Significance of Simpson grading system in modern meningioma surgery: integration of the grade with MIB-1 labeling index as a key to predict the recurrence of WHO Grade I meningiomas

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Techniques for the surgical treatment of meningioma have undergone many improvements since Simpson established the neurosurgical dogma for meningioma surgery in his seminal paper published in 1957. This study aims to assess the clinical significance and limitations of the Simpson grading system in relation to modern surgery for WHO Grade I benign meningiomas and to explore the potential of the cell proliferation index to complement the limitations in predicting their recurrence.


The surgical records of patients who underwent resection of intracranial meningiomas at the University of Tokyo Hospital between January 1995 and August 2010 were retrospectively analyzed. The authors investigated the relationships between recurrence-free survival (RFS) and Simpson grade or MIB-1 labeling index value.


A total of 240 patients harboring 248 benign meningiomas were included in this study. Simpson Grade IV resection was associated with a significantly shorter RFS than Simpson Grade I, II, or III resection (p < 0.001), while no statistically significant difference was noted in RFS between Simpson Grades I, II, and III. Among meningiomas treated by Simpson Grade II and III resections, however, multivariate analysis revealed that an MIB-1 index of 3% or higher was associated with a significantly shorter time to recurrence.


The clinical significance of the different management strategies related to Simpson Grade I–III resection may have been diluted in the modern surgical era. The MIB-1 index can differentiate tumors with a high risk of recurrence, which could be beneficial for planning tailored optimal follow-up strategies. The results of this study appear to provide a significant backing for the recent shift in meningioma surgery from attempting aggressive resection to valuing the quality of the patient's life.

Abbreviations used in this paper:LI = labeling index; RFS = recurrence-free survival.

Article Information

Address correspondence to: Soichi Oya, M.D., Ph.D., Department of Neurosurgery, University of Tokyo, 7-3-1 Hongo Bunkyo, Tokyo 113-8655, Japan. email:

Please include this information when citing this paper: published online May 4, 2012; DOI: 10.3171/2012.3.JNS111945.

© AANS, except where prohibited by US copyright law.



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    Images of meningiomas with (upper) and without (lower) recurrence during the follow-up period. A: Preoperative axial T1-weighted enhanced MRI study demonstrating a left temporal convexity meningioma. B: Postoperative MRI study obtained immediately after a Simpson Grade I resection. C: Axial MR image obtained 7 years after surgery showing no recurrence. D: Photomicrograph of this tumor with an MIB-1 staining index less than 1%. E: Preoperative coronal contrast-enhanced T1-weighted MRI study showing a left parasagittal meningioma. F: Postoperative MRI study obtained immediately after a Simpson Grade II resection. G: Coronal MRI study obtained 5 years after surgery, revealing a recurrent mass on the wall of the superior sagittal sinus. H: Photomicrograph of this meningioma with an MIB-1 staining index of 4%. Original magnification × 400 (D and H).

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    Kaplan-Meier curve showing the relationship between RFS and Simpson grade in all patients.

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    Kaplan-Meier curve showing that the Simpson grade was not significantly associated with RFS for convexity meningiomas.

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    Kaplan-Meier curve of RFS for falcine and parasagittal meningiomas according to Simpson grade

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    Kaplan-Meier curve of RFS for skull base meningiomas according to Simpson grade.

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    Bar graph showing the distribution of the values of MIB-1 labeling index. The numbers above the bars indicate the number of cases in each group.

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    Kaplan-Meier curve of RFS for meningiomas treated by Simpson Grade II or III resection according to MIB-1 labeling index

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    Illustrative case of a patient with a WHO Grade I meningioma that showed rapid regrowth. A: Enhanced T1-weighted MRI study obtained at the time of initial detection of the tumor. B: Enhanced T1-weighted MRI study obtained 3 years after surgery, showing no recurrence. C: Enhanced T1-weighted MRI obtained 7 years later, revealing recurrence of meningioma. D: A photomicrograph of the specimen from the first surgery demonstrating that 15% of tumor cells were positive for MIB-1 antibody. Original magnification × 400.



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