Joung H. Lee

Local control and overall survival in atypical meningioma: A retrospective study

PURPOSE To evaluate local control and overall survival after primary surgery for patients with atypical meningiomas. METHODS AND MATERIALS From the Department of Pathology database, we identified 491 cases of meningioma treated at the Cleveland Clinic Foundation from 1979 through 1995. Thirty-three were diagnosed with atypical meningioma. Eleven of the excluded patients had incomplete records, were lost to follow-up, or received treatment elsewhere. Of the 22 evaluable patients, 15 underwent gross total resection (GTR), 4 had a subtotal resection (STR), and 3 had a resection of unknown extent. Eight patients received radiation therapy (2 after initial resection and 6 after at least one recurrence). The median radiation dose was 5,400 cGy (range 3,500-5,940). The median age at presentation was 55.5 years, the male:female ratio was 14:8, and 19/22 patients had a Karnofsky performance score (KPS) > or =80. The independent variables analyzed for overall survival and local control were gender, KPS (> or =80 vs. < 80), extent of surgery (GTR vs. STR or unknown extent of surgery), and postoperative radiation therapy. RESULTS Median survival was 10.6 years, with a median follow-up of 5.5 years (range 1.5-14.8). Eight of the 22 patients had local recurrence, including 2/15 with GTR, 3/4 with STR, and all 3 patients who underwent resection of unknown extent. At 10 years, patients with GTR had a higher local control rate than those who had either a STR or a resection of unknown extent (87% vs. 17%; p = 0.02). The 5- and 10-year overall survival rates for the entire group were 91% and 76%, respectively. Patients who had GTR had 5- and 10-year overall survival of 87% and 87%, respectively. Patients with STR or resection of unknown extent had 5- and 10-year overall survival rates of 100% and 75%, respectively. CONCLUSION In patients with atypical meningiomas, gross total resection is associated with a lower recurrence rate than in subtotal resection.

Mild Hypothermia: Therapeutic Window after Experimental Cerebral Ischemia

The treatment of cerebral ischemia remains a formidable challenge in neuroscience today. Mild hypothermia has been shown to be an effective neuroprotective agent. Despite the great volume of published research, the therapeutic window of mild hypothermia has not been precisely elucidated. Using a model of reversible focal cerebral ischemia in the rat, this study was undertaken to define the optimal duration of hypothermic application and the maximal postischemic delay in hypothermic application before which optimal therapeutic effect is noted. Focal ischemia was induced by temporary occlusion of the middle cerebral artery and both carotid arteries in Sprague-Dawley rats for a period of 3 hours. In the first study, mild hypothermia (32-33 degrees C) was induced at the onset of ischemia in four groups of rats for varying lengths of time ranging from 1 to 4 hours. The animals were killed after 3 days, and their brains were sliced and stained. Infarcted volume was measured using a computerized image analyzer. The infarct volumes were 211 +/- 4.5, 214.2 +/- 8.0, 199.5 +/- 5.3, 171.3 +/- 9.1, and 169.8 +/- 6.5 mm3 (mean +/- standard error of the mean, n = 6 per group) for the control, 1-hour, 2-hour, 3-hour, and 4-hour groups, respectively. On the basis of the results from the above study, a 3-hour duration of hypothermia was then applied to animals at 0, 15, 30, or 45 minutes after the ischemic onset. The volumes of infarction for these four respective groups were: 171.3 +/- 9.1, 173 +/- 5.7, 179.3 +/- 5.2, and 206.2 +/- 8.4 mm3 (mean +/- standard error of the mean, n = 6 per group). These results demonstrated that optimal duration of mild hypothermia was at least 3 hours (P < 0.001) when applied within the first 30 minutes after the onset of ischemia (P < 0.001).

