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Moshayedi P, Liebeskind DS. Middle Meningeal Artery Embolization in Chronic Subdural Hematoma: Implications of Pathophysiology in Trial Design. Front Neurol 2020; 11:923. [PMID: 32973670 PMCID: PMC7481478 DOI: 10.3389/fneur.2020.00923] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/17/2020] [Indexed: 01/24/2023] Open
Abstract
Background: Chronic subdural hematoma (cSDH) is a debilitating condition with a high rate of recurrence after surgical evacuation. Summary: This review is focused on middle meningeal artery (MMA) embolization to treat cSDH. We discuss the underlying pathophysiology of chronic subdural hematoma and how cessation of arterial flow may resolve a venous hemorrhage. We also present the current evidence for MMA embolization and the roadmap for future trials. Conclusion: Frequent multimodal imaging and cSDH sampling would enable us to understand mechanisms of MMA embolization in cSDH treatment and therefore improve our ability to offer MMA embolization to the eligible population.
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Affiliation(s)
- Pouria Moshayedi
- Department of Neurology, UCLA Comprehensive Stroke Center, University of California, Los Angeles, Los Angeles, CA, United States
| | - David S Liebeskind
- Department of Neurology, UCLA Comprehensive Stroke Center, University of California, Los Angeles, Los Angeles, CA, United States
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2
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Wirsching HG, Richter JK, Sahm F, Morel C, Krayenbuehl N, Rushing EJ, von Deimling A, Valavanis A, Weller M. Post-operative cardiovascular complications and time to recurrence in meningioma patients treated with versus without pre-operative embolization: a retrospective cohort study of 741 patients. J Neurooncol 2018; 140:659-667. [PMID: 30196368 DOI: 10.1007/s11060-018-2996-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 09/04/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE Preoperative embolization of radiographically suspected meningiomas is often performed to facilitate tumor resection. Its effects on the subsequent disease course of meningioma patients have not been studied in detail and randomized trials are lacking. The purpose of this study was to explore associations of preoperative meningioma embolization with postoperative outcome. PATIENTS AND METHODS Patients undergoing resection of an intracranial meningioma at the University Hospital Zurich 2000-2013 (N = 741) were reviewed for the inclusion of pre-operative embolization in the management strategy. Annotations included demographics, radiographic, surgical, histological and hematological parameters, cardiovascular risk factors, pre- and postoperative neurological function and gene methylation-based classification. Binary regression and Cox proportional hazards models were applied to determine factors associated with outcome. RESULTS Pre-operative embolization was performed in 337 patients (42%). Cardiovascular events after surgery comprised mostly deep vein thrombosis (N = 39) and pulmonary embolisms (N = 64). On multivariate analyses of post-operative cardiovascular adverse events controlling for established risk factors, there were associations with embolization (OR 2.38, 95% CI 1.37-4.00), and with female gender (OR 2.18, 95% CI 1.17-4.08). Recurrence-free survival (RFS) of embolized patients was less favorable among patients with WHO grade II or grade III meningiomas (median RFS: 4.3 vs. 7.0 years, P = 0.029) or in patients with intermediate or malignant gene methylation subtype meningiomas (median RFS: 2.0 vs. 8.2 years, P = 0.005). CONCLUSION Pre-operative meningioma embolization may cause adverse outcomes. Randomized trials to determine benefit-risk ratios are warranted to clarify the role of pre-operative embolization for the treatment of meningioma patients.
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Affiliation(s)
- Hans-Georg Wirsching
- Department of Neurology, University Hospital and University of Zurich, Frauenklinikstrasse 26, 8091, Zurich, Switzerland.
