General Overview of Intracranial Meningiomas: 11 Years of Experience in an Oncological Reference Center

Abstract

Objective

To perform the clinical and therapeutic follow-up of patients with meningioma and to evaluate the risk and protective factors for the outcomes obtained during the treatment.

Materials and Methods

We conducted a retrospective cohort study using clinical, radiological, and histopathological data contained in the records of patients with meningiomas; we also performed retrospective monitoring for 5 years, evaluating the initial symptoms and clinical evolution, demographic data, risk factors, location, laterality and dimensions, treatment, complete radiological resection, death, additional deficits, and changes in the performance score.

Results

We followed up a sample of 86 patients with a mean age of 47 years and a predominance of female subjects. The most frequent histological types were the meningothelial, followed by the fibrous, the transitional subtype, and the mixed and psamomatous subtypes. Grade-II and -III injuries represented 8.13% and 3.12% of the total respectively. The initial clinical conditions presented nonspecific signs in 79% of the individuals and focal neurological signs in 12%, the most common being appendicular deficit, unilateral amaurosis, and cranial nerve syndrome. Regarding treatment distribution, all patients studied underwent surgical resection (Simpson 1: 15%; Simpson 2: 12%; Simpson 3: 35%; and Simpson 4: 36%), with a good correlation of the total radiological resection for the first 3 degrees.

Conclusion

Thus, the need for early diagnosis and therapy is emphasized to achieve a better outcome, and we recommend the performance of prospective studies that evaluate other variables to clarify the risk factors for mortality and recurrence.

 

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Resumo

Objetivo

Realizar o acompanhamento clínico e terapêutico de pacientes com meningioma e avaliar os fatores de risco e protetores para os desfechos obtidos durante o tratamento.

Materiais e Métodos

Conduziu-se um estudo de coorte retrospectivo em que foram utilizados os dados clínicos, radiológicos e histopatológicos dos registros de pacientes com meningiomas, e foi realizado um acompanhamento retrospectivo de 5 anos, com avaliação dos sintomas iniciais e da evolução clínica, dados demográficos, fatores de risco, localização, lateralidade e dimensões, tratamento, ressecção radiológica completa, óbito, déficits adicionais e alterações na pontuação de desempenho.

Resultados

Foi acompanhada uma amostra de 86 pacientes com idade média de 47 anos e predominância do sexo feminino. Os tipos histológicos mais frequentes foram o meningotelial, seguido pelo fibroso, o subtipo de transição e os subtipos misto e psamomatoso. As lesões de graus II e III representaram 8,13% e 3,12% do total, respectivamente. As condições clínicas iniciais apresentaram sinais inespecíficos em 79% dos indivíduos e sinais neurológicos focais em 12%, sendo os mais comuns o déficit apendicular, amaurose unilateral e síndrome do nervo craniano. Na distribuição do tratamento, todos os pacientes estudados foram submetidos à ressecção cirúrgica (Simpson 1: 15%; Simpson 2: 12%; Simpson 3: 35%; e Simpson 4: 36%), com boa correlação da ressecção radiológica total para os primeiros 3 graus.

Conclusão

Assim, enfatiza-se a necessidade de diagnóstico e terapia precoces para se alcançar um melhor resultado, e recomenda-se a realização de estudos prospectivos que avaliem outras variáveis para esclarecer os fatores de risco para mortalidade e recorrência.

 

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Keywords

meningioma - follow-up - survival analysis - neurosurgery

Palavras-chave

meningioma - seguimento - análise de sobrevida - neurocirurgia

Introduction

Meningiomas are the most frequently-encountered brain tumors in the adult population of North America.[1] They account for approximately 1/3 of the primary central nervous system (CNS) tumors, with a higher incidence among individuals aged between 50 and 60 years.[2] Approximately 2 out of every 100 thousand individuals are affected, with an increased incidence in recent decades attributed to the greater access to and effectiveness of imaging exams.[1]

