1
|
Polemikos M, Nakamura M, Merten R, Hermann EJ, Bronzlik P, Christiansen H, Krauss JK. Extended Long-Term Outcome After Conservative Decompressive Microsurgery and Routine Adjuvant Fractionated Stereotactic Radiotherapy for Symptomatic Cavernous Sinus Meningiomas. Neurosurgery 2024:00006123-990000000-01117. [PMID: 38973738 DOI: 10.1227/neu.0000000000002940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 02/08/2024] [Indexed: 07/09/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Cavernous sinus meningiomas (CSM) pose one of the most difficult to treat subgroup of skull base meningiomas. The purpose of this study was to evaluate the efficacy of an interdisciplinary treatment approach for symptomatic CSM which incorporated conservative function preserving microsurgery and routine adjuvant fractionated stereotactic radiotherapy (FSRT). METHODS A homogenous group of patients with symptomatic primary CSM with extracavernous extension was treated between 2005 and 2012. All patients were available for a minimum follow-up of 5 years. Clinical follow-up included detailed examination of oculomotor deficits, visual status, and endocrinologic function. Radiologic follow-up was conducted by tumor volumetry. RESULTS Overall, 23 patients were included in this study (78.3% women; median age 58 years). Diplopia was the most common presenting symptom, followed by headache and visual disturbances. Surgical morbidity was low (3/23; 13%). FSRT was applied after a median of 2 months after surgery. At a median clinical follow-up of 113 months, 70.45% of the presenting symptoms had improved, 25% remained unchanged, and in 2 cases (4.54%), worsening occurred. Overall tumor regression was evident in 19/21 World Health Organization 1 and in 1/2 of World Health Organization 2 CSM, respectively, at a median radiological follow-up of 103 months. CONCLUSION Our findings demonstrate the efficacy of an interdisciplinary treatment approach for symptomatic primary CSM with extracavernous extension with decompression of neurovascular elements followed by FSRT. Precise preoperative planning and intraoperative decision making in combination with routine postoperative radiotherapy can achieve excellent tumor control, improve neurologic function, and minimize long-term morbidity.
Collapse
Affiliation(s)
- Manolis Polemikos
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Makoto Nakamura
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
- Department of Neurosurgery, Hospital Merheim of the Clinics Cologne, University of Witten/Herdecke, Witten, Germany
| | - Roland Merten
- Department of Radiation Oncology, Hannover Medical School, Hannover, Germany
| | - Elvis J Hermann
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Paul Bronzlik
- Institute for Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
| | - Hans Christiansen
- Department of Radiation Oncology, Hannover Medical School, Hannover, Germany
| | - Joachim K Krauss
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| |
Collapse
|
2
|
He W, Liu Z, Zheng D, Xu C, Jie D, Tang L, Teng H, Xu J. Management of cavernous sinus meningiomas: Clinical features, treatment strategies, and long-term outcomes. Asian J Surg 2024; 47:1366-1377. [PMID: 38087690 DOI: 10.1016/j.asjsur.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 11/20/2023] [Accepted: 12/01/2023] [Indexed: 03/13/2024] Open
Abstract
OBJECTIVES The purpose of this research was to summarize the clinical and prognostic features of cavernous sinus meningiomas (CSM), evaluate the treatment strategies and long-term prognosis of CSM, and improve the management of CSM and the treatment effect for patients. METHODS We retrospectively studied the data of 54 patients who received initial surgical resection and 45 patients who received initial gamma knife radiosurgery (GKRS) for CSM at West China Hospital of Sichuan University from 2009 to 2021. Progression-free survival (PFS), Karnofsky Performance Scale (KPS) scores and neurological function recovery were adopted to assess a comprehensive management strategy for CSM. RESULTS Gross total resection (GTR) was performed in 51.9 % of cases with 3.7 % surgical mortality. The average follow-up time was 48.7 months, with a progression rate of 29.3 %. The overall improvement rate for cranial nerve function deficits was 50.0 %. By survival analysis, the extent of resection and the histological grade were significantly related to the prognosis. The role of postoperative GKRS is uncertain. For patients who received initial GKRS, the progression rate was 17.8 %, and the overall improvement rate for cranial nerve function deficits was 61.1 %. Primary treatment with GKRS showed better long-term tumor control in patients with CSM (P = 0.046). CONCLUSIONS Maximum safe resection of CSM can improve the neurological function and quality of life of patients, but aggressive resection will cause high perioperative mortality and complication rates. For CSM patients who are suitable for initial gamma knife treatment, choosing GKRS can achieve better long-term tumor control and neurological outcomes.
Collapse
Affiliation(s)
- Wenbo He
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China; West China School of Medicine, Sichuan University, Chengdu, Sichuan, China.
| | - Zhiyong Liu
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China.
| | - Datong Zheng
- West China School of Medicine, Sichuan University, Chengdu, Sichuan, China.
| | - Chongxi Xu
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China; West China School of Medicine, Sichuan University, Chengdu, Sichuan, China.
| | - Danyang Jie
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China; West China School of Medicine, Sichuan University, Chengdu, Sichuan, China.
| | - Liansha Tang
- West China School of Medicine, Sichuan University, Chengdu, Sichuan, China; Department of Biotherapy, Cancer Center, West China Hospital of Sichuan University, Chengdu, Sichuan, China.
| | - Haibo Teng
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China; West China School of Medicine, Sichuan University, Chengdu, Sichuan, China.
| | - Jianguo Xu
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China.
| |
Collapse
|
3
|
Bernardo A, Evins AI, Barbagli G, Kim MG, Kim N, Xia JJ, Nonaka M, Stieg PE. Tailored Surgical Access to the Cavernous Sinus and Parasellar Region: Assessment of Cavernous Sinus Entry Corridors and the Periclinoid and Pericavernous Surgical Maneuvers. World Neurosurg 2023; 171:e253-e275. [PMID: 36503120 DOI: 10.1016/j.wneu.2022.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/30/2022] [Accepted: 12/01/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Lesions involving the cavernous sinus (CS) represent some of the most challenging pathologies of the skull base owing to the dense traversing and surrounding neurovasculature. Extradural exposure and preparation of this region, whether as initial preparation for a combined intra-extradural approach or as the main avenue of surgical exposure, can enlarge surgical corridors and minimize the need for brain retraction in this very confined space. We provide a detailed assessment of the entry corridors to the CS that are available within each approach, the surgical exposure and freedom provided by each of these corridors, and demonstrate how extradural and intradural preparation of these corridors can be used to widen the available working space and facilitate surgery. METHODS Pterional, frontotemporal-orbital, frontotemporal-orbitozygomatic, frontotemporal-zygomatic, perilabyrinthine transtentorial, and endoscopic transnasal transsphenoidal approaches were performed on cadaveric heads to access the perisellar and CS regions. Periclinoid maneuvers (extradural cutting of the meningo-orbital band, anterior clinoidectomy, unroofing of the optic canal, opening of the superior orbital fissure, displacement of the extra-annular structures, opening of the annulus of Zinn, and interdural dissection), pericavernous maneuvers (intradural cutting of the distal dural ring, mobilization of the supraclinoid internal carotid artery, opening of the oculomotor porus, and mobilization of cranial nerve (CN) III), peritrigeminal extensions (extradural mobilization of CN V2 [maxillary] and/or V3 [mandibular]), and other surgical maneuvers were performed and evaluated. The CS was divided into 8 anatomical compartments and 9 entry corridors were described, and exposure and freedom were assessed accordingly. RESULTS Intradurally, the standard unextended pterional, frontotemporal-orbital, and frontotemporal orbitozygomatic transsylvian approaches provided access solely to the parasellar entry corridor into the superior wall of the CS. Expanding these approaches with extradural periclinoid maneuvers allowed for subsequent application of the intradural pericavernous maneuvers and enlargement of the parasellar corridor and exposure of the carotid cave. Extradurally, the frontotemporal-orbital approach could be expanded via application of periclinoid maneuvers, which provided access to the anterior portions of the main lateral wall entry corridors. The frontotemporal-orbitozygomatic approach could also be expanded with periclinoid maneuvers to provide extradural access to all 6 lateral wall entry corridors. The extradural frontotemporal-zygomatic approach only provided exposure following interdural dissection, which allowed for access to the inferolateral entry corridors into the lateral wall. Extradural peritrigeminal extension in the frontotemporal-orbitozygomatic and frontotemporal-zygomatic approaches allows for enlargement of the supramaxillary and pre- and postmandibular corridors. The perilabyrinthine approach to the posterior wall was enlarged with opening of Dorello's canal and the endoscopic transnasal transsphenoidal approach was enlarged with opening of the optic canal. CONCLUSIONS Targeted extradural preparation optimizes exposure and significantly improves access to deep-seated targets by enhancing surgical maneuverability through the unlocking of neurovascular structures and widening of surgical corridors without the need for additional brain retraction.
