Radiocirurgia

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BACKGROUND: Although population age increases, published evidence on meningioma treatment in the elderly is scarce.

OBJECTIVE: In order to improve selection for surgery, we investigated our patients’ collective, using 2 proposed risk assessment systems; the Clinical-Radiological Grading System (CRGS) and the SKALE score (Sex, Karnofsky, ASA, Location, Edema).

METHODS: We retrospectively assessed morbidity and mortality in 164 patients aged >=65, operated on an intracranial meningioma. Medical and surgical records were reviewed and analyzed. CRGS and SKALE were calculated. The ability of both CRGS and SKALE and all single factors to predict death within 12 months was analyzed using multivariate logistic regression modeling.

RESULTS: 11 patients died (6.7%). Logistic regression for CRGS/SKALE showed a significant relationship with 12 months mortality. Age, Simpson’s resection-grade and Sex were not significant predictors when investigated alone. In multivariate logistic-regression, including all proposed factors, only concomitant disease and edema (CRGS) and ASA-score and preoperative KPS (SKALE) showed a significant relationship to mortality. After stepwise reduction of the full multivariate regression model to its significant terms, only concomitant disease and ASA remained significant for CRGS (p< 0.001) and SKALE (p=0.003), respectively.

CONCLUSION: Meningioma resection in the elderly is possible with some mortality. We were unable to reproduce the utility of two proposed grading system for mortality prediction when extending to younger patients. In single factors analysis, only concomitant disease and ASA-score remained significant. Decision whether to operate should be taken individually. Patients with severe concomitant disease or high ASA-score should be advised not to undergo surgical therapy independently from other factors.

Full article access for Neurosurgery subscribers at Neurosurgery-Online.com.

http://neurosurgerycns.wordpress.com/2011/08/29/ahead-of-print-meningioma-surgery-in-the-elderly-outcome-and-validation-of-two-proposed-grading-scores-systems/

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Abstract The occurrence of neoplastic and nonneoplastic dural based masses that mimic meningiomas is infrequent and may not be considered during radiological and intraoperative analysis. We describe single institute study of 20 such rare cases. This study included total of 20 cases of meningioma mimics. The clinical, radiological and histopathological findings were evaluated. Tissue fixed in 10% formalin was routinely processed and 5 μ thick sections were cut and stained with hematoxylin & eosin. Histochemistry and immunohistochemistry using avidin–biotin complex immunoperoxidase method was done wherever indicated. In the present study group, 15 were male and 5 female with a male: female ratio of 3:1. The age ranged from 14 to 78 years. Radiologically all these lesions were extra-axial in location, predominantly hypointense on T2W, isointense on T1W images and showed intense homogenous enhancement on contrast administration. Four cases were in pediatric age group with histopathological diagnosis of Rosai Dorfman disease, medulloblastoma, hemangiopericytoma and malignant melanoma. In the adult population, the histopathological diagnoses were hemangiopericytoma, undifferentiated sarcoma, extraskeletal osteosarcoma, Rosai Dorfman disease, medulloblastoma, and metastases from systemic malignancies. Of the total 6 cases of metastases 1 was nonseminomatous germ cell tumor from a primary in testis, 1 was adenocarcinoma from an unknown primary, and 4 were adenocarcinoma from lung. There was a single case of dural based frontal lobe malignant melanoma with congenital hairy nevi on anterior chest wall, scalp, anterior abdominal wall and inguinal region. As the management and biologic behaviour of many of the MM are different, it is essential to familiarize ourselves to them.

• Content Type Journal Article
• Pages 1-14
• DOI 10.1007/s11060-011-0669-3
• Authors
  • Nandita Ghosal, Department of Pathology and Transfusion Medicine, Sri Sathya Sai Institute of Higher Medical Sciences (SSSIHMS), EPIP Area, Whitefield, Bangalore, 560066 India
  • Ravi Dadlani, Department of Pathology and Transfusion Medicine, Sri Sathya Sai Institute of Higher Medical Sciences (SSSIHMS), EPIP Area, Whitefield, Bangalore, 560066 India
  • Kanchan Gupta, Department of Pathology and Transfusion Medicine, Sri Sathya Sai Institute of Higher Medical Sciences (SSSIHMS), EPIP Area, Whitefield, Bangalore, 560066 India
  • Sunil V. Furtado, Department of Pathology and Transfusion Medicine, Sri Sathya Sai Institute of Higher Medical Sciences (SSSIHMS), EPIP Area, Whitefield, Bangalore, 560066 India
  • A. S. Hegde, Department of Pathology and Transfusion Medicine, Sri Sathya Sai Institute of Higher Medical Sciences (SSSIHMS), EPIP Area, Whitefield, Bangalore, 560066 India

• Journal Journal of Neuro-Oncology
• Online ISSN 1573-7373
• Print ISSN 0167-594X

http://www.springerlink.com/content/c6p3w0g488622382/

Abstract

Purpose

to assess the safety and efficacy of fractionated stereotactic radiotherapy (FSRT) for large skull base meningiomas.

