Adjuvant radiation versus observation with salvage radiation after gross-total resection of WHO grade II meningiomas: a propensity score–adjusted analysis

View More View Less
  • 1 Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland;
  • | 2 Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland;
  • | 3 Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, Cleveland;
  • | 4 Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland; and
  • | 5 Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $515.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
Print or Print + Online

OBJECTIVE

After gross-total resection (GTR) of a newly diagnosed WHO grade II meningioma, the decision to treat with radiation upfront or at initial recurrence remains controversial. A comparison of progression-free survival (PFS) between observation and adjuvant radiation fails to account for the potential success of salvage radiation, and a direct comparison of PFS between adjuvant and salvage radiation is hampered by strong selection bias against salvage radiation cohorts in which only more aggressive, recurrent tumors are included. To account for the limitations of traditional PFS measures, the authors evaluated radiation failure-free survival (RFFS) between two treatment strategies after GTR: adjuvant radiation versus observation with salvage radiation, if necessary.

METHODS

The authors performed a retrospective review of patients who underwent GTR of newly diagnosed WHO grade II meningiomas at their institution between 1996 and 2019. They assessed traditional PFS in patients who underwent adjuvant radiation, postoperative observation, and salvage radiation. For RFFS, treatment failure was defined as time from initial surgery to failure of first radiation. To assess the association between treatment strategy and RFFS while accounting for potential confounders, a multivariable Cox regression analysis adjusted for the propensity score (PS) and inverse probability of treatment weighted (IPTW) Cox regression analysis were performed.

RESULTS

A total of 160 patients underwent GTR and were included in this study. Of the 121 patients who underwent observation, 32 (26.4%) developed recurrence and required salvage radiation. PFS at 3, 5, and 10 years after observation was 75.1%, 65.6%, and 45.5%, respectively. PFS at 3 and 5 years after salvage radiation was 81.7% and 61.3%, respectively. Of 160 patients, 39 received adjuvant radiation, and 3- and 5-year PFS/RFFS rates were 86.1% and 59.2%, respectively. In patients who underwent observation with salvage radiation, if necessary, the 3-, 5-, and 10-year RFFS rates were 97.7%, 90.3%, and 87.9%, respectively. Both PS and IPTW Cox regression models demonstrated that patients who underwent observation with salvage radiation treatment, if necessary, had significantly longer RFFS (PS model: hazard ratio [HR] 0.21, p < 0.01; IPTW model: HR 0.21, p < 0.01).

CONCLUSIONS

In this retrospective, nonrandomized study, adjuvant radiation after GTR of a WHO II meningioma did not add significant benefit over a strategy of observation and salvage radiation at initial recurrence, if necessary, but results must be considered in the context of the limitations of the study design.

ABBREVIATIONS

CTCAE = Common Terminology Criteria for Adverse Events; GTR = gross-total resection; HR = hazard ratio; IMRT = intensity-modulated radiation therapy; IPTW = inverse probability of treatment weighted; IQR = interquartile range; KPS = Karnofsky Performance Status; PFS = progression-free survival; PS = propensity score; RFFS = radiation failure-free survival; RTOG = Radiation Therapy Oncology Group; SG = Simpson grade; SRS = stereotactic radiosurgery; STR = subtotal resection.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $515.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
  • 1

    Modha A, Gutin PH. Diagnosis and treatment of atypical and anaplastic meningiomas: a review. Neurosurgery. 2005;57(3):538550.

  • 2

    Durand A, Labrousse F, Jouvet A, et al. WHO grade II and III meningiomas: a study of prognostic factors. J Neurooncol. 2009;95(3):367375.

  • 3

    Yang SY, Park CK, Park SH, et al. Atypical and anaplastic meningiomas: prognostic implications of clinicopathological features. J Neurol Neurosurg Psychiatry. 2008;79(5):574580.

    • Search Google Scholar
    • Export Citation
  • 4

    Aghi MK, Carter BS, Cosgrove GR, et al. Long-term recurrence rates of atypical meningiomas after gross total resection with or without postoperative adjuvant radiation. Neurosurgery. 2009;64(1):5660.

    • Search Google Scholar
    • Export Citation
  • 5

    Rogers CL, Won M, Vogelbaum MA, et al. High-risk meningioma: initial outcomes from NRG Oncology/RTOG 0539. Int J Radiat Oncol Biol Phys. 2020;106(4):790799.

    • Search Google Scholar
    • Export Citation
  • 6

    Aizer AA, Arvold ND, Catalano P, et al. Adjuvant radiation therapy, local recurrence, and the need for salvage therapy in atypical meningioma. Neuro Oncol. 2014;16(11):15471553.

    • Search Google Scholar
    • Export Citation
  • 7

    Bagshaw HP, Burt LM, Jensen RL, et al. Adjuvant radiotherapy for atypical meningiomas. J Neurosurg. 2017;126(6):18221828.

  • 8

    Rogers L, Barani I, Chamberlain M, et al. Meningiomas: knowledge base, treatment outcomes, and uncertainties. A RANO review. J Neurosurg. 2015;122(1):423.

    • Search Google Scholar
    • Export Citation
  • 9

    Hardesty DA, Wolf AB, Brachman DG, et al. The impact of adjuvant stereotactic radiosurgery on atypical meningioma recurrence following aggressive microsurgical resection. J Neurosurg. 2013;119(2):475481.

    • Search Google Scholar
    • Export Citation
  • 10

    Sun SQ, Hawasli AH, Huang J, et al. An evidence-based treatment algorithm for the management of WHO Grade II and III meningiomas. Neurosurg Focus. 2015;38(3):E3.

