Prognostic Factors For Intermediate-Risk Atypical Meningiomas Determining Early Postoperative Adjuvant Radiotherapy Versus Active Monitoring After Gross Total Resection

Abstract Background Atypical meningiomas (AMs) constitute 18% of meningiomas. Predictors of recurrence are still indeterminate, and the timing of RT whether to treat with radiation upfront or at initial recurrence remains controversial, especially after gross total resection (GTR). Methods A retrospective study of AMs with uni-and multivariate analyses was conducted with clinical, surgical, radiological, and histopathological parameters. The prognostic factors associated with increased risk of recurrence were elucidated in the whole series and in the subgroup with GTR only. Results Subtotal resection (STR), skullbase-tentorium localization, no adjuvant RT, and progesterone-negativity caused tumor recurrence in 37 patients with a median follow-up of 48 (2-120) months. Among subgroup of 23 patients GTR only, 30.8% showed recurrence in a median of 39.65 months. AMs with a preoperative volume ≥27.5 cm3 disclosed a significantly higher risk of recurrence (a 9.3 fold increase) than those with <27.5 cm3 (66.7% vs. 14.3%, respectively). Skullbase-tentorium localization and progesterone negativity tend to have higher recurrence rates after GTR. Conclusions Preoperative volume was found to be a prognostic factor for AMs with a cut-off value of 27.5 cm3 for the first time in the literature. Our results disclosed that RT could be delayed with active monitorization after GTR for AMs, which are smaller than 27.5 cm3, not localized in skullbase-tentorium and progesterone-positive. Otherwise, early postop RT would be a safer approach without waiting the recurrence for AMs.

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Long-term efficacy of surgical resection with or without adjuvant therapy for treatment of secondary glioblastoma in adults

Neuro-Oncology Advances ◽

10.1093/noajnl/vdaa098 ◽

2020 ◽

Vol 2 (1) ◽

Author(s):

Ruoyu Huang ◽

Guanzhang Li ◽

Yiming Li ◽

Yinyan Wang ◽

Pei Yang ◽

...

Keyword(s):

Survival Analysis ◽

Prognostic Factors ◽

Adjuvant Therapy ◽

Clinical Outcomes ◽

Cox Regression ◽

Postoperative Radiotherapy ◽

Gross Total Resection ◽

Subtotal Resection ◽

Total Resection ◽

Secondary Glioblastoma

Abstract Background There are limited studies on treatment strategies and associated clinical outcomes in patients with secondary glioblastoma (sGBM). We sought to investigate the prognostic factors and treatment decisions in a retrospective cohort of patients with sGBM. Methods One hundred and seventy-one patients with sGBM who met the screening criteria were included in this study. Kaplan–Meier survival analysis and Cox survival analysis were used to detect prognostic factors. R (v3.5.0) and SPSS software (v25.0, IBM) were used to perform statistical analyses. Results The median overall survival was 303 days (range 23–2237 days) and the median progression-free survival was 229 days (range 33–1964 days) in patients with sGBM. When assessing the relationship between adjuvant treatment outcome and extent of resection (EOR), the results showed that patients underwent gross total resection can benefit from postoperative radiotherapy and chemotherapy, but not in patients underwent subtotal resection. In addition, we also found that aggressive adjuvant therapy can significantly improve clinical outcomes of IDH1-mutated patients but no significant prognostic value for IDH1-wildtyped patients. The univariate Cox regression analyses demonstrated that EOR, adjuvant therapy, and postoperative Karnofsky Performance Scores were prognostic factors for patients with sGBM, and multivariate COX analysis confirmed that adjuvant therapy and EOR were independent prognostic factors. Conclusions For patients with sGBM, aggressive postoperative adjuvant therapy after gross total resection was recommended. However, we did not detect a benefit in IDH1-wildtype patients in our cohort.

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H3K27me3 loss indicates an increased risk of recurrence in the Tübingen meningioma cohort

Neuro-Oncology ◽

10.1093/neuonc/noaa303 ◽

2020 ◽

Author(s):

Felix Behling ◽

Christina Fodi ◽

Irina Gepfner-Tuma ◽

Kristina Kaltenbach ◽

Mirjam Renovanz ◽

...

