The aim of this study was to evaluate the clinical outcome of sphenoid wing meningioma with periorbital invasion (PI) after operation.
Sixty one patients with sphenoid wing meningioma were enrolled in this study. Their clinical conditions were monitored after the operation and followed up more than 5 years at the outpatient clinic of a single institution. Clinical and radiologic information of the patients were all recorded including the following parameters : presence of PI, presence of peri-tumor structure invasion, pathologic grade, extents of resection, presence of hyperostosis, exophthalmos index (EI), and surgical complications. We compared the above clinical parameters of the patients with sphenoid wing meningioma in the presence or absence of PI (non-PI), then linked the analyzed data with the clinical outcome of the patients.
Of 61 cases, there were 14 PI and 47 non-PI patients. PI group showed a significantly higher score of EI (1.37±0.24 vs. 1.00±0.01,
The GTR group showed lower recurrence rate than the STR group without differences in the surgical complications. Therefore, the GTR is strongly recommended to treat sphenoid wing meningioma with PI for the better clinical outcome.
Unlike other neurosurgical tumors, even the experienced surgeons often encounter a dilemma during the planning process of treating sphenoid wing meningioma with periorbital invasion (PI). Firstly, these tumors are not found frequently, and they are somewhat anatomically unfamiliar due to the nature of tumor mass concealed deep in the skull base. Theoretically, the maximal removal of tumor as well as the lesions of PI with hyperostosis is ideal. However, an aggressive extent of operation may cost many surgical complications such as visual disturbance or proptosis of the eye ipsilaterally located to the tumor mass. Evidently, the anatomical structures in the proximity of the tumor mass are complex, and the eloquent regions around the tumor are susceptible to the injury during the operation. In addition, experienced surgical skills are often required to manage the periorbital fat, bony gliding of the hyperostosis site followed by careful periorbital reconstruction. In the real practice, the treatment options for the sphenoidal meningioma with PI depend on the surgeon’s personal training, experience and surgical preference, and surgery is not always recommended to every patient. Ringel et al. [
We hereby showed a single institutional study of the surgical cases of sphenoid wing meningioma with PI analyzed with multiple clinical factors to evaluate the final clinical outcome of the patients.
This study is retrospective study of a single institution based on electronic medical record chart review and does not require Institutional Review Board’s approval. Sixty one patients with sphenoid wing meningioma were enrolled in this study. They were followed up for more than 5 years post-operatively from 2010 to 2014. All the enrolled patients were divided into two groups based on the presence or absence of PI. All data was obtained through the radiologic findings and the electronic medical database of Gangnam Severance Hospital. Data collected included the following main information : basic demographics of patients with radiologic findings; extent of resection; hyperostosis; presence of tumor recurrence event; operation time; amount of intraoperative bleeding; pre-operative symptoms; changes in the pre-operative and post-operative exophthalmos index (EI); clinical outcomes; and surgical complications. Clinical factors to evaluate and define surgical difficulties were the amount of intraoperative bleeding and operation time. The surgical complications were divided into early and late in terms of time of the events. “Early” complications were defined as the onset of abnormal symptoms reported within 2 weeks after the operation and this was usually found while the patient was hospitalized. “Late” complications were defined as the surgical complications reported during the follow-up period at the outpatient clinic, usually 1 or 2 years after discharging from the hospital. We applied the method of measuring EI reported by Scarone et al. [
All studies were statistically analyzed using IBM SPSS version 23 (IBM Corp., Armonk, NY, USA). The continuous variables were presented as the means and standard deviations, whereas the categorical variables were presented as frequencies and percentages. An independent t-test was used to compare the continuous variables of the two groups. A chi-square test was used to compare the nominal factors of the two groups. The statistical significance was confirmed when the
Among the total of 61 patients, 14 patients had PI and 47 patients had non-PI. The mean follow-up periods were 7.43±1.41 years. In the PI group, the initial symptoms were eye-related problems were dominant, such as exophthalmos or visual impairment, whereas, in the non-PI group, headache was the main symptom. The symptom of exophthalmos was notably prevalent in the PI group (
The mean pre-operative EI score of PI group was 1.37 while the mean post-operative EI score was 1.12. The degree of exophthalmos was clearly reduced after the removal of tumor mass. Specifically, in the PI group, the post-operative EI score was decreased by 0.24. However, there was no statistically significant difference in the pre-operative and post-operative EI scores between the GTR and STR groups. This signifies that, regardless of the extents of tumor resection, debulking act of tumor mass clearly relieved the symptoms of exophthalmos.