Methods and Materials

Fifty-two patients with large skull base meningiomas aged 34-74 years (median age 56 years) were treated with FSRT between June 2004 and August 2009. All patients received FSRT for residual or progressive meningiomas more than 4 centimeters in greatest dimension. The median GTV was 35.4 cm3 (range 24.1-94.9 cm3), and the median PTV was 47.6 cm3 (range 33.5-142.7 cm3). Treatment volumes were achieved with 5-8 noncoplanar beams shaped using a micromultileaf collimator (MLC). Treatment was delivered in 30 daily fractions over 6 weeks to a total dose of 50 Gy using 6 MV photons. Outcome was assessed prospectively.

Results

At a median follow-up of 42 months (range 9-72 months) the 3-year and 5-year progression-free survival (PFS) rates were 96% and 93%, respectively, and survival was 100%. Three patients required further debulking surgery for progressive disease. Hypopituitarism was the most commonly reported late complication, with a new hormone pituitary deficit occurring in 10 (19%) of patients. Clinically significant late neurological toxicity was observed in 3 (5.5%) patients consisting of worsening of pre-existing cranial deficits.

Conclusion

FSRT as a high-precision technique of localized RT is suitable for the treatment of large skull base meningiomas. The local control is comparable to that reported following conventional external beam RT. Longer follow-up is required to assess long term efficacy and toxicity, particularly in terms of potential reduction of treatment-related late toxicity.

http://www.ro-journal.com/content/6/1/36
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Giuseppe Minniti, Maurizio Amichetti, Riccardo M Enrici
Radiation Oncology 2009, 4:42 (14 October 2009)

Abstract

Meningiomas located in the region of the base of skull are difficult to access. Complex combined surgical approaches are more likely to achieve complete tumor removal, but frequently at a cost of treatment related high morbidity. Local control following subtotal excision of benign meningiomas can be improved with conventional fractionated external beam radiation therapy with a reported 5-year progression-free survival up to 95%. New radiation techniques, including stereotactic radiosurgery (SRS), fractionated stereotactic radiotherapy (FSRT), and intensity-modulated radiotherapy (IMRT) have been developed as a more accurate technique of irradiation with more precise tumor localization, and consequently a reduction in the volume of normal brain irradiated to high radiation doses. SRS achieves a high tumour control rate in the range of 85-97% at 5 years, although it should be recommended only for tumors less than 3 cm away more than 3 mm from the optic pathway because of high risk of long-term neurological deficits. Fractionated RT delivered as FSRT, IMRT and protons is useful for larger and irregularly or complex-shaped skull base meningiomas close to critical structures not suitable for single-fraction SRS. The reported results indicate a high tumour control rate in the range of 85-100% at 5 years with a low risk of significant incidence of long-term toxicity. Because of the long natural history of benign meningiomas, larger series and longer follow-up are necessary to compare results and toxicity of different techniques.

http://www.ro-journal.com/content/4/1/42

Cyberknife Stereotactic Radiosurgery for Treatment of Atypical (Who Grade II) Cranial Meningiomas

BACKGROUND: The optimal management of subtotally resected atypical meningiomas is unknown.
OBJECTIVE: To perform a retrospective review of patients with residual or recurrent atypical meningiomas treated with stereotactic radiosurgery (SRS).
METHODS: Twenty-five patients were treated, either immediately after surgery (n = 15) or at the time of radiographic progression or treatment failure (n = 10). SRS was delivered to with a median marginal dose of 22 Gy (range, 16-30) in 1 to 4 fractions (median, 1), targeting a median tumor volume of 5.3 cm
(range, 0.3-26.0).
RESULTS: With a median follow-up time of 28 months (range, 3-67), the 12-, 24-, and 36-month actuarial local and regional control rates for all patients were 94%, 94%, 74%, and 90%, 90%, 62%, respectively. There were 2 cases of radiation toxicity. On univariate analysis, the number of recurrences before SRS (
= .046), late SRS (ie, waiting until tumor progression to initiate treatment) (
= .03), and age at treatment ≥60 years (
= .01) were significant predictors of recurrence. Of the 20 radiation-naïve patients, 2 patients failed with the targeted lesion and 3 elsewhere in the resection bed, resulting in 12-, 24- and 36-month actuarial local and regional control rates of 100%, 100%, 73% and 93%, 93%, 75%, respectively. The overall locoregional control rates at 12, 24, and 36 months were 93%, 93%, and 54%, respectively.
CONCLUSION: Irradiation of the entire postoperative tumor bed may not be necessary for the majority of patients with subtotally resected atypical meningiomas. Patients in this series achieved outcomes comparable to that of historical control rates for larger volume, conventionally fractionated radiotherapy.