These neoplasms originate in the arachnoid cap cells,[3] and they are classified histologically into grades I (benign: 90% of the cases); II (atypical: 5–7% of the cases); and III (anaplastic: 1–2% of the cases), according to the World Health Organization (WHO).[4] Progression to malignancy in meningiomas is associated with the accumulation of mutations, mainly linked to the loss of tumor-suppressor genes, with atypical and anaplastic subtypes representing malignancy.[5] [6] [7]

Furthermore, meningioma recurrence correlates with its malignancy, with rates of 7% to 20% for the benign and of 29% to 78% for the malignant forms, requiring complementary therapies such as chemotherapy and radiotherapy to improve prognosis.[6] [8]

Thus, the optimal treatment for this neoplasm is represented by complete resection or good tumor control with low morbidity rates, which is achievable through advanced microneurosurgical techniques. In cases of residual tumor, follow-up with serial imaging, radiosurgery, or a new surgical approach in case of regrowth are the preferred measures to achieve a better prognosis.[9]

For the diagnosis of brain tumors, magnetic resonance imaging (MRI) and computed tomography (CT) are essential techniques;[10] MRI plays a role in classification, providing anatomical and functional information about the tumor.[11] Additionally, imaging may suggest cerebral invasion, which can lead to resection of involved brain parenchyma.[12] The diagnostic confirmation of meningioma is obtained through histopathology.[13] This neoplasm presents 15 histological subtypes, indicating clinical and genetic heterogeneity, which is reflected in its behavior.[14]

The divergence of data in the literature supports the need for a longitudinal clinical investigation of the risk factors and methods to prevent recurrence, providing a basis for research into clinical, imaging, histopathological, and molecular predictors of treatment response and tumor progression.[15] The association of this information can help guide and refine the surgical and complementary treatments, through studies that profile patients with the disease, for example.[16] Despite that, longitudinal studies are rare.

Therefore, we herein aim to conduct clinical and therapeutic monitoring of patients with meningioma at an oncological reference center in Northern Brazil and, through a cohort study, evaluate the risk and protective factors for outcomes obtained during the treatment of these patients.

 

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Materials and Methods

Ethical Aspects

The present study was conducted according to the principles of the Declaration of Helsinki and the Nuremberg Code, respecting the standards for research involving human beings of the Brazilian National Health Council (Conselho Nacional de Saúde, CNS, in Portuguese, through Resolution no. 466/2012). Moreover, the study was approved by the Teaching and Research Center and the Human Research Ethics Committee of Hospital Ophir Loyola, a reference center in oncology and neurosurgery in the State of Pará, under protocol number 4.284.742.

 

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Study Characterization

The current is a retrospective cohort study using clinical, radiological, and histopathological data contained in the records of patients with meningiomas treated at the Neurosurgery Service of Hospital Ophir Loyola from January 2005 to December 2015. We evaluated the profile of the patients, their neurosurgical outcomes, and the independent variables related to survival outcomes, recurrence, and clinical evolution.

 

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Inclusion and Exclusion Criteria

Individuals of both sexes and all age groups diagnosed with meningiomas through a histopathological study within the specified period and who underwent surgical or radiological treatment were included.

Thus, patients whose records were incomplete, illegible, outside the intended study period, with missing demographic or radiological data, partially or entirely, were excluded from the study. Additionally, patients with inconsistent histopathological diagnoses (using expressions such as suggestive of, consistent with, suspected of etc.) or whose diagnosis was confirmed by other methods were excluded. Patients whose postoperative follow-up was conducted at other institutions were also excluded.

 

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Data Collection

Data collection occurred in three stages:

• 1) Pre- and intraoperative data collection: analysis of the clinical, radiological, and therapeutic profiles of the patients.

• 2) Immediate postoperative period (up to 30 days of follow-up): analysis of the complete radiological resection rate, the occurrence of death, additional deficits, changes in the performance status score, instituted complementary treatment, and histological type presented.

• 3) Follow-up period of up to 5 years: analysis of the clinical and radiological outcomes, the need for reintervention during the period, the improvement in the performance status score, and histological type in case of reapproaches.

