The selection of the optimal therapeutic strategy for petroclival meningiomas

doi:10.1016/j.surneu.2005.12.024

Surgical Neurology

Volume 66, Issue 2, August 2006, Pages 160-165

https://doi.org/10.1016/j.surneu.2005.12.024 Get rights and content

Abstract

Background

Broad experience with the management of petroclival meningiomas was analyzed to optimize therapeutic strategy.

Methods

The records of 75 patients with petroclival meningioma were reviewed. The population was divided into a microsurgery group (n = 49), a radiosurgery group (n = 12), a radiation therapy group (n = 5), and an observation group (n = 9) according to the modality of primary treatment. In the microsurgery group, the tumor was completely resected in 10 patients. Eleven of the 39 patients with incomplete resections sequentially underwent adjuvant radiation therapy or radiosurgery. The median follow-up period was 86 months (range, 48-210 months). The median follow-up period of the radiosurgery, the radiation therapy, and the observation group was 52 months (range, 48-71 months), 56 months (range, 51-72 months), and 63 months (range, 53-68 months), respectively. Management outcomes were evaluated with respect to tumor control rate, neurological deficit, and functional status assessed by the Karnofsky Performance Score.

Results

In the microsurgery group, 11 (22.4%) patients eventually showed tumor progression. However, there was only one recurrence if adjuvant therapy was used after incomplete removal. The incidence of favorable outcomes for cranial neuropathies was better in the incomplete resection group (69.2%) than for patients in the complete resection group (20%, P = .032). Moreover, a favorable functional outcome predominated in the incomplete resection group (76.9%) compared with the complete resection group (30%, P = .049). The disease was stable in both the radiation therapy and the radiosurgery groups during the follow-up period, with functional status and cranial nerve function perfectly preserved in these patients. No predictive factor other than short symptom duration was found to be significant.

Conclusions

Because the growth rate of petroclival meningioma is low and good functional status can be guaranteed, intended incomplete resection should be considered as an acceptable treatment option. Adjuvant treatment after surgery is useful in the control of residual tumors. Radiosurgery may be appropriate as the primary treatment in asymptomatic patients with small tumor; however, more aggressive treatment is needed in young patients or patients with short symptom durations.

Introduction

During the past decades, major advances have been made in microsurgical techniques for skull base surgery. However, petroclival meningiomas remain formidable challenges for most neurosurgeons because of their proximity to critical neural and vascular structures and because of their large size at diagnosis. Although surgical mortality has been reduced from more than 50% before 1970 to less than 10% in recent operations, the rate of permanent postoperative complications is reported to be as high as 50% [2], [5], [6], [7], [10], [14]. The ideal goal of total resection with no surgical morbidity is difficult to achieve consistently for this tumor. Neurosurgeons agonize in trying to balance grave morbidity after aggressive resection against the uncertain natural history for any residual tumor. Although the natural history for petroclival meningiomas is variable, most are benign and grow slowly [8], [19]. Selecting an optimal therapeutic strategy for each patient involves various considerations, including prognostic factors, application of novel tools such as radiosurgery, and the consequences for the quality of life of the patient. The decision depends on answers to the following questions. First, is radical resection always the best option for ensuring an acceptable quality of life for the patient? Second, can we predict the tumor progression? Third, what options other than surgery are there? To find answers to these questions, we have reviewed our broad experience with the management of petroclival meningiomas, and from this review, we propose guidelines for the management of this disease.

Section snippets

Patients and methods

Meningiomas of petroclival area are defined as the mass that emanates at or medial to the skull base foramina of cranial nerves V through XI and encompasses the upper two-thirds of the clivus. A total of 75 patients with petroclival meningiomas were studied during the period from 1986 to 2000. Careful retrospective reviews of their clinical records and radiological analyses were done. The mean age was 46.2 years (15-74 years) and the male to female ratio was 1:4. Only patients with at least 4

Outcomes for patients initially treated with microsurgery

Thirty-eight (77.6%) patients exhibited no recurrence or regrowth after microsurgery during the follow-up period, whereas the other 11 (22.4%) patients eventually showed tumor progression. Patients with tumor progression all had incomplete resections. The median time to progression was 36 months. According to Kaplan-Meier survival plots, the 5-year progression-free rate was 75% and median progression-free period was 64 months (Fig. 1). The most common histological identification was the

Is radical resection always the best option for preserving high quality of life in the patient?