Keyword(s):

Prognostic Factors ◽

Clinical Utility ◽

Univariate Analysis ◽

University Hospital ◽

Rank Test ◽

Subtotal Resection ◽

Who Grade ◽

Risk Of Recurrence ◽

Increased Risk

Abstract Background A loss of the trimethylation of lysine 27 of histone H3 (H3K27me3) in meningioma has been recently suggested as an adjunct to identify subsets of higher risk of recurrence. The aim of the present study was to assess the prognostic value of H3K27 histone trimethylation and its potential clinical utility in the “Tübingen meningioma cohort”. Methods Patients who underwent meningioma resection between 10/2003 and 1/22015 at the University Hospital Tübingen were included. Immunohistochemical stainings for H3K27me3 and the proliferation marker MIB1 were assessed and correlated with clinical parameters using univariate and multivariate cox regressions as well as Pearson’s chi-squared and log-rank test. Results Overall, 1268 meningiomas were analyzed with a female to male ratio of 2.6 and a mean age of 58.7 years (range 8.3 – 91.0). With 163 cases lost to follow up, 1103 cases were available for further analysis with a mean follow-up of 40.3 months (range 1.1 – 186.3). Male gender, younger age, intracranial tumor localization, progressive tumor, subtotal resection, higher WHO grade, increased MIB1 rate and loss of H3K27me3 were significant negative prognostic factors in the univariate analysis. H3K27me3 status and all other prognostic factors, except age and tumor location, remained significant in the multivariate model. Furthermore, adjuvant radiotherapy was an independent positive prognostic factor. Conclusions Loss of H3K27me3 combined with MIB1 labeling index are independent prognostic factors in meningioma. These data from the Tübingen meningioma cohort support the clinical utility of H3K27me3 immunohistochemical staining in meningioma and its integration into the routine histopathological workup.

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Anaplastic meningioma: an analysis of the National Cancer Database from 2004 to 2012

Journal of Neurosurgery ◽

10.3171/2017.2.jns162282 ◽

2018 ◽

Vol 128 (6) ◽

pp. 1684-1689 ◽

Cited By ~ 12

Author(s):

Andrew Orton ◽

Jonathan Frandsen ◽

Randy Jensen ◽

Dennis C. Shrieve ◽

Gita Suneja

Keyword(s):

Poor Prognosis ◽

Cox Proportional Hazards ◽

Gross Total Resection ◽

Subtotal Resection ◽

National Cancer Database ◽

Limited Information ◽

Total Resection ◽

Anaplastic Meningioma ◽

Risk Of Death ◽

Increased Risk

OBJECTIVEAnaplastic meningiomas represent 1%–2% of meningioma diagnoses and portend a poor prognosis. Limited information is available on practice patterns and optimal management. The purpose of this study was to define treatment patterns and outcomes by treatment modality using a large national cancer registry.METHODSThe National Cancer Database was used to identify patients diagnosed with anaplastic meningioma from 2004 to 2012. Log-rank statistics were used to compare survival outcomes by extent of resection, use of adjuvant radiotherapy (RT), and use of adjuvant chemotherapy. Least-squares linear regression was used to evaluate the utilization of RT over time. Logistic regression modeling was used to identify predictors of receipt of RT. Cox proportional hazards modeling was used to evaluate the effect of RT, gross-total resection (GTR), and chemotherapy on survival.RESULTSA total of 755 adults with anaplastic meningioma were identified. The 5-year overall survival rate was 41.4%. Fifty-two percent of patients received RT, 7% received chemotherapy, and 58% underwent GTR. Older patients were less likely to receive RT (OR 0.98, p < 0.01). Older age (HR 1.04, p < 0.01), high comorbidity score (HR 1.33, p = 0.02), and subtotal resection (HR 1.57, p = 0.02) were associated with increased risk of death on multivariate modeling, while RT receipt was associated with decreased risk of death (HR 0.79, p = 0.04). Chemotherapy did not have a demonstrable effect on survival (HR 1.33, p = 0.18).CONCLUSIONSAnaplastic meningioma portends a poor prognosis. Gross-total resection and RT are associated with improved survival, but utilization of RT is low. Unless medically contraindicated, patients with anaplastic meningioma should be offered RT.

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The role of radiotherapy following gross-total resection of atypical meningiomas

Journal of Neurosurgery ◽

10.3171/2012.7.jns112113 ◽

2012 ◽

Vol 117 (4) ◽

pp. 679-686 ◽

Cited By ~ 86

Author(s):

Ricardo J. Komotar ◽

J. Bryan Iorgulescu ◽

Daniel M. S. Raper ◽

Eric C. Holland ◽

Kathryn Beal ◽

...