| | - Johannes Konstantin Richter
- Department of Neuroradiology, University Hospital and University of Zurich, Zurich, Switzerland.,Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital and University of Bern, Bern, Switzerland
| | - Felix Sahm
- Department of Neuropathology, University Hospital Heidelberg, Heidelberg, Germany.,Clinical Cooperation Unit Neuropathology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Corinne Morel
- Department of Neurology, University Hospital and University of Zurich, Frauenklinikstrasse 26, 8091, Zurich, Switzerland
| | - Niklaus Krayenbuehl
- Department of Neurosurgery, University Hospital and University of Zurich, Zurich, Switzerland
| | - Elisabeth Jane Rushing
- Department of Neuropathology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Andreas von Deimling
- Department of Neuropathology, University Hospital Heidelberg, Heidelberg, Germany.,Clinical Cooperation Unit Neuropathology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Antonios Valavanis
- Department of Neuroradiology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Michael Weller
- Department of Neurology, University Hospital and University of Zurich, Frauenklinikstrasse 26, 8091, Zurich, Switzerland
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Tanaka Y, Hashimoto T, Watanabe D, Okada H, Kato D, Aoyagi S, Akimoto J, Kohno M. Post-embolization neurological syndrome after embolization for intracranial and skull base tumors: transient exacerbation of neurological symptoms with inflammatory responses. Neuroradiology 2018; 60:843-851. [DOI: 10.1007/s00234-018-2047-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 06/07/2018] [Indexed: 02/07/2023]
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4
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Sun SQ, Cai C, Murphy RKJ, DeWees T, Dacey RG, Grubb RL, Rich KM, Zipfel GJ, Dowling JL, Leuthardt EC, Simpson JR, Robinson CG, Chicoine MR, Perrin RJ, Huang J, Kim AH. Radiation Therapy for Residual or Recurrent Atypical Meningioma: The Effects of Modality, Timing, and Tumor Pathology on Long-Term Outcomes. Neurosurgery 2017; 79:23-32. [PMID: 26645969 DOI: 10.1227/neu.0000000000001160] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Optimal use of stereotactic radiosurgery (SRS) vs external beam radiation therapy (EBRT) for treatment of residual/recurrent atypical meningioma is unclear. OBJECTIVE To analyze features associated with progression after radiation therapy. METHODS Fifty radiation-naive patients who received SRS or EBRT for residual and/or recurrent atypical meningioma were examined for predictors of progression using Cox regression and Kaplan-Meier analyses. RESULTS Thirty-two patients (64%) received adjuvant radiation after subtotal resection, 12 patients (24%) received salvage radiation after progression following subtotal resection, and 6 patients (12%) received salvage radiation after recurrence following gross total resection. Twenty-one patients (42%) received SRS (median 18 Gy), and 7 (33%) had tumor progression. Twenty-nine patients (58%) received EBRT (median 54 Gy), and 13 (45%) had tumor progression. Whereas tumor volume (P = .53), SRS vs EBRT (P = .45), and adjuvant vs salvage (P = .34) were not associated with progression after radiation therapy, spontaneous necrosis (hazard ratio [HR] = 82.3, P < .001), embolization necrosis (HR = 15.6, P = .03), and brain invasion (HR = 3.8, P = .008) predicted progression in univariate and multivariate analyses. Tumors treated with SRS/EBRT had 2- and 5-year actuarial locoregional control rates of 91%/88% and 71%/69%, respectively. Tumors with spontaneous necrosis, embolization necrosis, and no necrosis had 2- and 5-year locoregional control rates of 76%, 92%, and 100% and 36%, 73%, and 100%, respectively (P < .001). CONCLUSION This study suggests that necrosis may be a negative predictor of radiation response regardless of radiation timing or modality. ABBREVIATIONS AM, atypical meningiomaEBRT, external beam radiation therapyGTR, gross total resectionLC, locoregional controlOS, overall survivalPOE, preoperative embolizationRT, radiation therapySRS, stereotactic radiosurgerySTR, subtotal resection.
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Affiliation(s)
- Sam Q Sun
- ‡Washington University School of Medicine, St. Louis, Missouri; §Department of Pathology and Immunology, Washington University, St. Louis, Missouri; ¶Department of Neurosurgery, Washington University, St. Louis, Missouri; ‖Department of Radiation Oncology, Washington University, St. Louis, Missouri
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Harb OA, Elsayed WSH, Ismail EI, Toam MM, Ammar MG. Thioredoxin-Interact ing-Pro t e in [TXNIP] and Transglutaminase 2 [TGM2] Expression in Meningiomas of Different Grades and the Role of Their Expression in
Meningioma Recurrence and Prognosis. Asian Pac J Cancer Prev 2017; 18:2299-2308. [PMID: 28843270 PMCID: PMC5697495 DOI: 10.22034/apjcp.2017.18.8.2299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Background: Meningiomas are common central nervous system (CNS) tumors that account for thirty percent of
primary intracranial tumors.. The accuracy of predicting meningioma recurrence and progression is not enough. So, there
is a real need for discovering recent factors for identification of the relapse risk, progression rates, which patients will
need aggressive treatment and predicting and improving patients’ survival. Thioredoxin-interacting-protein [TXNIP]
is an alpha-arrestin-protein family member that is mapped on chromosome 1-q21–22 and is found to participate in
cellular redox reactions regulations and control. Transglutaminase 2 (TGM2) is a transglutaminase enzyme family
member that is found in many human cells, it may act as an enzyme, a structural protein and also has multiple roles
in many cellular activities. Aim of our study: It was to explore the expression of TXNIP, TGM2 and Ki-67 using
immunohistochemistry in different pathological grades of meningiomas, and to investigate the relevance between
their expressions, clinicopathological criteria, disease recurrence and prognosis of meningioma patients. Methods: we
included 50 cases of meningioma of different pathological grades; all patients were managed according to their grade
by surgery alone, with radiotherapy or combined modalities. Sections from paraffin blocks prepared from samples of all
patients stained by TXNIP, TGM2 and Ki-67 using immunohistochemistry. Results: high expression of TXNIP in 28
out of 50 (56%) cases of meningioma of different pathological grades and was positively correlated with meningioma
lower grade, low KI labeling index (p=0.000), adequacy of resection, negatively correlated with high incidence of
recurrence after surgery and it was negatively correlated with meningioma higher pathological grades (p=0.000). We
detected high expression of TGM2 in 21 out of 50 (42%) cases of meningioma and it was positively correlated with
meningioma higher grade (p= 0.002), high KI labeling index (p=0.000), high incidence of recurrence after surgery,
progression to higher pathological grades and was negatively correlated with adequacy of resection of meningioma
(p=0.000). Conclusion: There is inverse relation between both [TXNIP and TGM2 expression in meningiomas and the
combination of decreased expression of TXNIP and increased expression of TGM2 could predict risk of meningioma
recurrence and progression in to higher pathological grades.
