Abstract
Although surgical excision of meningioma and its dural base is the most common primary management, skull base meningiomas are quite different, and contemporary management usually consists of multimodal treatment with the aim of achieving the best possible functional outcome and quality of life (QOL) for these patients. As surgery plays an important role in the treatment of skull base meningiomas, it is crucial for neurosurgeons to appreciate the surgical outcome and QOL after meningioma surgery. Outcome is usually measured for meningiomas in terms of morbidity, mortality, time to recurrence, and QOL. The extent of resection, tumor grade, proliferative markers, and tumor location are significant factors in predicting the surgical outcome. Therefore, we address each of these factors in detail in this review. Advances in recent decades in microsurgical techniques, neuroimaging modalities, neuroanesthesia, and perioperative intensive care have substantially improved the surgical outcome; therefore, most surgical outcomes discussed in this review are cited from contemporary literature (2000 to the present) in order to depict the surgical outcome of contemporary microsurgery.
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Michael W. McDermott, San Francisco, USA
The authors have provided a very nice review of the literature since 2000, indicating that challenges remain in the management of the most common primary brain tumor in adults, a meningioma. Not since Cushing first wrote about the significant difficulties these tumors present to the surgeon in 1939 have we been able to provide patients with a definitive surgical cure and acceptable morbidity for our efforts. At our institution, we have published on our own series to document, like the authors here, what the current status of surgical and radiosurgical treatment is (see attached references below; none include in the current paper). Still, many of our efforts are associated with not insignificant morbidity and residual chance for recurrence. Compared to 20 years ago, the neurosurgical community has for the most part accepted that the maximal “safe” resection, followed by observation or adjuvant therapy, provides patients with a better quality of life than attempting complete tumor removal. Soon I suspect that not only the patients, but medical insurers, medical review boards, and government-run health systems will dictate some of the options for treatment for our patients. If we can prove with quality of life follow-up studies and not just freedom from progression or overall survival data that our surgical treatment leaves the patients able to live a nearly normal life postoperatively, then our future surgical endeavors will continue to advance.
References
1. Kane AJ, Sughrue ME, Rutkowski MJ, Shangari G, Fang S, McDermott MW, Berger MS, Parsa AT (2001) Anatomic location is a risk factor for atypical and malignant meningiomas. Cancer 117(6):1272–1278 (Mar 15). doi:10.1002/cncr.25591. Epub 2010 Nov 8. PMID: 21381014 [PubMed—in process]. Related citations
2. Sughrue ME, Rutkowski MJ, Shangari G, Fang S, Parsa AT, Berger MS, McDermott MW (2011) Incidence, risk factors, and outcome of venous infarction after meningioma surgery in 705 patients. J Clin Neurosci 18(5):628–632 (May). Epub 2011 Feb 23. PMID: 21349725 [PubMed—in process]. Related citations
3. Kane AJ, Sughrue ME, Rutkowski MJ, Shangari G, Fang S, McDermott MW, Berger MS, Parsa AT (2010) Anatomic location is a risk factor for atypical and malignant meningiomas. Cancer (Nov 8). [Epub ahead of print]. PMID: 21061397 [PubMed—as supplied by publisher]. Related citations
4. Zlotnick D, Kalkanis SN, Quinones-Hinojosa A, Chung K, Linskey ME, Jensen RL, DeMonte F, Barker FG, Racine CA, Berger MS, Black PM, Cusimano M, Sekhar LN, Parsa A, Aghi M, McDermott MW (2010) FACT-MNG: tumor site specific web-based outcome instrument for meningioma patients. J Neurooncol 99(3):423–431 (Sep). Epub 2010 Sep 18. Review. PMID: 20853019 [PubMed—indexed for MEDLINE] Free PMC Article. Free full text. Related citations
5. Sughrue ME, Rutkowski MJ, Shangari G, Chang HQ, Parsa AT, Berger MS, McDermott MW (2011) Risk factors for the development of serious medical complications after resection of meningiomas. J Neurosurg 114(3):697–704 (Mar). Epub 2010 Jul 23. PMID: 20653395 [PubMed—in process]. Related citations
6. Sughrue ME, Rutkowski MJ, Chang EF, Shangari G, Kane AJ, McDermott MW, Berger MS, Parsa AT (2011) Postoperative seizures following the resection of convexity meningiomas: are prophylactic anticonvulsants indicated? J Neurosurg 114(3):705–709 (Mar). Epub 2010 Jun 25. PMID: 20578801 [PubMed—in process]. Related citations