Keyword(s):

Postoperative Radiotherapy ◽

Prospective Trial ◽

Gross Total Resection ◽

Recurrence Rates ◽

Total Resection ◽

Who Grade ◽

Strong Trend ◽

Time To Recurrence ◽

Atypical Meningiomas

Object Atypical (WHO Grade II) meningiomas comprise a heterogeneous group of tumors, with histopathology delineated under the guidance of the WHO and a spectrum of clinical outcomes. The role of postoperative radiotherapy for patients with atypical meningiomas who have undergone gross-total resection (GTR) remains unclear. In this paper, the authors sought to clarify this role by reviewing their experience over the past 2 decades. Methods The authors retrospectively analyzed all patients at their institution who underwent GTR between 1992 and 2011 with a final histology demonstrating atypical meningioma. Information regarding patients, tumor characteristics, and postoperative adjuvant therapy was gleaned from medical records. Time to recurrence and overall survival were analyzed using univariate, multivariate, and Kaplan-Meier survival analyses. Results Forty-five patients who met the inclusion criteria underwent GTR for atypical meningiomas. By a median follow-up of 44.1 months, 22% of atypical meningiomas had recurred. There was no recurrence in 12 (92%) of 13 patients who received postoperative radiotherapy or in 19 (59%) of 32 patients who did not undergo postoperative radiotherapy (p = 0.085), demonstrating a strong trend toward improved local control with postoperative radiotherapy. No other factors were significantly associated with recurrence in univariate or multivariate analyses. Conclusions This retrospective series supports the observation that postoperative radiotherapy likely results in lower recurrence rates of gross totally resected atypical meningiomas. Although a multicenter prospective trial will ultimately be needed to fully define the role of radiotherapy in managing gross totally resected atypical meningiomas, the authors' results contribute to a growing number of series that support routine postoperative radiotherapy as an adjuvant treatment for these lesions.

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Sodium Fluorescein-Guided Gross Total Resection of Pediatric Exophytic Brainstem Glioma: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opaa357 ◽

2020 ◽

Author(s):

Christopher Markosian ◽

Catherine A Mazzola ◽

Luke D Tomycz

Keyword(s):

Normal Tissue ◽

Clinical Case ◽

Aminolevulinic Acid ◽

Significant Risk ◽

Gross Total Resection ◽

Subtotal Resection ◽

Sodium Fluorescein ◽

Total Resection ◽

Term Survival ◽

Patient Consent

Abstract Brainstem gliomas comprise 10% to 20% of pediatric intracranial tumors.1 Gross total resection is associated with the greatest long-term survival.1 However, due to the eloquence of surrounding brain tissue, an aggressive resection is not always achievable and can be associated with significant risk.2 Sodium fluorescein can be used to help differentiate between tumor and normal tissue.3,4 In this operative video, we demonstrate the step-by-step technique to utilize fluorescence in surgically resecting an exophytic glioma arising from the midbrain in a 16-yr-old male. Technical nuances are highlighted in this operative video, including the use of the YELLOW 560 (Zeiss) filter to differentiate fluorescent tumor from normal tissue as well as strategic splitting of the tentorium to expose the supratentorial component of the tumor. A decrease in motor potentials of the right leg during the case did not translate into neurological worsening postoperatively; at 3-mo follow-up, the patient attests to better strength and coordination on his affected side. In summary, sodium fluorescein can be used as a critical adjunctive tool for successful surgery in the case of a brainstem tumor. Alternatives to this procedure included gross total resection with 5-aminolevulinic acid, subtotal resection with chemotherapy, and active monitoring, but were not chosen due to their limitations in this clinical case.5-7 Appropriate patient consent was obtained to perform this procedure and present this clinical case and surgical video for academic purposes.

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Surgical Management of Petroclival Meningiomas: Defining Resection Goals Based on Risk of Neurological Morbidity and Tumor Recurrence Rates in 137 Patients

Neurosurgery ◽

10.1227/01.neu.0000153906.12640.62 ◽

2005 ◽

Vol 56 (3) ◽

pp. 546-559 ◽

Cited By ~ 141

Author(s):

Kenneth M. Little ◽

Allan H. Friedman ◽

John H. Sampson ◽

Masahiko Wanibuchi ◽

Takanori Fukushima

Keyword(s):