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Affiliation(s)
- Ola A Harb
- Pathology Department, Faculty of Medicine, Zagazig University, Egypt.
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6
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Palma L. Letter to the Editor: Malignant meningiomas. J Neurosurg 2015; 122:1514-5. [PMID: 25859809 DOI: 10.3171/2011.10.jns111109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Lucio Palma
- Clinica Neurochirurgica dell'Università di Siena, Siena, Italy
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7
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SHIBUYA M. Pathology and molecular genetics of meningioma: recent advances. Neurol Med Chir (Tokyo) 2014; 55:14-27. [PMID: 25744347 PMCID: PMC4533397 DOI: 10.2176/nmc.ra.2014-0233] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 08/21/2014] [Indexed: 01/16/2023] Open
Abstract
Meningiomas are the most common intracranial primary neoplasm in adults. Although the spectrum of clinical and molecular genetic issues regarding meningiomas remains undefined, novel genetic alterations that are associated with tumor morphology, malignancy, or location have recently been discovered. This review focuses on recent advances in understanding of the heterogenous pathology of meningiomas, particularly on associations between the clinical, histological, etiological, epidemiological, and molecular genetical aspects of the neoplasm.
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Affiliation(s)
- Makoto SHIBUYA
- Central Laboratory, Hachioji Medical Center, Tokyo Medical University, Tokyo
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van de Nes JAP, Griewank KG, Schmid KW, Grabellus F. Immunocytochemical analysis of glucose transporter protein-1 (GLUT-1) in typical, brain invasive, atypical and anaplastic meningioma. Neuropathology 2014; 35:24-36. [PMID: 25168354 DOI: 10.1111/neup.12148] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 07/21/2014] [Accepted: 07/22/2014] [Indexed: 11/27/2022]
Abstract
Glucose transporter-1 (GLUT-1) is one of the major isoforms of the family of glucose transporter proteins that facilitates the import of glucose in human cells to fuel anaerobic metabolism. The present study was meant to determine the extent of the anaerobic/hypoxic state of the intratumoral microenvironment by staining for GLUT-1 in intracranial non-embolized typical (WHO grade I; n = 40), brain invasive and atypical (each WHO grade II; n = 38) and anaplastic meningiomas (WHO grade III, n = 6). In addition, GLUT-1 staining levels were compared with the various histological criteria used for diagnosing WHO grade II and III meningiomas, namely, brain invasion, increased mitotic activity and atypical cytoarchitectural change, defined by the presence of at least three out of hypercellularity, sheet-like growth, prominent nucleoli, small cell change and "spontaneous" necrosis. The level of tumor hypoxia was assessed by converting the extent and intensity of the stainings by multiplication in an immunoreactive score (IRS) and statistically evaluated. The results were as follows. (1) While GLUT-1 expression was found to be mainly weak in WHO grade I meningiomas (IRS = 1-4) and to be consistently strong in WHO grade III meningiomas (IRS = 6-12), in WHO grade II meningiomas GLUT-1 expression was variable (IRS = 1-9). (2) Histologically typical, but brain invasive meningiomas (WHO grade II) showed no or similarly low levels of GLUT-1 expression as observed in WHO grade I meningiomas (IRS = 0-4). (3) GLUT-1 expression was observed in the form of a patchy, multifocal staining reaction in 76% of stained WHO grade I-III meningiomas, while diffuse staining (in 11%) and combined multifocal and areas of diffuse staining (in 13%) were only detected in WHO grades II and III meningiomas, except for uniform staining in angiomatous WHO grade I meningioma. (4) "Spontaneous" necrosis and small cell change typically occurred away from the intratumoral capillary network embedded within the pattern of GLUT-1 staining. Taken together, GLUT-1 staining cannot be applied as a substitute for histologic grading in order to predict tumor behavior. However, assessment of tumor hypoxia in association with "spontaneous" necrosis and foci of small cell change may substantially contribute to the neuropathologic diagnosis of WHO grades II and III meningioma.
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9
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Preoperative Embolization for Intracranial Meningiomas: Selecting Optimal Targets Based on Tumor Anatomy and Angioarchitecture. Clin Neuroradiol 2014; 25:327-8. [DOI: 10.1007/s00062-014-0317-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 06/14/2014] [Indexed: 10/25/2022]
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10
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Sun SQ, Cai C, Murphy RK, DeWees T, Dacey RG, Grubb RL, Rich KM, Zipfel GJ, Dowling JL, Leuthardt EC, Leonard JR, Evans J, Simpson JR, Robinson CG, Perrin RJ, Huang J, Chicoine MR, Kim AH. Management of Atypical Cranial Meningiomas, Part 2. Neurosurgery 2014; 75:356-63; discussion 363. [DOI: 10.1227/neu.0000000000000462] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Abstract
BACKGROUND:
The efficacies of adjuvant stereotactic radiosurgery (SRS) and external beam radiation therapy (EBRT) for atypical meningiomas (AMs) after subtotal resection (STR) remain unclear.