We also analyzed the complication rates based on the presence of PI. Early complications were consisted of cranial nerve palsy (n=14), infarction (n=3), infection (n=1), diplopia (n=3), changes in facial sensation (n=6), and other symptoms (n=3). Late complications included the following symptoms : cranial nerve palsy (n=14), infarction (n=3), exposure of fixation plates (n=1), and changes in facial sensation (n=2). We performed the statistical analysis of various parameters focused on the late complications. According to the univariate analysis, the tumor size, the presence of hyperostosis, EI score, the presence of PI, extent of resection, invasion of major vessel, optic apparatus, and cavernous sinus were significantly correlated with the rates of recurrence (
This study investigated in detail about the importance of GTR in treating sphenoid wing meningioma with PI. Sphenoid wing meningioma accounts for approximately 18% of total intracranial meningioma [
In this clinical study, we investigated whether the presence of PI affected the degree of surgical difficulty. The criteria for surgical difficulty were defined by the following parameters : operation time, bleeding amount during the operation, and the rates of GTR. As a result, longer operation time was taken in the cases with the PI while the number of cases with GTR was also lesser than those patients without the PI. Moreover, the rates of hyperostosis were higher in the cases with PI, and this finding showed a statistical significance. Based on this analysis, it is clear that the degree of surgical difficulties is increased if the sphenoid wing meningioma is accompanied with the PI. We also investigated the relationship of the extent of the resection with the incidences of surgical complication or with the recurrence rates of tumor after the operation. Resultantly, the recurrence rates in the patients of PI group, who received GTR, were lower while the incidences of surgical complication between the groups of GTR and STR showed no significant difference.
Surgical resection of sphenoid wing meningioma with PI is technically demanding due to the difficult removal of hyperostosis with enough resection margin, reconstruction of bony structure and dura mater, and conservation of important anatomical structures such as optic nerve, oculomotor nerve, trigeminal nerve or internal carotid artery [
The limitation of our study is that this is a retrospective investigation in a single institution. Our institution has a large skull base surgery center, and the surgical data were obtained from a single neurosurgeon with extensive experience and expertise in skull base tumors. The surgical goal of this type tumor has to be flexible as the medical conditions of the patients with this kind of tumors are diverse. Surgical difficulties must be considered differently in the individual cases. Hence, the treatment regimen must be tailored to fit the individual patients based on the various clinical situations. Nevertheless, this study has proven, in part, that the rates of post-operative tumor recurrences can be markedly reduced in the cases of sphenoid wing meningioma with PI when the GTR was conducted aggressively. There is no doubt that this is closely related to the long-term clinical outcome of the patients with this specific types of skull base tumor.
We hereby report our neurosurgical experiences in the cases of sphenoid wing meningioma with PI. According to our data, the most critical factor in determining the rate of recurrence was the extent of surgical resection. The incidences of surgical complication were not notably different between the GTR and STR of the tumor mass. The treatment option of this type of tumor is still controversial as there are many hurdles of surgical difficulties present to be overcome. The acceptable level of minimal morbidity and preservation of cranial nerve functions are crucial for long-term outcomes of the patients. Nevertheless, the active consideration of GTR in sphenoid wing meningioma with PI is highly recommended for the better clinical outcomes of the patients.
No potential conflict of interest relevant to this article was reported.
This type of study does not require informed consent.