7. Sughrue ME, Cage T, Shangari G, Parsa AT, McDermott MW (2010) Clinical characteristics and surgical outcomes of patients presenting with meningiomas arising predominantly from the floor of the middle fossa. Neurosurgery 67(1):80–86; discussion 86 (Jul). PMID: 20559094 [PubMed—in process]. Related citations
8. Sughrue ME, Rutkowski MJ, Aranda D, Barani IJ, McDermott MW, Parsa AT (2010) Factors affecting outcome following treatment of patients with cavernous sinus meningiomas. J Neurosurg 113(5):1087–1092 (Nov). Epub 2010 May 7. PMID: 20450274 [PubMed—indexed for MEDLINE]. Related citations
9. Sughrue ME, Rutkowski MJ, Aranda D, Barani IJ, McDermott MW, Parsa AT (2010) Treatment decision making based on the published natural history and growth rate of small meningiomas. J Neurosurg 113(5):1036–1042 (Nov). Epub 2010 Apr 30. Review. PMID: 20433281 [PubMed—indexed for MEDLINE]. Related citations
10. Sughrue ME, Kane AJ, Shangari G, Parsa AT, Berger MS, McDermott MW (2010) Prevalence of previous extracranial malignancies in a series of 1228 patients presenting with meningioma. J Neurosurg 113(5):1115–1121 (Nov). Epub 2010 Apr 30. PMID: 20433279 [PubMed—indexed for MEDLINE]. Related citations
11. Sughrue ME, Kane AJ, Shangari G, Rutkowski MJ, McDermott MW, Berger MS, Parsa AT (2010) The relevance of Simpson grade I and II resection in modern neurosurgical treatment of World Health Organization grade I meningiomas. J Neurosurg 113(5):1029–1035 (Nov). Epub 2010 Apr 9. PMID: 20380529 [PubMed—indexed for MEDLINE]. Related citations
12. Sughrue ME, Sanai N, Shangari G, Parsa AT, Berger MS, McDermott MW (2010) Outcome and survival following primary and repeat surgery for World Health Organization grade III meningiomas. J Neurosurg 113(2):202–209 (Aug). PMID: 20225922 [PubMed—indexed for MEDLINE]. Related citations
13. Sanai N, McDermott MW (2010) A modified far-lateral approach for large or giant meningiomas of the posterior fossa. J Neurosurg 112(5):907–912 (May). PMID: 19877805 [PubMed—indexed for MEDLINE]. Related citations
14. Quiñones-Hinojosa A, Kaprealian T, Chaichana KL, Sanai N, Parsa AT, Berger MS, McDermott MW (2009) Pre-operative factors affecting resectability of giant intracranial meningiomas. Can J Neurol Sci 36(5):623–630 (Sep). PMID: 19831133 [PubMed—indexed for MEDLINE]. Related citations
15. Sanai N, Sughrue ME, Shangari G, Chung K, Berger MS, McDermott MW (2010) Risk profile associated with convexity meningioma resection in the modern neurosurgical era. J Neurosurg 112(5):913–919 (May). PMID: 19645533 [PubMed—indexed for MEDLINE]. Related citations
16. Cage TA, Lamborn KR, Ware ML, Frankfurt A, Chakalian L, Berger MS, McDermott MW (2009) Adjuvant enoxaparin therapy may decrease the incidence of postoperative thrombotic events though does not increase the incidence of postoperative intracranial hemorrhage in patients with meningiomas. J Neurooncol 93(1):151–156 (May). Epub 2009 May 9. PMID: 19430892 [PubMed—indexed for MEDLINE]. Related citations
17. Quiñones-Hinojosa A, Chang EF, Chaichana KL, McDermott MW (2009) Surgical considerations in the management of falcotentorial meningiomas: advantages of the bilateral occipital transtentorial/transfalcine craniotomy for large tumors. Neurosurgery 64(5 Suppl 2):260–268; discussion 268 (May). PMID: 19287325 [PubMed—indexed for MEDLINE]. Related citations
18. Smith JS, Lal A, Harmon-Smith M, Bollen AW, McDermott MW (2007) Association between absence of epidermal growth factor receptor immunoreactivity and poor prognosis in patients with atypical meningioma. J Neurosurg 106(6):1034–1040 (Jun). PMID: 17564176 [PubMed—indexed for MEDLINE]. Related citations
19. Chi JH, Parsa AT, Berger MS, Kunwar S, McDermott MW (2006) Extended bifrontal craniotomy for midline anterior fossa meningiomas: minimization of retraction-related edema and surgical outcomes. Neurosurgery 59(4 Suppl 2):ONS426–ONS433; discussion ONS433–ONS434 (Oct). PMID: 17041513 [PubMed—indexed for MEDLINE]. Related citations
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21. Quinones-Hinojosa A, Chang EF, McDermott MW (2003) Falcotentorial meningiomas: clinical, neuroimaging, and surgical features in six patients. Neurosurg Focus 14(6):e11 (Jun 15). Review. PMID: 15669786 [PubMed—indexed for MEDLINE]. Related citations
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23. Ware ML, Larson DA, Sneed PK, Wara WW, McDermott MW (2004) Surgical resection and permanent brachytherapy for recurrent atypical and malignant meningioma. Neurosurgery 54(1):55–63; discussion 63–64 (Jan). PMID: 14683541 [PubMed—indexed for MEDLINE]. Related citations
24. Chun JY, McDermott MW, Lamborn KR, Wilson CB, Higashida R, Berger MS (2002) Delayed surgical resection reduces intraoperative blood loss for embolized meningiomas. Neurosurgery 50(6):1231–1235; discussion 1235–1237 (Jun). PMID: 12015840 [PubMed—indexed for MEDLINE]. Related citations
