The relevance of Simpson Grade I and II resection in modern neurosurgical treatment of World Health Organization Grade I meningiomas

Clinical article

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Object

In 1957, Simpson published a seminal paper defining the risk factors for recurrence following surgical treatment of intracranial meningiomas. Given that Simpson's study was published more than 50 years ago, preceding image guidance technology and MR imaging, the authors reviewed their own experience with surgical treatment of Grade I meningiomas to determine if Simpson's grading scale is still relevant to modern neurosurgical practice.

Methods

From this cohort, the authors evaluated all patients undergoing craniotomy for resection of a histologically proven WHO Grade I meningioma as their initial therapy. Clinical information was retrospectively reconstructed using patient medical records and radiological data. Recurrence analysis was performed using the Kaplan-Meier method.

Results

The 5-year recurrence/progression-free survival for all patients receiving a Simpson Grade I, II, III, or IV resection was 95, 85, 88, and 81%, respectively (p = not significant, log-rank test). Kaplan-Meier analysis revealed no significant difference in recurrence-free survival between patients receiving a Simpson Grade I, II, III, or IV resection. Analysis limited to meningiomas arising from the skull base (excluding the cavernous sinus) similarly found no significant benefit to Simpson Grade I or II resection, and the survival curves were nearly superimposed.

Conclusions

In this study of a cohort of patients undergoing surgery for WHO Grade I meningiomas, the authors demonstrate that the benefit of more aggressive attempts to resect the tumor with dura and underlying bone was negligible compared with simply removing the entire tumor, or even leaving small amounts of tumor attached to critical structures. The authors believe that these data reflect an evolution in the nature of meningioma surgery over the past 2 decades, and bring into question the relevance of using Simpson's grading system as the sole predictor of recurrence.

Abbreviations used in this paper: CUSA = Cavitron Ultrasonic Aspirator; UCSF = University of California, San Francisco.

Article Information

Address correspondence to: Andrew T. Parsa, M.D., Ph.D., Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, California 94143. email: parsaa@neurosurg.ucsf.edu.

Please include this information when citing this paper: published online April 9, 2010; DOI: 10.3171/2010.3.JNS091971.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Upper: Kaplan-Meier curves depicting recurrence survival for all patients undergoing Simpson Grades I–IV resections of a WHO Grade I meningioma. Lower: The same analysis limited to patients with more than 4 years of postoperative follow-up. The numeric labels at the right signify the Simpson grade of resection associated with that Kaplan-Meier curve. No statistically significant difference was noted between groups.

  • View in gallery

    Results of Kaplan-Meier subgroup analyses, stratified by tumor location. The numeric labels at the right signify the Simpson grade of resection associated with that Kaplan-Meier curve. No statistically significant difference was noted between groups for any subgroup analysis. A: Kaplan-Meier curves depicting recurrence survival for patients with a convexity meningioma undergoing Simpson Grades I–IV resections. B: Kaplan-Meier curves depicting recurrence survival for patients with a falcine or parasagittal meningioma undergoing Simpson Grades I–IV resections. C: Kaplan-Meier curves depicting recurrence survival for patients with a skull base meningioma undergoing Simpson Grades I–IV resections.

  • View in gallery

    Kaplan-Meier analysis depicting recurrence-free survival in patients undergoing surgery without preoperative embolization.

References

  • 1

    Adachi KKawase TYoshida KYazaki TOnozuka S: ABC Surgical Risk Scale for skull base meningioma: a new scoring system for predicting the extent of tumor removal and neurological outcome. Clinical article. J Neurosurg 111:105310612009

    • Search Google Scholar
    • Export Citation
  • 2

    Adegbite ABKhan MIPaine KWTan LK: The recurrence of intracranial meningiomas after surgical treatment. J Neurosurg 58:51561983

    • Search Google Scholar
    • Export Citation
  • 3

    Black PMMorokoff APZauberman J: Surgery for extra-axial tumors of the cerebral convexity and midline. Neurosurgery 62:6 Suppl 3111511232008

    • Search Google Scholar
    • Export Citation
  • 4

    Bozkurt SUAyan EBolukbasi FElmaci IPamir NSav A: Immunohistochemical expression of SPARC is correlated with recurrence, survival and malignant potential in meningiomas. APMIS 117:6516592009

    • Search Google Scholar
    • Export Citation
  • 5

    Caroli EOrlando ERMastronardi LFerrante L: Meningiomas infiltrating the superior sagittal sinus: surgical considerations of 328 cases. Neurosurg Rev 29:2362412006

    • Search Google Scholar
    • Export Citation
  • 6

    Chun JYMcDermott MWLamborn KRWilson CBHigashida RBerger MS: Delayed surgical resection reduces intraoperative blood loss for embolized meningiomas. Neurosurgery 50:123112372002

