Multimodal therapy of cavernous sinus meningioma: impact of surgery and 68Ga-DOTATATE PET-guided radiation therapy on tumor control and functional outcome

Background Functional preservation in patients with WHO grade I meningioma involving the cavernous sinus (CSM) is crucial for long-term tumor control. Concise data on the functional outcome of an interdisciplinary, multimodal treatment are scarce. We analyzed functional outcome and tumor control in CSM patients following maximal safe resection (MSR), fractionated stereotactic radiotherapy (FSRT) or combination of them, retrospectively. Methods Patients with WHO°I CSM treated between 2003 and 2017 were included. Prior to FSRT, a 68Ga-DOTATATE PET/CT was performed for radiation planning. Progression-free survival (PFS) was analyzed using Kaplan-Meier method and log-rank test was performed to test differences between groups. Visual function were analyzed at baseline and follow-up. Results Eighty-five patients were included. MSR alone was performed in 48 patients (group A), MSR followed by FSRT in 25 patients (group B), and FSRT alone in 12 patients (group C). Intracranial tumor volumes were higher in A and B compared to C (median 9.2/10.8/4.3ccm for A/B/C, p=0.023). Median follow-up was 47/46/45 months and PFS at 5-years 55.7%, 100%, and 100% in A/B/C, respectively (p<0.001). Optic nerve compression was more common in A (91.7%) and B (84.0%) than C (16.7%), p<0.001. Post-therapeutic new onset or deterioration of double vision was observed in 29%(A), 17%(B) and 0%(C). Conclusion Personalized treatment strategies for CSM are essential to control space-occupying or functionally compromising lesions. The additional potential side effect of radiotherapy seems to be justified under the aspect of longer tumor control with low functional risk. Without space-occupying effect of CSM, FSRT alone is reasonably possible.

Aggressive Radiation-Induced Cavernous Sinus Meningioma: 2-Dimensional Operative Video

Radiation-induced meningiomas are the most common radiation-induced neoplasms. They exhibit a distinct aggressive clinical behavior as rapid growth, recurrences, multiplicity, and malignant progression are common features.1-4 Atypical histological findings and aberrant cytogenetics are increasingly identified.5-7 Radical resection of aggressive radiation-induced meningiomas is the best treatment option and would offer the best chance for control of the disease. Wide bone and dural margins should be pursued in the resection. Parasellar extension creates significant surgical challenges. Cavernous sinus exploration through the multidirectional axis provided by the cranioorbital zygomatic approach allows radical resection of the tumor, cranial nerve decompression, and carotid artery preservation and control.8-11 This article describes a cavernous sinus radiation-induced meningioma after radiation for Cushing disease. It demonstrates the details of the extra- and intradural exploration and dissection of the neurovascular structures in the cavernous sinus, with proximal and distal control of the carotid artery. However, even after radical resection, recurrence is a common finding in this malignant behavioral radiation-induced tumor. Patient consented for surgery. Image at 9:41 comes from the Science Museum Group, United Kingdom. Refer to the Wellcome blog post (archive). This image is licensed under the CC-BY 4.0 International license.

STA-MCA Bypass in Carotid Stenosis after Radiosurgery for Cavernous Sinus Meningioma

Background: Cavernous sinus meningiomas (CSM) are mostly non-surgical tumors. Stereotactic radiosurgery (SRS) or radiotherapy (SRT) allow tumor control and improvement of pre-existing cranial nerve (CN) deficits. We report the case of a patient with radiation-induced internal carotid artery (ICA) stenosis. We complete the picture with a review of the literature of vascular and non-vascular complications following the treatment of CSMs with SRS or SRT. Methods: After a case description, a systematic literature review is presented, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2015 guidelines. Results: 115 abstracts were screened and 70 titles were retained for full-paper screening. A total of 58 articles did not meet the inclusion criteria. There were 12 articles included in our review, with a follow-up ranging from 33 to 120 months. Two cases of post-SRT ischemic stroke and one case of asymptomatic ICA stenosis were described. Non-vascular complications were reported in all articles. Conclusion: SRS and SRT carry fewer complications than open surgery, with similar rates of tumor control. Our case shows the importance of a follow-up of irradiated CSMs not only by a radio-oncologist, but also by a neurosurgeon, illustrating the importance of multidisciplinary management of CSMs.