OBJECTIVE:
To analyze the clinical, histopathological, and radiographic features associated with progression in AM patients after STR.
METHODS:
Fifty-nine primary AMs after STR were examined for predictors of progression, including the impact of SRS and EBRT, in a retrospective cohort study.
RESULTS:
Twenty-seven patients (46%) progressed after STR (median, 30 months). On univariate analysis, spontaneous necrosis positively (hazard ratio = 5.2; P = .006) and adjuvant radiation negatively (hazard ratio = 0.3; P = .009) correlated with progression; on multivariate analysis, only adjuvant radiation remained independently significant (hazard ratio = 0.3; P = .006). SRS and EBRT were associated with greater local control (LC; P = .02) and progression-free survival (P = .007). The 2-, 5-, and 10-year actuarial LC rates after STR vs STR/EBRT were 60%, 34%, and 34% vs 96%, 65%, and 45%. The 2-, 5-, and 10-year actuarial progression-free survival rates after STR vs STR/EBRT were 60%, 30%, and 26% vs 96%, 65%, and 45%. Compared with STR alone, adjuvant radiation therapy significantly improved LC in AMs that lack spontaneous necrosis (P = .003) but did not improve LC in AMs with spontaneous necrosis (P = .6).
CONCLUSION:
Adjuvant SRS or EBRT improved LC of AMs after STR but only for tumors without spontaneous necrosis. Spontaneous necrosis may aid in decisions to administer adjuvant SRS or EBRT after STR of AMs.
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Affiliation(s)
- Sam Q. Sun
- Washington University School of Medicine, St. Louis, Missouri
| | - Chunyu Cai
- Departments of Pathology and Immunology Washington University, St. Louis, Missouri
| | | | - Todd DeWees
- Radiation Oncology, Washington University, St. Louis, Missouri
| | - Ralph G. Dacey
- Neurosurgery, and Washington University, St. Louis, Missouri
| | - Robert L. Grubb
- Neurosurgery, and Washington University, St. Louis, Missouri
| | - Keith M. Rich
- Neurosurgery, and Washington University, St. Louis, Missouri
| | | | | | | | | | - John Evans
- Neurosurgery, and Washington University, St. Louis, Missouri
| | | | | | | | - Jiayi Huang
- Radiation Oncology, Washington University, St. Louis, Missouri
| | | | - Albert H. Kim
- Neurosurgery, and Washington University, St. Louis, Missouri
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Nania A, Granata F, Vinci S, Pitrone A, Barresi V, Morabito R, Settineri N, Tomasello F, Alafaci C, Longo M. Necrosis Score, Surgical Time, and Transfused Blood Volume in Patients Treated with Preoperative Embolization of Intracranial Meningiomas. Analysis of a Single-Centre Experience and a Review of Literature. Clin Neuroradiol 2013; 24:29-36. [DOI: 10.1007/s00062-013-0215-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Accepted: 02/19/2013] [Indexed: 11/28/2022]
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12
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Abdihalim MM, Hassan AE, Qureshi AI. Off-label use of drugs and devices in the neuroendovascular suite. AJNR Am J Neuroradiol 2013; 34:2054-63. [PMID: 23518356 DOI: 10.3174/ajnr.a3447] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
SUMMARY The off-label use of drugs and devices in neuroendovascular procedures is common. Neurointerventionalists should be well aware of the level of evidence available in support of the off-label use of drugs and devices in their practice and some of the potential adverse events associated with them. These uses are categorized as I or II if they have been evaluated as primary or ancillary interventions in prospective trials/registries of neuroendovascular procedures and III if they were evaluated in case series. Category IV use is based on evaluation as primary or ancillary interventions in prospective trials/registries of non-neuroendovascular procedures. Physicians are allowed to use off-label drugs and procedures if there is strong evidence that they are beneficial for the patient. The neurointerventional professional societies agree that off-label use of drugs and devices is an important part of the specialty, but practicing providers should base their decisions on sound evidence when using such drugs and devices.