Collapse
Affiliation(s)
- Antonio Bernardo
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York, USA.
| | - Alexander I Evins
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York, USA
| | - Giovanni Barbagli
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York, USA
| | - Michael G Kim
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York, USA; Department of Neurological Surgery, University of California, Irvine, Orange, California, USA
| | - NamHee Kim
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York, USA
| | - Jimmy J Xia
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York, USA; Department of Radiology, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York, USA
| | - Motonobu Nonaka
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York, USA
| | - Philip E Stieg
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York, USA
| |
Collapse
|
4
|
Masalha W, Heiland DH, Steiert C, Krüger MT, Schnell D, Heiland P, Bissolo M, Grosu AL, Schnell O, Beck J, Grauvogel J. Management of Medial Sphenoid Wing Meningioma Involving the Cavernous Sinus: A Single-Center Series of 105 Cases. Cancers (Basel) 2022; 14:2201. [PMID: 35565330 PMCID: PMC9102569 DOI: 10.3390/cancers14092201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/21/2022] [Accepted: 04/26/2022] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Medial sphenoid wing meningiomas are among the three most common intracranial meningiomas. These tumors pose a challenge to neurosurgeons in terms of surgical treatment, as they may involve critical neurovascular structures and invade the cavernous sinus. In case of the latter, a complete resection may not be achievable. The purpose of this study was to investigate prognostic features affecting recurrence and progression-free survival (PFS) of medial sphenoid wing meningiomas involving the cavernous sinus, focusing on the contribution of surgery and postoperative radiotherapy. METHODS A retrospective analysis was conducted of the database of our institution, and 105 cases of medial sphenoid wing meningioma with invasion of the cavernous sinus, which were treated between 1998 and 2019, were included. Surgical treatment only was performed in 64 cases, and surgical treatment plus postoperative radiotherapy was performed in 41 cases. Kaplan-Meier analysis was conducted to estimate median survival and PFS rates, and Cox regression analysis was applied to determine significant factors that were associated with each therapeutic modality. RESULTS The risk of recurrence was significantly reduced after near-total resection (NTR) (p-value = 0.0011) compared to subtotal resection. Progression-free survival was also significantly prolonged after postoperative radiotherapy (p-value = 0.0002). CONCLUSIONS Maximal safe resection and postoperative stereotactic radiotherapy significantly reduced the recurrence rate of medial sphenoid wing meningiomas with infiltration of the cavernous sinus.
Collapse
Affiliation(s)
- Waseem Masalha
- Department of Neurosurgery, Medical Centre—University of Freiburg, 79106 Freiburg, Germany; (D.H.H.); (C.S.); (M.T.K.); (P.H.); (M.B.); (O.S.); (J.B.); (J.G.)
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; (D.S.); (A.-L.G.)
| | - Dieter Henrik Heiland
- Department of Neurosurgery, Medical Centre—University of Freiburg, 79106 Freiburg, Germany; (D.H.H.); (C.S.); (M.T.K.); (P.H.); (M.B.); (O.S.); (J.B.); (J.G.)
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; (D.S.); (A.-L.G.)
| | - Christine Steiert
- Department of Neurosurgery, Medical Centre—University of Freiburg, 79106 Freiburg, Germany; (D.H.H.); (C.S.); (M.T.K.); (P.H.); (M.B.); (O.S.); (J.B.); (J.G.)
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; (D.S.); (A.-L.G.)
| | - Marie T. Krüger
- Department of Neurosurgery, Medical Centre—University of Freiburg, 79106 Freiburg, Germany; (D.H.H.); (C.S.); (M.T.K.); (P.H.); (M.B.); (O.S.); (J.B.); (J.G.)
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; (D.S.); (A.-L.G.)
- Department of Neurosurgery, Cantonal Hospital St. Gallen, 9000 St. Gallen, Switzerland
| | - Daniel Schnell
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; (D.S.); (A.-L.G.)
- Department of Radiation Oncology, Medical Centre—University of Freiburg, 79106 Freiburg, Germany
- German Cancer Consortium (DKTK), Partner Site Freiburg, 79106 Freiburg, Germany
| | - Pamela Heiland
- Department of Neurosurgery, Medical Centre—University of Freiburg, 79106 Freiburg, Germany; (D.H.H.); (C.S.); (M.T.K.); (P.H.); (M.B.); (O.S.); (J.B.); (J.G.)
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; (D.S.); (A.-L.G.)
| | - Marco Bissolo
- Department of Neurosurgery, Medical Centre—University of Freiburg, 79106 Freiburg, Germany; (D.H.H.); (C.S.); (M.T.K.); (P.H.); (M.B.); (O.S.); (J.B.); (J.G.)
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; (D.S.); (A.-L.G.)
| | - Anca-L. Grosu
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; (D.S.); (A.-L.G.)
- Department of Radiation Oncology, Medical Centre—University of Freiburg, 79106 Freiburg, Germany
- German Cancer Consortium (DKTK), Partner Site Freiburg, 79106 Freiburg, Germany
| | - Oliver Schnell
- Department of Neurosurgery, Medical Centre—University of Freiburg, 79106 Freiburg, Germany; (D.H.H.); (C.S.); (M.T.K.); (P.H.); (M.B.); (O.S.); (J.B.); (J.G.)
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; (D.S.); (A.-L.G.)
| | - Jürgen Beck
- Department of Neurosurgery, Medical Centre—University of Freiburg, 79106 Freiburg, Germany; (D.H.H.); (C.S.); (M.T.K.); (P.H.); (M.B.); (O.S.); (J.B.); (J.G.)
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; (D.S.); (A.-L.G.)
| | - Jürgen Grauvogel
- Department of Neurosurgery, Medical Centre—University of Freiburg, 79106 Freiburg, Germany; (D.H.H.); (C.S.); (M.T.K.); (P.H.); (M.B.); (O.S.); (J.B.); (J.G.)
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; (D.S.); (A.-L.G.)
| |
Collapse
|
5
|
Almeida JP, de Andrade E, Reghin-Neto M, Radovanovic I, Recinos PF, Kshettry VR. From Above and Below: The Microsurgical Anatomy of Endoscopic Endonasal and Transcranial Microsurgical Approaches to the Parasellar Region. World Neurosurg 2021; 159:e139-e160. [PMID: 34906753 DOI: 10.1016/j.wneu.2021.12.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 12/05/2021] [Accepted: 12/06/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The parasellar region is one of the most complex of the skull base. In this study, we review the anatomy and approaches to this region through a 360° perspective, correlating microsurgical and endoscopic anatomic nuances of this area. METHODS An endoscopic endonasal approach (EEA) and microsurgical dissections were performed. The parasellar anatomy is reviewed and common areas of tumor extensions are assessed. Surgical approaches are discussed based on the anatomic nuances of those regions. RESULTS The cavernous sinus (CS) can be divided into 2 spaces: posterosuperior, above and behind the internal carotid artery (ICA); and anterior, in front of the cavernous ICA. Those spaces can be approached through the CS walls: anterior and/or medial wall via EEA; or superior and/or lateral wall via transcranial approaches. The relationship of the Meckel cave, adjacent to the lateral and posterior wall of the CS, is relevant for surgical planning. Areas often affected by tumor extension can be divided into 6 regions: superior (cisternal), superolateral (parapeduncular), posterolateral (Meckel cave and petrous bone), medial (sella), anterior (superior orbital fissure), and anterior inferior (pterygopalatine fossa). Anatomic and technical nuances of each of those regions should be taken into consideration when dealing with tumors in the parasellar space. CONCLUSIONS A transcranial approach and EEA provide effective access to the parasellar region. Management of cavernous sinus and Meckel cave tumors requires familiarity with those approaches. Understanding of the surgical anatomy of the parasellar region, from above and below, is therefore necessary for adequate surgical planning and execution.
