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Hyperostosing Spheno-Orbital Meningioma Classification Paradigm

Hyperostosing Spheno-Orbital Meningioma Classification Paradigm. John R. Floyd, II M.D . Franco DeMonte , M.D. UT, MD Anderson Cancer Center UT, Health Science Center San Antonio.

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Hyperostosing Spheno-Orbital Meningioma Classification Paradigm

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  1. Hyperostosing Spheno-Orbital MeningiomaClassification Paradigm John R. Floyd, II M.D. Franco DeMonte, M.D. UT, MD Anderson Cancer Center UT, Health Science Center San Antonio

  2. Cushing, H. and L. Eisenhardt, Meningiomas. Their classificaion, regional behavior, life history, and surgical end results. 1938, Springfield, IL: Charles C. Thomas. en plaque meningiomas with carpet like growth patterns, osseous invasion, and hyperostosis. globalmeningiomas grow into the Sylvian fissure, and its diameter is typically greater than the base.

  3. Incidence • Castellano (1952) reviewed 608 cases of meningiomas • 111 (18.4%) were along the sphenoid ridge • 15 (2.5%) were associated with hyperostosis • Incidence varies from 4-9% in case series Castellano, F., B. Guidetti, and H. Olivecrona, Pterional meningiomas en plaque. J Neurosurg, 1952. 9(2): p. 188-96

  4. 1950’s….conservative • “It is true that vision on the affected side may be severely impaired or entirely lost….Nevertheless….this hardly seems to be sufficient reason to run the risk of a 10-15% mortality” • “ The bone must be burred away, which is a rather dangerous procedure, as the fraise (burr) might slip. In one of our cases, this happened and the carotid artery was torn completely off at its point of entrance into the cranial chamber. This patient died two days later from the effects of cerebral ischaemia. • Castellano, F., B. Guidetti, and H. Olivecrona, Pterional meningiomas en plaque. J Neurosurg, 1952. 9(2): p. 188-96.

  5. Bonnal, J., et al., Invading meningiomas of the sphenoid ridge. J Neurosurg, 1980. 53(5): p. 587-99.

  6. Roser, F., et al., Sphenoid wing meningiomas with osseous involvement.SurgNeurol, 2005. 64(1): p. 37-43; discussion 43.

  7. Confusing Nomenclature En masse En plaque Sphenoid ridge meningiomas Pterional tumors en plaque Hyperostosing lesions of the ala magna Invading meningiomas of the sphenoid wing Spheno-cavernous meningiomas Intraosseous meningiomas Osteomeningioma Extraduralmeningiomas Spheno-Orbital Meningiomas

  8. Rationale Multiple classification schemes. Confusing nomenclature. Currently, there are no Preoperative Classification schemes

  9. Purpose of the Preoperative Scale • allows the surgeon to carefully evaluate the surgical condition, • to determine risk factors for and against a procedure, • to anticipate outcomes and problems in the postoperative period, • to educate patients

  10. Proposed Classification Scheme • Osseous invasion • Soft tissue invasion • Presence of cranial nerve neuropathy

  11. Osseous InvasionSphenoid Bone: Posterior Superior View

  12. Osseous Invasion Anteriolateral and inferiomedial greater wing of sphenoid affected; body of sphenoid, lesser wing, and anterior clinoid are not involved.

  13. Soft Tissue Invasion

  14. Soft Tissue Invasion Lateral temporal dura and small intradural component.

  15. Soft Tissue Invasion Lateral cavernous sinus, superior orbital fissure, orbital apex

  16. Cranial Nerve Neuropathy

  17. Proposed Scale forHyperostosing Spheno-Orbital Meningiomas (HSOMs)

  18. Patients were identified from the Departmental database from February 1994 until April 2008. • All meningiomas of the sphenoid ridge, cavernous sinus, and orbit were included if there was associated hyperostosis. Demographics

  19. Presenting Symptoms

  20. Patients had formal ophthalmological evaluations pre and postop. • Patients had detailed neuro-imaging including CT scan, MRI brain =/- Gad with orbital fat sat sequences. • Bicoronal incision, extradural approach was utilized, with orbital and zygomatic osteotomies as needed. Methods

  21. Preoperative Score

  22. Outcomes Evaluated • Clinical Outcomes • Proptosis • Vision • Diplopia • Technical Outcomes • Extent of Resection ( Simpson Grade) • Oncologic Outcome • Time to Progression

