Effect of dural detachment on long-term tumor control for meningiomas treated using Simpson Grade IV resection

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Meningiomas treated by subtotal or partial resection are associated with significantly shorter recurrence-free survival than those treated by gross-total resection. The Simpson grading system classifies incomplete resections into a single category, namely Simpson Grade IV, with wide variations in the volume and location of residual tumors, making it complicated to evaluate the achievement of surgical goals and predict the prognosis of these tumors. Authors of the present study investigated the factors related to necessity of retreatment and tried to identify any surgical nuances achievable with the aid of modern neurosurgical techniques for meningiomas treated using Simpson Grade IV resection.


This retrospective analysis included patients with WHO Grade I meningiomas treated using Simpson Grade IV resection as the initial therapy at the University of Tokyo Hospital between January 1995 and April 2010. Retreatment was defined as reresection or stereotactic radiosurgery due to postoperative tumor growth.


A total of 38 patients were included in this study. Regrowth of residual tumor was observed in 22 patients with a mean follow-up period of 6.1 years. Retreatment was performed for 20 of these 22 tumors with regrowth. Risk factors related to significantly shorter retreatment-free survival were age younger than 50 years (p = 0.006), postresection tumor volume of 4 cm3 or more (p = 0.016), no dural detachment (p = 0.001), and skull base location (p = 0.016). Multivariate analysis revealed that no dural detachment (hazard ratio [HR] 6.42, 95% CI 1.41–45.0; p = 0.02) and skull base location (HR 11.6, 95% CI 2.18–218; p = 0.002) were independent risk factors for the necessity of early retreatment, whereas postresection tumor volume of 4 cm3 or more was not a statistically significant risk factor.


Compared with Simpson Grade I, II, and III resections, Simpson Grade IV resection includes highly heterogeneous tumors in terms of resection rate and location of the residual mass. Despite the difficulty in analyzing such diverse data, these results draw attention to the favorable effect of dural detachment (instead of maximizing the resection rate) on long-term tumor control. Surgical strategy with an emphasis on detaching the tumor from the affected dura might be another important option in resection of high-risk meningiomas not amenable to gross-total resection.

Abbreviations used in this paper:HR = hazard ratio; KPS = Karnofsky Performance Scale; RFS = retreatment-free survival.

Article Information

Address correspondence to: Soichi Oya, M.D., Ph.D., Department of Neurosurgery, University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan. email: sooya-tky@umin.ac.jp.

Please include this information when citing this paper: published online September 20, 2013; DOI: 10.3171/2013.8.JNS13832.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Kaplan-Meier curves of time to retreatment in 38 patients with meningiomas. Time-to-retreatment curves are stratified by age (A), sex (B), preresection volume (C), postresection volume (D), resection rate (E), laterality (F), MIB-1 labeling index (G), management of dural attachment (H), skull base location (I), and peritumoral edema (J).

  • View in gallery

    Representative meningiomas with (A–C; Case 1) and without (D–F; Case 2) dural detachment during the follow-up period. A: Preoperative coronal T1-weighted MR image with contrast medium demonstrating a tuberculum sellae meningioma. B: Postoperative MR image performed immediately after Simpson Grade IV resection with dural detachment. C: Coronal MR image performed 7 years after surgery showing no tumor growth. D: Preoperative axial T1-weighted MR image with contrast medium demonstrating a paraclinoid meningioma. E: Postoperative MR image performed immediately after Simpson Grade IV resection without dural detachment. F: Axial MR image performed 2 years after surgery showing tumor growth.



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