Prognostic variables in surgery for skull base meningiomas

Immunohistochemical Expression of Ki-67, Dopamine D1 and Dopamine D2 Receptors in Meningiomas in a Tertiary Institution in Mexico

Objectives Meningiomas (MNGs) are the most common intracranial tumors found in the adult population. While most intracranial MNGs may be surgically removed, a subset of patients remains ineligible for conventional treatment. This is either because of a lack of surgical access or due to atypical, anaplastic or invasive characteristics of the tumors. These patients may benefit from targeted therapies that focus on cell receptor expression. The aim of this study was to assess dopamine receptor (DR) and Ki-67 expression in the MGNs of patients treated with surgery in the Instituto Nacional de Neurología y Neurocirugía, Mexico. Materials and methods This study analyzed 23 patients with confirmed MNG diagnoses (10 female and 13 male (mean age: 44.5 years)) who had undergone surgical resection between 2010 and 2014 at our institution. In the collected samples, we performed analyses for Ki-67, Dopamine 1 and Dopamine 2 receptors' expression. Results For the markers Ki-67, DR-D1 and DR-D2, the mean percentual expressions were 18.9%, 23.02% and 8.33%. No significant correlation was found between the expressions of these receptors and the studied MNG characteristics. The expression index of Ki-67 showed a significant relation with mean age (p = 0.03) and prolactin levels (p = 0.02). Conclusions Samples showed varied expressions of the studied receptors. Despite the difference in expressions between the markers, more studies are needed to confirm the findings. In contrast to previous studies, we could not find any relationship between D2-R and tumor characteristics.

Long-term health-related quality of life and neurocognitive functioning after treatment in skull base meningioma patients

OBJECTIVE

Patients with skull base meningioma (SBM) often require complex surgery around critical neurovascular structures, placing them at high risk of poor health-related quality of life (HRQOL) and possibly neurocognitive dysfunction. As the survival of meningioma patients is near normal, long-term neurocognitive and HRQOL outcomes are important to evaluate, including evaluation of the impact of specific tumor location and treatment modalities on these outcomes.

METHODS

In this multicenter cross-sectional study including patients 5 years or more after their last tumor intervention, Short-Form Health Survey (SF-36) and European Organisation for Research and Treatment of Cancer (EORTC) QLQ-BN20 questionnaires were used to assess generic and disease-specific HRQOL. Neurocognitive functioning was assessed with standardized neuropsychological assessment. SBM patient assessments were compared with those of 1) informal caregivers of SBM patients who served as controls and 2) convexity meningioma patients. In addition, the authors compared anterior/middle SBM patients with posterior SBM patients and anterior/middle and posterior SBM patients separately with controls. Multivariable and propensity score regression analyses were performed to correct for possible confounders.

RESULTS

Patients with SBM (n = 89) with a median follow-up of 9 years after the last intervention did not significantly differ from controls (n = 65) or convexity meningioma patients (n = 84) on generic HRQOL assessment. Statistically significantly but not clinically relevantly better disease-specific HRQOL was found for SBM patients compared with convexity meningioma patients. Anterior/middle SBM patients (n = 62) had significantly and clinically relevantly better HRQOL in SF-36 and EORTC QLQ-BN20 scores than posterior SBM patients (n = 27): physical role functioning (corrected difference 17.1, 95% CI 0.2-34.0), motor dysfunction (-10.1, 95% CI -17.5 to -2.7), communication deficit (-14.2, 95% CI -22.7 to -5.6), and weakness in both legs (-10.1, 95% CI -18.8 to -1.5). SBM patients whose primary treatment was radiotherapy had lower HRQOL scores compared with SBM patients who underwent surgery on two domains: bodily pain (-33.0, 95% CI -55.2 to -10.9) and vitality (-18.9. 95% CI -33.7 to -4.1). Tumor location and treatment modality did not result in significant differences in neurocognitive functioning, although 44% of SBM patients had deficits in at least one domain.

CONCLUSIONS

In the long term, SBM patients do not experience significantly more sequelae in HRQOL and neurocognitive functioning than do controls or patients with convexity meningioma. Patients with posterior SBM had poorer HRQOL than anterior/middle SBM patients, and primary treatment with radiotherapy was associated with worse HRQOL. Neurocognitive functioning was not affected by tumor location or treatment modality.