25. Ojemann SG, Sneed PK, Larson DA, Gutin PH, Berger MS, Verhey L, Smith V, Petti P, Wara W, Park E, McDermott MW (2000) Radiosurgery for malignant meningioma: results in 22 patients. J Neurosurg 93(Suppl 3):62–67 (Dec). PMID: 11143265 [PubMed—indexed for MEDLINE]. Related citations
Kenji Ohata, Osaka, Japan
The authors reviewed the contemporary literature regarding the surgical outcome and quality of life after the surgery of skull base meningiomas in different locations. Their endeavor of reviewing 120 articles is worthy of praise and very informative. In the history of the treatment of skull base meningioma, the advancement of skull base surgery in the 1980s greatly contributed to the surgical resectability of the basal meningioma even from the complex area including cavernous sinus and petroclival region, whereas the surgical mortality after the radical resection became the issue of discussion for QOL. In the 1990s, stereotactic radiosurgery provided a resolution of this problem and multimodal treatment is now commonly applied in order to achieve a satisfactory functional outcome and control the tumor. However, I am concerned that the role of stereotactic radiosurgery has been overestimated and the role of radical resection has a tendency of underestimation. As the radiation technology is advanced, the surgical techniques also could be advanced for the cure of this disease. We need the long-term follow-up results over 10 or 20 years in order to obtain the truth of the treatment philosophy. Our recent analysis of this particular tumor in the long-term follow-up periods showed that radical resection could provide a satisfactory outcome with 91.5% recurrence-free survival rate at 20 years [1]. As a result, I advocate that radical resection has the most important role even in the era of multimodal treatment. Additionally, I completely agree with the authors’ comment that the most important factors are the experience, philosophy, and techniques of the surgeon.
References
1. Ichinose T, Goto T, Ishibashi K, Takami T, Ohata K (2010) The role of radical microsurgical resection in multimodal treatment for skull base meningioma. J Neurosurg 113:1072–1078
Madjid Samii, Venelin Miroslav Gerganov, Hannover, Germany
The authors present a comprehensive review of the current management of skull base meningiomas with a special emphasize on the role of surgery. The significance of extent of resection, of tumor grade, and of various proliferative markers as predictors of the outcome and of the risk of recurrence is presented in detail. The surgical outcome in regards to tumor location is discussed, summarizing the results published by recognized expert groups in the last 10 years.
Some areas of future research are suggested in the manuscript. The current grading system of meningiomas is based on histopathological criteria, which do not account for the many individual tumor differences that are of paramount importance for the outcome. We believe that meningiomas, regardless of their histopathological grade, are two types: encapsulated or infiltrating. Encapsulated meningiomas can be removed completely without or with minimal morbidity. Infiltrating meningiomas, which frequently but not always, are microcystic, atypical, or anaplastic, tend to infiltrate the pial covering and even the neural tissue. In such cases, the attempt to remove the tumor completely may have dramatic consequences. The infiltration of the pia is not restricted to the aforementioned tumor categories and does not necessarily indicate malignant tumor: it may occur also in WHO grade I meningiomas. The possibility to predict these relationships of the meningioma to surrounding structures reliably before surgery would be of great value for the selection of appropriate management in each individual patient. In the future, meningioma grading will be certainly refined by inclusion of molecular and genetic criteria.
The goal of surgery in skull base meningiomas, according to the authors, is to “achieve as extensive resection as possible while minimizing neurological morbidity”—a statement that should be generally accepted. Radiosurgery has a certain place in the management of patients with meningiomas that are not amenable to complete removal due to the aforementioned tumor characteristics, due to tumor critical location (e.g., cavernous sinus), or in case the patient’s general condition precludes open surgery.
Chien-Min Chen and Abel Po-Hao Huang contributed equally to this study.
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Chen, CM., Huang, A.PH., Kuo, LT. et al. Contemporary surgical outcome for skull base meningiomas. Neurosurg Rev 34, 281–296 (2011). https://doi.org/10.1007/s10143-011-0321-x
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DOI: https://doi.org/10.1007/s10143-011-0321-x