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Embolized meningiomas: risk of overgrading and neo-angiogenesis. J Neurooncol 2013; 113:207-19. [DOI: 10.1007/s11060-013-1117-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Accepted: 03/12/2013] [Indexed: 12/23/2022]
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Atypical and ischemic features of embolized meningiomas. Brain Tumor Pathol 2011; 29:17-24. [DOI: 10.1007/s10014-011-0058-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2011] [Accepted: 07/04/2011] [Indexed: 10/18/2022]
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15
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Jiménez-Heffernan JA, Corbacho C, Cañizal JM, Pérez-Campos A, Vicandi B, López-Ibor L, Viguer JM. Cytological changes induced by embolization in meningiomas. Cytopathology 2011; 23:57-60. [PMID: 21214650 DOI: 10.1111/j.1365-2303.2010.00836.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe cytological changes in meningiomas induced by embolization, which may be carried out a few days before surgery in order to soften the tumour and minimize intraoperative bleeding. Although histological changes have been described, we have found no description of such changes in the cytological literature. METHODS We reviewed 22 cases of meningiomas with prior embolization in which cytological material was obtained during intraoperative consultation. In 13 of them recognizable cytological changes induced by embolization were present. On histology, these 13 tumours were grade I and showed intravascular embolic material. RESULTS Cellular dissociation was prominent, with frequent single cells and small groups. Ischaemic cellular changes were a common finding and consisted of cell shrinkage, nuclear pyknosis and karyorrhexis. Confluent areas of necrosis were seen in one case. Additionally, numerous macrophages were present, many containing cellular debris, and neutrophils, giving a characteristic appearance of acute cellular ischaemia. Embolic material was seen cytologically in four cases as well-defined spherules surrounded by empty halos. Features of viable meningioma were recognized in all cases. CONCLUSION Embolization of meningiomas induces cytological changes that mirror those seen on histology, but cellular dissociation with changes of ischaemia may result in a worrisome image. When faced with such changes the pathologist should consider the possibility of embolization, avoiding misdiagnosis of higher grade meningioma or metastatic carcinoma.
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Mawrin C, Perry A. Pathological classification and molecular genetics of meningiomas. J Neurooncol 2010; 99:379-91. [PMID: 20809251 DOI: 10.1007/s11060-010-0342-2] [Citation(s) in RCA: 276] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2010] [Accepted: 08/04/2010] [Indexed: 12/11/2022]
Abstract
Meningiomas are extremely common adult brain tumors originating from meningeal coverings of the brain and spinal cord. While most are slowly growing Word Health organization (WHO) grade I tumors, rare variants (clear cell, chordoid, papillary, and rhabdoid), as well as brain invasive (WHO grade II), atypical (WHO grade II), and anaplastic (WHO grade III) meningiomas are considerably more aggressive. This review summarizes the histopathological and genetic features of meningiomas, including differential diagnosis, pitfalls, and grading challenges. Early stages of meningioma tumorigenesis are closely linked to inactivation of one or more members of the 4.1 superfamily, including the neurofibromatosis type 2 (NF2) and 4.1B (DAL-1) genes, which interact with the 14-3-3 protein family. Other chromosome 22q genes implicated include BAM22, BCR (breakpoint cluster region), and TIMP-1, the last of which is implicated in higher-grade meningiomas. Atypical meningiomas also commonly show chromosomal losses of 1p, 6q, 10, 14q, and 18q, as well as multiple chromosomal gains. While most relevant genes remain unknown, two chromosome 14q candidates (MEG3 and NDRG2) have recently been identified. In addition to alterations of CDKN2A, p14(ARF), and CDKN2B tumor suppressor genes on 9p21, a contribution of the wingless (wnt) pathway with alterations of the E-cadherin and beta-catenin proteins, as well as alterations of the hedgehog signaling pathway have been implicated in anaplastic meningiomas. The integration of histopathological appearance, complex genetic/genomic data, and outcome will likely result in the identification of clinically distinct meningioma subgroups, which in turn can facilitate the development of targeted therapeutic strategies.
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Affiliation(s)
- Christian Mawrin
- Department of Neuropathology, Otto-von-Guericke-University Magdeburg, Leipziger Strasse 44, Magdeburg, Germany.
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Alexiou GA, Gogou P, Markoula S, Kyritsis AP. Management of meningiomas. Clin Neurol Neurosurg 2010; 112:177-82. [DOI: 10.1016/j.clineuro.2009.12.011] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2009] [Revised: 10/14/2009] [Accepted: 12/11/2009] [Indexed: 10/20/2022]
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18
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Sensitivity and usefulness of anti-phosphohistone-H3 antibody immunostaining for counting mitotic figures in meningioma cases. Brain Tumor Pathol 2009; 26:51-7. [DOI: 10.1007/s10014-009-0249-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2008] [Accepted: 03/09/2009] [Indexed: 10/20/2022]
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19
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Bozkurt SU, Ayan E, Bolukbasi F, Elmaci I, Pamir N, Sav A. Immunohistochemical expression of SPARC is correlated with recurrence, survival and malignant potential in meningiomas. APMIS 2009; 117:651-9. [PMID: 19703125 DOI: 10.1111/j.1600-0463.2009.02516.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Meningioma is a common neoplasm that constitutes almost 30% of all primary central nervous system tumors and is associated with inconsistent clinical outcomes. The extracellular matrix proteins play a crucial role in meningioma cell biology and are important in tumor cell invasion and in progression to malignancy. SPARC (secreted protein, acidic and rich in cysteine) (osteonectin) is a matricellular glycoprotein that regulates cell function by interacting with different extracellular matrix proteins. The aim of this study was to evaluate the expression of SPARC with proliferation index, p53 reactivity in WHO grade 1 (benign), grade 2 (atypical) and grade 3 (anaplastic) meningiomas and correlate with clinical features of the patients, including location of the tumor, recurrence of the tumor and survival of patients. We studied 111 meningiomas, 69 being benign, 34 being atypical and eight being anaplastic meningiomas of various histological types. Using immunohistochemical analysis, we evaluated the expression of SPARC, Ki-67 (MIB-1) and p53 in meningiomas. Immunohistochemical scores of SPARC were determined as the sum of frequency (0-3) and intensity (0-3) of immunolabeling of the tumor cells. A high immunohistochemical score (4-6) for SPARC was more frequent in atypical and in anaplastic meningiomas than in benign meningiomas (p < 0.01). MIB-1 proliferation index showed significant association between tumor grades in meningiomas (p < 0.01). At the end of a follow-up period of 47.53 +/- 25.04 months, 30 tumors recurred. A high SPARC expression was significantly associated with tumor recurrence (p = 0.02). The immunoreactivity of p53 protein and MIB-1 score were significantly higher in recurrent meningiomas than in non-recurrent meningiomas. The cumulative survival of patients with high SPARC expression was significantly lower than patients with low SPARC expression. The high SPARC expression scores were predominantly identified in meningothelial, fibrous and chordoid meningiomas; low SPARC expression scores were mostly spotted in secretory and psammomatous meningiomas. Evaluating SPARC expression might help assessing recurrence risk and survival estimation in meningiomas.