    • Search Google Scholar
    • Export Citation
  • 7

    Flickinger JCKondziolka DMaitz AHLunsford LD: Gamma knife radiosurgery of imaging-diagnosed intracranial meningioma. Int J Radiat Oncol Biol Phys 56:8018062003

    • Search Google Scholar
    • Export Citation
  • 8

    Jääskeläinen J: Seemingly complete removal of histologically benign intracranial meningioma: late recurrence rate and factors predicting recurrence in 657 patients. A multivariate analysis. Surg Neurol 26:4614691986

    • Search Google Scholar
    • Export Citation
  • 9

    Kondziolka DFlickinger JCPerez B: Judicious resection and/or radiosurgery for parasagittal meningiomas: outcomes from a multicenter review. Neurosurgery 43:4054141998

    • Search Google Scholar
    • Export Citation
  • 10

    Kondziolka DLevy EINiranjan AFlickinger JCLunsford LD: Long-term outcomes after meningioma radiosurgery: physician and patient perspectives. J Neurosurg 91:44501999

    • Search Google Scholar
    • Export Citation
  • 11

    Krejchi DCaldemeyer KSVakili STPritz MB: Neurosarcoidosis resembling meningioma: MRI characteristics and pathologic correlation. J Neuroimaging 8:1771791998

    • Search Google Scholar
    • Export Citation
  • 12

    Levine ZTBuchanan RISekhar LNRosen CLWright DC: Proposed grading system to predict the extent of resection and outcomes for cranial base meningiomas. Neurosurgery 45:2212301999

    • Search Google Scholar
    • Export Citation
  • 13

    Liu YLiu MLi FWu CZhu S: Malignant meningiomas: a retrospective study of 22 cases. Bull Cancer 94:E27E312007

  • 14

    Maiuri FDonzelli RMariniello GDel Basso De Caro MLColella APeca C: Local versus diffuse recurrences of meningiomas: factors correlated to the extent of the recurrence. Clin Neuropathol 27:29362008

    • Search Google Scholar
    • Export Citation
  • 15

    Mathiesen TLindquist CKihlström LKarlsson B: Recurrence of cranial base meningiomas. Neurosurgery 39:291996

  • 16

    Mirimanoff RODosoretz DELinggood RMOjemann RGMartuza RL: Meningioma: analysis of recurrence and progression following neurosurgical resection. J Neurosurg 62:18241985

    • Search Google Scholar
    • Export Citation
  • 17

    Nakane YNatsume AWakabayashi TOi SIto MInao S: Malignant transformation-related genes in meningiomas: allelic loss on 1p36 and methylation status of p73 and RASSF1A. J Neurosurg 107:3984042007

    • Search Google Scholar
    • Export Citation
  • 18

    Naumann MMeixensberger J: Factors influencing meningioma recurrence rate. Acta Neurochir (Wien) 107:1081111990

  • 19

    Obeid FAl-Mefty O: Recurrence of olfactory groove meningiomas. Neurosurgery 53:5345432003

  • 20

    Pollock BEStafford SLUtter AGiannini CSchreiner SA: Stereotactic radiosurgery provides equivalent tumor control to Simpson Grade 1 resection for patients with small- to medium-size meningiomas. Int J Radiat Oncol Biol Phys 55:100010052003

    • Search Google Scholar
    • Export Citation
  • 21

    Rosenberg LAPrayson RALee JReddy CChao STBarnett GH: Long-term experience with World Health Organization grade III (malignant) meningiomas at a single institution. Int J Radiat Oncol Biol Phys 74:4274322009

    • Search Google Scholar
    • Export Citation
  • 22

    Sanai NSughrue MEShangari GChung KBerger MSMcDermott MW: Risk profile associated with convexity meningioma resection in the modern neurosurgical era. Clinical article. J Neurosurg [epub ahead of print July 31 2009. DOI: 10.3171/2009.6.JNS081490]

    • Search Google Scholar
    • Export Citation
  • 23

    Simpson D: The recurrence of intracranial meningiomas after surgical treatment. J Neurol Neurosurg Psychiatry 20:22391957

  • 24

    Smith SJBoddu SMacarthur DC: Atypical meningiomas: WHO moved the goalposts?. Br J Neurosurg 21:5885922007

  • 25

    Stafford SLPerry ASuman VJMeyer FBScheithauer BWLohse CM: Primarily resected meningiomas: outcome and prognostic factors in 581 Mayo Clinic patients, 1978 through 1988. Mayo Clin Proc 73:9369421998

    • Search Google Scholar
    • Export Citation
  • 26

    Strassner CBuhl RMehdorn HM: Recurrence of intracranial meningiomas: did better methods of diagnosis and surgical treatment change the outcome in the last 30 years?. Neurol Res 31:4784822009

    • Search Google Scholar
    • Export Citation

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