  23. Clinical Outcomes: Proptosis • Roser, F., et al., Sphenoid wing meningiomas with osseous involvement.SurgNeurol, 2005. 64(1): p. 37-43; discussion 43. • Shrivastava, R.K., et al., Sphenoorbital meningiomas: surgical limitations and lessons learned in their long-term management. J Neurosurg, 2005. 103(3): p. 491-7. • Bikmaz, K., R. Mrak, and O. Al-Mefty, Management of bone-invasive, hyperostotic sphenoid wing meningiomas. J Neurosurg, 2007. 107(5): p. 905-12. • Honeybul, S., et al., Sphenoid wing meningioma en plaque: a clinical review.ActaNeurochir (Wien), 2001. 143(8): p. 749-57; discussion 758. • Ringel, F., C. Cedzich, and J. Schramm, Microsurgical technique and results of a series of 63 spheno-orbital meningiomas. Neurosurgery, 2007. 60(4 Suppl 2): p. 214-21; discussion 221-2. • Sandalcioglu, I.E., et al., Spheno-orbital meningiomas: interdisciplinary surgical approach, resectability and long-term results. J CraniomaxillofacSurg, 2005. 33(4): p. 260-6. • Schick, U., et al., Management of meningiomas en plaque of the sphenoid wing. J Neurosurg, 2006. 104(2): p. 208-14.

  24. Proptosis • No statistical trend across preoperative grades, eg, Grade IA vs Grade IIIB. • The bone score as an independent variable did not predict the Simpson Grade of resection or recurrence/progression.

  25. Clinical Outcomes: Vision APD =Afferent Pupillary Defect; CD = Color Desaturation; ECF = Enlarged Central Field; * Acuity; LPO = Light Perception Only

  26. Clinical Outcomes: Vision Positive trend toward absence of Optic Neuropathy (ON) and Simpson Grade I resection and Preoperative Grade IA. (not statistically significant). Positive trend (p=0.074) toward the presence of ON and Simpson Grade IV resection (not statistically significant). Presence of Optice Neuropathy as an independent variable did not predict the Simpson Grade of resection or progression or recurrence

  27. Clinical Outcomes: Diplopia • 4/9 (44%) patients diplopia resolved • Double vision caused from rectus muscle constriction. • Orbital decompression relieved symptoms. • 5/9 (55%) patients had unchanged diplopia • 4 were due to true CN III, IV or VI palsy • 1 pt had previous TBI • 1 patient developed delayed double vision due to lateral rectus fibosis

  28. Diplopia • Positive trend for the absence of CN palsy in the preoperative Grade IA HSOMs (not statistically significant). • The presence of cranial nerve palsy did not independently predict the Simpson Grade of resection, progression or recurrence.

  29. Clinical Outcomes

  30. Technical and Oncological Outcomes

  31. Technical and Oncological Outcomes

  32. Technical and Oncological Outcomes • Positive trend toward HSOM Grade IA and Simpson Grade I with no recurrences (not statistically significant). • The individual bone score, presence or degree of optic neuropathy, presence or absence of cranial nerve palsy did not predict Simpson Grade resection, progression, or recurrence • Soft tissue score was highly predictive of Simpson Grade resection ( p<0.001) • When grouping soft tissue score 1 +2 vs. 3, this did predict tumor progression. ( p <0.045) • When analyzed as a continuous variable, • the hazard score for the total score ( eg 2-9; not by Grade), is 3.7, 95% CI 0.95 – 14.4, with a p value close to significance p = 0.06

  33. Oncologic Outcomes • Areas of progression: • cavernous sinus (two), • orbital apex and cavernous sinus (two), • and intraorbital (one). • All patients have had tumor stabilization with either: • SRS • IMRT

  34. Other Variables • No statistical difference between preoperative score or grade and: • Gender • Histological grade • MIB rate • Progression was unrelated to MIB rate or histology • Positive trend between higher preoperative grade and increasing age (not statistically significant).

  35. Overall, proptosis will improve 80% of time • Vision will improve about 40% of time ( no improvement if LPO) • Cranial nerve III,IV, or VI palsy tend not to improve • The strongest correlation with predicting outcomes is the soft tissue score: • Extent of resection ( Simpson Grade) • Risk for Progression • Progression occurs from residual tumor in the cavernous sinus, superior orbital fissure, orbital apex Conclusions • Limitations • Limited number of patients • Short follow-up for certain patients

  36. Trends • Grade IA: • Improved Clinical Symptoms • Complete Resections • No recurrences • Grade IIA: • Improved or Stabilized Clinical Symptoms • Incomplete Resections • More likely to have recurrence/progression • Grade IIB or IIIB • Stabilized Clinical Symptoms • Incomplete Resections • More likely to have recurrence/progression Conclusions

  37. The approach to HSOMs has shifted • from a nonsurgical stance, • to a present day patient outcome oriented strategy. Summary

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