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Affiliation(s)
- Suheyla Uyar Bozkurt
- Department of Pathology, Institute for Neurological Sciences, Marmara University, Istanbul, Turkey.
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20
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Ali S, Nassar A, Siddiqui MT. Crush preparations of meningiomas: Can grading be accomplished? Diagn Cytopathol 2008; 36:827-31. [DOI: 10.1002/dc.20929] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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21
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Abstract
✓The histological appearance of a meningioma is an important predictor of tumor behavior and is frequently a factor in decisions concerning therapy. The relationship between histological features and prognosis is formalized in grading schemes such as those published by the World Health Organization (WHO), most recently in 2007. Although the latest edition is an improvement over previous grading schemes, the WHO scheme still fails to fully address a variety of important issues regarding the relationship between meningioma histological characteristics and behavior. In particular, routine histological examination fails to identify the subset of Grade I tumors that behave aggressively. Because of this, many additional prognostic markers that require immunohistochemical, cytogenetic, or molecular techniques to evaluate are under investigation. Only one, immunohistochemistry for the proliferation marker, Ki 67 (MIB-1), is used routinely and it has only limited utility. It is hoped that an understanding of the genetic changes that underlie tumor progression will improve healthcare professionals' ability to predict the behavior of meningiomas.
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Affiliation(s)
| | | | - Margaret E. Burnett
- 1Department of Pathology and
- 2Department of Neurology, University of Southern California Keck School of Medicine, Los Angeles, California
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22
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Yoo H, Baia GS, Smith JS, McDermott MW, Bollen AW, Vandenberg SR, Lamborn KR, Lal A. Expression of the hypoxia marker carbonic anhydrase 9 is associated with anaplastic phenotypes in meningiomas. Clin Cancer Res 2007; 13:68-75. [PMID: 17200340 DOI: 10.1158/1078-0432.ccr-06-1377] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Hypoxia in the tumor microenvironment triggers a variety of genetic and adaptive responses that regulate tumor growth. Tumor hypoxia is often associated with more malignant phenotypes, resistance to therapy, and poor survival. The purpose of this study was to evaluate the prevalence of hypoxia in meningiomas using the endogenous hypoxia marker carbonic anhydrase 9 (CA9) and to relate the expression of CA9 to tumor vascularity, histopathologic grade, and clinical variables, such as recurrent tumor status. EXPERIMENTAL DESIGN Expression of CA9 and CD34, an endothelial cell marker, was examined in serial paraffin-embedded sections by immunohistochemistry in 25 grade 1, 17 grade 2, and 20 grade 3 meningiomas. Areas of immunoreactivity were semiquantitatively scored and correlated to clinical variables using Statistical Analysis System statistical software. RESULTS Approximately 50% (29 of 62) of all meningiomas contained regions of hypoxia as judged by expression of CA9, and this expression was significantly associated with higher-grade histology (P = 0.001). In contrast, vascularity, as assessed by the percentage of vascular hotspots, was inversely associated with tumor grade (P = 0.023) and was not associated with CA9 expression. Among lower-grade meningiomas, CA9 expression tended to be more common in recurrent tumors. CONCLUSIONS Tumor hypoxia is an endogenous feature of meningiomas, and therapeutic regimens should include strategies to target the subpopulation of hypoxic as well as the normoxic cells within the tumor. Hypoxia in meningiomas is associated with an aggressive phenotype. Further studies to define the contribution of hypoxia to meningioma pathophysiology are warranted.