The natural history of intracranial meningiomas

OBJECT Despite the increased detection of incidental or small meningiomas, the lesions natural history is largely unknown. METHODS One year or longer of follow-up was conducted in 244 patients with 273 meningiomas managed conservatively by a single surgeon between 2003 and 2008. Data were stratified according to age, sex, tumor location, symptoms, initial tumor diameter, calcification, MR imaging intensity, and edema. Linear tumor growth was defined as a 2-mm or larger increase in the maximum diameter in any direction of the tumor. Volumetric analysis (ImageJ version 1.43) was also conducted in 154 of 273 meningiomas for which complete radiological data were available in the form of DICOM files throughout the follow-up period. A volume increase greater than 8.2% was regarded as significant because the preliminary volumetry based on 20 randomly selected meningiomas showed that the average SD was 4.1%. RESULTS Linear growth was observed in 120 tumors (44.0%) with a mean follow-up of 3.8 years. Factors related to tumor growth were age of 60 or younger (p = 0.0004), absence of calcification (p = 0.027), MR imaging T2 signal hyperintensity (p = 0.021), and edema (p = 0.018). Kaplan-Meier analysis and Cox proportional hazards regression analysis revealed that age 60 or younger (hazard ratio [HR] 1.54, 95% CI 1.05-2.30, p = 0.026), initial tumor diameter greater than 25 mm (HR 2.23, 95% CI 1.44-3.38, p = 0.0004), and the absence of calcification (HR 4.57, 95% CI 2.69-8.20, p < 0.0001) were factors associated with a short time to progression. Volumetric growth was seen in 74.0% of the cases. Factors associated with a higher annual growth rate were male sex (p = 0.0002), initial tumor diameter greater than 25 mm (p < 0.0001), MR imaging T2 signal hyperintensity (p = 0.0001), presence of symptoms (p = 0.037), and edema (p < 0.0001). CONCLUSIONS Although the authors could obtain variable results depending on the measurement method, the data demonstrate patients younger than 60 years of age and those with meningiomas characterized by hyperintensity on T2-weighted MR imaging, no calcification, diameter greater than 25 mm, and edema need to be observed more closely. Volumetry was more sensitive to detecting tumor growth than measuring the linear diameter.

Resection of anterior skull base tumors: Comparison of combined traditional and endoscopic techniques

Background Traditional craniofacial resection (tCFR) has been used successfully for resection of anterior skull base (ASB) tumors. Minimally invasive endoscopic resection (MIER) also has been used recently; this strategy facilitates superior visualization, avoids facial incisions, and preserves local structures. The goal of this study was to compare the outcome for these two approaches. Methods Retrospective chart analysis was conducted to identify patients undergoing resection of ASB tumors between January 1995 and January 2003. Demographic data, tumor characteristics, and the surgical approach used were determined. The mean operative time, estimated blood loss, hospital stay, and complications were analyzed. Recurrence and mortality rates were calculated. Results Nine patients were managed with the MIER approach, and 16 patients were treated with the traditional open approach. No significant difference was observed between groups on operative time, estimated blood loss, or hospital stay. Major complications were encountered in 2/9 (22%) and 7/16 (44%) patients in the MIER and tCFR groups, respectively. Recurrence was observed in 3/9 (33%) and 5/14 (36%) of the patients in the MIER and tCFR groups, respectively. Mortality rates in the MIER and tCFR groups were 0/9 (0%) and 4/15 (27%), respectively. Conclusion In this preliminary study, MIER of ASB neoplasia did not differ significantly from tCFR in operative time, estimated blood loss, hospital stay, or complication rate. Survival and recurrence rates were similar also. This early experience suggests that MIER is a viable alternative for the surgical management of ASB lesions in appropriately selected patients.

Surgical management of clinoidal meningiomas.

OBJECTIVE Surgical outcome has been less than desirable in the management of patients with clinoidal meningiomas in the past, and little attention has been directed at improving their visual function. The purpose of this article is to advocate an available cranial base technique for removing these difficult tumors and to delineate the technique’s advantages that aid in achieving an improved extent of tumor resection and enhancing the patients’ overall outcome, particularly their visual outcome. METHODS A retrospective analysis was performed on 15 consecutive patients with clinoidal meningiomas (including a patient with hemangiopericytoma) who underwent surgical resection at the Cleveland Clinic Foundation between June 1995 and January 2000. A cranial base technique consisting of extradural anterior clinoidectomy, coupled with optic canal unroofing and optic sheath opening, was used in 13 patients, and standard pterional craniotomy was used in 2. Eight of 15 patients had significant visual deficits preoperatively. All patients had thorough preoperative and postoperative ophthalmological evaluations. The follow-up period ranged from 6 to 60 months (mean, 37.2 mo). RESULTS Total resection was achieved in 13 (86.7%) of the 15 patients in this series, and the majority of the patients with preoperative visual impairment experienced significant improvement (6 of 8 patients; 75%). CONCLUSION In the majority of patients with clinoidal meningiomas, total resection may be achieved with minimal complications. For large tumors encasing the optic nerve and internal carotid artery, or for those tumors causing preoperative visual impairment, use of the cranial base technique delineated in this study may lead to significant improvement in the patients’ visual and overall outcomes.

