Aggressive Surgery and Focal Radiation in the Management of Meningiomas of the Skull Base: Preservation of Function with Maintenance of Local Control

Pm, Black; At, Villavicencio; Rhouddou, C; Js, Loeffler

doi:10.1007/s007010170060

Cited by 68 publications

(31 citation statements)

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“…This is in part due to the concurrent rise of Gamma Knife radiosurgery (GKRS) as an acceptable treatment modality for newly diagnosed, recurrent, or progressive meningiomas within the posterior fossa, with large series demonstrating excellent tumor control rates and minimal adverse effects. [2][3][4]8,12,20,25 In the present study, we review the experience of a single surgeon over the past 24 years in the treatment of meningiomas of the CPA treated with GKRS, surgery, or a combination. We use a treatment approach in which GKRS is the first treatment option for tumors smaller than 2.5 cm, with the option of aggressive resection using facial nerve-sparing microsurgical techniques for tumors 2.5 cm or larger with adjuvant GKRS for recurrent disease or progressive residual.…”

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confidence: 99%

Efficacy and outcomes of facial nerve–sparing treatment approach to cerebellopontine angle meningiomas

D’Amico¹,

Banu²,

Petridis³

et al. 2017

Journal of Neurosurgery

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ABBREVIATIONS CN = cranial nerve; CPA = cerebellopontine angle; EMG = electromyography; EOR = extent of resection; GKRS = Gamma Knife radiosurgery; GTR = gross-total resection; IAC = internal auditory canal; STR = subtotal resection; TTP = time to progression. SUBMITTED August 3, 2016 OBJECTIVE Advanced microsurgical techniques contribute to reduced morbidity and improved surgical management of meningiomas arising within the cerebellopontine angle (CPA). However, the goal of surgery has evolved to preserve the quality of the patient's life, even if it means leaving residual tumor. Concurrently, Gamma Knife radiosurgery (GKRS) has become an acceptable and effective treatment modality for newly diagnosed, recurrent, or progressive meningiomas of the CPA. The authors review their institutional experience with CPA meningiomas treated with GKRS, surgery, or a combination of surgery and GKRS. They specifically focus on rates of facial nerve preservation and characterize specific anatomical features of tumor location with respect to the internal auditory canal (IAC). METHODS Medical records of 76 patients with radiographic evidence or a postoperative diagnosis of CPA meningioma, treated by a single surgeon between 1992 and 2016, were retrospectively reviewed. Patients with CPA meningiomas smaller than 2.5 cm in greatest dimension were treated with GKRS, while patients with tumors 2.5 cm or larger underwent facial nerve-sparing microsurgical resection where appropriate. Various patient, clinical, and tumor data were gathered. Anatomical features of the tumor origin as seen on preoperative imaging confirmed by intraoperative investigation were evaluated for prognostic significance. Facial nerve preservation rates were evaluated. RESULTS According to our treatment paradigm, 51 (67.1%) patients underwent microsurgical resection and 25 (32.9%) patients underwent GKRS. Gross-total resection (GTR) was achieved in 34 (66.7%) patients, and subtotal resection (STR) in 17 (33.3%) patients. Tumors recurred in 12 (23.5%) patients initially treated surgically, requiring additional surgery and/or GKRS. Facial nerve function was unchanged or improved in 68 (89.5%) patients. Worsening facial nerve function occurred in 8 (10.5%) patients, all of whom had undergone microsurgical resection. Upfront treatment with GKRS for CPA meningiomas smaller than 2.5 cm was associated with preservation of facial nerve function in all patients over a median follow-up of 46 months, regardless of IAC invasion and tumor origin. Anatomical origin was associated with extent of resection but did not correlate with postoperative facial nerve function. Tumor size, extent of resection, and the presence of an arachnoid plane separating the tumor and the contents of the IAC were associated with postoperative facial nerve outcomes. CONCLUSIONS CPA meningiomas remain challenging lesions to treat, given their proximity to critical neurovascular structures. GKRS is a safe and effective option for managing CPA meningiomas smaller than 2.5 cm without associated mass ef...