Cranial Nerve ◽

Tumor Recurrence ◽

Critical Role ◽

Recurrence Rates ◽

Total Resection ◽

Petroclival Region ◽

Petroclival Meningiomas ◽

Increased Risk ◽

Neurological Morbidity

Abstract OBJECTIVE: Meningiomas arising from the petroclival region remain a challenging surgical problem. Because of the substantial risk of neurological morbidity, uniformly pursuing a gross total resection (GTR) to minimize tumor recurrence rates may not be justified. We sought to define optimal resection goals based on risk factors for postoperative neurological morbidity and tumor recurrence rates. METHODS: This series represents our experience with 137 meningiomas arising from the petroclival region resected between June 1993 and October 2002. There were 38 male and 99 female patients with a mean age of 53 years. RESULTS: GTR was achieved in 40% of patients, and near total resection (NTR) was achieved in 40% of patients. One operative death occurred. Twenty-six percent of patients experienced new postoperative cranial nerve deficits, paresis, or ataxia when assessed at a mean follow-up of 8.3 months. The risk of cranial nerve deficits increased with prior resection (P < 0.001), preoperative cranial nerve deficit (P = 0.005), tumor adherence to neurovascular structures (P = 0.046), and fibrous tumor consistency (P = 0.005). The risk of paresis or ataxia increased with prior resection (P = 0.001) and tumor adherence (P = 0.045). Selective NTR rather than GTR in patients with adherent or fibrous tumors significantly reduced the rate of neurological deficits. Radiographic recurrence or progression occurred in 17.6% of patients at a mean follow-up of 29.8 months. Tumor recurrence rates after GTR and NTR did not differ significantly (P = 0.111). CONCLUSION: Intraoperatively defined tumor characteristics played a critical role in identifying the subset of patients with an increased risk of postoperative deficits. By selectively pursuing an NTR rather than a GTR, neurological morbidity was reduced significantly without significantly increasing the rate of tumor recurrence.

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The Role of Adjuvant Radiotherapy After Gross Total Resection of Atypical Meningiomas

World Neurosurgery ◽

10.1016/j.wneu.2014.12.037 ◽

2015 ◽

Vol 83 (5) ◽

pp. 808-815 ◽

Cited By ~ 46

Author(s):

Shaakir Hasan ◽

Michael Young ◽

Trevine Albert ◽

Ashish H. Shah ◽

Christian Okoye ◽

...

Keyword(s):

Adjuvant Radiotherapy ◽

Gross Total Resection ◽

Total Resection ◽

Atypical Meningiomas

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A management strategy for intraventricular subependymal giant cell astrocytomas in tuberous sclerosis complex

Journal of Neurosurgery Pediatrics ◽

10.3171/2013.9.peds13193 ◽

2014 ◽

Vol 13 (1) ◽

pp. 21-28 ◽

Cited By ~ 12

Author(s):

David H. Harter ◽

Luigi Bassani ◽

Shaun D. Rodgers ◽

Jonathan Roth ◽

Orrin Devinsky ◽

...

Keyword(s):

Tumor Progression ◽

Tuberous Sclerosis ◽

Giant Cell ◽

Tuberous Sclerosis Complex ◽

Primary Tumor ◽

Management Strategy ◽

Gross Total Resection ◽

Subtotal Resection ◽

Total Resection ◽

Shunt Placement

Object Subependymal giant cell astrocytomas (SEGAs) are benign tumors, most commonly associated with tuberous sclerosis complex (TSC). The vast majority of these tumors arise from the lateral ependymal surface adjacent to the foramen of Monro, therefore potentially encroaching on one or both foramina, and resulting in obstructive hydrocephalus that necessitates surgical decompression. The indications for surgery, intraoperative considerations, and evolution of the authors' management paradigm are presented. Methods Patients with TSC who underwent craniotomy for SEGA resection at New York University Langone Medical Center between January 1997 and March 2011 were identified. Preoperative imaging, clinical characteristics, management decisions, operative procedures, and outcomes were reviewed. Results Eighteen patients with TSC underwent 22 primary tumor resections for SEGAs. The indication for surgery was meaningful radiographic tumor progression in 16 of 21 cases. The average age at the time of operation was 10.3 years. Average follow-up duration was 52 months (range 12–124 months). The operative approach was intrahemispheric-transcallosal in 16 cases, transcortical-transventricular in 5, and neuroendoscopic in 1. Nine tumors were on the right, 9 on the left, and 3 were bilateral. Gross-total resection was documented in 16 of 22 cases in our series, with radical subtotal resection achieved in 4 cases, and subtotal resection (STR) in 2 cases. Two patients had undergone ventriculoperitoneal shunt placement preoperatively and 7 patients required shunt placement after surgery for moderate to severe ventriculomegaly. Two patients experienced tumor progression requiring reoperation; both of these patients had initially undergone STR. Conclusions The authors present their management strategy for TSC patients with SEGAs. Select patients underwent microsurgical resection of SEGAs with acceptable morbidity. Gross-total resection or radical STR was achieved in 90.9% of our series (20 of 22 primary tumor resections), with no recurrences in this group. Approximately half of our patient series required CSF diversionary procedures. There were no instances of permanent neurological morbidity associated with surgery.