Conceptualization : CKH, JO
Data curation : JO, GOP
Formal analysis : HHP
Methodology : JY
Project administration : GOP
Visualization : GOP, JO
Writing - original draft : GOP
Writing - review & editing : GOP, JO
None
None
Definition of exophthalmos index (EI). EI=a/b. The length of perpendicular line from the base line connecting the bilateral zygomatic bones to the most anterior point of the orbital globe is measured for both eyes. The ratio of the length (a) of the ipsilateral side of the tumor over the length (b) of the contralateral side of the tumor were calculated as EI score.
Clinical symptoms of patients
Clinical symptom | Periorbital invasion |
|||
---|---|---|---|---|
Yes (n=14) | No (n=47) | |||
Headache | 4 (28.6) | 17 (36.1) | 0.181 | |
Exophthalmos | 6 (42.9) | 0 (0.0) | <0.001 | |
Diplopia, visual impairment | 4 (28.6) | 8 (17.0) | 0.275 | |
Seizure | 0 (0.0) | 5 (10.6) | 0.258 | |
Dizziness | 0 (0.0) | 2 (4.3) | 0.591 | |
Incidental finding | 2 (14.3) | 9 (19.1) | 0.512 | |
Others (e.g., hand tremor, general weakness, confusion) | 3 (21.4) | 10 (21.2) | 0.626 |
Values are presented as number (%).
Chi-square
Relationship between periorbital invasion and various surgery-related factors
Surgical factor | Periorbital invasion |
|||
---|---|---|---|---|
Yes (n=14) | No (n=47) | |||
Operation time (hours) | 8.63±2.91 | 6.26±3.25 | 0.018 | |
Exophthalmos index | 1.37±0.24 | 1.00±0.01 | <0.001 | |
Tumor size (cm) | 4.72±1.68 | 4.10±1.55 | 0.206 | |
Intra-operative bleeding (mL) | 972±614 | 950±729 | 0.939 | |
Presence of hyperostosis | 12 (85.7) | 2 (14.3) | <0.001 | |
Extent of resection | 0.032 | |||
Gross total resection (n=37) | 5 (35.7) | 32 (68.1) | ||
Subtotal resection (n=24) | 9 (64.3) | 15 (31.9) |
Values are presented as mean±standard deviation or number (%).
Chi-square, Independent t-test
Relationship between recurrence rates and surgical factors
Presence of recurrences |
||||||
---|---|---|---|---|---|---|
Univariate analysis |
Multivariate analysis |
|||||
Recurrence (n=11) | No recurrence (n=50) | OR | 95% CI | |||
Age (years) | 40.0±9.5 | 54.6±11.4 | 0.018 | 0.961 | 0.89–1.04 | 0.304 |
Gender, M : F | 4 : 7 | 10 : 40 | 0.215 | 0.449 | 0.21–9.79 | 0.610 |
Tumor size (cm) | 5.31±1.92 | 4.01±1.42 | 0.013 | 1.947 | 0.77–6.03 | 0.147 |
Pre-operative exophthalmos index | 1.28±0.33 | 1.04±0.11 | 0.034 | 0.084 | 0.03–902.28 | 0.516 |
Presence of periorbital invasion | 0.002 | 2.126 | 0.02–224.87 | 0.751 | ||
Yes (n=14) | 7 (50.0) | 7 (50.0) | ||||
No (n=47) | 4 (8.5) | 43 (91.5) | ||||
Presence of hyperostosis | 0.003 | 0.084 | 0.03–2.54 | 0.154 | ||
Yes (n=15) | 7 (53.3) | 8 (46.7) | ||||
No (n=46) | 4 (8.7) | 42 (91.3) | ||||
Extent of resection | 0.002 | 0.082 | 0.05–1.26 | 0.043 | ||
GTR (n=37) | 2 (5.4) | 35 (94.6) | ||||
STR (n=24) | 9 (37.5) | 15 (62.5) | ||||
WHO grade | 0.630 | 0.683 | 0.01–35.99 | 0.851 | ||
I (n=54) | 10 (18.5) | 44 (81.5) | ||||
II (n=7) | 1 (14.3) | 6 (85.7) | ||||
Optic apparatus invasion | 0.020 | 1.662 | 0.10–28.43 | 0.725 | ||
Yes (n=14) | 7 (50.0) | 7 (50.0) | ||||
No (n=47) | 4 (8.5) | 43 (91.5) | ||||
Major vessel invasion | 0.042 | 1.009 | 0.50–20.07 | 0.995 | ||
Yes (n=33) | 9 (27.3) | 24 (72.7) | ||||
No (n=28) | 2 (7.1) | 26 (92.9) | ||||
Cavernous sinus invasion | 0.014 | 1.849 | 0.11–31.53 | 0.671 | ||
Yes (n=23) | 8 (34.8) | 15 (62.2) | ||||
No (n=38) | 3 (7.9) | 35 (92.1) |
Values are presented as mean±standard deviation or number (%) unless otherwise indicated.
