Long-term follow-up after surgical removal of meningioma of the inner third of the sphenoidal wing: outcome determinants and different strategies

Abstract

Meningioma arising in the inner third of the sphenoidal wing has been well recognized since the origin of neurosurgery, yet it still poses a formidable challenge for the surgeon. Treatment strategies can be optimized through a tailored approach to surgical timing and use of a non-surgical armamentarium. The aim of this study was to evaluate the long-term effect of different strategies on progression-free survival and overall survival. We examined the clinical records of brain tumor patients to assess determinants for surgery (extent of tumor removal, postoperative complications) and for progression-free survival and overall survival in relation to timing of surgery eventually followed by stereotactic radiosurgery (SRS). The records of 60 patients were retrospectively reviewed, from preoperative assessment to a median follow-up of 104 months. All were symptomatic with prevalently visual symptoms (42.2%), large tumors (median diameter 3.44 cm), extension into the cavernous sinus (38.3%), and severe vascular involvement of one or more encased or narrowed vessels (50%). Subtotal removal was achieved in 40% of cases, mainly determined by cavernous sinus and vascular involvement; neurological complications occurred in 18.3% (persistent in 6.7% due to oculomotor and vascular injury). The overall rate of symptom improvement was 32.3% at 3 months and 49.5% at 12 months. Radiological monitoring prevented clinical progression; tumor progression occurred in 11.7% of cases. There were significant differences in progression-free survival between patients with (median 46 months) and those without (median 104 months) recurrence (p = 0.002): 12.5% after total removal, 6.2% after subtotal removal and adjuvant SRS, and 28.5% after subtotal removal and observation. The related Kaplan-Meier survival curve showed no significant difference between the three strategies. Further, disease progression after recurrence was noted in 28.6% of cases, but overall survival was not influenced by either tumor recurrence or type of treatment. Treatment failure was recorded in four cases (6.7%): one perioperative death and three later on. Surgery is the mainstay for the treatment of symptomatic meningioma and to restore neurological function; however, resectability is limited by vascular and cavernous sinus involvement. Careful postoperative monitoring prevented clinical progression and adjuvant or adjunctive SRS proved effective in tumor control. A low surgical complication rate and excellent long-term outcomes were achieved with this strategy.

Gamma Knife Radiosurgery for Anterior Clinoid Process Meningiomas: A Series of 61 Consecutive Patients

“…2,3 Gamma Knife radiosurgery (GKRS) has emerged as an important primary or adjuvant treatment modality for meningiomas. [4][5][6][7] In the present study, we evaluated presenting features, radiosurgery parameters, and radiologic and clinical outcomes in a series of patients who underwent GKRS for ACP meningiomas.…”

Extradural anterior clinoidectomy in surgical management of clinoidal meningiomas

“…Many studies reported the use of the extradural cranial base technique through pterional approach or FTOZ and anterior clinoidectomy [2,11,13,[16][17][18][19][20][21]. Pterional approach with intradural anterior clinoidectomy [4,[22][23][24][25], lateral supraorbital approach [25][26][27], and lateral sub-frontal approach [13] were also performed in many studies. In our series, the extradural cranial base approach was performed in all patients; our purpose is to localize and decompress the optic nerve before tumor removal, avoiding excessive manipulation on the optic nerve during tumor debulking.…”

“…They reported a limitation with their approach that it did not allow exploration of the cavernous sinus in case there is CS invasion by the tumor [4]. In literature, other studies reported the use of standard pterional approach [14,[22][23][24][25]27] and lateral supraorbital approach [25][26][27] with intradural anterior clinoidectomy when needed for the surgical management of ACMs. They reported visual improvement ranged from 15.4 to 73% with 5 out of 7 studies had visual outcome below 50%.…”

Advances in Multidisciplinary Management of Skull Base Meningiomas

“…Radiosurgery in an early post-operative stage is nowadays routinely performed in patients with Grade 1 MN after incomplete resection [ 119 , 120 , 121 , 136 , 137 ]. A combined MS–SRS strategy has proved to be particularly worthy in cases of SBMs [ 137 , 138 ] and in some centers, this strategy is decided with the patients before surgery [ 138 ]. On the other hand, several studies have reported a progression of an untreated remnant for which a “wait and scan” policy is adopted [ 136 ].…”

“…Neurological status was stable or improved in 147 patients (86.5%), independently of tumor shrinkage. WHO Grade I vs. Grade II histology ( p = 0.019) was proven to be the only independent variable for LTR [ 137 ].…”