The surgical management of petroclival meningiomas has frustrated neurosurgeons for many years, and its conquest has not yet been achieved. The operative outcomes for petroclival meningiomas previously reported are summarized in Table 5 [2], [5], [7], [10], [12], [14], [16], [21]. Even in the expert hands of neurosurgeons, the functional outcome after surgery is disappointing. This may be due to the complex anatomical relationships of significant neurovascular structures as well as to the

Conclusions

Because the growth rate of petroclival meningioma is low and good functional status can be preserved, incomplete resection should be considered. Adjuvant treatment, especially radiosurgery, after resection can be used to control the residual tumor. Radiosurgery may also be the preferred primary treatment for asymptomatic patients with small tumors. However, more aggressive treatment is needed for young patients or patients with short symptom durations.

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Correlation of Surgical Outcomes of Petroclival Meningiomas with Clinicoradiologic Parameters and Molecular and Chromosomal Alterations
2023, World Neurosurgery
To identify clinical, radiologic, intraoperative, histopathologic, and molecular factors that might affect the surgical outcome of petroclival meningiomas.
Medical records of 53 cases of petroclival meningiomas operated from 2003 to 2021 were reviewed for clinicoradiologic and molecular factors that were correlated with extent of resection.
Modified Dolenc-Kawase anterior transpetrous rhomboid (44, 83.0%) was the most commonly used approach, followed by retrosigmoid (2, 3.8%) and combined (7, 13.2%) approaches. Hypointense tumors on T2-weighted magnetic resonance imaging (odds ratio [OR] 5.85; 95% confidence interval [CI] 1.70–20.41) and presence of brainstem edema (OR 4.53; 95% CI 1.36–15.12) were found to be significant factors increasing the likelihood of subtotal resection (STR; P = 0.004 and P = 0.011, respectively). In the presence of both tumor T2 hypointensity and brainstem edema, there was a significant increase in the likelihood of STR (P = 0.001; OR 25; 95% CI 3.52–177.48). Of the 16 cases for which molecular analysis was performed, no specimen was found to have pTERT, AKT-1 E17K, and SMO L412F and W535L mutations. All (100%) the patients harboring H3K27me3 loss and/or hemizygous CDKN2A deletion had cavernous sinus extension compared with 62.5% of patients without H3K27me3 loss and 72.7% with hemizygous CDKN2A retention. Similarly, hemizygous CDKN2A deletion and H3K27me3 loss were associated with an increase in the rate of brainstem edema from 27.3% to 60% and 25% to 50%, respectively.
T2 hypointense tumor and brainstem edema on preoperative imaging are significant predictors of STR. H3K27me3 loss and hemizygous CDKN2A deletion may be associated with cavernous sinus extension, suggesting their role in tumor spread.
The Minimally Invasive Posterolateral Transcavernous-Transtentorial Approach. Technical Nuances, Proof of Feasibility, and Surgical Outcomes Throughout a Case Series of Sphenopetroclival Meningiomas
2021, World Neurosurgery
Sphenopetroclival (SPC) meningiomas are considered among the most complex skull-base neoplasms to approach surgically. We aim to determine whether some SPC meningiomas can be safely and effectively treated using a modified minimally invasive pterional posterolateral transcavernous-transtentorial approach (MIPLATTA).
Fourteen patients harboring SPC meningiomas were surgically treated through a MIPLATTA. MIPLATTA includes a minipterional craniotomy, anterior extradural clinoidectomy, peeling of the temporal fossa, decompression of cranial nerves (CNs) in the cavernous sinus, and sectioning of the tentorium to reach the upper part of the posterior fossa.
Gross total resection was achieved in 11 of 14 patients (78%), whereas near-total resection was accomplished in the other 3 patients (22%), each of whom underwent a further complementary retrosigmoid approach for gross total tumor resection. There were no deaths, and 13 of 14 patients were independent at 6 months follow-up (modified Rankin Scale score ≤2). One patient had pontine infarction after the procedure and experienced moderate disability at follow-up (modified Rankin Scale score 3). All patients had some degree of CN impairment. Of 38 cranial neuropathies, 15 (39%) improved, 20 (53%) remained stable, and 3 (8%) worsened postoperatively. Four new CN deficits were observed postoperatively in 3 patients (fourth CN, 2 patients; third CN, 1; fifth CN, 1).