Collapse
Affiliation(s)
| | - Erion de Andrade
- Rosa Ella Burkhardt Brain Tumor Center, Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mateus Reghin-Neto
- Institute of Neurological Sciences, Hospital BP Sao Paulo, Sao Paulo, Brazil
| | - Ivan Radovanovic
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Pablo F Recinos
- Rosa Ella Burkhardt Brain Tumor Center, Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Varun R Kshettry
- Rosa Ella Burkhardt Brain Tumor Center, Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| |
Collapse
|
6
|
Surgical Treatment of Recurrent Spheno-Orbital Meningioma. J Craniofac Surg 2021; 33:901-905. [PMID: 34743161 DOI: 10.1097/scs.0000000000008346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE The extensive bone infiltration and carpet-like growth characteristics of spheno-orbital meningioma (SOM) make it hard to remove entirely, and recurrence and proptosis are the main reasons for reoperation. The authors report 20 cases of surgical treatment for recurrence of SOM, including surgical technique and symptom improvement. METHODS The clinical data and follow-up results of 20 cases of recurrent SOM at our institution from 2000 to 2017 were retrospectively analyzed. RESULTS All of the 20 patients with recurrence had received at least one operation before admission, with a mean age of 56 years and 70% female. The mean follow-up time was 36 months (1-72 months). All patients mainly showed symptoms such as proptosis and headache, and were found to be affected by supraorbital fissure during the operation. In 17 patients with recurrence, the affected sphenoid wing became tumor-like hyperplasia. Patients with extraocular muscle involvement have obvious protrusion and are often accompanied by diplopia. After surgical removal of the tumor, the symptoms of proptosis in 19 patients were significantly improved. During the follow-up, only 3 cases of proptosis recurred. After 15 patients underwent Simpson grade IV resection, 4 patients (27%) relapsed again. Five patients underwent Simpson III resection, and only 1 patient (20%) had tumor recurrence 18th months after surgery, and no proptosis recurred. CONCLUSIONS The complete surgical removal of recurrent SOM is practically impossible. The main direction of surgical treatment should be to improve the symptoms of proptosis.
Collapse
|
7
|
Hadi I, Biczok A, Terpolilli N, Thorsteinsdottir J, Forbrig R, Albert NL, Yanchovski P, Zollner B, Bodensohn R, Corradini S, Bartenstein P, Belka C, Tonn JC, Schichor C, Niyazi M. Multimodal therapy of cavernous sinus meningioma: Impact of surgery and 68Ga-DOTATATE PET-guided radiation therapy on tumor control and functional outcome. Neurooncol Adv 2021; 3:vdab114. [PMID: 34704034 PMCID: PMC8541706 DOI: 10.1093/noajnl/vdab114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
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 grade 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 was 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 9.2/10.8/4.3 ccm for A/B/C, P = .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 < .001). Optic nerve compression was more common in A (91.7%) and B (84.0%) than C (16.7%), P < .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.
Collapse
Affiliation(s)
- Indrawati Hadi
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Annamaria Biczok
- Department of Neurosurgery, University Hospital, LMU Munich, Munich, Germany
| | - Nicole Terpolilli
- Department of Neurosurgery, University Hospital, LMU Munich, Munich, Germany
| | | | - Robert Forbrig
- Department of Neuroradiology, University Hospital, LMU Munich, Munich, Germany
| | - Nathalie L Albert
- Department of Nuclear Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Petar Yanchovski
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Barbara Zollner
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Raphael Bodensohn
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Peter Bartenstein
- Department of Nuclear Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), partner site Munich, Munich, Germany
| | - Jörg-Christian Tonn
- Department of Neurosurgery, University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), partner site Munich, Munich, Germany
| | - Christian Schichor
- Department of Neurosurgery, University Hospital, LMU Munich, Munich, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), partner site Munich, Munich, Germany
| |
Collapse
|
8
|
Balasa A, Hurghis C, Tamas F, Chinezu R. Surgical Strategies and Clinical Outcome of Large to Giant Sphenoid Wing Meningiomas: A Case Series Study. Brain Sci 2020; 10:brainsci10120957. [PMID: 33317116 PMCID: PMC7764378 DOI: 10.3390/brainsci10120957] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 12/07/2020] [Accepted: 12/08/2020] [Indexed: 12/20/2022] Open
Abstract
Large to giant sphenoid wing meningiomas (SWMs) remain surgically challenging due to frequent vascular encasement and a tendency for tumoral invasion of the cavernous sinus and optic canal. We aimed to study the quality of resection, postoperative clinical evolution, and recurrence rate of large SWMs. This retrospective study enrolled 21 patients who underwent surgery between January 2014 and December 2019 for SWMs > 5 cm in diameter (average 6.3 cm). Tumor association with cerebral edema, extension into the cavernous sinus or optic canal, degree of encasement of the major intracranial arteries, and tumor resection grade were recorded. Cognitive decline was the most common symptom (65% of patients), followed by visual decline (52%). Infiltration of the cavernous sinus and optical canal were identified in five and six patients, respectively. Varying degrees of arterial encasement were seen. Gross total resection was achieved in 67% of patients. Long-term follow-up revealed improvement in 17 patients (81%), deterioration in two patients (9.5%), and one death (4.7%) directly related to the surgical procedure. Seven patients displayed postoperative tumor progression and two required reintervention 3 years post initial surgery. Tumor size, vascular encasement, and skull base invasion mean that, despite technological advancements, surgical results are dependent on surgical strategy and skill. Appropriate microsurgical techniques can adequately solve arterial encasement but tumor progression remains an issue.
Collapse
Affiliation(s)
- Adrian Balasa
- Department of Neurosurgery, George Emil Palade University of Medicine, Pharmacy, Science and Technology, 540142 Tîrgu Mureș, Romania; (A.B.); (C.H.); (F.T.)
- Department of Neurosurgery, Tîrgu Mureș Emergency Clinical County Hospital, 540136 Tîrgu Mureș, Romania
| | - Corina Hurghis
- Department of Neurosurgery, George Emil Palade University of Medicine, Pharmacy, Science and Technology, 540142 Tîrgu Mureș, Romania; (A.B.); (C.H.); (F.T.)
- Department of Neurosurgery, Tîrgu Mureș Emergency Clinical County Hospital, 540136 Tîrgu Mureș, Romania
| | - Flaviu Tamas
- Department of Neurosurgery, George Emil Palade University of Medicine, Pharmacy, Science and Technology, 540142 Tîrgu Mureș, Romania; (A.B.); (C.H.); (F.T.)
- Department of Neurosurgery, Tîrgu Mureș Emergency Clinical County Hospital, 540136 Tîrgu Mureș, Romania
| | - Rares Chinezu
- Department of Neurosurgery, George Emil Palade University of Medicine, Pharmacy, Science and Technology, 540142 Tîrgu Mureș, Romania; (A.B.); (C.H.); (F.T.)
- Department of Neurosurgery, Tîrgu Mureș Emergency Clinical County Hospital, 540136 Tîrgu Mureș, Romania
- Correspondence:
| |
Collapse
|
9
|
Raheja A, Couldwell WT. Cavernous Sinus Meningioma with Orbital Involvement: Algorithmic Decision-Making and Treatment Strategy. Skull Base Surg 2020; 81:348-356. [PMID: 33072476 DOI: 10.1055/s-0040-1715471] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Cavernous sinus meningioma (CSM) with orbital involvement presents a unique challenge to modern-day neurosurgeons. In the modern era of preventive medicine with enhanced screening tools, physicians encounter CSM more frequently. An indolent natural history, late clinical presentation, close proximity to vital neurovascular structures, poor tumor-to-normal tissue interface, and high risk of iatrogenic morbidity and mortality with aggressive resection add to the complexity of decision-making and optimal management of these lesions. The clinical dilemma of deciding whether to observe or intervene first for asymptomatic lesions remains an enigma in current practice. The concepts of management for CSM with orbital involvement have gradually evolved from radical resection to a more conservative surgical approach with maximal safe resection, with the specific goals of preserving function and reducing proptosis. This change in surgical attitude has enabled better long-term functional outcomes with conservative approaches as compared with functionally disabled outcomes resulting from the pursuit of anatomical cure from disease with radical resection. The advent of stereotactic radiosurgery as an adjunct tool to treat residual CSM has greatly shaped our resection principles and planning. Interdisciplinary collaboration for multimodality management is key to successful management of these difficult to treat lesions and tailor management as per individual's requirement.