The radiological follow-up of patients included at least 1 preoperative MRI scan, 1 contrasted control study within the first 30 days of surgery for the evaluation of residual lesions, 1 MRI scan within the first 6 months of the study, and at least 2 late control exams within the 5-year follow-up period.

As for the outcomes assessed as dependent variables, we considered intraoperative mortality, postoperative mortality, resolution of symptoms/additional deficits related to the surgical procedure, clinical evolution according to the score on the Karnofsky Performance Status (KPS) scale,[17] and radiological cure of the lesion.

In our research protocol, information contained in the hospital records was transcribed, including a review of: 1) demographic information and hospital records; 2) clinical presentation (neurological signs and KPS score); 3) location and size of the lesion; 4) treatment instituted (if surgical resection, the type according to the Simpson[18] criteria); 5) histopathological diagnosis and classification according to the WHO;[14] 6) complementary treatment and its doses; 7) morbidity and mortality during the 5-year follow-up; and 8) postoperative radiological evolution.

 

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Statistical Analysis

The analysis of the categorical variables was performed using the Chi-squared test to compare observed and expected frequency distributions and, in cases of occurrences with N ≤ 5 scores, the Fisher's exact test was used.

Comparison of parametric means among groups was conducted using the paired t-test. Evaluation of therapeutic response to surgical approach and distribution of histological types on other independent variables was performed using the Pearson's linear correlation tests, and for ordinal samples, the Mann-Whitney and Kruskal-Wallis tests were employed. All statistical tests were conducted using the BioEstat 5.3 software (free), with a confidence interval and a fixed decision Alpha level set at p-value < 0.05.

 

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Results

Data Collection Statistics

An assessment was conducted on patients treated with the surgical or radiotherapeutic modalities, whose diagnoses were histopathologically confirmed. The initial sample consisted of 131 individuals.

From the initial cohort, 8 patients were excluded, as they were children who were not followed up at the center in question. Out of the remaining 123, a total of 30 patients were lost to follow-up at the institution, or their respective follow-up records were not found during the data collection period, making it impossible to track their postoperative outcomes throughout 5 years.

Of the resulting 93 patients, 7 had incomplete medical records, lacking information about the surgical procedure or necessary postoperative neuroimaging studies and were excluded from the study. Consequently, 86 patients met the inclusion criteria.

 

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Descriptive Statistics and Data Analysis

The average age of patients was of 47.01 years, with a median of 47 years and a first quartile and third quartile distribution of 39 and 55 years respectively. The recorded minimum and maximum ages were 16 and 81 years. Out of the 86 studied patients, 49 were female and 37 were male, resulting in a female-to-male ratio of 1.3243.

Among patients first approached at the proposing institution, the most frequently-encountered histological types were meningothelial, with 38 cases (38.44%), followed by the fibrous subtype, with 8.9%, the transitional subtype, with 13.15%, and the mixed and psammomatous subtypes, with 5 occurrences (5.6%) each; it should be noted that these lesions are classified as grade I by the WHO. The atypical subtype, a grade-II tumor, represented only 3.4% of the total, paired with the clear cell subtype. Grade-III subtypes, such as rhabdoid, appear in the 9th position with 2.2%.

Through imaging examination, the expansive processes were classified by location into cranial base, parasagittal lesions, and intraventricular lesions. Only one case of intraventricular meningioma of the transitional subtype was identified in the study: it was included in the descriptive statistics but excluded from the comparative statistics because it was a single case. The distribution by histological type and lesion site is presented in [Table 1]; most of the evaluated lesions were convexity lesions (parasagittal).

Table 1 Distribution of meningiomas by histological type and site

Histological subtype	Convexity	Skull base	Intraventricular	Total
Meningothelial	16	22	0	38
Transitional	9	4	1	13
Fibroblastic	4	4	0	8
Mixed	3	2	0	5
Psammomatous	3	2	0	5
Angiomatous	4	0	0	4
Atypical	1	2	0	3
Clear cells	1	2	0	3
Rhabdoid	1	1	0	2
Secretory	1	1	0	2
Anaplastic	1	0	0	1
Chordoid	1	0	0	1
Lymphoplasmacytic	1	0	0	1
Total	46	40	1	86

When comparing unilateral and bilateral lesions, there was a significant difference between the groups, with the cranial base being 4.94 times more likely to present bilateral lesions than the parasagittal region ([Table 2]).

