Microsurgical resectability, outcomes, and tumor control in meningiomas occupying the cavernous sinus

Abstract

Cavernous sinus meningiomas (CSMs) represent a subset of intracranial tumors that continue to pose a formidable challenge to neurosurgeons. The various factors contributing to the challenging management of CSMs include not only their location, which limits their resectability and increases the risk of injuring critical neurovascular structures, but also achieving long-term tumor control and maintaining or improving patient quality-of-life outcomes. 1,5,6,9,10,13,20,21,27,30,32,38,41,44 Initially, CSMs were deemed inoperable due to the considerable mortality and morbidity related to removal of the tumor from what was deemed a surgically inaccessible area. With the introduction of the operating microscope and advances in neuroimaging, resection of these tumors became a realistic goal. The advances in microneurosurgical techniques in the 1980s and early 1990s allowed attempts at aggressive resection of these tumors. In the last 2 decades, the enthusiasm for aggressive resection has been tempered and the pendulum has swung toward a more conservative surgical strategy for treating the tumors of the parasellar compartment. Major factors that seem to be responsible for this paradigm shift include the efficacy and abbreviatioNs CN = cranial nerve; CND = CN dysfunction; CS = cavernous sinus; CSM = CS meningioma; ECA = external carotid artery; FT = frontotemporal; FTO = FT craniotomy with orbital osteotomy; FTOZ = FT orbitozygomatic; ICA = internal carotid artery; KPS = Karnofsky Performance Scale; MF = middle fossa; RT = radiotherapy; SRS = stereotactic radiosurgery. obJective Cavernous sinus meningiomas (CSMs) represent a cohort of challenging skull base tumors. Proper management requires achieving a balance between optimal resection, restoration of cranial nerve (CN) function, and maintaining or improving quality of life. The objective of this study was to assess the pre-, intra-, and postoperative factors related to clinical and neurological outcomes, morbidity, mortality, and tumor control in patients with CSM. methods A retrospective review of a single surgeon's experience with microsurgical removal of CSM in 65 patients between January 1996 and August 2013 was done. Sekhar's classification, modified Kobayashi grading, and the Karnofsky Performance Scale were used to define tumor extension, tumor removal, and clinical outcomes, respectively. results Preoperative CN dysfunction was evident in 64.6% of patients. CN II deficits were most common. The greatest improvement was seen for CN V deficits, whereas CN II and CN IV deficits showed the smallest degree of recovery. Complete resection was achieved in 41.5% of cases and was not significantly associated with functional CN recovery. Internal carotid artery encasement significantly limited the complete microscopic resection of CSM (p < 0.0001). Overall, 18.5% of patients showed symptomatic recurrence after their initial surgery (mean follow-up 60.8 months [range 3-199 months]). The use of adjuvant stereotactic radiosurgery (SRS) after microsurgery independently decreas...

Stereotactic Radiosurgery of Cavernous Sinus Meningiomas

“…3,4,6,15 Apart from the higher risk for morbidity, complete resection does not naturally result in effective tumor control. For instance, in a current series of Nanda et al, 5 complete resection has no effect on tumor recurrence. These authors found a better outcome with SRS adjuvant to surgery than with surgery alone.…”

“…3,4 Also, it became obvious in the recent decade that even an aggressive surgical approach cannot totally erase CSM in particular in cases with microscopic infiltration of neurovascular elements. 5 The innovations in radiotherapy and radiosurgery opened alternative approaches for the definitive or adjuvant treatment of CSM. Stereotactic radiosurgery (SRS) has the potential to induce long-term tumor control while maintaining neurovascular and CN function.…”

Gamma Knife Radiosurgery for Cavernous Sinus Meningiomas: Analysis of Outcome in 166 Patients

“…It is now clear that curative surgery as the sole treatment is not a secure and sufficient option in many cases of CSM [6]. According to the present literature, primary GKRS is a reasonable, safe, and effective option for these tumors.…”

“…However, this enthusiasm has declined down to a plateau when it became clear that there is a high burden on quality of life with an aggressive surgical approach while microscopic infiltration of neurovascular elements cannot be eliminated in CS by surgery alone [4,5,6]. These observations paved the road for reconsideration of radiotherapeutic approaches as the sole or adjunctive treatment modalities.…”

Evaluation of Biopathogenesis of Meningioma Cases in the Light of Literature

“…Chan ve ark. 26 ise benzer sınıflama sistemini kullanarak gerçekleştirdikleri araştırmala-rında, grade I rezeksiyon yapılan olguların %11'inde, grade II rezeksiyon yapılan olguların %22'sinde, grade III rezeksiyon yapılan olguların %50'sinde, grade IV rezeksiyon yapılan olguların %37'sinde, grade V yapı-lan olguların ise %100'ünde takipleri esnasında nüks saptandığını ileri sürmüşlerdir. .…”