Clinical and radiologic outcomes after stereotactic radiosurgery for meningiomas in direct contact with the optic apparatus: an international multicenter study

Abstract

OBJECTIVE Resection of meningiomas in direct contact with the anterior optic apparatus carries risk of injury to the visual pathway. Stereotactic radiosurgery (SRS) offers a minimally invasive alternative. However, its use is limited owing to the risk of radiation-induced optic neuropathy. Few SRS studies have specifically assessed the risks and benefits of treating meningiomas in direct contact with the optic nerve, chiasm, or optic tract. The authors hypothesized that SRS is safe for select patients with meningiomas in direct contact with the anterior optic apparatus. METHODS The authors performed an international multicenter retrospective analysis of 328 patients across 11 institutions. All patients had meningiomas in direct contract with the optic apparatus. Patients were followed for a median duration of 56 months after SRS. Neurological examinations, including visual function evaluations, were performed at follow-up visits. Clinical and treatment variables were collected at each site according to protocol. Tumor volumes were assessed with serial MR imaging. Variables predictive of visual deficit were identified using univariable and multivariable logistic regression. RESULTS SRS was the initial treatment modality for 64.6% of patients, and 93% of patients received SRS as a single fraction. Visual information was available for 302 patients. Of these patients, visual decline occurred in 29 patients (9.6%), of whom 12 (41.4%) had evidence of tumor progression. Visual decline in the remaining 17 patients (5.6%) was not associated with tumor progression. Pre-SRS Karnofsky Performance Status predicted visual decline in adjusted analysis (adjusted OR 0.9, 95% CI 0.9–1.0, p < 0.01). Follow-up imaging data were available for 322 patients. Of these patients, 294 patients (91.3%) had radiographic evidence of stability or tumor regression at last follow up. Symptom duration was associated with tumor progression in adjusted analysis (adjusted OR 1.01, adjusted 95% CI 1.0–1.02, adjusted p = 0.02). CONCLUSIONS In this international multicenter study, the vast majority of patients exhibited tumor control and preservation of visual function when SRS was used to treat meningioma in direct contact with the anterior optic pathways. SRS is a relatively safe treatment modality for select patients with perioptic meningiomas in direct contact with the optic apparatus.

Tumor Location Impacts the Development of Radiation Necrosis in Benign Intracranial Tumors

“…In our cohort we found a higher incidence of RN compared to large international trials of different intracranial tumors [38][39][40]. On the one hand, this could be due to the fact that many studies included only symptomatic RN requiring treatment.…”

Tumor location impacts the development of radiation necrosis in benign intracranial tumors

“…In our cohort we found a higher incidence of RN compared to large international trials of different intracranial tumors. [33][34][35] On the one hand, this could be due to the fact that many studies included only symptomatic RN requiring treatment. However, in our study, we also included those limited to imaging based diagnosis of RN, potentially leading to a higher incidence thereof.…”

In Reply: International Tuberculum Sellae Meningioma Study: Surgical Outcomes and Management Trends

“…1,3,4 In addition to Samanci et al, large multicenter groups have reported acceptable safety of SRS for appropriately selected meningiomas in direct contact with the optic nerves or chiasm. [5][6][7] For residual tumor that is not amenable to resection, postoperative SRS or fractionated radiotherapy can offer excellent and safe tumor control, particularly considering that 93% of TSM are World Health Organization grade 1. 3 The safety profile of postoperative adjuvant radiation benefits from the surgically decompressed optic nerves during the operation.…”

“…8 Many TSM invade the optic canal, compressing and deforming the optic nerve, which can create a difficult volume to treat with radiotherapy without causing unacceptable radiation dose exposure to the compressed optic nerves, which is why we recommend surgery as the first-line treatment if the patient is amenable and can tolerate surgery (Figure). Certainly, in patients who refuse surgery or are not surgical candidates, fully fractionated radiotherapy or multisession (3)(4)(5) radiosurgery are treatment options to consider for symptomatic or growing tumors, but it is our strong opinion that the first-line treatment for symptomatic TSM in contact with the optic apparatus should be surgical resection with decompression of the optic nerves. SRS remains an excellent option for small asymptomatic TSM without optic nerve compression or for unresectable residual tumor or small recurrences, as used in the patients in the Samanci et al cohort.…”