Recurrent head-and-neck chemodectomas: a comparison of surgical and radiotherapeutic results.

PURPOSE To compare the outcome of salvage radiotherapy (RT) and surgery for recurrent head-and-neck chemodectomas. MATERIALS AND METHODS We retrospectively studied 70 patients with benign chemodectomas of the head and neck treated with surgery at the Cleveland Clinic between July 1969 and August 1999; 29 of these patients were diagnosed with recurrent tumors. Salvage RT was used in 12 patients (gamma knife radiosurgery for 7, conventional external beam RT for 4, and intensity-modulated RT for 1 patient). The median follow-up was 55 months for the entire group of 70 patients. RESULTS The median time to recurrence was 36 months. Of the recurrences, 16 were glomus jugulare, 7 were carotid body tumors, 5 were glomus tympanicum, and 1 was thyroid paraganglioma. RT was used in 12 patients (9 patients with glomus jugulare, 2 with glomus tympanicum, and 1 with thyroid paraganglioma). Surgery was performed in 17 patients (7 patients with glomus jugulare, 7 with carotid body, and 3 with glomus tympanicum). For patients with glomus jugulare and glomus tympanicum tumors, the 5-year freedom from disease progression was 100% for patients treated with RT vs. 62% for those treated with surgery (p = 0.0124). Seven patients with carotid body tumors and 1 patient with thyroid paraganglioma were treated successfully with surgery and RT, respectively. No significant side effects were associated with RT; however, postoperative complications occurred in 8 of the 17 surgery patients (new cranial nerve palsies, meningitis, infection, and cerebrospinal fluid leak). CONCLUSION Salvage RT appears superior to surgery and should be considered the treatment of choice for patients with recurrent glomus jugulare and glomus tympanicum tumors. For recurrent carotid body tumors, surgery produced excellent local control, most likely because of the easier resectability in this location.

Esthesioneuroblastoma: 25-year experience at a single institution

Objectives To evaluate outcomes for patients with esthesioneuroblastoma treated at a single institution during a 25-year period. Design Eighteen patients with pathologic diagnosis of esthesioneuroblastoma between 1980 and 2004 were retrospectively identified. Results Two patients had Kadish A, seven had Kadish B, and nine had Kadish C disease. The mean follow-up was 71 months. Treatment regimens consisted of surgery alone (four patients), surgery followed by postoperative radiation (six patients), surgery followed by postoperative chemoradiotherapy (three patients), preoperative radiotherapy (two patients), preoperative chemoradiotherapy (one patient), chemoradiotherapy (one patient), and surgery plus chemotherapy (one patient). Surgical approaches (n = 17) consisted of 13 traditional craniofacial resections, one endoscopic-assisted cranionasal resection, and three minimally invasive endoscopic resections. The 10-year disease-specific survival was 80%. The overall recurrence-free survival at five and 10 years was 62% and 46%, respectively. Positive surgical margins and TNM staging predicted survival. Conclusion Both endoscopic and open surgical approaches have been successful in treating a small number of esthesioneuroblastoma patients with high survival and low rate of surgical complications.

