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Johannes Kerschbaumer, Christian F. Freyschlag, Günter Stockhammer, Susanne Taucher, Hans Maier, Claudius Thomé and Marcel Seiz-Rosenhagen

Meningiomas are known to be associated with female sex hormones. Worsening neurological symptoms or newly diagnosed meningiomas have been described in the context of elevated levels of sex hormones, for example, in pregnancy. To the authors’ knowledge, tumor shrinkage after the normalization of hormones has not been described, even if it is known that neurological deficits due to meningioma compression may improve after giving birth.

A 32-year-old female patient presented with severe headache and vision disturbances at the end of her second pregnancy. Magnetic resonance imaging revealed an extended mass at the lateral left-sided sphenoid wing that was suspected to be a meningioma. After delivery, the patient’s symptoms improved, and MRI obtained 2 months postpartum showed significant shrinkage of the lesion.

Significant tumor shrinkage can occur after pregnancy. Thus, repeat imaging is indicated in these patients.

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Maria Wostrack, Florian Ringel, Sven O. Eicker, Max Jägersberg, Karl Schaller, Johannes Kerschbaumer, Claudius Thomé, Ehab Shiban, Michael Stoffel, Benjamin Friedrich, Victoria Kehl, Peter Vajkoczy, Bernhard Meyer and Julia Onken

OBJECTIVE

Spinal ependymomas are rare glial neoplasms. Because their incidence is low, only a few larger studies have investigated this condition. There are no clear data concerning prognosis and therapy. The aim of the study was to describe the natural history, perioperative clinical course, and local tumor control of adult patients with spinal ependymomas who were surgically treated under modern treatment standards.

METHODS

The authors performed a multicenter retrospective study. They identified 158 adult patients with spinal ependymomas who had received surgical treatment between January 2006 and June 2013. The authors analyzed the clinical and histological aspects of these cases to identify the predictive factors for postoperative morbidity, tumor resectability, and recurrence.

RESULTS

Gross-total resection (GTR) was achieved in 80% of cases. At discharge, 37% of the patients showed a neurological decline. During follow-up the majority recovered, whereas 76% showed at least preoperative status. Permanent functional deterioration remained in 2% of the patients. Transient deficits were more frequent in patients with cervically located ependymomas (p = 0.004) and in older patients (p = 0.002). Permanent deficits were independently predicted only by older age (p = 0.026). Tumor progression was observed in 15 cases. The 5-year progression-free survival (PFS) rate was 80%, and GTR (p = 0.037), WHO grade II (p = 0.009), and low Ki-67 index (p = 0.005) were independent prognostic factors for PFS. Adjuvant radiation therapy was performed in 15 cases. No statistically relevant effects of radiation therapy were observed among patients with incompletely resected ependymomas (p = 0.079).

CONCLUSIONS

Due to its beneficial value for PFS, GTR is important in the treatment of spinal ependymoma. Gross-total resection is feasible in the majority of cases, with acceptable rates of permanent deficits. Also, Ki-67 appears to be an important prognostic factor and should be included in a grading scheme for spinal ependymomas.

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Victor E. Staartjes, Morgan Broggi, Costanza Maria Zattra, Flavio Vasella, Julia Velz, Silvia Schiavolin, Carlo Serra, Jiri Bartek Jr., Alexander Fletcher-Sandersjöö, Petter Förander, Darius Kalasauskas, Mirjam Renovanz, Florian Ringel, Konstantin R. Brawanski, Johannes Kerschbaumer, Christian F. Freyschlag, Asgeir S. Jakola, Kristin Sjåvik, Ole Solheim, Bawarjan Schatlo, Alexandra Sachkova, Hans Christoph Bock, Abdelhalim Hussein, Veit Rohde, Marike L. D. Broekman, Claudine O. Nogarede, Cynthia M. C. Lemmens, Julius M. Kernbach, Georg Neuloh, Oliver Bozinov, Niklaus Krayenbühl, Johannes Sarnthein, Paolo Ferroli, Luca Regli, Martin N. Stienen and FEBNS

OBJECTIVE

Decision-making for intracranial tumor surgery requires balancing the oncological benefit against the risk for resection-related impairment. Risk estimates are commonly based on subjective experience and generalized numbers from the literature, but even experienced surgeons overestimate functional outcome after surgery. Today, there is no reliable and objective way to preoperatively predict an individual patient’s risk of experiencing any functional impairment.

METHODS

The authors developed a prediction model for functional impairment at 3 to 6 months after microsurgical resection, defined as a decrease in Karnofsky Performance Status of ≥ 10 points. Two prospective registries in Switzerland and Italy were used for development. External validation was performed in 7 cohorts from Sweden, Norway, Germany, Austria, and the Netherlands. Age, sex, prior surgery, tumor histology and maximum diameter, expected major brain vessel or cranial nerve manipulation, resection in eloquent areas and the posterior fossa, and surgical approach were recorded. Discrimination and calibration metrics were evaluated.

RESULTS

In the development (2437 patients, 48.2% male; mean age ± SD: 55 ± 15 years) and external validation (2427 patients, 42.4% male; mean age ± SD: 58 ± 13 years) cohorts, functional impairment rates were 21.5% and 28.5%, respectively. In the development cohort, area under the curve (AUC) values of 0.72 (95% CI 0.69–0.74) were observed. In the pooled external validation cohort, the AUC was 0.72 (95% CI 0.69–0.74), confirming generalizability. Calibration plots indicated fair calibration in both cohorts. The tool has been incorporated into a web-based application available at https://neurosurgery.shinyapps.io/impairment/.

CONCLUSIONS

Functional impairment after intracranial tumor surgery remains extraordinarily difficult to predict, although machine learning can help quantify risk. This externally validated prediction tool can serve as the basis for case-by-case discussions and risk-to-benefit estimation of surgical treatment in the individual patient.