MIPLATTA is a useful and safe treatment alternative that allows resection of large SPC tumors with dominant invasion of cavernous sinus and middle fossa, preserves hearing and facial motor function, and provides good chances of recovery of visual and oculomotor deficits.
Natural history of intracranial meningiomas
2020, Handbook of Clinical Neurology
Citation Excerpt :
A significant portion of patients presenting with preoperative cranial neuropathies will experience improvement after surgical resection. In particular, authors have noted preoperative lower cranial nerve palsies to have the highest likelihood for recovery, while those presenting with hearing loss had the least chance of recovery (Park et al., 2006). As many as 90% of those presenting with preoperative hemiparesis and 75%–77% presenting with cerebellar symptoms experienced improvement after resection (Abdel Aziz et al., 2000; Park et al., 2006).
We know that the extent of resection is the greatest predictor of long-term survival. However, the potential tradeoff for gross total resection in difficult locations is diminished quality of life. Benign subtotally resected or small incidentally discovered meningiomas may be followed clinically especially in the elderly. In addition, radiosurgery plays a role in the treatment of meningiomas as a primary treatment modality, or as a salvage therapy. Decisions regarding management should be made with an understanding of the natural history and rate of growth. In this chapter we review the known meningioma epidemiology as well as the growth patterns of meningiomas based upon location.
Outcomes of Endonasal and Lateral Approaches to Petroclival Meningiomas
2017, World Neurosurgery
Citation Excerpt :
Despite the development of complex and sophisticated surgical approaches, gross total resection (GTR) is not always feasible and surgical morbidity remains a substantial risk.1,2 Given the high rates of postoperative morbidity regardless of the surgical approach, clinical status usually deteriorates after surgery with return to baseline or improvement in the long-term.3-5 The indolent growth of petroclival meningiomas and the excellent results of radiosurgery for controlling residual tumor with minimal morbidity have prompted surgeons to be less aggressive in resecting invasive petroclival meningiomas and to accept a subtotal resection of high-risk cases.2,4,6-14
Transpetrosal approaches for the treatment of petroclival meningiomas are often associated with substantial morbidity and long recovery. With the goal of early clinical improvement, we have used less invasive surgical approaches for petroclival meningiomas.
We retrospectively reviewed 32 patients with petroclival meningiomas. Eleven patients (34.4%) were managed with lateral approaches (retrosigmoid or far lateral approach), 17 (53.1%) with anterior midline approaches (endoscopic endonasal approach [EEA]), and 4 (12.5%) with a combination.
The average Karnofsky Performance Score (KPS) at presentation was 73.8. The average postoperative KPS improved to 87.9 (P < 0.001) during short-term follow-up of 14 months (range, 1–42) and was significantly higher in primary tumors (P = 0.013), tumors <4 cm (P = 0.039), and tumors without vascular encasement (P = 0.002) but remained significant regardless of age, tumor size, or vascular encasement. The greatest benefit occurred with primary tumors, in young patients and in those who underwent nontotal resection (P < 0.001). EEA had a significantly greater potential for improved KPS (P = 0.002). Gross (n = 6) or near total (n = 9) resection was achieved in 15 of 32 cases (47%). Complications included new cranial nerve palsies affecting mainly the abducens nerve (18.7%). New lower cranial nerve palsies occurred in only 1 case (3.1%). Other complications included postoperative hydrocephalus (15.6%) and cerebrospinal fluid leak (28.1%). One patient died in the perioperative period (3.1%).
In the short-term, less aggressive cranial base approaches, including retrosigmoid exposures and the recently introduced EEA, are effective alternatives to transpetrosal approaches for debulking petroclival meningiomas with significant early clinical improvement and limited major surgical complications.
