

The healthcare costs, or the costs incurred by the healthcare system, associated with a single concussion in American high school football are unknown. We reviewed the records of 144 high school football players who received concussion care at our sport concussion center and calculated the direct healthcare costs associated with the appointments, imaging studies and therapies received, when applicable. We found that each concussion results in about $800 of healthcare system spending. A few factors were associated with greater costs, including visiting the emergency department and having symptoms for over 1 month. Furthermore, the more symptoms an athlete had at their first clinic visit, the higher total cost of care. Understanding these costs can potentially help clinicians and researchers determine the best ways to maximize care while minimizing the costs.