MON-310 Factors Associated with Remission After Surgery for Acromegaly

Abstract Background: Acromegaly is a disorder characterized by excessive growth hormone (GH) secretion, which, in most cases, is caused by a GH secreting adenoma. Surgical removal of the tumor via a transsphenoidal approach is the first choice treatment for most patients. The remission rate after an initial resection is 80 to 90 percent for microadenomas and less than 50 percent for macroadenomas. Objective: To analyze predictive factors of remission in acromegaly patients who underwent transsphenoidal surgery for GH secreting adenoma. Methods: From January 2006 to October 2019, 75 patients with GH secreting pituitary adenoma were evaluated at our center. Patients who had undergone medical treatment or radiotherapy as first treatment were excluded. A total of 60 patients were included in the analysis. Remission was defined as normal serum insulin-like growth factor-1 (IGF-1) age and sex adjusted and a random serum GH less than 1 ng/mL and/or nadir GH during oral glucose tolerance test <0.4 ng/mL. Results: We evaluated 60 patients (41 females and 19 males), with a mean age at diagnosis of 49.6 (ranged from 23 to 77 years). Mean initial IGF-1 was 905.3 ng/mL (range 100-324) and mean initial GH was 25.0 ng/mL (<2.5). Macroadenomas were more common than microadenomas (48 vs 12). The average maximum tumor diameter was 15.6 mm and 21 patients were graded as Knosp 3 or 4, which indicated cavernous sinus invasion. Patients were follow for 11.8 years. Overall, the remission rate was 50.0% after surgery. Mean age of patients in surgical remission (51.6 years) was higher than those patients not in remission (47.5 years) (p=0.439). Remission rates for microadenomas and macroadenomas were 75.0% and 44.9%, respectively (p=0.04). Patients who achieved remission had smaller tumors compared with those who failed to attain remission (mean diameter 11.6mm versus 17.8 mm). Using the Knosp classification system and preoperative magnetic resonance images to determine cavernous sinus invasion, Knosp grade 3 to 4 tumors were found in 5 patients in remission and in 16 patients with persistence of disease (p=0.003). Patients who achieved remission had a significantly lower preoperative IGF-1 level (650.5 ng/mL) compared with those who did not (1211.0 ng/mL) (p=0.04). Preoperative GH levels were lower for the patients who achieved remission (18.7 ng/mL) than for those who did not (32.5 ng/mL, p=0.006). Conclusions: In our study, predictors of biochemical remission after surgery were smaller tumor size, lower Knosp grade, and lower preoperative GH and IGF-1 levels.

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Outcomes of Therapy for Cushing’s Disease due to Adrenocorticotropin-Secreting Pituitary Macroadenomas1

The Journal of Clinical Endocrinology & Metabolism ◽

10.1210/jcem.83.1.4525 ◽

1998 ◽

Vol 83 (1) ◽

pp. 63-67 ◽

Cited By ~ 1

Author(s):

Lewis S. Blevins ◽

James H. Christy ◽

Masheed Khajavi ◽

George T. Tindall

Keyword(s):

Confidence Interval ◽

Cavernous Sinus ◽

Cushing’S Disease ◽

Odds Ratio ◽

Remission Rate ◽

Cushing's Disease ◽

Tumor Diameter ◽

Cavernous Sinus Invasion ◽

Free Cortisol ◽

Acth Secreting

We reviewed our experience with 21 patients who had Cushing’s disease due to ACTH-secreting macroadenomas to clarify the natural history of this disease. All patients had typical clinical and biochemical features of ACTH-dependent hypercortisolism. Their mean maximal tumor diameter was 1.6 ± 0.1 cm, and the range was 1.0–2.7 cm. Six patients had cavernous sinus invasion, three had invasion of the floor of their sella, and nine had suprasellar extension. The observed remission rate was significantly lower in macroadenoma patients than in microadenoma patients (67% vs. 91%; χ2 = 5.7; P < 0.02). Cavernous sinus invasion (odds ratio, 35; 95% confidence interval, 2.6–475; P < 0.008) and presence of a maximum tumor diameter 2.0 cm or more (odds ratio, 12.9; 95% confidence interval, 1.4–124; P< 0.02) emerged as the only predictors of residual disease after surgery. The observed recurrence rate was significantly higher in macroadenoma patients than in microadenoma patients (36% vs. 12%; χ2 = 4.2; P< 0.05). Macroadenoma patients tended to suffer from recurrences earlier than did microadenoma patients (16 vs. 49 months). Stepwise multiple logistic regression did not identify any predictors of disease recurrence in macroadenoma patients. Eight macroadenoma patients underwent a total of nine repeat surgical procedures, but none of these resulted in clinical remissions. Only four of seven (57%) patients followed for a sufficient period of time achieved normal urinary free cortisol levels after conventional radiotherapy. Three (75%) of these four patients had re-recurrent hypercortisolism after brief periods of eucortisolism. Pharmacological agents and adrenalectomy were effective in the management of hypercortisolism in patients with residual and recurrent disease. Our results indicate that ACTH-secreting macroadenomas are more refractory to conventional treatments than are ACTH-secreting microadenomas.

