Introduction: Because meningiomas often involve the adjacent calvarium, partial or complete removal
of infiltrated bone is required to achieve a gross total, Simpson grade 1 resection.Reconstruction of the resulting bone defect is typically achieved with a non-native
implant, which can often result in poor cosmesis, foreign body reaction, or infection.Extracorporeal irradiation and reimplantation of tumorous bone has been used for limb-sparing
surgery with excellent results, but this treatment option is not routinely considered
in meningioma surgery.We present a case of anterior fossa meningioma with tumorous overlying calvarium that
was successfully managed with intraoperative extracorporeal irradiation and reimplantation.
Case Report: A 37-year-old woman with persistent chronic headaches was found to have an anterior
skull base meningioma with extension into the forehead frontal bone. A bifrontal craniotomy
was performed to encompass the area of involvement on preoperative imaging. The bone
flap was sterilely packed in saline-soaked gauze, transported to the radiation oncology
suite, irradiated with 120 Gy, and returned to the operating room promptly thereafter.
After gross-total resection of the tumor, the bone flap was replaced in its native
position and affixed to the calvarium using titanium plates and screws. Nineteen months
postoperatively, the patient had an excellent cosmetic outcome with no radiographic
evidence of tumor recurrence or significant bone flap resorption.
Discussion: To achieve complete gross-total resection of meningioma, tumorous calvaria must either
be eradicated of tumor cells or discarded and the defect reconstructed.Commonly used reconstructive options include titanium mesh or a variety of other alloplastic
implants, but these can result in foreign-body reactions, infection, poor cosmesis,
and increased cost.Replacement of the patient’s native flap may provide ideal cosmesis but is only appropriate
if it has been cleared of all tumor cells. Previously described sterilization techniques
include autoclaving, boiling, or pasteurization, but each of these may compromise
structural integrity resulting in resorption that leads to poor cosmesis.Intraoperative extracorporeal irradiation of tumorous calvaria during meningioma surgery
is an effective, logistically feasible treatment option to achieve local tumor control
and excellent cosmetic outcome.