Long-Term Experience With World Health Organization Grade III (Malignant) Meningiomas at a Single Institution

PURPOSE To evaluate the outcomes for patients with Grade III meningiomas as defined by the 2007 World Health Organization standards. METHODS AND MATERIALS The slides from patients who had been treated at the Cleveland Clinic for malignant meningiomas were reviewed by a single neuropathologist. The data from 13 patients treated between 1984 and 2006 satisfied the World Health Organization 2007 definition of Grade III meningioma. A total of 24 surgeries were performed, including 13 primary, 7 salvage, and 4 second salvage. Also, 14 courses of radiotherapy (RT) were administered, including fractionated RT in 3 patients after primary surgery, fractionated RT in 4 patients after salvage surgery, salvage stereotactic radiosurgery to six separate areas in 3 patients, and salvage intensity-modulated RT in 1 patient. RESULTS From the primary surgery, the median survival was 3.4 years, the 5-year survival rate was 47.2%, and the 8-year survival rate was 12.2%. The median time to recurrence was 9.6 months. A trend was seen toward longer survival for patients who had received adjuvant RT after initial surgery compared with those treated with surgery alone. Two patients developed radiation necrosis, and three had surgical complications. CONCLUSION This is one of the few studies reporting the outcomes for malignant meningioma patients according to recent definitions. Our results are consistent with existing reports of the overall poor outcomes for atypical and malignant meningioma patients. From the available data, surgical resection followed by RT and salvage therapy can lead to extended survival.

Pre- versus post-anterior clinoidectomy measurements of the optic nerve, internal carotid artery, and opticocarotid triangle : A cadaveric morphometric study

OBJECTIVE Published morphometric data supporting the microsurgical advantages of anterior clinoidectomy are scant. The goal of this study was to quantify, with direct measurements, the improved exposure of the optic nerve, internal carotid artery (ICA), and opticocarotid triangle (OCT) after extradural removal of the anterior clinoid process. METHODS Ten formalin-fixed adult cadaver heads were dissected bilaterally, and measurements were made both before and after anterior clinoidectomy. Twenty sets of pre- and post-anterior clinoidectomy measurements were collected, consisting of: 1) optic nerve length from the optic chiasm to the optic canal (pre) and to the anulus of Zinn (post); 2) ICA length from the ICA bifurcation to the distal limit of the anterior clinoid process (pre) and to the ICA distal dural ring (post); 3) OCT width, the widest in situ distance between the optic nerve and the ICA (pre) and the analogous measurement with allowable retraction on the mobilized ICA and optic nerve (post); and 4) OCT length from the point where the A1 segment crosses the optic chiasm to the optic canal (pre) and to the anulus of Zinn (post). RESULTS The right and left combined mean values +/- standard error of the mean before and after removal of the anterior clinoid process, respectively, were: optic nerve length, 10.28 +/- 2.30 mm and 22.83 +/- 2.54 mm; ICA length, 10.48 +/- 2.39 mm and 14.78 +/- 3.02 mm; OCT width, 3.93 +/- 1.16 mm and 12.95 +/- 2.61 mm; and OCT length, 10.38 +/- 2.84 mm and 23.55 +/- 2.79 mm. CONCLUSION Anterior clinoidectomy can provide a twofold increase in exposure of the optic nerve length and the OCT length, as well as a three- to fourfold increase in the maximum OCT width. This dramatically improves surgical exposure in the suprasellar and periclinoid regions.

World Health Organization Grades II and III meningiomas are rare in the cranial base and spine.

OBJECTIVEThis study was undertaken to assess a possible relationship between the tumor location and the incidence of World Health Organization (WHO) Grades II and III meningiomas. METHODSA retrospective review of 794 consecutive patients who underwent meningioma resection between January 1991 and March 2004 was conducted. Among these, 47 patients (5.9%) with WHO Grade II meningiomas and 16 patients (2%) with Grade III meningiomas were further analyzed. Tumor location was assessed using preoperative magnetic resonance imaging scans and/or operative reports. Histological grading was done according to the WHO 2000 Classification scheme. RESULTSWHO Grade II tumors were found in eight out of 289 (2.8%) cranial base meningiomas and in zero spinal meningiomas, compared with 39 out of 429 (9.1%) non-cranial base meningiomas. Grade III histology was encountered in two (0.7%) cranial base tumors and in one out of 76 (1.3%) spinal tumors, compared with 13 (3%) non-cranial base tumors. The combined incidence of Grades II and III meningiomas was significantly lower in the cranial base (3.5%) and spinal (1.3%) locations compared with non-cranial base locations (12.1%) (P < 0.001). CONCLUSIONWHO Grades II and III meningiomas occur far less frequently in the cranial base and spinal locations. Tumors arising from these locations may have different mechanisms of tumorigenesis and/or progression compared with meningiomas arising from other (non-cranial base) regions.