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Association of different pathologic subtypes of growth hormone producing pituitary adenoma and remission in acromegaly patients: a retrospective cohort study

BMC Endocrine Disorders ◽

10.1186/s12902-021-00850-2 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Maryam Dehghani ◽

Zahra Davoodi ◽

Farahnaz Bidari ◽

Amin Momeni Moghaddam ◽

Davood Khalili ◽

...

Keyword(s):

Growth Hormone ◽

Cohort Study ◽

Cavernous Sinus ◽

Retrospective Cohort Study ◽

Pituitary Adenomas ◽

Retrospective Cohort ◽

Remission Rate ◽

Cavernous Sinus Invasion ◽

Dual Staining

Abstract Background Regarding the inconclusive results of previous investigations, this study aimed to determine the association between pathology, as a possible predictor, with remission outcomes, to know the role of pathology in the personalized decision making in acromegaly patients. Methods A retrospective cohort study was performed on the consecutive surgeries for growth hormone (GH) producing pituitary adenomas from February 2015 to January 2021. Seventy-one patients were assessed for granulation patterns and prolactin co-expression as dual staining adenomas. The role of pathology and some other predictors on surgical remission was evaluated using logistic regression models. Results Among 71 included patients, 34 (47.9%) patients had densely granulated (DG), 14 (19.7%) had sparsely granulated (SG), 23 (32.4%) had dual staining pituitary adenomas. The remission rate was about 62.5% in the patients with SG and DG adenomas named single staining and 52.2% in dual staining groups. Postoperative remission was 1.53-folds higher in the single staining adenomas than dual staining-one (non-significant). The remission rate was doubled in DG group compared to two other groups (non-significant). By adjusting different predictors, cavernous sinus invasion and one-day postoperative GH levels decreased remission rate by 91% (95% CI: 0.01–0.67; p = 0.015) and 64% (95% CI: 0.19–0.69; p < 0.001), respectively. Responses to the medications were not significantly different among three groups. Conclusion Various pathological subtypes of pituitary adenomas do not appear to have a predictive role in estimating remission outcomes. Cavernous sinus invasion followed by one-day postoperative GH is the strongest parameter to predict biochemical remission.

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Safety and efficacy of mini doppler in recurrent pituitary tumours

Romanian Neurosurgery ◽

10.33962/roneuro-2020-051 ◽

2020 ◽

pp. 336-342

Author(s):

Moshiur Rahman ◽

Ezequiel Garcia-Ballestas ◽

Luis Rafael Moscote-Salazar

Keyword(s):

Cavernous Sinus ◽

Surgical Excision ◽

Pituitary Surgery ◽

Pituitary Tumour ◽

Csf Leak ◽

Surgical Removal ◽

Pituitary Tumours ◽

Female Ratio ◽

Cavernous Sinus Invasion ◽

Number Of Patients

Background: Pituitary surgery is the most common surgery used to remove pituitary tumours. The use of mini doppler in surgical removal of an endonasal pituitary tumour has shown good short-term clinical outcomes and few complications in patients. Cavernous sinus invasion limits the surgical excision and still a challenge of gross total resection. Objective: The main objective of this study is to evaluate the outcome of surgical removal of an endonasal pituitary tumour using mini doppler. Method: A total of 12 patients were studied retrospectively from 2012 to 2018 in a single institution (Private hospital) in Dhaka, Bangladesh. The male and female ratio was 7:5. Results: 92% of cases of the total number of patients had satisfactory removal/ neurological improvement/hormonal improvement. Among 12 cases, 8 cases had transient diabetes insipidus and one patient had CSF leak. Conclusion: The intraoperative Doppler is a useful tool to localize the carotids, which provides safer resection of endonasal pituitary tumours. Thus, it is very safe and effective for laterosellar resection of recurrent pituitary tumours and for cavernous sinus invasions.