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confidence: 99%

Efficacy and outcomes of facial nerve–sparing treatment approach to cerebellopontine angle meningiomas

D’Amico¹,

Banu²,

Petridis³

et al. 2017

Journal of Neurosurgery

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“…Gross-total resection rates reported in the literature for posterior fossa meningiomas vary significantly, from 40% to 96%, and resections are often associated with significant morbidity, mortality, and recurrence. [1][2][3][4][5]7,[9][10][11][12][15][16][17][20][21][22]24,27,28,[31][32][33]36,38,[41][42][43][45][46][47][48]51,54,56 Extent of resection and morbidity rates vary by location of the tumor in the posterior fossa. For instance, in a recent study, morbidity following resection of petroclival meningiomas and cerebellopontine angle (CPA) meningiomas varied from 20.3% to 47% and 10.4% to 35.7%, respectively.…”

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confidence: 99%

“…5 Others have advocated for aggressive maximal resection of meningiomas at first presentation with the use of radiosurgery to treat recurrent or residual meningiomas. 8,11,26,60 Stereotactic radiosurgery (SRS) has become an acceptable treatment option for recurrent/residual meningiomas as well as an upfront option.…”

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confidence: 99%

Gamma Knife radiosurgery for posterior fossa meningiomas: a multicenter study

Sheehan

Starke

Kano

et al. 2015

JNS

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abbreviatioNs CI = confidence interval; CN = cranial nerve; CPA = cerebellopontine angle; GKRS = Gamma Knife radiosurgery; HR = hazard ratio; OR = odds ratio; SRS = stereotactic radiosurgery. obJect Posterior fossa meningiomas represent a common yet challenging clinical entity. They are often associated with neurovascular structures and adjacent to the brainstem. Resection can be undertaken for posterior fossa meningiomas, but residual or recurrent tumor is frequent. Stereotactic radiosurgery (SRS) has been used to treat meningiomas, and this study evaluates the outcome of this approach for those located in the posterior fossa.methods At 7 medical centers participating in the North American Gamma Knife Consortium, 675 patients undergoing SRS for a posterior fossa meningioma were identified, and clinical and radiological data were obtained for these cases. Females outnumbered males at a ratio of 3.8 to 1, and the median patient age was 57.6 years (range 12-89 years). Prior resection was performed in 43.3% of the patient sample. The mean tumor volume was 6.5 cm 3 , and a median margin dose of 13.6 Gy (range 8-40 Gy) was delivered to the tumor.results At a mean follow-up of 60.1 months, tumor control was achieved in 91.2% of cases. Actuarial tumor control was 95%, 92%, and 81% at 3, 5, and 10 years after radiosurgery. Factors predictive of tumor progression included age greater than 65 years (hazard ratio [HR] 2.36, 95% CI 1.30-4.29, p = 0.005), prior history of radiotherapy (HR 5.19, 95% CI 1.69-15.94, p = 0.004), and increasing tumor volume (HR 1.05, 95% CI 1.01-1.08, p = 0.005). Clinical stability or improvement was achieved in 92.3% of patients. Increasing tumor volume (odds ratio [OR] 1.06, 95% CI 1.01-1.10, p = 0.009) and clival, petrous, or cerebellopontine angle location as compared with petroclival, tentorial, and foramen magnum location (OR 1.95, 95% CI 1.05-3.65, p = 0.036) were predictive of neurological decline after radiosurgery. After radiosurgery, ventriculoperitoneal shunt placement, resection, and radiation therapy were performed in 1.6%, 3.6%, and 1.5%, respectively.coNclusioNs Stereotactic radiosurgery affords a high rate of tumor control and neurological preservation for patients with posterior fossa meningiomas. Those with a smaller tumor volume and no prior radiation therapy were more likely to have a favorable response after radiosurgery. Rarely, additional procedures may be required for hydrocephalus or tumor progression.

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“…Kayama 12 reported that the surgical strategy of using adjuvant gamma knife radiosurgery improved the treatment outcomes of patients with petrouscavernous meningiomas. Black et al 1 also reported treatment results of patients with skull-based meningiomas that improved with the combination of surgery and radiosurgery, showing a 0% rate of operative mortality and 7% rate of operative morbidity. Parasellar meningiomas, especially cavernous sinus meningiomas, can be treated less aggressively surgically when using combination radiosurgery.…”

Section: Discussionmentioning

confidence: 92%

Adjuvant gamma knife radiosurgery after meningioma resection

Iwai

Yamanaka

Morikawa

2004

Journal of Clinical Neuroscience

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Aggressive Surgery and Focal Radiation in the Management of Meningiomas of the Skull Base: Preservation of Function with Maintenance of Local Control

Abstract: These results demonstrate that skull base meningiomas which require treatment can be managed with a combination of aggressive surgery and conformal radiation with an acceptable functional status in 99% of cases.

Cited by 68 publications

References 42 publications

Efficacy and outcomes of facial nerve–sparing treatment approach to cerebellopontine angle meningiomas

Efficacy and outcomes of facial nerve–sparing treatment approach to cerebellopontine angle meningiomas

Gamma Knife radiosurgery for posterior fossa meningiomas: a multicenter study

Adjuvant gamma knife radiosurgery after meningioma resection

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