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Affiliation(s)
- Heon Yoo
- Brain Tumor Research Center, Department of Neurological Surgery, University of California, San Francisco, California 94143, USA
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23
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Modha A, Gutin PH. Diagnosis and treatment of atypical and anaplastic meningiomas: a review. Neurosurgery 2006; 57:538-50; discussion 538-50. [PMID: 16145534 DOI: 10.1227/01.neu.0000170980.47582.a5] [Citation(s) in RCA: 227] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Atypical and anaplastic meningiomas are uncommon tumors with a poorer prognosis than benign meningiomas. We reviewed the current literature and attempted to integrate and summarize available information to determine a logical approach to these tumors. Both tumors are rare and are often integrated with benign meningiomas when treatments are evaluated. In addition, because there has not been one histopathological classification scheme for atypical and anaplastic meningiomas in the past, there are numerous inconsistencies in the literature. Malignant progression with accumulation of mutations in a benign meningioma can result in an atypical and/or anaplastic meningioma. Both tumors are difficult to manage and have high recurrence and poor survival rates. The extent of tumor resection and histological grade are the key determinants for recurrence. In addition, metastases are unusual, but they do occur. We also review the evidence available that has resulted in the current World Health Organization classification. Radiation therapy can be used as an adjunctive treatment after both total and subtotal resection. In addition, the role of stereotactic radiosurgery is increasing, along with a possible role for brachytherapy. There are no effective chemotherapeutic agents available. A treatment algorithm is suggested.
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Affiliation(s)
- Ashok Modha
- Memorial Sloan-Kettering Cancer Center, Department of Neurological Surgery, Weill Medical College of Cornell University, New York, New York, USA
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24
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Perry A, Schmidt RE. Cancer therapy-associated CNS neuropathology: an update and review of the literature. Acta Neuropathol 2006; 111:197-212. [PMID: 16463065 DOI: 10.1007/s00401-005-0023-y] [Citation(s) in RCA: 161] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2005] [Revised: 12/08/2005] [Accepted: 12/09/2005] [Indexed: 01/28/2023]
Abstract
Standard therapeutic options for brain tumors include surgery, radiation, and chemotherapy. Unfortunately, these same therapies pose risks of neurotoxicity, the most common long-term complications being radiation necrosis, chemotherapy-associated leukoencephalopathy, and secondary neoplasms. These side effects remain difficult to predict, but are associated with risk factors that include patient age, therapeutic modality and dosage, genetic background, and idiosyncratic predispositions. Experimental treatments designed to enhance efficacy and to minimize neurotoxicity include molecularly targeted, genetic, stem cell, and immune therapies. Newer modifications in radiation and drug delivery include stereotactic radiosurgery, interstitial therapy such as intracavitary brachytherapy and gliadel wafer placement, 3D conformal radiation, boron neutron capture therapy, radiosensitizers, blood-brain barrier disrupting agents, and convection enhanced delivery. Toxicities associated with these newer modalities have yet to be fully investigated and documented. Additionally, a number of recently implemented radiographic techniques such as PET and SPECT imaging have enhanced the ability to distinguish recurrent tumor from radiation necrosis. Nevertheless, post-therapeutic brain biopsies and autopsies remain the gold standard for assessing neurotoxicity, therapeutic efficacy, tumor progression, and the development of secondary neoplasms. At the same time, treatment-associated changes such as tumor necrosis, vasculopathy, inflammation, and cytologic atypia can pose significant diagnostic pitfalls, particularly if the pathologist is not provided a detailed therapeutic history. Therefore, it is critical to recognize the full spectrum of cancer therapy-associated neuropathology, the topic of the current review.
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Affiliation(s)
- Arie Perry
- Division of Neuropathology, Washington University School of Medicine, St. Louis, MO 63110-1093, USA.
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25
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Roser F, Nakamura M, Bellinzona M, Ritz R, Ostertag H, Tatagiba MS. Proliferation potential of spinal meningiomas. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2006; 15:211-5. [PMID: 15926055 PMCID: PMC3489402 DOI: 10.1007/s00586-005-0937-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2004] [Revised: 02/08/2005] [Accepted: 03/10/2005] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The goal of the present study was to quantitatively assess the proliferation index and progesterone receptor status of spinal versus intracranial meningiomas and to determine if these biological indicators can describe the clinical behavior of these tumors. This information could provide the spinal surgeon with important additional information concerning surgical management and follow-up recommendations for the individual patient. METHODS The study group consisted of 26 patients with spinal and 241 patients with intracranial meningiomas. Patients with atypical or anaplastic tumors as well as with neurofibromatosis type II were excluded from the study. Furthermore both groups were matched according to age, sex and resection grade (total resection according the Simpson classification). Proliferation index (Ki-67 Labelling index [LI]) and progesterone-receptor (PR) status of spinal and intracranial meningiomas were compared. Clinical charts including surgical and histological records and imaging studies were reviewed. Correlations with histological subtype, intratumoral calcifications, tumor vascularity and recurrence-free survival were analyzed. RESULTS Compared to the spinal group with a mean Ki-67 LI of 2.48% and a positive PR-status of 46%, proliferation rates of intracranial meningiomas were significant higher (Ki-67 LI 3.6%; P-value 0.041). No significant difference in PR status was seen (spinal PR-status 46%, P-value 0.261). Furthermore spinal meningiomas were less vascularized and showed less intratumoral calcifications. Time to recurrence was similar in spinal and intracranial tumors. CONCLUSION Spinal and intracranial meningiomas differ in their proliferation activity but not in their PR status. However, despite lower proliferation rates, time to recurrence in spinal and cranial meningiomas is comparable in totally excised tumors. Further studies are needed to determine the role of other biological indicators in spinal meningioma growth and response to therapy.