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Outcomes after a purely endoscopic transsphenoidal resection of growth hormone–secreting pituitary adenomas

Neurosurgical FOCUS ◽

10.3171/2010.7.focus10153 ◽

2010 ◽

Vol 29 (4) ◽

pp. E5 ◽

Cited By ~ 53

Author(s):

Peter G. Campbell ◽

Erin Kenning ◽

David W. Andrews ◽

Sanjay Yadla ◽

Marc Rosen ◽

...

Keyword(s):

Growth Hormone ◽

Pituitary Adenomas ◽

Remission Rate ◽

Csf Leak ◽

Oral Glucose ◽

Cure Rate ◽

Cavernous Sinus Invasion ◽

Remission Criteria ◽

Biochemical Cure ◽

Transsphenoidal Resection

Object Using strict biochemical remission criteria, the authors assessed surgical outcomes after endoscopic transsphenoidal resection of growth hormone (GH)–secreting pituitary adenomas and identified preoperative factors that significantly influence the rate of remission. Methods A retrospective review of a prospectively maintained database was performed. The authors reviewed cases in which an endoscopic resection of GH-secreting pituitary adenomas was performed. The cohort consisted of 26 patients who had been followed for 3–60 months (mean 24.5 months). The thresholds of an age-appropriate, normalized insulin-like growth factor–I concentration, a nadir GH level after oral glucose load of less than 1.0 μg/l, and a random GH value of less than 2.5 μg/l were required to establish biochemical cure postoperatively. Results Overall, in 57.7% of patients undergoing a purely endoscopic transsphenoidal pituitary adenectomy for acromegaly, an endocrinological cure was achieved. The mean clinical follow-up duration was 24.5 months. In patients with microadenomas (4 cases) the cure rate was 75%, whereas in patients harboring macroadenomas (22 cases) the cure rate was 54.5%. Cavernous sinus invasion (Knosp Grades 3 and 4) was associated with a significantly lower remission rate (p = 0.0068). Hardy Grade 3 and 4 tumors were also less likely to achieve biochemical cure (p = 0.013). The overall complication rate was 11.5% including 2 incidents of transient diabetes insipidus and 1 postoperative CSF leak, which were treated nonoperatively. Conclusions A purely endoscopic transsphenoidal approach to GH-secreting pituitary adenomas leads to similar outcome for noninvasive macroadenomas compared with traditional microsurgical techniques. Furthermore, this approach may often provide maximal visualization of the tumor, the pituitary gland, and the surrounding neurovascular structures.

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Gamma Knife Radiosurgery for the Treatment of Cavernous Sinus Meningiomas

Neurosurgery ◽

10.1227/01.neu.0000047814.18819.9f ◽

2003 ◽

Vol 52 (3) ◽

pp. 517-524 ◽

Cited By ~ 111

Author(s):

Yoshiyasu Iwai ◽

Kazuhiro Yamanaka ◽

Tomoya Ishiguro

Keyword(s):