Table 2 Distribution of meningiomas by location group according to histological subtype and comparison of the presence of bilateral lesions regarding the lesion site

Distribution of location and laterality
	Unilateral	Bilateral
Parasagittal	43	3
Skull base	29	10
Total	72	13	85

Upon imaging diagnosis, 91% of the patients presented with nonspecific symptoms or focal neurological signs (localizing) or both, while asymptomatic cases accounted for only 8.9%. The presence of signs from this modality was evidenced in 40.47% of the patients, being the sole presentation in 10.12% of the total. Conversely, 38.44% presented symptoms without localizing signs.

Regarding the most frequent symptoms, there was a predominance of headache with or without intracranial hypertension (ICH). Among the localizing signs, the most common were appendicular deficit, unilateral amaurosis, and cranial nerve syndrome (except for bilateral VI nerve paralysis, framed within the context of ICH) ([Figs. 1] [2]).

Fig. 1 Frequency of presentation of non-localizing signs, which may occur individually or in combination.

Fig. 2 Frequency of presentation of localizing signs, which may occur individually or in combination.

According to the KPS scale, most patients presented a preoperative score of 80, and none scored below 60, as evidenced in [Fig. 3].

Fig. 3 Distribution of performance status scores among the studied patients.

At the initial diagnosis, the lesions presented with a volume ranging from 2 cm³ to 482 cm³. The median was 51.50 cm³, with an arithmetic mean of 86 cm³. The first and third quartiles were between 27 cm³ and 93 cm³ ([Fig. 4]). Regarding the largest tumor dimensions, they ranged from 1.5 cm to 8.2 cm, with a median of 4.15 cm (first quartile at 3 cm and second quartile at 5.15 cm) and a mean of 4.43 cm.

Fig. 4 Distribution of meningioma volume at diagnosis.

Patients with aggressive lesions (histological grades II and III) presented smaller volumes at diagnosis, although there was no statistical difference compared with the less aggressive behavior groups by the WHO (grade I), possibly due to the reduced sample size in the more aggressive group in the current study ([Fig. 5]).

Fig. 5 Comparison of tumor volume with histological grade at diagnosis: grade-I (on the left) – mean of 88.22 cm³; grades II and III (on the right) –mean of 79.13 cm³. Notes: Comparison conducted through the t-test; p-value = 0.4317.

The average waiting time from radiological diagnosis with surgical indication to treatment was 129.85 days. There was no difference in the KPS score upon admission concerning the time elapsed from diagnosis to treatment when assessed by the Pearson's correlation coefficient (p-value = 0.6758).

In terms of the treatments, all studied patients underwent surgical resection ([Table 3]), and none underwent biopsy alone (Simpson grade 5) or complementary subpial resection (Simpson grade 0). Radiation therapy was offered as adjuvant treatment for 3 patients who presented residual lesions on the postoperative control examination; their histological diagnosis was of meningothelial meningioma (grade I).

Table 3 Levels of resection employed according to the Simpson classification

Simpson	%
0	0
1	15.1
2	10.1
3	30.3
4	31.3
5	0

Regarding the postoperative radiological control, the number of images with indeterminate resectability was high ([Fig. 6]). There was a good correlation between the extent of intraoperative resection observed and the postoperative control image. There was room for doubt in 21 (24.41%) of the postoperative MRI scans. Of these, we were unable to define resection in 5 due to intraoperative death. Resectability was defined in 65 patients.

Fig. 6 Confirmation of resectability in the immediate postoperative period and after 5 years by magnetic resonance imaging (MRI) scans.

When comparing postoperative the performance status, there were no changes in relation to the preoperative KPS score in 56 patients and worsening or death were observed in 30 patients ([Table 4]). There were 5 intraoperative deaths: 3 patients with lesions in the convexity region and 2, in the skull base. There was no statistical difference in terms of the presence of postoperative complications dependent on the extent of the resection employed, as observed in the comparison between groups by the Kruskal-Wallis's test.