Univariate analysis : chi-square test, independent t-test.
Multivariate analysis : logistic regression analysis.
OR : odds ratio, CI : confidence interval, M : male, F : female, GTR : gross total resection, STR : subtotal resection, WHO : World Health Organization
Relationship between complication rates and surgical factors
Complications |
||||||
---|---|---|---|---|---|---|
Univariate analysis |
Multivariate analysis |
|||||
Complications (n=20) | No complications (n=41) | OR | 95% CI | |||
Age (years) | 47.9±13.0 | 51.76±12.9 | 0.288 | 0.977 | 0.92–1.03 | 0.444 |
Gender, M : F | 5 : 15 | 9 : 42 | 0.515 | 0.192 | 0.03–1.49 | 0.158 |
Tumor size (cm) | 5.2±1.6 | 3.7±1.3 | 0.001 | 2.602 | 1.35–5.00 | 0.017 |
Pre-operative exophthalmos index | 1.13±0.31 | 1.07±0.12 | 0.270 | 43.27 | 0.09–214.20 | 0.069 |
Presence of periorbital invasion | 0.515 | 18.57 | 0.54–634.10 | 0.093 | ||
Yes (n=14) | 5 (35.7) | 9 (25.0) | ||||
No (n=47) | 15 (31.9) | 32 (68.1) | ||||
Presence of hyperostosis | 0.597 | 0.489 | 0.05–4.89 | 0.435 | ||
Yes (n=15) | 5 (33.3) | 10 (66.7) | ||||
No (n=46) | 15 (32.6) | 31 (67.4) | ||||
Extent of resection | 0.071 | 0.316 | 0.74–1.34 | 0.884 | ||
GTR (n=37) | 9 (24.3) | 28 (75.7) | ||||
STR (n=24) | 11 (45.8) | 13 (54.2) | ||||
WHO grade | 0.416 | 0.463 | 0.04–6.10 | 0.558 | ||
I (n=54) | 17 (31.5) | 37 (68.5) | ||||
II (n=7) | 3 (42.9) | 4 (57.1) | ||||
Optic apparatus invasion | 0.032 | 0.393 | 0.20–7.63 | 0.567 | ||
Yes (n=14) | 8 (57.1) | 6 (42.9) | ||||
No (n=47) | 12 (25.5) | 35 (74.5) | ||||
Major vessel invasion | 0.179 | 3.419 | 0.55–21.28 | 0.188 | ||
Yes (n=33) | 13 (39.4) | 20 (60.6) | ||||
No (n=28) | 7 (25.0) | 21 (75.0) | ||||
Cavernous sinus invasion | 0.001 | 0.180 | 0.02–1.36 | 0.096 | ||
Yes (n=23) | 14 (60.9) | 9 (39.1) | ||||
No (n=38) | 6 (15.8) | 32 (84.2) |
Values are presented as mean±standard deviation or number (%) unless otherwise indicated.
Univariate analysis : chi-square test, independent t-test.
Multivariate analysis : logistic regression analysis.
OR : odds ratio, CI : confidence interval, M : male, F : female, GTR : gross total resection, STR : subtotal resection, WHO : World Health Organization