Tumor Growth ◽

Gamma Knife ◽

Cavernous Sinus ◽

Tumor Regression ◽

Gamma Knife Radiosurgery ◽

Growth Control ◽

Neurological Deficits ◽

Surgical Removal ◽

Tumor Diameter

Abstract OBJECTIVE We report on the efficacy of gamma knife radiosurgery for cavernous sinus meningiomas. METHODS Between January 1994 and December 1999, we used gamma knife radiosurgery for the treatment of 43 patients with cavernous sinus meningiomas. Forty-two patients were followed up for a mean of 49.4 months (range, 18–84 mo). The patients' average age was 55 years (range, 18–81 yr). Twenty-two patients (52%) underwent operations before radiosurgery, and 20 patients (48%) underwent radiosurgery after the diagnosis was made by magnetic resonance imaging. The tumor volumes ranged from 1.2 to 101.5 cm3 (mean, 14.7 cm3). The tumors either compressed or were attached to the optic apparatus in 17 patients (40.5%). The marginal radiation dose was 8 to 15 Gy (mean, 11 Gy), and the optic apparatus was irradiated with 2 to 12 Gy (mean, 6.2 Gy). Three patients with a mean tumor diameter greater than 4 cm were treated by two-stage radiosurgery. RESULTS Thirty-eight patients (90.5%) demonstrated tumor growth control during the follow-up period after radiosurgery. Tumor regression was observed in 25 patients (59.5%), and growth was unchanged in 13 patients (31%). Regrowth or recurrence occurred in four patients (9.5%). The actual tumor growth control rate at 5 years was 92%. Only one patient (2.4%) experienced regrowth within the treatment field; in other patients, regrowth occurred at sites peripheral to or outside the treatment field. Twelve patients (28.6%) had improved clinically by the time of the follow-up examination. None of the patients experienced optic neuropathy caused by radiation injury or any new neurological deficits after radiosurgery. CONCLUSION Gamma knife radiosurgery may be a useful option for the treatment of cavernous sinus meningiomas not only as an adjuvant to surgery but also as an alternative to surgical removal. We have shown it to be safe and effective even in tumors that adhere to or are in close proximity to the optic apparatus.

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Bromocriptine treatment of invasive giant prolactinomas involving the cavernous sinus: results of a long-term follow up

Journal of Neurosurgery ◽

10.3171/jns.2006.104.1.54 ◽

2006 ◽

Vol 104 (1) ◽

pp. 54-61 ◽

Cited By ~ 51

Author(s):

Zhe Bao Wu ◽

Chun Jiang Yu ◽

Zhi Peng Su ◽

Qi Chuan Zhuge ◽

Jin Sen Wu ◽

...

Keyword(s):

Cavernous Sinus ◽

Tumor Volume ◽

Residual Tumor ◽

Magnetic Resonance Images ◽

Serum Prolactin ◽

Cerebrospinal Fluid Leakage ◽

Tumor Diameter ◽

Giant Prolactinomas

Object The aim of this study was to observe long-term clinical outcomes in a group of patients treated with bromocriptine for invasive giant prolactinomas involving the cavernous sinus. Methods Data from 20 patients with invasive giant prolactinomas at the authors’ institutions between July 1997 and June 2004 were retrospectively reviewed. The criteria to qualify for study participation included: 1) tumor diameter greater than 4 cm, invading the cavernous sinus to an extent corresponding to Grade III or IV in the classification scheme of Knosp and colleagues; 2) serum prolactin (PRL) level greater than 200 ng/ml; and 3) clinical signs of hyperprolactinemia and mass effect. Among the 20 patients who met the criteria, six had undergone unsuccessful transcranial or transsphenoidal microsurgery prior to bromocriptine treatment and 14 patients received bromocriptine as the primary treatment. Eleven of the 20 patients underwent adjuvant radiotherapy. After a mean follow-up period of 37.3 months, the clinical symptoms in all patients improved by different degrees. Tumor volume on magnetic resonance images was decreased by a mean of 93.3%. In 11 patients, the tumor had almost completely disappeared; in the other nine patients, residual tumor invaded the cavernous sinus. Visual symptoms improved in 13 of the patients who had presented with visual loss. Eight patients had normal PRL levels. The postoperative PRL level was more than 200 ng/ml in seven patients. During the course of drug administration, cerebrospinal fluid leakage occurred in one patient, who subsequently underwent transsphenoidal surgery. No case of apoplexy occurred during bromocriptine treatment. Conclusions Dopamine agonist medications are effective as a first-line therapy for invasive giant prolactinomas, because they can significantly shrink tumor volume and control the PRL level. Tumor mass vanishes in some patients after bromocriptine treatment; in other patients with localized residual tumor, stereotactic radiosurgery is a viable option so that unnecessary surgery can be avoided. The application of radiotherapy does not reliably shrink tumor volume.

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Aggressive transsphenoidal resection of tumors invading the cavernous sinus in patients with acromegaly: predictive factors, strategies, and outcomes

Journal of Neurosurgery ◽

10.3171/2014.3.jns132214 ◽

2014 ◽

Vol 121 (3) ◽

pp. 505-510 ◽

Cited By ~ 48

Author(s):

Hiroshi Nishioka ◽

Noriaki Fukuhara ◽

Kentaro Horiguchi ◽

Shozo Yamada

Keyword(s):