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Affiliation(s)
- Florian Roser
- Department of Neurosurgery, University of Tübingen, Hoppe-Seyler-Strasse 3, 72076 Tuebingen, Germany.
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26
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Willis J, Smith C, Ironside JW, Erridge S, Whittle IR, Everington D. The accuracy of meningioma grading: a 10-year retrospective audit. Neuropathol Appl Neurobiol 2005; 31:141-9. [PMID: 15771707 DOI: 10.1111/j.1365-2990.2004.00621.x] [Citation(s) in RCA: 151] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Although descriptive classifications of meningioma subtypes are well established, there has been inconsistency in the categorization of meningiomas into benign, atypical and anaplastic groups. The aim of this study was to reassess the incidence of atypical (grade II) meningiomas over a 10-year period by applying the World Health Organization (WHO) 2000 classification system. A secondary aim was to determine if grade II and III tumours were becoming more common. Sections of 314 meningiomas resected between 1994 and 2003 were retrieved from the archives of the Western General Hospital's neuropathology unit in Edinburgh. They were reassessed and graded by using the WHO 2000 classification system. The reviewers were blind to the original classification and grading. There was a gradual increase in the numbers of meningiomas being resected annually over the 10-year period. On reclassification, 78% of the meningiomas were classified as grade I, 20.4% as grade II and 1.6% as grade III. With regard to grade II meningiomas classified by using the WHO 2000 classification system, 38.1% had originally been classified as grade I prior to 2000, whereas 13.6% had originally been classified as grade I after 2000. In most cases, reclassification was due to formal counts of mitotic figures. Atypical meningiomas are diagnosed more frequently under the current WHO classification system than they were under the previous classification systems. Although the current WHO (2000) classification is more prescriptive than its predecessors, interobserver variability is likely to remain because of the subjective nature of some of the criteria.
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Affiliation(s)
- J Willis
- Neuropathology Unit, Department of Pathology, University of Edinburgh, Western General Hospital, Edinburgh, UK
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Deshmukh VR, Fiorella DJ, McDougall CG, Spetzler RF, Albuquerque FC. Preoperative embolization of central nervous system tumors. Neurosurg Clin N Am 2005; 16:411-32, xi. [PMID: 15694171 DOI: 10.1016/j.nec.2004.08.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Vivek R Deshmukh
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 West Thomas Road, Phoenix, AZ 85013, USA
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Kato A, Fujimoto Y, Taniguchi M, Hashimoto N, Hirayama A, Kinoshita M, Baba T, Maruno M, Yoshimine T. Volumetric thermal devascularization of large meningiomas. J Neurosurg 2004; 101:779-86. [PMID: 15540916 DOI: 10.3171/jns.2004.101.5.0779] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object. Controlling hemorrhage is crucial in the safe and efficient removal of large meningiomas. Intravascular embolization is not always a satisfactory means of accomplishing this goal because of the procedure's hemostatic effect and risk of complications. The authors in this study used a volumetric thermal ablation technique incorporating radiofrequency energy, image guidance, and local temperature control to devascularize tumor tissue.
Methods. Five patients with large meningiomas were treated. The target and orientation of the radiofrequency thermal ablation (RFTA) were simulated preoperatively to maximize devascularization of the lesion without thermal injury to adjacent critical structures. Image fusion, three-dimensional reconstruction, and image-guided methods provided for optimized trajectories and targets for insertion of the RFTA needle. During ablation, local temperatures of the tissue being cauterized were monitored continuously to limit the ablated lesion to within the target volume.
The effects of devascularization and the softening of the tumor parenchyma facilitated lesion removal. The intracranial ablated meningioma changed into necrotic tissue and shrank within a few months. Histopathological examination of the ablated lesion revealed sharply demarcated coagulation necrosis.
Conclusions. Volumetric thermal devascularization can be applied safely in the treatment of large meningiomas to facilitate surgical manipulation of the lesion as well as to reduce its size palliatively. The procedure's usefulness should be studied further in a larger number of cases with different tumor characteristics.
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Affiliation(s)
- Amami Kato
- Department of Neurosurgery, Osaka University Medical School, Suita, Japan.
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29
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Abstract
Meningiomas are by far the most common tumours arising from the meninges. Progressive enlargement of the tumour leads to focal or generalised seizure disorders or neurological deficits caused by compression of adjacent neural tissue. Surgery remains the primary treatment of choice, although the use of fractionated radiotherapy or stereotactic single-dose radiosurgery is increasing for meningiomas that are incompletely excised, surgically inaccessible, or recurrent and either atypical or anaplastic. Although most meningiomas have good long-term prognosis after treatment, there are still controversies over management in a proportion of cases. We review various features of meningioma biology, diagnosis, and treatment and provide an overview of the current rationale and evidence base for the various therapeutic approaches.
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Affiliation(s)
- Ian R Whittle
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh EH4 2XU, UK.
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