Collapse
Affiliation(s)
- Amol Raheja
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, United States
| |
Collapse
|
10
|
Glenn CA, Tullos HJ, Sughrue ME. Natural history of intracranial meningiomas. HANDBOOK OF CLINICAL NEUROLOGY 2020; 169:205-227. [PMID: 32553291 DOI: 10.1016/b978-0-12-804280-9.00014-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
We know that the extent of resection is the greatest predictor of long-term survival. However, the potential tradeoff for gross total resection in difficult locations is diminished quality of life. Benign subtotally resected or small incidentally discovered meningiomas may be followed clinically especially in the elderly. In addition, radiosurgery plays a role in the treatment of meningiomas as a primary treatment modality, or as a salvage therapy. Decisions regarding management should be made with an understanding of the natural history and rate of growth. In this chapter we review the known meningioma epidemiology as well as the growth patterns of meningiomas based upon location.
Collapse
Affiliation(s)
- Chad A Glenn
- Department of Neurological Surgery, University of Oklahoma, Oklahoma City, OK, United States
| | - Hurtis J Tullos
- Department of Neurological Surgery, University of Oklahoma, Oklahoma City, OK, United States
| | - Michael E Sughrue
- Department of Neurosurgery, Prince of Wales Hospital, Randwick, NSW, Australia.
| |
Collapse
|
11
|
Abstract
Cavernous sinus meningioma (CSM) presents a management challenge to present-day neurosurgeons. Lack of adequate understanding of the natural history of these lesions, the early involvement of vital neurovascular structures, the absence of clear tissue planes with normal surrounding structures, and a high rate of aggressive surgery-related morbidity each pose management dilemmas for neurosurgeons. Over the past few decades, the enthusiasm of the neurosurgical community has shifted from aggressive microsurgical resection to maximal safe resection and institution of adjuvant radiotherapy, if necessary. This paradigm shift has ensured better functional outcome in treated patients. This chapter has been designed to discuss the current treatment algorithm and the importance of multimodality management for optimal outcome in patients with CSM. The technical aspects of this approach to management are presented, and the various treatment options are compared.
Collapse
Affiliation(s)
- Amol Raheja
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, United States
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, United States.
| |
Collapse
|
12
|
Brahimi Y, Antoni D, Srour R, Proust F, Thiery A, Wagner P, Noel G. Efficacy and Tolerance of Intensity Modulated Radiation Therapy for Skull Base Meningioma. Adv Radiat Oncol 2019; 4:587-595. [PMID: 31673652 PMCID: PMC6817551 DOI: 10.1016/j.adro.2019.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 07/06/2019] [Accepted: 07/11/2019] [Indexed: 11/29/2022] Open
Abstract
Purpose The purpose of this study was to evaluate the efficacy and tolerance of normofractionated stereotactic radiation therapy (RT) and intensity modulated RT with helical tomotherapy for skull base meningioma. Methods and Materials Between January 2009 and 2014, 46 patients with skull base meningioma were treated with normofractionated intensity modulated RT in stereotactic conditions (50%) or with helical tomotherapy (50%). Most of the lesions were localized in the cavernous sinus (59%). The mean planning target volume was 47.2 mL (range, 1.1-223 mL). Results After treatment, 5 lesions exhibited a partial response radiologically and 39 lesions were stable. At the time of treatment, 35 patients were symptomatic with a mean of 2 symptoms per patient. The most frequent symptoms were visual impairment (41%), cranial nerve dysfunction (20%), and headache (16%). The median follow-up time was 42 months (range, 10-76 months). After RT, 71% of patients exhibited an improvement of at least 1 symptom with a median interval of 15.6 months (range, 5.3-30.5 months). The most frequent improved symptoms were cranial nerve deficits (47%), visual impairment (45%), and headache (42%).The clinical response was correlated with the clinical target volume (CTV) margin (P = .06), extended clinical follow-up time (P = .004), and larger planning target volume (P = .05) by univariate analysis. Taking in account correlation factors, in the multivariate analysis, only CTV was a favorable significant factor of clinical improvement (P = .049; hazard ratio: 5 95%; confidence interval, 1.1-28). We observed 3 cases of trigeminal nerve dysfunction at 4.2, 5.7, and 24.6 months; 2 cases of visual disturbance at 10.1 and 24 months; 2 cases of neurocognitive disorders at 12.9 and 35.2 months; and 1 case of stroke at 20.3 months. Conclusions RT for skull base meningiomas is an effective and safe treatment, leading in most cases to clinical improvement. The addition of a CTV margin to meningioma volume improved the symptoms of patients.
Collapse
Affiliation(s)
- Youssef Brahimi
- University Radiation Oncology Department, Comprehensive Cancer Center Paul Strauss, Strasbourg, France
| | - Delphine Antoni
- University Radiation Oncology Department, Comprehensive Cancer Center Paul Strauss, Strasbourg, France.,Laboratory of Radiobiology, Federation of Translational Medicine, Strasbourg University, Strasbourg, France
| | - Robin Srour
- Neurosurgery Department, Hôpital Pasteur, Colmar, France
| | - François Proust
- Neurosurgery Department, University Hospital of Strasbourg, Strasbourg, France
| | - Alicia Thiery
- Epidemiology and Biostatistics Department, Comprehensive Cancer Center Paul Strauss, Strasbourg, France
| | - Pierre Wagner
- Radiology Department, Comprehensive Cancer Center Paul Strauss, Strasbourg, France
| | - Georges Noel
- University Radiation Oncology Department, Comprehensive Cancer Center Paul Strauss, Strasbourg, France.,Laboratory of Radiobiology, Federation of Translational Medicine, Strasbourg University, Strasbourg, France
| |
Collapse
|
13
|
Immunological and vascular characteristics in cavernous sinus meningioma. J Clin Neurosci 2019; 67:198-203. [PMID: 31213381 DOI: 10.1016/j.jocn.2019.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 06/10/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVES It is difficult to treat cavernous sinus (CS) meningiomas because of their complex vascular and neurological structures. Recently, immunotherapy has become an attractive therapeutic modality, but the role of tumor immune microenvironment is yet to be investigated for CS meningiomas. In the current study, these molecular and histopathological characteristics were examined in CS meningiomas. METHODS The present study used twenty-eight meningioma tissues arising in two different locations (8 CS and 20 convexity meningiomas). Immunohistochemical analyses were performed with CD3, CD4, CD8, Foxp3, CD163, PDGFR-β, VEGF receptors 1 & 2 (VEGFR-1, VEGFR-2), VEGF-A and HIF-1α. Quantitative polymerase chain reaction (qPCR) was performed to assess the expression of Foxp3, VEGF-A, CD163, VEGFRs-1 & 2 and HIF-1α. RESULTS The numbers of different tumor-infiltrating immune cells, such as immunosuppressive cells, were significantly lower in CS meningiomas compared with convexity meningiomas. Analysis of the vascular characteristics showed the vessels in the CS meningiomas were covered with PDGFR-β-positive pericytes and were negative or had only very low amounts of VEGFR-1 and VEGFR-2. However, most vessels in convexity meningiomas showed high VEGFRs expression and were not covered with pericytes. Immunohistochemical and qPCR analyses revealed that the expression of HIF-1α, VEGF-A and VEGFRs-1 & 2 was lower in CS meningiomas. CONCLUSION Fewer immunocompetent cells were observed in CS meningiomas compared with convexity meningiomas. Lower expression of VEGF-A, VEGFRs-1 and 2, and the vascular structure may contribute to this specific immune microenvironment.