Effects of Surgery and Radiotherapy on Recurrent Skull Base Meningiomas: Clinical and Biological Analyses

We reviewed the medical records of 392 patients who underwent initial surgery for skull base meningiomas between 1983 and 2008. Among them, 32 (8.2%) showed tumor recurrence. Risk factors for recurrence were analyzed clinically and biologically. Recurrent cases were treated with radiotherapy, surgery, or both. In reoperation cases, pathological and biological changes were analyzed and compared between groups with or without radiotherapy. The recurrence rate was statistically high in cases of partial tumor removal and in patients with tumor in the cavernous sinus, tumors with histological WHO (World Health Organization) grade ≥ II or MIB-1 index > 3. The local control rate of postoperative radiotherapy for recurrent cases was 66.7%. Malignant transformation and MIB-1 index elevation was observed more frequently in patients who underwent reoperation after radiotherapy than in the reoperation-only group. Risk factors for recurrence of skull base meningiomas are as follows: (1) partial tumor removal, (2) tumor in the cavernous sinus, (3) histological WHO grade ≥ II, or (4) MIB-1 index > 3. Postoperative radiotherapy might be effective for tumor recurrence. However, the indications for radiotherapy should be carefully considered because postsurgical radiotherapy may increase biological activity, inducing malignant transformation.

Common Histologically Benign Tumors of the Brain

PURPOSE OF REVIEW

As a group, benign tumors account for the majority of primary neoplasms affecting the central nervous system (CNS). This article reviews the epidemiology, clinical presentation, neuroimaging features, and management of the most common of these tumors: meningiomas, schwannomas, and pituitary adenomas.

RECENT FINDINGS

Awareness of the most common nonmalignant tumors of the CNS and their management guidelines is important as many of these tumors are managed conservatively, with neurologists playing a primary role in both surveillance and symptom management. Knowledge of the varied neurologic consequences of these tumors allows optimizing interventions that improve quality of life in people living with these tumors without incurring treatment-related complications. Awareness of the clinical features that require surgery, radiation therapy, or chemotherapy is imperative. Finally, important discoveries in both germline and somatic mutations underlying some of these lesions have contributed to the launch of several novel drug trials for these tumors.

SUMMARY

As a group, nonmalignant neoplasms are the most common neoplasms affecting the CNS in adults. Because of their unique neuroanatomic location or containment within the bony skull, these histologically benign lesions can cause significant neurologic morbidity. Management with a multidisciplinary team that includes neurologists, neuro-oncologists, radiologists, neurosurgeons, radiation oncologists, otolaryngologists, pathologists, neuropsychologists, physiatrists, and others is necessary for the optimal management of these lesions.

Posterior cranial fossa meningiomas

This study evaluated the outcomes, complications, and recurrence rates of posterior cranial fossa meningiomas. We retrospectively reviewed our surgical experience with 64 posterior cranial fossa meningiomas. Mean age was 56 years with a female preponderance (67.2%). Headache was the most common symptom. Retrosigmoid approach was the commonest surgical procedure (23.4%). The incidence of cranial nerve related complications was 28%. Postoperatively facial nerve weakness was observed in 11%. The incidence of cerebrospinal fluid leak was 4.6%. Gross total resection was achieved in 37 patients (58%). Sixteen patients (25%) with residual tumors underwent Gamma knife radiosurgery. Recurrence or tumor progression was observed in 12 patients (18.7%). Operative mortality was 3.1%. At their last follow-up, 93% of the cases achieved Glasgow Outcome Scale scores 4 or 5. Total excision is the ideal goal which can be achieved with meningiomas located in certain location, such as lateral convexity, but for other posterior fossa meningiomas the close proximity of critical structures is a major obstacle in achieving this goal. In practicality, a balance between good functional outcome and extent of resection is important for posterior cranial fossa meningiomas in proximity to critical structures.

Recurrence and outcome in skull base meningiomas: do they differ from other intracranial meningiomas?

BACKGROUND AND OBJECTIVES

Meningiomas have diverse presentations and the skull base harbors the most difficult of them to operate upon. The objective of this study was to learn whether the recurrence and outcome of these tumors may differ based on their location.

DESIGN

Consecutive admissions with intracranial meningiomas between 1999 and 2004 were considered according to their location, WHO grade, recurrence, and outcome following treatment.

RESULTS

There were 83 skull base meningiomas and 86 at other locations. In 22 cases of skull base tumors there was recurrence (26.5%), while 15% (13) of the other group showed recurrence. There was no statistically significant difference in the outcome between the two groups; though skull base lesions had a better outcome based upon a raw count. Only 5.1% of skull base meningiomas in comparison to 10.6% of non-skull base meningiomas had death or significant morbidity. Increasing age was associated with poor outcome (p < 0.001) while recurrence was a function of skull base location (p < 0.03) on logistic regression analysis.

CONCLUSION

Skull base meningiomas can be operated upon with good outcome, which is comparable to the convexity meningiomas. Except for the increasing age, skull base location does not contribute to increased mortality or morbidity.

Predicting postoperative hydrocephalus in 227 patients with skull base meningioma

Object

Some patients develop communicating hydrocephalus after meningioma surgery, and this can develop into a serious clinical condition. However, this has rarely been addressed in the literature. Therefore, the authors sought to determine predictive patient variables for the occurrence of postoperative hydrocephalus following skull base meningioma surgery.