Gross Total Resection of a Recurrent Cavernous Sinus Meningioma through a Combined Transzygomatic Transcavernous and Extended Middle Fossa Approach with Cavernous Carotid Denudation

Objective The aim of this study is to describe surgical management of invasive cavernous sinus meningioma with a combination of skull base approaches. Design This study is an operative video. Results Resection of the recurrent skull base meningioma is still challenging, especially if the tumor involves or encases the carotid artery. In this video, we describe our experience with the successful treatment of a recurrent skull base meningioma, which involved the entire cavernous sinus and the internal carotid artery. A 53-year-old male presented with a 1-year history of progressing right-side complete oculomotor palsy and facial dysesthesia. The patient had previously undergone craniotomy for the right-side petroclival cavernous meningioma (Fig. 1A and B). Total 8 years after the first surgery, the remaining portion of the cavernous sinus grew up and extended into the posterior fossa (Fig. 1C). Then the second surgery was performed to resect only the posterior fossa component (Fig. 1D). However, the follow-up magnetic resonance imaging revealed an aggressive tumor regrowth in 2 years. The tumor occupied the right middle fossa with an extension to the posterior fossa and infratemporal fossa (Fig. 1E and F). We scheduled to perform gross total resection of the tumor through a combined transzygomatic transcavernous and extended middle fossa approach with preparation for vessel reconstruction. Mild adhesion between the tumor and the cavernous carotid artery facilitated complete resection of the intracavernous component of the tumor (Fig. 2A–C). Conclusion A combination of skull base approaches provides multidirectional operative corridors and wide exposure of the skull base lesions.The link to the video can be found at https://youtu.be/DB_WXFeyBvo.

Gross Total Resection of a Recurrent in-and-around Cavernous Sinus Meningioma through a Combined Transcavernous Anterior and Middle Infratemporal Fossa Approach with Extracranial-Intracranial Bypass

Objectives The study aims to describe surgical management of an invasive cavernous sinus meningioma with a combination of several skull base approaches and bypass surgery. Design This study is an operative video. Results Resection of the recurrent skull base meningioma is still challenging, especially if the tumor involves or encases the carotid artery. Cerebral bypass surgery is an essential adjunct in the armamentarium of skull base surgery when vessel reconstruction is required. In this paper, we describe our experience of successful treatment of an invasive recurrent skull base meningioma, which involved the entire cavernous sinus and the internal carotid artery. A 46-year-old woman presented with a 2-year history of gradually worsening left-sided exophthalmos and visual impairment. The patient had previously undergone two craniotomies for resection of the left-sided spheno-orbital meningioma. Pathological diagnosis was chordoid meningioma, which is classified as an intermediate-grade meningioma. The second surgery had been performed for a rapid tumor regrowth 6 months after the first surgery. The patient lost her left-side vision after the second surgery. Aggressive tumor regrowth was confirmed with extension into the left orbit, infratemporal fossa, and cavernous sinus with engulfment of the carotid artery. A balloon occlusion test revealed intolerance of the left internal carotid artery occlusion. Considering the patient's age, tumor behavior, and intolerance of the carotid artery of the lesion side, we scheduled gross total resection of the tumor with vessel reconstruction. Conclusion Although cerebral bypass surgery is a technically challenging procedure, it plays an important role in the surgical management of the complex vessel-engulfing tumor.The link to the video can be found at https://youtu.be/GCmpxK3hW18.