    • Search Google Scholar
    • Export Citation
  • 11

    Choi CYH, Soltys SG, Gibbs IC, et al. Cyberknife stereotactic radiosurgery for treatment of atypical (WHO grade II) cranial meningiomas. Neurosurgery. 2010;67(5):11801188.

    • Search Google Scholar
    • Export Citation
  • 12

    Mair R, Morris K, Scott I, Carroll TA. Radiotherapy for atypical meningiomas. J Neurosurg. 2011;115(4):811819.

  • 13

    Sun SQ, Kim AH, Cai C, et al. Management of atypical cranial meningiomas, part 1: predictors of recurrence and the role of adjuvant radiation after gross total resection. Neurosurgery. 2014;75(4):347355.

    • Search Google Scholar
    • Export Citation
  • 14

    Park HJ, Kang HC, Kim IH, et al. The role of adjuvant radiotherapy in atypical meningioma. J Neurooncol. 2013;115(2):241247.

  • 15

    Wang YC, Chuang CC, Wei KC, et al. Skull base atypical meningioma: long term surgical outcome and prognostic factors. Clin Neurol Neurosurg. 2015;128:112116.

    • Search Google Scholar
    • Export Citation
  • 16

    Chao S, Rogers L. External beam radiation therapy for meningioma. Handb Clin Neurol. 2020;170:259278.

  • 17

    Sun SQ, Cai C, Murphy RKJ, et al. Radiation therapy for residual or recurrent atypical meningioma: the effects of modality, timing, and tumor pathology on long-term outcomes. Neurosurgery. 2016;79(1):2332.

    • Search Google Scholar
    • Export Citation
  • 18

    Louis DN, Perry A, Reifenberger G, et al. The 2016 World Health Organization Classification of Tumors of the Central Nervous System: a summary. Acta Neuropathol. 2016;131(6):803820.

    • Search Google Scholar
    • Export Citation
  • 19

    Austin PC, Stuart EA. Moving towards best practice when using inverse probability of treatment weighting (IPTW) using the propensity score to estimate causal treatment effects in observational studies. Stat Med. 2015;34(28):36613679.

    • Search Google Scholar
    • Export Citation
  • 20

    al-Mefty O, Kersh JE, Routh A, Smith RR. The long-term side effects of radiation therapy for benign brain tumors in adults. J Neurosurg. 1990;73(4):502512.

    • Search Google Scholar
    • Export Citation
  • 21

    Mathiesen T, Kihlström L, Karlsson B, Lindquist C. Potential complications following radiotherapy for meningiomas. Surg Neurol. 2003;60(3):193200.

    • Search Google Scholar
    • Export Citation
  • 22

    Lee G, Lamba N, Niemierko A, et al. Adjuvant radiation therapy versus surveillance after surgical resection of atypical meningiomas. Int J Radiat Oncol Biol Phys. 2021;109(1):252266.

    • Search Google Scholar
    • Export Citation
  • 23

    Rogers L, Zhang P, Vogelbaum MA, et al. Intermediate-risk meningioma: initial outcomes from NRG Oncology RTOG 0539. J Neurosurg. 2018;129(1):3547.

    • Search Google Scholar
    • Export Citation
  • 24

    Harris AE, Lee JYK, Omalu B, et al. The effect of radiosurgery during management of aggressive meningiomas. Surg Neurol. 2003;60(4):298305.

  • 25

    Choi Y, Lim DH, Jo K, et al. Efficacy of postoperative radiotherapy for high grade meningiomas. J Neurooncol. 2014;119(2):405412.

  • 26

    Komotar RJ, Iorgulescu JB, Raper DMS, et al. The role of radiotherapy following gross-total resection of atypical meningiomas. J Neurosurg. 2012;117(4):679686.

    • Search Google Scholar
    • Export Citation
  • 27

    Soni P, Davison MA, Shao J, et al. Extent of resection and survival outcomes in World Health Organization grade II meningiomas. J Neurooncol. 2021;151(2):173179.

    • Search Google Scholar
    • Export Citation
  • 28

    Chen WC, Hara J, Magill ST, et al. Salvage therapy outcomes for atypical meningioma. J Neurooncol. 2018;138(2):425433.

  • 29

    Momin AA, Shao J, Soni P, et al. Outcomes of salvage radiation for recurrent world health organization grade II meningiomas: a retrospective cohort study. J Neurooncol. 2021;152:373382.

    • Search Google Scholar
    • Export Citation
  • 30

    Sahm F, Schrimpf D, Stichel D, et al. DNA methylation-based classification and grading system for meningioma: a multicentre, retrospective analysis. Lancet Oncol. 2017;18(5):682694.

    • Search Google Scholar
    • Export Citation
  • 31

    Sahm F, Schrimpf D, Jones DTW, et al. Next-generation sequencing in routine brain tumor diagnostics enables an integrated diagnosis and identifies actionable targets. Acta Neuropathol. 2016;131(6):903910.

    • Search Google Scholar
    • Export Citation
  • 32

    Olar A, Wani KM, Wilson CD, et al. Global epigenetic profiling identifies methylation subgroups associated with recurrence-free survival in meningioma. Acta Neuropathol. 2017;133(3):431444.

    • Search Google Scholar
    • Export Citation
  • 33

    Sievers P, Hielscher T, Schrimpf D, et al. CDKN2A/B homozygous deletion is associated with early recurrence in meningiomas. Acta Neuropathol. 2020;140(3):409413.

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 110 110 110
Full Text Views 39 39 39
PDF Downloads 56 56 56
EPUB Downloads 0 0 0