Methods

For this purpose, the authors retrospectively analyzed all patients who underwent resection of intracranial meningiomas between 1998 and 2009 at the Department of Neurosurgery, University Hospital Zurich, Switzerland. Of 594 patients with meningioma, 227 (38%) had a lesion located at the skull base, and thus were included for analysis. The following patient variables were examined: demographic data (age and sex); tumor number (solitary vs multiple); tumor side and localization within the skull base region (anterior, medial, posterior); infiltration of the cavernous sinus; compression of the optic channel/optic nerve; tumor volume; preoperative embolization (yes/no); duration of surgery; Simpson grade of resection; histopathological features (WHO grade); number of surgeries (single vs multiple); preoperative embolization; duration of hospital stay; tumor recurrence; use of an artificial dural substitute; postoperative infection rate; and clinical outcome (Glasgow Outcome Scale score at discharge and at 3 months, and vital status at last follow-up). Hierarchical clustering, factor analysis, and stepwise regression models revealed a ranking list for the top predictive variables for the occurrence of postoperative hydrocephalus.

Results

A total of 35 patients (5.9%) of the cohort of 594 developed communicating postoperative hydrocephalus, with no patient manifesting obstructive hydrocephalus. Of these 35 patients, 18 had a meningioma located at the skull base (18 [7.9%] of 227), in contrast to 17 patients with meningiomas in other locations (17 [4.6%] of 367). The following patient variables correlated with the occurrence of hydrocephalus, as defined by factor analysis: age, duration of surgery, duration of hospital stay, tumor volume, postoperative infection, and preoperative embolization. A stepwise regression analysis of the latter variables identified 2 variables as significantly predictive: age (p = 0.0012) and duration of surgery (p = 0.0013).

Conclusions

In this study, the incidence of communicating postoperative hydrocephalus was almost twice as high in patients with skull base lesions as in patients with meningiomas in other locations. Patient age, duration of surgery, duration of hospital stay, tumor volume, postoperative infection, and preoperative embolization were associated with the occurrence of hydrocephalus. In the statistical prediction model, patient age and duration of surgery were the most significant predictors of postoperative hydrocephalus after skull base meningioma surgery.

Petroclival meningiomas: study on outcomes, complications and recurrence rates

OBJECT

Petroclival meningiomas are notoriously difficult lesions to manage surgically, given the critical neurovascular structures that are intimately associated with the tumors. In this paper, the authors' aim was to review their series of patients with petroclival meningiomas who underwent surgical treatment; emphasis was placed on evaluating modes of presentation, postoperative neurological outcome, complications, and recurrence rates.

METHODS

Fifty patients underwent surgical treatment for petroclival meningiomas. The majority of the patients were women (72%). The authors retrospectively reviewed the patients' medical records, imaging studies, and pathology reports to analyze presentation, surgical approach, neurological outcomes, complications, and recurrence rates.

RESULTS

Headache was the most common presentation (58%). The most commonly used approach was the transpetrous approach (in 16 patients), followed by the orbitozygomatic approach (in 13). Gross-total resection was performed in 14 patients (28%), and in the remaining patients there was residual tumor (72%). Eighteen patients with tumor remnants were treated with Gamma Knife surgery. New postoperative cranial neuropathies were noted in 22 patients (44%). The most common cranial nerve (CN) deficit following surgery was CN III dysfunction (in 11 patients) and facial weakness (in 10). In 9 patients, the CN dysfunction was transient (41%), and 7 patients had permanent dysfunction (32%). Eight patients developed hydrocephalus and all required placement of a ventriculoperitoneal shunt. A CSF leak was noted in only 2 patients (4%), and wound dehiscence was noted in 1. The CSF leaks and the wound dehiscence occurred in patients who were undergoing reoperations. Adequate radiographic follow-up (minimum 6 months) was available for 31 patients (62%). The mean follow-up was 22.1 months. In 6 patients, tumor progression or recurrences were noted. The median time to recurrence was 84 months. At the time of discharge from the hospital, 92% of the patients had good outcomes (Glasgow Outcome Scale Scores 4 and 5). Three patients died of causes not directly related to the surgery.

CONCLUSIONS

Petroclival meningiomas still pose a formidable challenge to neurosurgeons. In their series, the authors used multiple skull base approaches and careful microneurosurgical technique to achieve a good functional outcome (Glasgow Outcome Scale Score 4 or 5) in 92% of patients, although the extent of gross-total resection was only 28%. The authors' primary surgical goal was to achieve maximal tumor resection while maintaining or improving neurological function. The authors favor the treatment of residual tumor or recurrent tumor with stereotactic radiosurgery.