Cavernous Sinus ◽

Transsphenoidal Surgery ◽

Independent Predictor ◽

Remission Rate ◽

Unfavorable Outcome ◽

Medial Wall ◽

Significant Independent Predictor ◽

Cavernous Sinus Invasion ◽

Histological Verification ◽

Transsphenoidal Resection

Object Cavernous sinus (CS) invasion is the most important preoperative predictor of remission in the surgical treatment of growth hormone–producing pituitary adenomas. The purpose of this study was to evaluate the effectiveness of an aggressive technique for removal of tumors invading the CS in patients with acromegaly. Methods The authors retrospectively reviewed the cases of 150 consecutive patients with acromegaly who underwent primary transsphenoidal surgery in 2010 and 2011. The authors reviewed preoperative Knosp grade, intraoperative findings, histology of the medial wall of the CS, and surgical outcome according to the current consensus criteria for acromegaly. Results Cavernous sinus invasion was identified in 55 patients (36.7%): definite CS involvement by the tumor was observed under direct vision in 41 patients (74.5%), while invasion was histologically verified in 39 patients (70.9%). Invasion increased in frequency with the higher Knosp grade but was observed in 14.4% (13 of 90) of Grade 0 and 1 tumors. Overall, the remission rate fulfilling stringent criteria was 84.7% (127 of 150). Although CS invasion was significantly associated with an unfavorable outcome (p < 0.0001), remission was achieved in 69.1% (38 of 55) of patients with invasion. No major complications occurred in this series. Conclusions Cavernous sinus invasion is the most significant, independent predictor of unfavorable outcome. Confirmation of invasion requires direct observation within the CS regardless of the microscope or endoscope used. Particularly in cases in which only the medial wall is involved, histological verification is always necessary to detect the occult invasion. Direct removal of the invading tumor, by sharp excision of the medial wall of the CS, is effective and safe and increases the chance of remission.

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Racial disparities in acromegaly and Cushing’s disease: a referral center study in 241 patients

Journal of the Endocrine Society ◽

10.1210/jendso/bvab176 ◽

2021 ◽

Author(s):

Adriana G Ioachimescu ◽

Neevedita Goswami ◽

Talin Handa ◽

Adlai Pappy ◽

Emir Veledar ◽

...

Keyword(s):

Cushing’S Disease ◽

Census Data ◽

Remission Rate ◽

Black Population ◽

Postoperative Outcomes ◽

Cushing's Disease ◽

Tumor Diameter ◽

Cavernous Sinus Invasion ◽

Black Patients ◽

The Impact

Abstract Purpose The impact of race on presentation and postoperative outcomes in adults with acromegaly (ACM) and Cushing’s disease (CD) has not been evaluated. Methods This is a retrospective study of consecutive patients operated at a large-volume pituitary center. We evaluated: 1) racial distribution of patients residing in the metropolitan area (Metro, N=124) versus 2010 U.S. Census data, 2) presentation and postoperative outcomes in Black versus White for patients from the entire catchment area (N=241). Results For Metro area (32.4% Black population), Black patients represented 16.75% ACM (p=0.006) and 29.2% CD (p=0.56).Among 112 total ACM patients, presentations with headaches or incidentaloma were more common in Black patients (76.9% versus 31% White, p=0.01). Black patients had a higher prevalence of diabetes (54% versus 16% White, p=0.005), significantly lower IGF-1 deviation from normal (p=0.03) and borderline lower median GH levels (p=0.09). Mean tumor diameter and proportion of tumors with cavernous sinus invasion were similar. Three-month biochemical remission (46% Black, 55% White, p=0.76) and long-term IGF-1 control by multimodality therapy (92.3% Black, 80.5% White, p=0.45) were similar. Among 129 total CD patients, Black patients had more hypopituitarism (69% vs 45% White, p=0.04) and macroadenomas (33% vs 15% White, p=0.05). At 3 months, remission rate was borderline higher in White (92% vs 78% Black, p=0.08) which was attributed to macroadenomas by logistic regression. Conclusion We identified disparities regarding racial distribution, clinical and biochemical characteristics in ACM, suggesting late or missed diagnosis in Black patients. Large nationwide studies are necessary to confirm our findings.

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Pasireotide: successful treatment of a sparsely granulated tumour in a resistant case of acromegaly

Endocrinology Diabetes and Metabolism Case Reports ◽

10.1530/edm-17-0067 ◽

2017 ◽

Vol 2017 ◽

Author(s):

W K M G Amarawardena ◽

K D Liyanarachchi ◽

J D C Newell-Price ◽

R J M Ross ◽

D Iacovazzo ◽

...