Collapse
|
14
|
Brahimi Y, Antoni D, Srour R, Wagner P, Proust F, Thiery A, Labani A, Noël G. [Skull base meningioma: Clinical and radiological efficacy based on a quantitative volumetric analysis]. Cancer Radiother 2019; 23:290-295. [PMID: 31128988 DOI: 10.1016/j.canrad.2018.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 06/23/2018] [Accepted: 11/13/2018] [Indexed: 11/17/2022]
Abstract
PURPOSE To date, no correlation has been found between clinical and radiological efficacy after irradiation of skull base meningiomas. However, the evaluation of the radiological response was most often made by questionable methods that may have underestimated the radiological effectiveness of radiotherapy. The objective of this work is to verify this hypothesis by quantitative volumetric analysis. MATERIAL AND METHODS Data from 35 patients treated with either helical tomotherapy (45.7%) or fractionated stereotactic radiotherapy (54.3%) were retrospectively analysed. These were mainly women (94%) aged 59 (43-81) with lesions mainly of the cavernous sinus (60%). There was a median of 2 (1-4) symptoms and the main symptoms were visual impairment (39%), cranial nerve deficits (23.4%) and headaches (17.2%). RESULTS Median tumour volume decreased significantly (P<0.05) from 9.6mL (0.3-36.6) to 6.8mL (0.1-26.5) after median follow-up of 44 months (24-77). Sixty-three percent of patients had an improvement of at least one symptom. In univariate analysis, clinical efficacy (P<0.05), radiotherapy technique (P<0.05), tumor topography (P<0.05) and initial tumor volume (P<0.05) were predictive factors for radiological response. In multivariate analysis, only the inverse correlation between radiological response and initial tumor volume remained significant (ρ: -0.47 95% CI -3.2 to 5.7; P<0.05). CONCLUSION The quantitative volumetric monitoring demonstrates a major radiological efficiency of radiotherapy. However, no clear correlation between clinical and radiological efficacy was found.
Collapse
Affiliation(s)
- Y Brahimi
- University radiation oncology department, centre Paul-Strauss, 3, rue de la Porte-de-l'Hôpital, 67065 Strasbourg cedex, France
| | - D Antoni
- University radiation oncology department, centre Paul-Strauss, 3, rue de la Porte-de-l'Hôpital, 67065 Strasbourg cedex, France; Laboratory of radiobiology, EA 3430, Federation of translational medicine, Strasbourg (FMTS), Strasbourg university, 67000 Strasbourg, France
| | - R Srour
- Neurosurgery department, hôpital Pasteur, 39, avenue de la Liberté, 68000 Colmar, France
| | - P Wagner
- Department of radiology, centre Paul-Strauss, 3, rue de la Porte-de-l'Hôpital, 67065 Strasbourg cedex, France
| | - F Proust
- Neurosurgery department, CHU de Strasbourg, 1, rue Molière, 67000 Strasbourg, France
| | - A Thiery
- Epidemiology and biostatistics department, centre Paul-Strauss, 3, rue de la Porte-de-l'Hôpital, 67065 Strasbourg cedex, France
| | - A Labani
- Department of radiology, CHU de Strasbourg, 1, place de l'Hôpital, 67000 Strasbourg, France
| | - G Noël
- University radiation oncology department, centre Paul-Strauss, 3, rue de la Porte-de-l'Hôpital, 67065 Strasbourg cedex, France; Laboratory of radiobiology, EA 3430, Federation of translational medicine, Strasbourg (FMTS), Strasbourg university, 67000 Strasbourg, France.
| |
Collapse
|
15
|
Direct Transcavernous Sinus Approach for Endoscopic Endonasal Resection of Intracavernous Sinus Tumors. World Neurosurg 2019; 128:e478-e487. [PMID: 31048053 DOI: 10.1016/j.wneu.2019.04.182] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 04/20/2019] [Accepted: 04/22/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Because of its vascular supply and neurovascular contents, the cavernous sinus (CS) is a challenging area to dissect in the setting of skull base tumors with intracavernous extension or invasion. In the present study, we report the clinical outcomes of 14 patients with tumors with CS invasion that were surgically treated using a direct transcavernous sinus approach for endoscopic endonasal resection of their intracavernous sinus tumors. METHODS Fourteen patients had undergone surgery using a direct endoscopic endonasal transcavernous sinus approach. The pathologic entities included Knosp grade 3-4 pituitary adenomas (n = 8), meningioma (n = 3), squamous cell carcinoma (n = 2), and chondrosarcoma (n = 1). The indications, surgical technique, and outcomes are discussed. RESULTS Gross total resection was achieved in 11 patients (78.6%). All patients experienced resolution or improvement of symptoms. One patient experienced a transient oculomotor nerve palsy, which had resolved within 2 months postoperatively. No other complications occurred. For those tumors that had been grossly resected, no recurrence developed in any patient (mean follow-up, 40.4 ± 24.8 months; range 10-84). CONCLUSIONS Depending on the space created by intracavernous sinus tumors, use of the transanterior wall for the CS approach in endoscopic endonasal surgery could adequately treat most patients in our case series. This approach provided good visualization of the CS and can be used to treat tumors with favorable outcomes and a low incidence of complications in appropriately evaluated patients.
Collapse
|
16
|
Alzhrani G, Derrico N, Abou-Al-Shaar H, Couldwell WT. Management of Cavernous Sinus Meningioma Presenting With Cerebrovascular Insufficiency Secondary to Cavernous Carotid Artery Occlusion: Report of 2 Cases. Oper Neurosurg (Hagerstown) 2019; 16:503-513. [PMID: 29850864 DOI: 10.1093/ons/opy120] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 04/23/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Surgical removal of cavernous sinus meningiomas is challenging and associated with high morbidities as a result of the anatomic location and the surrounding neurovascular structures that are often invaded or encased by the tumor. Advances in radiotherapy techniques have led to the adoption of more conservative approaches in the management of cavernous sinus meningioma. Internal carotid artery encasement and invasion has been documented in these cases; however, ischemic presentation secondary to internal carotid artery stenosis or occlusion by meningioma in the region of the cavernous sinus is rare, with only few cases reported in the literature. OBJECTIVE To report our surgical technique and experience with bypass grafting for cavernous sinus meningiomas that invade or narrow the internal carotid artery. METHODS We report 2 patients who presented with signs and symptoms attributed to cavernous carotid artery occlusion secondary to cavernous sinus meningioma in the last 5 yr. Both patients were treated with flow augmentation without surgical intervention for the cavernous sinus meningioma. RESULTS In both cases, the clinical and radiological signs of cerebrovascular insufficiency improved markedly, and the patients' tumors are currently being monitored. CONCLUSION Although the cerebrovascular insufficiency in this subset of patients is attributed to the occlusion of the cavernous carotid artery caused by the tumor, we propose treating those patients with flow augmentation first with or without radiation therapy when there is a clear imaging feature suggestive of meningioma in the absence of significant cranial nerve deficit.
Collapse
Affiliation(s)
- Gmaan Alzhrani
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Nicholas Derrico
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Hussam Abou-Al-Shaar
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| |
Collapse
|
17
|
Gozal YM, Alzhrani G, Abou-Al-Shaar H, Azab MA, Walsh MT, Couldwell WT. Outcomes of decompressive surgery for cavernous sinus meningiomas: long-term follow-up in 50 patients. J Neurosurg 2019; 132:380-387. [PMID: 30771770 DOI: 10.3171/2018.10.jns181480] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 10/26/2018] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Cavernous sinus meningiomas are complex tumors that offer a perpetual challenge to skull base surgeons. The senior author has employed a management strategy for these lesions aimed at maximizing tumor control while minimizing neurological morbidity. This approach emphasizes combining "safe" tumor resection and direct decompression of the roof and lateral wall of the cavernous sinus as well as the optic nerve. Here, the authors review their experience with the application of this technique for the management of cavernous sinus meningiomas over the past 15 years. METHODS A retrospective analysis was performed for patients with cavernous sinus meningiomas treated over a 15-year period (2002-2017) with this approach. Patient outcomes, including cranial nerve function, tumor control, and surgical complications were recorded. RESULTS The authors identified 50 patients who underwent subtotal resection via frontotemporal craniotomy concurrently with decompression of the cavernous sinus and ipsilateral optic nerve. Of these, 25 (50%) underwent adjuvant radiation to the remaining tumor within the cavernous sinus. Patients most commonly presented with a cranial nerve (CN) palsy involving CN III-VI (70%), a visual deficit (62%), headaches (52%), or proptosis (44%). Thirty-five patients had cranial nerve deficits preoperatively. In 52% of these cases, the neuropathy improved postoperatively; it remained stable in 46%; and it worsened in only 2%. Similarly, 97% of preoperative visual deficits either improved or were stable postoperatively. Notably, 12 new cranial nerve deficits occurred postoperatively in 10 patients. Of these, half were transient and ultimately resolved. Finally, radiographic recurrence was noted in 5 patients (10%), with a median time to recurrence of 4.6 years. CONCLUSIONS The treatment of cavernous sinus meningiomas using surgical decompression with or without adjuvant radiation is an effective oncological strategy, achieving excellent tumor control rates with low risk of neurological morbidity.
