Complete Versus Incomplete Surgical Resection in Intramedullary Ependymomas: A Systematic Review and Meta-analysis

Abstract

Study Design: Systematic review. Objective: To compare outcomes of complete versus incomplete resection in primary intramedullary spinal cord ependymoma. Methods: A comprehensive search of the MEDLINE, CENTRAL, and Embase databases was conducted by 2 independent investigators. Random-effect meta-analysis and meta-regression with seven covariates were performed to evaluate the reason for the heterogeneity among studies. We also used individual patient data in the integrative analysis to compare complete and incomplete resection based on 4 outcomes: progression-free survival (PFS), overall survival (OS), postoperative neurological improvement (PNI), and follow-up neurological improvement (FNI). Results: A total of 23 studies were identified, including 407 cases. Significant heterogeneity among included studies was observed in risk estimates (I2 for PFS, FNI, and PNI were 49.5%, 78.3%, and 87.2%, respectively). The mean follow-up time across cases was 48.6 ± 2.35 months. Cox proportional multivariable analysis revealed that the complete resection can prolong PFS (model, hazard ratio = 0.18, CI 0.05-0.54, P = .004,) and improve the FNI (binary logistic regression, adjusted odds ratio = 16.5, CI 1.6-171, P = .019). However, PNI and OS were similar in patients with incomplete resected spinal cord ependymoma compared with complete resection (binary logistic regression respectively and Cox multivariable analysis, P > .5). Conclusion: The data presented in this study showed that OS was not significantly affected by the degree of surgery. However, complete resection of intramedullary ependymomas provides the optimal outcomes with longer PFS and better long-term neurological outcomes than incomplete resection.

Predictors of Progression-Free Survival in Patients With Spinal Intramedullary Ependymoma: A Multicenter Retrospective Study by the Neurospinal Society of Japan

“…Preoperative neurological condition, tumor size, and extent of resection usually correlate with postoperative neurological condition, but WHO grade does not seem to correlate. [24][25][26] Various studies have been conducted to clarify prognostic factors for SIE. PFS.…”

“…Preoperative neurological condition, tumor size, and extent of resection usually correlate with postoperative neurological condition, but WHO grade does not seem to correlate. 24-26 Various studies have been conducted to clarify prognostic factors for SIE. 8,13-23 Several prognostic factors for longer PFS including histopathological type, extent of resection, tumor size, or preoperative neurological condition have been proposed.…”

Multisegmental versus monosegmental intramedullary spinal cord ependymomas: perioperative neurological functions and surgical outcomes

“…Although numerous studies have discussed the predictors of surgical outcomes in patients with spinal ependymomas, the majority of existing evidence focuses on tumor recurrence and overall survival [18,15,[22][23][24], and investigations concerning neurological functions remain limited [5,19,24]. In 2011, Boström and colleagues retrospectively analyzed functional outcomes in 57 cases of spinal ependymoma, in which complete resection was gained in 83% of cases.…”

“…Ge et al found that the neurological deterioration rate was signi cantly higher in patients undergoing subtotal resection than that in the patient receiving gross total resection (P = 0.011) [10]. Recently, Salari et al performed a systematic review involving 407 cases in 23 studies; the authors concluded that complete surgical resection of intramedullary spinal cord ependymoma could prolong the progressionfree survival (P = 0.004) and improve follow-up neurological functions (P = 0.019) in comparison with incomplete resection [19]. In the current study, 51 (94.4%) patients achieved gross total resection, and incomplete resection was only performed in 3 (5.6%) patients.…”

Complete Versus Incomplete Surgical Resection in Intramedullary Astrocytoma: Systematic Review with Individual Patient Data Meta-Analysis

“…A detailed protocol has been published in PROSPERO (CRD42018103513) to study "Biopsy vs resection for intramedullary spinal cord tumors" and a systematic review specifically on intramedullary ependymoma has been performed according to the protocol. 6 Simultaneously, we conducted a systematic review of intramedullary astrocytoma based on the same protocol and the records identified by searching databases. In the section below, we provided a summary of the method used.…”