Table 4 Comparison of resection type with poor clinical outcome regarding immediate postoperative period

	Simpson 1	Simpson 2	Simpson 3	Simpson 4	Total
Clinical improvement/maintenance	10	7	21	18	56
Worsening of KPS score/Death	5	3	9	13	330
	15	10	30	31	86

Abbreviation: KPS, Karnofsky Performance Status scale.

Notes: No statistically significant difference according to the Kruskal-Wallis test; p-value = 0.2123.

At the end of the 5-year follow-up, the following outcomes were observed among the 86 patients ([Table 5]): 5 had an unfavorable clinical outcome intraoperatively as they evolved to death, and 81 patients were followed up. From the total resection group, 1 patient evolved to death due to complications related to the surgical procedure in the late postoperative period (> 30 days after the surgery), and 1 evolved to death as a complication of tumor recurrence (9 months after the tumor approach).

Table 5 Absolute values of outcomes obtained in the study

Outcome	n
Late death	2
Early death in up to 30 days	3
Intraoperative death	5
5-year disease survival	33
5-year disease-free survival	43
Total	86

From the partial resection group, 2 patients died due to surgery complications within the recent postoperative period (up to 30 days) without being reoperated. Among the group without a defined surgical resection in the immediate postoperative period, in addition to the 5 patients who died intraoperatively, 1 experienced mortality at 5 months without signs of tumor regrowth, evolving with infectious complications secondary to cerebrospinal fluid fistula.

When comparing the initial approach employed and the recurrence rate of patients who achieved complete radiological resection, the group with more radical resection according to the Simpson classification showed lower rates of lesion recurrence ([Fig. 7]).

Fig. 7 Comparison of the tumor recurrence group (on the left) and disease-free survival group (on the right) regarding the Simpson resection employed. Notes: Comparison conducted through the Mann-Whitney test; median of the recurrence group: Simpson III; disease control group: Simpson II; p-value = 0.0353.

The comparison of the groups with partial radiological resection revealed similar outcomes, characterized by the subtotal nature of Simpson IV resection and the absence of patients undergoing Simpson V, when compared regarding lesion stability or regrowth over the 5-year follow-up period.

Despite being a modifying factor for recurrence in patients undergoing total resection, the Simpson resection type did not appear to alter overall survival, as evidenced in [Fig. 8]. It is worth noting that the study did not include an untreated control group to evaluate whether resection is superior to the natural course of the disease.

Fig. 8 Comparison of the extent of resection employed in patients who deceased (left) versus patients who survived (regardless of recurrence) during the 5-year follow-up. Notes: Comparison conducted through the Mann-Whitney test; median of the groups of 3; p-value = 0.3964.

Among patients with residual lesions, 2 exhibited changes in diagnosis, with 1 of the tumor specimens showing an increase in histological grade from meningothelial (grade I) to clear cells (grade II). The other case involved a meningothelial tumor changing to fibroblastic (both grade I). Most patients (6) with complete radiological resection in the postoperative period underwent reoperation, and among these, 1 presented degeneration from the clear cell subtype (initially grade II) to the anaplastic subtype (grade III), while another exhibited a change from the meningothelial type (grade I) to atypical (grade II). The rest maintained the initial histological diagnosis ([Table 6]).

Table 6 Distribution of actions taken during the follow-up of recurrent/residual cases and recurrence in patients with radiologically total resection according to histological grade of the lesion

	Conservative treatment	Reoperation	Diagnosis change	Histological grade increase	Total
Residual lesion stable at the end of the study	13	2	0	0	15
Residual lesion growing at the end of the study	6	5	2	1	14
Recurrence after complete resection	2	6	2	2	12
No confirmation of initial complete resection with apparent recurrence	0	2	0	0	2
Total	21	15	4	3	43
	Recurrence	No recurrence
WHO grade I	7	29		36
WHO grades II and III	1	2		3
Total	8	31		39

Abbreviation: WHO, World Health Organization.