Keyword(s):

Cavernous Sinus ◽

First Generation ◽

Somatostatin Receptor ◽

Oral Glucose ◽

List Type ◽

Residual Tumour ◽

Receptor Ligands ◽

Cavernous Sinus Invasion ◽

Somatostatin Receptor Ligands ◽

Eosinophilic Cytoplasm

Summary The granulation pattern of somatotroph adenomas is well known to be associated with differing clinical and biochemical characteristics, and it has been shown that sparsely granulated tumours respond poorly to commonly used somatostatin receptor ligands (SRLs). We report a challenging case of acromegaly with a sparsely granulated tumour resistant to multiple modalities of treatment, ultimately achieving biochemical control with pasireotide. A 26-year-old lady presented with classical features of acromegaly, which was confirmed by an oral glucose tolerance test. Insulin-like growth factor 1 (IGF1) was 1710 µg/L (103–310 µg/L) and mean growth hormone (GH) was >600 U/L. MRI scan showed a 4 cm pituitary macroadenoma with suprasellar extension and right-sided cavernous sinus invasion. She underwent trans-sphenoidal pituitary surgery. Histology displayed moderate amounts of sparsely granular eosinophilic cytoplasm, staining only for GH. Postoperative investigations showed uncontrolled disease (IGF1:1474 µg/L, mean GH:228 U/L) and residual tumour in the cavernous sinus. She received external beam fractionated radiation. Over the years, she received octreotide LAR (up to 30 mg), lanreotide (up to 120 mg) two weekly, cabergoline, pegvisomant and stereotactic radiosurgery to no avail. Only pegvisomant resulted in an element of disease control; however, this had to be stopped due to abnormal liver function tests. Fifteen years after the diagnosis, she was started on pasireotide 40 mg monthly. Within a month, her IGF1 dropped and has remained within the normal range (103–310 µg/L). Pasireotide has been well tolerated, and there has been significant clinical improvement. Somatostatin receptor subtyping revealed a positivity score of two for both sst5 and sst2a subtypes. Learning points: Age, size of the tumour, GH levels on presentation, histopathological type and the somatostatin receptor status of the tumour in acromegaly should be reviewed in patients who poorly respond to first-generation somatostatin receptor ligands. Tumours that respond poorly to first-generation somatostatin receptor ligands, especially sparsely granulated somatotroph adenomas, can respond to pasireotide and treatment should be considered early in the management of resistant tumours. Patients with membranous expression of sst5 are likely to be more responsive to pasireotide.

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Petroclival meningiomas: surgical experience in 109 cases

Journal of Neurosurgery ◽

10.3171/jns.1996.84.1.0020 ◽

1996 ◽

Vol 84 (1) ◽

pp. 20-28 ◽

Cited By ~ 206

Author(s):

William T. Couldwell ◽

Takanori Fukushima ◽

Steven L. Giannotta ◽

Martin H. Weiss

Keyword(s):

Cavernous Sinus ◽

Surgical Approaches ◽

Surgical Removal ◽

Total Removal ◽

Content Type ◽

Cavernous Sinus Invasion ◽

Petroclival Meningiomas ◽

High Incidence ◽

Progression Of Disease

✓ The surgical removal of petroclival meningiomas has historically been associated with a high incidence of morbidity and mortality. The 109 consecutive patients included in the present retrospective study represent a combined series of tumors operated on by the four authors during a period from 1980 to 1992. The series is composed of 40 men and 69 women ranging in age from 25 to 75 years (mean 51 years). Surgical approaches to tumors in this series included simple retromastoid (60 cases), combined supra- and infratentorial petrosal (22), transtemporal (primary transsigmoid retrolabyrinthine, translabyrinthine, or transcochlear (12)), subtemporal (11), and frontotemporal transcavernous (eight). Gross-total removal was achieved in 75 patients (69%). Recurrence or progression of disease occurred in 14 patients (13%) over a 6.1-year mean follow-up period, and it was found within the cavernous sinus in 12 of these cases. Four recurrent cases demonstrated histological compatibility with malignant meningioma. Perioperative death occurred in four patients, and there were 56 significant complications in 35 other patients. Review of this series, with the attendant complications, has facilitated the authors' decision-making when considering the risk of gross-total removal in selected patients with asymptomatic cavernous sinus invasion or tumor adherent to the brainstem.

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