Radiation-induced cavernous malformation after stereotactic radiosurgery for cavernous sinus meningioma: a case report

Background Radiation-induced cavernous malformation (RICM) is a rare sequela of stereotactic radiosurgery (SRS) treatment of intracranial tumors. To date, no study reported on RICM after SRS for meningiomas originating from the skull base. The relationship between locus of initial meningioma and RICM has not been studied. Case presentation A 57-year-old woman presented with persistent headaches and blepharoptosis at initial episode. MRI disclosed a right parasellar lesion, diagnosed as a cavernous sinus meningioma (CSM). After receiving a single-fractionated SRS, headache relieved, but blepharoptosis did not significantly improve. Three years and three months later, she returned with headaches and dizziness. MRI showed an enlarged CSM. Moreover, a new mass-like lesion, suspected hemangioma, appeared in the nearby right temporal lobe. After surgical removal of the new lesion and the CSM, the patient’s neurological symptoms significantly improved. Pathology confirmed CSM and temporal RICM. Conclusions We report the first rare case of RICM occurring after SRS for CSM. The RICM may be in the same region as the initial tumor. Surgical intervention was preferred for symptomatic RICM and initial meningioma. We recommend long-term regular followup MRIs for patients with meningioma after SRS treatment.

Risk of internal carotid artery stenosis or occlusion after single-fraction radiosurgery for benign parasellar tumors

OBJECTIVEStereotactic radiosurgery (SRS) is an accepted treatment option for patients with benign parasellar tumors. Here, the authors’ objective was to determine the risk of developing new or progressive internal carotid artery (ICA) stenosis or occlusion after single-fraction SRS for cavernous sinus meningioma (CSM) or growth hormone–secreting pituitary adenoma (GHPA).METHODSThe authors queried their prospectively maintained registry for patients treated with single-fraction SRS for CSM or GHPA in the period from 1990 to 2015. Study criteria included no prior irradiation and ≥ 12 months of post-SRS radiological follow-up. Pre-SRS grading of ICA involvement was applied according to the 1993 classification schemes of Hirsch for CSM or Knosp for GHPA.RESULTSThe authors conducted a retrospective review of 283 patients, 155 with CSMs and 128 with GHPAs. Ninety-three (60%) CSMs were Hirsch category 2 and 3 tumors; 97 (76%) GHPAs were Knosp grade 2–4 tumors. Median follow-up after SRS was 6.6 years (IQR 1–24.9 years). No GHPA or category 1 CSM developed ICA stenosis or occlusion. Three (5.2%) patients with category 2 CSMs had asymptomatic ICA stenosis (n = 2) or occlusion (n = 1); 1 (1.1%) category 2 CSM patient had transient ischemic symptoms. Five (14.3%) category 3 CSMs progressed to ICA occlusion (4 asymptomatic, 1 symptomatic). The median time to stenosis/occlusion was 4.8 years (IQR 1.8–7.6). Five- and 10-year risks of ICA stenosis/occlusion in category 2 and 3 CSM patients were 7.5% and 12.4%, respectively. Five- and 10-year risks of ischemic stroke from ICA stenosis/occlusion in category 2 and 3 CSM patients were both 1.2%. Multivariate analysis showed patient age (HR 0.92, 95% CI 0.86–0.98, p = 0.01), meningioma pathology (HR and 95% CI not defined, p = 0.03), and pre-SRS carotid category (HR 4.51, 95% CI 1.77–14.61, p = 0.004) to be associated with ICA stenosis/occlusion. Internal carotid artery stenosis/occlusion was not related to post-SRS tumor growth (HR and 95% CI not defined, p = 0.41).CONCLUSIONSNew or progressive ICA stenosis/occlusion was common after SRS for CSM but was not observed after SRS for GHPA, suggesting a tumor-specific mechanism unrelated to radiation dose. Pre-SRS ICA encasement or constriction increases the risk of ICA stenosis/occlusion; however, the risk of ischemic complications is very low.