Collapse
Affiliation(s)
- Yair M Gozal
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah; and
| | - Gmaan Alzhrani
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah; and
| | - Hussam Abou-Al-Shaar
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah; and
| | - Mohammed A Azab
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah; and
| | - Michael T Walsh
- 2Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - William T Couldwell
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah; and
| |
Collapse
|
18
|
Brahimi Y, Antoni D, Srour R, Proust F, Cebula H, Labani A, Noël G. [Base of the skull meningioma: Efficacy, clinical tolerance and radiological evaluation after radiotherapy]. Cancer Radiother 2018; 22:264-286. [PMID: 29773473 DOI: 10.1016/j.canrad.2017.09.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 09/15/2017] [Accepted: 09/20/2017] [Indexed: 11/29/2022]
Abstract
Skull base meningioma leads to functional disturbances, which can significantly alter the quality of life. The optimal management of these lesions, whose goals are neurological preservation and tumour local control, is not yet clearly established. It is widely recognized that the goal of a radical excision should be abandoned despite the advances in the field of microsurgery of skull base lesions. Although less morbid, partial tumour excision would be associated with increased risk of local tumour recurrence. Although discussed both exclusive and adjuvant have proven to be highly successful in terms of clinical improvement and local control. Various radiation techniques have demonstrated their efficacy in the management of this pathology. However, high rates of clinical improvement are in contrast with low rates of radiological improvement. The notion of clinical and radiological dissociation appeared. However, in most of these studies, the analysis of the radiological response could be subject of legitimate criticism. This work proposes to review the local control, the efficacy and the clinical tolerance and the radiological response of the various radiation techniques for the meningioma of the base of the skull and to demonstrate the interest of quantitative volumetric analyses in the follow-up of meningioma after radiotherapy.
Collapse
Affiliation(s)
- Y Brahimi
- Département universitaire de radiothérapie, centre Paul-Strauss, Unicancer, 3, rue de la Porte-de-l'Hôpital, 67065 Strasbourg cedex, France
| | - D Antoni
- Département universitaire de radiothérapie, centre Paul-Strauss, Unicancer, 3, rue de la Porte-de-l'Hôpital, 67065 Strasbourg cedex, France; Laboratoire de radiobiologie, UMR 7178 institut pluridisciplinaire Hubert-Curien (IPHC), université de Strasbourg, 67000 Strasbourg, France; CNRS, IPHC UMR 7178, 67000 Strasbourg, France
| | - R Srour
- Service de neurochirurgie, hôpital Pasteur, 39, avenue de la Liberté, 68024 Colmar cedex, France
| | - F Proust
- Service de neurochirurgie, hôpital universitaire de Strasbourg, 1, rue Molière, 67000 Strasbourg, France
| | - H Cebula
- Service de neurochirurgie, hôpital universitaire de Strasbourg, 1, rue Molière, 67000 Strasbourg, France
| | - A Labani
- Service de radiologie, hôpital universitaire de Strasbourg, 1, place de l'Hôpital, 67000 Strasbourg, France
| | - G Noël
- Département universitaire de radiothérapie, centre Paul-Strauss, Unicancer, 3, rue de la Porte-de-l'Hôpital, 67065 Strasbourg cedex, France; Laboratoire de radiobiologie, UMR 7178 institut pluridisciplinaire Hubert-Curien (IPHC), université de Strasbourg, 67000 Strasbourg, France; CNRS, IPHC UMR 7178, 67000 Strasbourg, France.
| |
Collapse
|
19
|
Koutourousiou M, Vaz Guimaraes Filho F, Fernandez-Miranda JC, Wang EW, Stefko ST, Snyderman CH, Gardner PA. Endoscopic Endonasal Surgery for Tumors of the Cavernous Sinus: A Series of 234 Patients. World Neurosurg 2017; 103:713-732. [PMID: 28450229 DOI: 10.1016/j.wneu.2017.04.096] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 04/13/2017] [Accepted: 04/15/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Cavernous sinus (CS) tumors often are considered inoperable. We present our experience with endoscopic endonasal surgery (EES) and compare the outcomes for different tumor. METHODS EES (medial or lateral approach) was used in 234 patients with CS tumors. The cohort included 175 (75%) pituitary adenomas and 59 (25%) nonadenomatous lesions. RESULTS Presenting symptoms were significantly different between the 2 groups, with cranial neuropathies occurring mainly in nonadenomas (P < 0.0001). The overall gross total tumor resection rate from the CS was 37.3% (37.1% in adenomas, 38.1% in non-adenomas). In total, preexisting cranial nerve (CN) dysfunction improved in 56.4% of the patients. After treatment completion (including radiation of residual tumor), 83.3% of acromegalic patients, 50% of prolactinomas and 33.3% of Cushing's disease, were in remission. Visual loss improved in 86.8% of adenomas and in 70.8% of nonadenomas. Intracavernous CN palsies improved in 77.3% of adenomas and 42.4% of nonadenomas. New permanent CN palsies occurred in 7 nonadenomas, which is significantly greater than in adenomas (P = 0.007). The leak rate of cerebrospinal fluid was 6.3% for adenomas and 11.9% for nonadenomas. Four patients suffered an internal carotid artery injury with no neurologic sequelae in 3 cases and 1 death (0.4%). CONCLUSIONS EES provides an easily accessible midline corridor to the CS with equivalent or superior results to transcranial approaches in the management of select tumors. Symptomatology due to CS invasion is more likely to improve in pituitary adenomas and the rate of surgical complications is greater in nonadenomas. Using a team approach, the overall mortality due to vascular injury is low.
Collapse
Affiliation(s)
- Maria Koutourousiou
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA; Department of Neurological Surgery, University of Louisville, Louisville, Kentucky, USA
| | | | - Juan C Fernandez-Miranda
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Eric W Wang
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Susan Tonya Stefko
- Department of Ophthalmology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Carl H Snyderman
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
| |
Collapse
|
20
|
Chabot JD, Gardner PA, Stefko ST, Zwagerman NT, Fernandez- Miranda JC. Lateral Orbitotomy Approach for Lesions Involving the Middle Fossa: A Retrospective Review of Thirteen Patients. Neurosurgery 2017; 80:309-322. [DOI: 10.1093/neuros/nyw045] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 11/11/2016] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND: Classically used for treatment of orbital lesions, the lateral orbitotomy with cantholysis can be combined with a temporal craniectomy for lesions involving the middle cranial fossa.
OBJECTIVE: To present a single-center experience with the lateral orbitotomy approach for lesions involving the middle fossa.
METHODS: Twenty-five patients underwent lateral orbitotomies from April 2012 to July 2015. Excluding patients with solely intraorbital pathologies, 13 patients’ clinical and radiographic records were retrospectively reviewed.