Petroclival meningiomas: Remaining controversies in light of minimally invasive approaches
2017, Clinical Neurology and Neurosurgery
Surgical resection of petroclival meningiomas remains challenging due to their deep location and relationship to vital neurovascular structures. Although the natural history of these tumors involves a slow course, the incidence of cranial nerve deficits and the extent of tumor resection vary widely in the literature. Some reviews on this topic have been conducted, but data remain fragmentary and based on retrospective case series, which hinders attempts at meta-analysis. Within this context, research into the use of minimally invasive approaches, including in neuroendoscopy, continues to emerge. The objective of this narrative review is to analyze the available literature on the surgical treatment of petroclival meningiomas, with a focus on attempts at endoscopy-assisted resection.
True Petroclival Meningiomas: Proposal of Classification and Role of the Combined Supra-Infratentorial Presigmoid Retrolabyrinthine Approach
2016, World Neurosurgery
The evolution of the surgical treatment of petroclival meningiomas (PMs) has led to a tendency to abandon complex petrous approaches and return to “less-aggressive” skull base approaches.
To propose a classification of PMs and establish the role of the combined supra-infratentorial presigmoid retrolabyrinthine (CSIPR) approach in the treatment of PMs rigorously matching the anatomical definition.
A retrospective analysis was conducted of 51 cases of PMs strictly adhering to the anatomical definition who were operated on from January 1990 to December 2011. On the basis of the different patterns of growth from a common anatomical region of origin, a classification of PMs in 4 groups is proposed.
Gross total resection was achieved in 32 patients (63%) and subtotal resection (at least 90% tumor volume removal) in 14 patients (27%). Each of the 4 groups of the proposed classification lends itself to be removed by a distinct surgical approach. Statistical analysis confirmed that such group-approach pairings significantly correlate with radical surgical removal (P < 0.001). Despite the high incidence of early postoperative complications, at late follow-up 82% of patients were free of significant postoperative neurological deficits (95% confidence interval: 70–90). Comparable neurological improvement was observed limited to cases treated by CSIPR (P = 0.60).
For each PM group, the most suitable approach was identified in terms of surgical radicality and low postoperative morbidity. CSIPR can be considered the approach of choice for the most frequent group of PMs in our series. We believe that the CSIPR remains a valuable option for the treatment of PMs.

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^☆: This work was partially supported by grants from the Clinical Research Institute, Seoul National University Hospital, and The Korea Brain and Spinal Cord Research Foundation.

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NeoplasmThe selection of the optimal therapeutic strategy for petroclival meningiomas☆

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Patients and methods

Outcomes for patients initially treated with microsurgery

Is radical resection always the best option for preserving high quality of life in the patient?

Conclusions

Surg Neurol

Int J Radiat Oncol Biol Phys

Petroclival meningiomas: predictive parameters for transpetrosal approaches

Neurosurgery

Petrosal approach for petroclival meningiomas

Neurosurgery

The long-term side effects of radiation therapy for benign brain tumors in adults

J Neurosurg

Radiation therapy in the treatment of partially resected meningiomas

Neurosurgery

Microsurgical removal of petroclival meningiomas: a report of 33 patients

Neurosurgery

Clivus meningiomas

Neurology

Petroclival meningiomas: surgical experience in 109 cases

J Neurosurg

Long-term outcome and growth rate of subtotally resected petroclival meningiomas: experience with 38 cases

Neurosurgery

The clinical evaluation of chemotherapeutic agents in cancer

Neoplasm
The selection of the optimal therapeutic strategy for petroclival meningiomas☆