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P.041 Adult craniopharyngioma: case series, systematic review and meta-analysis

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2017.126 ◽

2017 ◽

Vol 44 (S2) ◽

pp. S24-S24

Author(s):

C Dandurand ◽

AA Sepehry ◽

MH Asadi Lari ◽

R Akagami ◽

PA Gooderham

Keyword(s):

Meta Analysis ◽

Case Series ◽

Gross Total Resection ◽

Subtotal Resection ◽

Total Resection ◽

Childhood Population ◽

Institutional Experience ◽

The Difference ◽

Meta Analyses ◽

Case Basis

Background: The optimal therapeutic approach for adult craniopharyngioma remains controversial. Some advocate for gross total resection (GTR), while others support subtotal resection followed by adjuvant radiotherapy (STR + XRT). Methods: MEDLINE (1946 to July 1st 2016) and EMBASE (1980 to June 30th 2016) were systematically reviewed. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was followed. At our institution, from 1975 to 2013, 33 patients were treated with initial surgical resection for adult onset craniopharyngioma. 22 patients were included in the present case series. Results: Eligible studies (n=21) were identified from the literature in addition to a case series of our institutional experience. Three groups were available for analysis: GTR, STR + XRT, and STR. The rates of recurrence were 17 %, 27 % and 45%, respectively. This differs from childhood population. The difference in risk of recurrence after GTR vs. STR + XRT did not reach significance (OR: 0.63, 95% confidence interval: 0.33-1.24, P=0.18). This maybe because of low pooled sample size (n=99) who underwent STR+XRT. Conclusions: This is the first and largest meta-analysis examining rate of recurrence in adult craniopharyngioma. Thus, when safe and feasible, a goal of gross total resection should be favored. Each patient should be considered on a case-by-case basis.

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Profound hearing loss following surgery in pediatric patients with posterior fossa low-grade glioma

Neuro-Oncology Practice ◽

10.1093/nop/npx025 ◽

2017 ◽

Vol 5 (2) ◽

pp. 96-103 ◽

Cited By ~ 1

Author(s):

Yahya Ghazwani ◽

Ibrahim Qaddoumi ◽

Johnnie K Bass ◽

Shengjie Wu ◽

Jason Chiang ◽

...

Keyword(s):

Hearing Loss ◽

Posterior Fossa ◽

Extent Of Resection ◽

Tumor Location ◽

Low Grade Glioma ◽

Gross Total Resection ◽

Subtotal Resection ◽

Low Grade ◽

Total Resection ◽

Profound Hearing Loss

Abstract Background Hearing loss may occur in patients with posterior fossa low-grade glioma who undergo surgery. Methods We retrospectively reviewed 217 patients with posterior fossa low-grade glioma, including 115 for whom results of hearing tests performed after surgery and before chemotherapy or radiation therapy were available. We explored the association of UHL with age at diagnosis, sex, race, tumor location, extent of resection, posterior fossa syndrome, ventriculoperitoneal shunt placement, and histology. Results Of the 115 patients, 15 (13.0%: 11 male, 6 black, 8 white, 1 multiracial; median age 7 years [range, 1.3–17.2 years]) had profound UHL after surgery alone or before receiving ototoxic therapy. Median age at tumor diagnosis was 6.8 years (range, 0.7–14.1 years), and median age at surgery was 6.8 years (range, 0.7–14.1 years). Patients with UHL had pathology characteristic of pilocytic astrocytoma (n = 10), ganglioglioma (n = 4), or low-grade astrocytoma (n = 1). Of these 15 patients, 4 underwent biopsy, 1 underwent gross total resection, 1 underwent near-total resection, and 9 underwent subtotal resection. UHL was more frequent in black patients than in white patients (OR 7.3, P = .007) and less frequent in patients who underwent gross total resection or near-total resection than in those who underwent subtotal resection (OR 0.11, P = .02). Conclusions Children undergoing surgery for posterior fossa low-grade glioma are at risk for UHL, which may be related to race or extent of resection. These patients should receive postoperative audiologic testing, as earlier intervention may improve outcomes.

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