RESULTS: Signs/symptoms in the 13 patients (ages 28-81) included proptosis (69%), decreased visual acuity (31%), diplopia (54%), and afferent pupillary defect (69%). Pathologies were meningioma (8), esthesioneuroblastoma, lymphoma, chordoma, Ewing's sarcoma, and squamous cell carcinoma. Surgical goals were maximal safe resection in 8 patients, palliative debulking in 3 patients, and cavernous sinus biopsy in 2 patients. In 8 patients for whom maximal resection was the goal, 2 had gross total resection, while 6 had near-total resection. All patients (3) for whom palliation was the goal had symptomatic improvement. Both cavernous sinus biopsies obtained diagnostic tissue without complications. All patients with proptosis (n = 9) and diplopia (n = 7), and 2 of 4 patients with decreased visual acuity had improvement in their symptoms. No patient reported worsening of their symptoms. Mean follow-up was 12 mo (2-30 mo). Complications included oculorrhea (1), pseudomeningocele (2), transient ptosis (2), and forehead numbness (1).
CONCLUSION: The lateral orbitotomy is a promising approach for carefully selected lesions with involvement of both the lateral orbit and middle cranial fossa. It provides minimally invasive access for biopsy, decompression, or resection.
Collapse
Affiliation(s)
- Joseph D. Chabot
- Department of Neurosurgery, Univer-sity of Pittsburgh Medical Center, Pitts-burgh, Pennsylvania
| | - Paul A. Gardner
- Department of Neurosurgery, Univer-sity of Pittsburgh Medical Center, Pitts-burgh, Pennsylvania
| | - S. Tonya Stefko
- Department of Ophthalmology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Nathan T. Zwagerman
- Department of Neurosurgery, Univer-sity of Pittsburgh Medical Center, Pitts-burgh, Pennsylvania
| | | |
Collapse
|
21
|
Spheno-Orbital Meningiomas: A 16-Year Surgical Experience. World Neurosurg 2016; 99:369-380. [PMID: 28017748 DOI: 10.1016/j.wneu.2016.12.063] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 12/11/2016] [Accepted: 12/14/2016] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To examine the efficacy of spheno-orbital meningioma (SOM) resection aimed at symptomatic improvement, rather than gross total resection, followed by radiation therapy for recurrence. METHODS A retrospective review of all patients having undergone resection between 2000 and 2016 was performed. Demographics, operative details, postoperative outcomes, recurrence rates, and radiation treatment plans were analyzed. Statistical analysis was performed to assess for factors affecting recurrence (Fisher exact and Student t test), changes in exophthalmos index (EI) (Student t test), and progression-free survival (Kaplan-Meier and log rank). RESULTS Twenty-five patients were included; 92% of participants were women. Mean age was 51 years. World Health Organization grades were I (n = 21) and II (n = 4). Simpson grades were I (n = 14), II (n = 3), and IV (n = 8). Mean follow-up time was 44.8 months. Proptosis was significantly improved at the 3- to 6-month postoperative visit (mean ΔEI, 0.15; P < 0.05) and at last follow-up (mean ΔEI, 0.13; P < 0.05). Visual acuity was either improved or stable in 18 of 19 patients. There were 12 recurrences; mean time to recurrence was 21.8 months. Increased recurrence rate was significantly associated with younger age. Eight patients received fractionated radiation at time of recurrence. To date, all treated patients are progression free. CONCLUSIONS Among this cohort, surgery provided a lasting improvement in proptosis and improved or stabilized visual deficits. Surgery followed by radiation at recurrence provided excellent tumor control and lends credence to the growing body of literature demonstrating effective control of subtotally resected skull base meningiomas.
Collapse
|
22
|
Patrona A, Patel KS, Bander ED, Mehta A, Tsiouris AJ, Anand VK, Schwartz TH. Endoscopic endonasal surgery for nonadenomatous, nonmeningeal pathology involving the cavernous sinus. J Neurosurg 2016; 126:880-888. [PMID: 27128582 DOI: 10.3171/2015.8.jns15275] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Surgery within the cavernous sinus (CS) remains a controversial topic because of the delicate and complex anatomy. The risk also varies with tumor consistency. Softer tumors such as pituitary adenomas are more likely to be surgically treated, while firm tumors such as meningiomas are often treated with radiosurgery. However, a wide range of pathologies that can involve the CS are amenable to surgery. The authors describe and analyze their results using endonasal endoscopic "medial-to-lateral" approaches for nonadenomatous, nonmeningeal tumors, in relation to the degree of invasion within the CS. METHODS A prospectively acquired database of consecutive endoscopic approaches for tumors with verified intraoperative CS invasion was reviewed. Pituitary adenomas and meningiomas were excluded. Degree of invasion of the CS was classified using the Knosp-Steiner (KS) grading system as well as the percentage of cavernous carotid artery (CCA) encasement. Extent of resection of the entire tumor and of the CS component was assessed by independent neuroradiologists using volumetric measurements of the pre- and postoperative MRI studies. Demographic data and complications were noted. RESULTS Fifteen patients (mean age 51.1 years who received endoscopic surgery between 2007 and 2013 met the selection criteria. There were 11 malignant tumors, including chordoma, chondrosarcoma, hemangiopericytoma, lymphoma, and metastatic cancer, and 4 benign tumors, including 3 cavernous hemangiomas and 1 dermoid. All cases were discussed before treatment in a tumor board. Adjuvant treatment options included chemotherapy and radiotherapy. The mean pre- and postoperative tumor volumes were 12.74 ml and 3.86 ml. Gross-total resection (GTR; ie, resection greater than 95%) was the goal in 13 cases and was achieved in 6 patients (46%) while in addition 5 patients had a greater than 80% resection. Gross-total resection in the CS was accomplished in 55% of the tumors with KS Grades 1-2 and in 16.6% of the tumors with KS grades 3-4, respectively. Likewise, GTR was accomplished in 55% of the tumors with CCA encasement under 75% and in 14.3% of the lesions with CCA encasement over 75%, irrespective of tumor volume and underlying pathology. There were 18 preexisting cranial neuropathies involving cranial nerves III-VI, of which 9 fully resolved, 4 improved, and 3 remained unchanged; 2 of these worsened with tumor recurrence. Surgical complications included 1 transient new cranial nerve VI palsy associated with Horner's syndrome and 1 case of panhypopituitarism. There were no postoperative CSF leaks and no infections. The mean extended follow-up was 34.4 months. CONCLUSIONS Endonasal endoscopic approaches can play a role in the management of nonmeningeal, nonadenomatous tumors invading the CS, either through biopsy, debulking, or GTR. An advantage of this method is the relief of preexisting cranial neuropathies with low risk for new neurological deficit. Extent of resection within the CS varies with KS grade and degree of carotid encasement irrespective of the underlying pathology. The goals of surgery should be clearly established preoperatively in consultation with radiation and medical oncologists.
Collapse
Affiliation(s)
- Aikaterini Patrona
- Department of Neurosurgery, Medizinische Hochschule Brandenburg, Ruppiner Kliniken, Neuruppin, Germany; and
| | | | | | | | | | - Vijay K Anand
- Otolaryngology, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
| | | |
Collapse
|
23
|
Resection of the intracavernous sinus tumors using a purely endoscopic endonasal approach. J Craniofac Surg 2015; 25:295-302. [PMID: 24406594 DOI: 10.1097/scs.0000000000000428] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Resection of the cavernous sinus (CS) lesions has been a surgical challenge because the anatomy of the CS presents a high grade of complexity. This report describes the feasibility of the purely endoscopic endonasal approach to the CS. Twenty-five patients with intracavernous sinus tumors were treated with a purely endoscopic endonasal approach. The indications, efficacy, surgical techniques, and complications of this approach were discussed. Gross total resection occurred in 19 cases (76%), subtotal resection occurred in 2 cases (8%), and partial resection occurred in 4 cases (16%) including pituitary adenoma in 10 cases (total 70%; subtotal 10%; partial 20%), meningioma in 6 cases (total 66.6%; subtotal 16.7%, partial 16.7%), schwannoma in 5 cases (100%, total 5), malignant tumor in 4 cases (total 75%; subtotal 25%). All patients experienced resolution or improvement of symptoms. No patient experienced intraoperative complication and new neurological deficit. Only 1 case of postoperative cerebrospinal fluid leakage repaired via endoscopic endonasal approach on the 14th day after the surgery. The purely endoscopic endonasal approach to the CS in appropriately evaluated patients can be used to address a wide variety of benign and malignant tumor pathology with favorable outcomes and a low incidence of complications.
Collapse
|
24
|
Hao S, Tian R, Wu Z, Jia G, Wang L, Tang J, Xiao X, Liu B, Zhang L, Zhang J. Clinical characteristics and prognosis factors analysis for post-operative ptosis of sphenocavernous meningiomas: A single institution study. Clin Neurol Neurosurg 2015; 131:35-41. [DOI: 10.1016/j.clineuro.2015.01.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Revised: 01/21/2015] [Accepted: 01/29/2015] [Indexed: 10/24/2022]
|
25
|
Graillon T, Fuentes S, Metellus P, Adetchessi T, Gras R, Dufour H. Limited endoscopic transsphenoidal approach for cavernous sinus biopsy: Illustration of 3 cases and discussion. Neurochirurgie 2014; 60:42-7. [DOI: 10.1016/j.neuchi.2014.01.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Revised: 09/05/2013] [Accepted: 01/25/2014] [Indexed: 11/25/2022]
|
26
|
Di Maio S, Ramanathan D, Garcia-Lopez R, Rocha MH, Guerrero FP, Ferreira M, Sekhar LN. Evolution and future of skull base surgery: the paradigm of skull base meningiomas. World Neurosurg 2011; 78:260-75. [PMID: 22120278 DOI: 10.1016/j.wneu.2011.09.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Revised: 06/20/2011] [Accepted: 09/01/2011] [Indexed: 10/15/2022]
Abstract
BACKGROUND Skull base meningiomas represent the paradigm for the evolution of skull base surgery within the past 50 years into a distinct neurosurgical subspecialty. METHODS From 2005 to 2011, 117 patients with cranial base meningiomas underwent surgical resection. Extent of resection, histologic grade, complications, functional status, and recurrence-free and overall survival data are presented. RESULTS The summary rate of gross total resection was 53.0%. The surgical complication and mortality rates were 17.9% and 0.9%, respectively. Five-year recurrence-free survival was 88.0% for grade I meningiomas. A total of 90.3% of patients had a Karnofsky performance score ≥ 80 at last follow-up. CONCLUSIONS A large contemporary series of skull base meningiomas is presented. In addition, the evolution of surgical approaches to skull base meningiomas is reviewed, together with the current issues regarding radiation therapy, management of cavernous sinus tumor, oncologic management of atypical and malignant subtypes, molecular genetics, and future therapeutic options.
Collapse
Affiliation(s)
- Salvatore Di Maio
- Department of Neurological Surgery, University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | | | | | | | | | | | | |
Collapse
|
27
|
Taussky P, Kalra R, Coppens J, Mohebali J, Jensen R, Couldwell WT. Endocrinological outcome after pituitary transposition (hypophysopexy) and adjuvant radiotherapy for tumors involving the cavernous sinus. J Neurosurg 2011; 115:55-62. [DOI: 10.3171/2011.2.jns10566] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Stereotactic radiosurgery and fractionated stereotactic radiotherapy are commonly used in the treatment of residual or recurrent benign tumors of the skull base and cavernous sinus. A major risk associated with radiosurgical or radiotherapy treatment of residual or recurrent tumors adjacent to normal functional pituitary gland is radiation of the pituitary, which frequently leads to the development of hypopituitarism. The authors have used a technique of pituitary transposition to reduce the radiation dose to the normal pituitary gland in cases of planned radiosurgical treatment of residual tumor within the cavernous sinus. Here, the authors analyze the long-term endocrinological outcomes in patients with residual and recurrent tumors who undergo hypophysopexy and adjuvant radiosurgical or conformal fractionated radiotherapy treatment.
Methods
Pituitary transposition involves placement of a fat graft between the normal pituitary gland and residual tumor in the cavernous sinus. A sellar exploration for tumor resection is performed, the pituitary gland is transposed from the region of the cavernous sinus, and the graft is interposed between the pituitary gland and the residual tumor. The residual tumor may then be treated with stereotactic radiosurgery or conformal fractionated radiation therapy. The authors evaluated endocrinological outcome, safety of the procedure, and postoperative complications in patients who underwent this procedure during a 7-year period.
Results
Hypophysopexy has been used in 34 patients with nonfunctioning pituitary adenomas (19), functional pituitary adenomas (8), chordomas (2), meningiomas (2), chondrosarcoma (1), hemangiopericytoma (1), or hemangioma (1) involving the sella and cavernous sinus. Follow-up (radiographic and endocrinological) has been performed yearly in all patients. Two patients experienced postoperative endocrine deficits before radiosurgery (1 transient), but none of the patients developed new hypopituitarism during the median 4-year follow-up (range 1–8 years) after radiosurgery or fractionated stereotactic radiotherapy.
Conclusions
The increased distance between the normal pituitary gland and the residual tumor facilitates treatment of the tumor with radiosurgery or radiotherapy and effectively reduces the incidence of radiation injury to the normal pituitary gland when compared with historical controls.
Collapse
|
28
|
Chen CM, Huang APH, Kuo LT, Tu YK. Contemporary surgical outcome for skull base meningiomas. Neurosurg Rev 2011; 34:281-96; discussion 296. [PMID: 21614426 DOI: 10.1007/s10143-011-0321-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Revised: 02/03/2011] [Accepted: 03/06/2011] [Indexed: 11/25/2022]
Abstract
Although surgical excision of meningioma and its dural base is the most common primary management, skull base meningiomas are quite different, and contemporary management usually consists of multimodal treatment with the aim of achieving the best possible functional outcome and quality of life (QOL) for these patients. As surgery plays an important role in the treatment of skull base meningiomas, it is crucial for neurosurgeons to appreciate the surgical outcome and QOL after meningioma surgery. Outcome is usually measured for meningiomas in terms of morbidity, mortality, time to recurrence, and QOL. The extent of resection, tumor grade, proliferative markers, and tumor location are significant factors in predicting the surgical outcome. Therefore, we address each of these factors in detail in this review. Advances in recent decades in microsurgical techniques, neuroimaging modalities, neuroanesthesia, and perioperative intensive care have substantially improved the surgical outcome; therefore, most surgical outcomes discussed in this review are cited from contemporary literature (2000 to the present) in order to depict the surgical outcome of contemporary microsurgery.
Collapse
Affiliation(s)
- Chien-Min Chen
- Division of Neurosurgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan.
| | | | | | | |
Collapse
|
29
|
Long-term outcomes of stereotactic radiosurgery for treatment of cavernous sinus meningiomas. Int J Radiat Oncol Biol Phys 2010; 81:1436-41. [PMID: 20971572 DOI: 10.1016/j.ijrobp.2010.07.2002] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Revised: 07/16/2010] [Accepted: 07/29/2010] [Indexed: 11/23/2022]
Abstract
PURPOSE Patients with cavernous sinus meningiomas (CSM) have an elevated risk of surgical morbidity and mortality. Recurrence is often observed after partial resection. Stereotactic radiosurgery (SRS), either alone or combined with surgery, represents an important advance in CSM management, but long-term results are lacking. METHODS AND MATERIALS A total of 88 CSM patients, treated from January 1991 to December 2005, were retrospectively reviewed. The mean follow-up was 86.8 months (range, 17.1-179.4 months). Among the patients, 22 were followed for more than 10 years. There was a female predominance (84.1%). The age varied from 16 to 90 years (mean, 51.6). In all, 47 patients (53.4%) received SRS alone, and 41 patients (46.6%) had undergone surgery before SRS. A dose of 14 Gy was prescribed to isodose curves from 50% to 90%. In 25 patients (28.4%), as a result of the proximity to organs at risk, the prescribed dose did not completely cover the target. RESULTS After SRS, 65 (73.8%) patients presented with tumor volume reduction; 14 (15.9%) remained stable, and 9 (10.2%) had tumor progression. The progression-free survival was 92.5% at 5 years, and 82.5% at 10 years. Age, sex, maximal diameter of the treated tumor, previous surgery, and complete target coverage did not show significant associations with prognosis. Among the 88 treated patients, 17 experienced morbidity that was related to SRS, and 6 of these patients spontaneously recovered. CONCLUSIONS SRS is an effective and safe treatment for CSM, feasible either in the primary or the postsurgical setting. Incomplete coverage of the target did not worsen outcomes. More than 80% of the patients remained free of disease progression during long-term follow-up.
Collapse
|