Notes: Comparison conductrd through the Fisher's exact test; p-value = 0.5020.

In the group of patients who experienced recurrence after complete resection, the mean age was lower than that of the patients who remained disease-free after 5 years of follow-up ([Fig. 9]).

Fig. 9 Comparison of the age of the patients who presented lesion recurrence (on the left; mean age: 42 years) and those without lesion after 5 years of follow-up (on the right; mean age: 55 years). Notes: Comparison conducted through the t-test; p-value = 0,0470; CI: -16.8406 to - 0.1194.

 

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Discussion

In terms of age, the most common age group found in the present was from 39 to 55 years. This result contrasts with the findings of Park (2020),[19] who observed an average age of 65 years. Regarding gender, the current study and the by Park[19] presented similar results, with a higher number of cases among female subjects.

The predominance of female patients in meningioma cases has been identified in most of the reviewed literature. However, concerning progesterone receptors, there is a tendency for tumors without them to present larger sizes.[20]

Global literature shows that most of these tumors are located in the supratentorial compartment, specifically in the cerebral convexity,[21] similar to the findings of Acurio-Padilla (2017),[22] who reported 45.3% of cases in this location; 12% in the lesser wing of the sphenoid bone, and 10.9% in the cerebellar convexity. In the present study, most tumors were in the parasagittal region followed by those at the base of the skull.

The histological variety was marked by the predominance of the meningothelial type, followed by transitional and fibroblastic types. In the study by Benítez et al. (2019),[23] the meningothelial type was also the most frequent. Conversely, other authors[24] have reported rates of transitional types of 45% of the cases, followed by meningothelial at 22%.

According to the WHO histological classification, the present study corroborates with the findings of Afumu et al. (2014),[25] who observed 78.2% of grade-I lesions, 19% of grade-II, and 2.1% of grade-III. The present study showed similar proportions regarding the histological grades, with grade I representing 88% of the cases.

When comparing unilateral with bilateral lesions, there was a significant difference between the groups, with the cranial base being 4.94 times more prone to bilateral lesions than the convexity.

Clinical manifestations generally present as headache, seizure (mostly focal), hemiparesis, and intracranial hypertension, according to Guillermo et al. (2009).[21] This is consistent with the findings of the present study, in which headache and seizures were the most frequent symptoms, and the most common localizing sign was the appendicular deficit.

Meningiomas cause signs and symptoms that reflect their location, and due to their slow growth, they can reach large proportions before manifesting any signs or symptoms. Meningiomas of the falx and parasagittal midlle third of the sagittal sinus are the most frequent and usually manifest with contralateral paresis.[26]

Regarding pre- and postoperative performance status, no changes in the KPS score were evidenced in 56 patients, while 30 presented worsening or death. These data are consistent with those of the study by Colli et al. (2015),[3] in which 27.9% of the patients had a KPS score ≤ 70, and 32.6% presented a similar score postoperatively, confirming that there was no significant difference between overall survival and patient performance, both with KPS score > 70 and those with values lower than this upon admission.

The association between size and location may be related to the fact that certain locations do not allow for large volumes due to their anatomical characteristics.[27] In the current study, there was no difference regarding tumor sites, which is contrary to the findings of Mascarenhas et al. (2005):[27] their sample of 72 patients showed larger lesions in the skull base and smaller ones in the convexity.

Regarding the histological subtype, the average size found by Mascarenhas et al.[27] was 4.6 cm for grade-II and -III lesions, and of 3.4 cm for grade-I lesions. In the present study, there was also no difference regarding lesion size and histological grade. Concerning the largest tumor diameter, upon the initial diagnosis the diameters ranged from 1.5 cm to 8.2 cm, with a median of 4.15 cm, and grade-I lesions presented a larger volume. This finding contradicts the literature, as histological characteristics of malignancy are correlated with the proliferation index according to the Ki-67 marker. Consequently, tumors with a high proliferation rate exhibit accelerated growth and thus rapidly reach large dimensions.[28]

The surgical treatment performed was assessed by the Simpson scale. In the current study, most postoperative results were represented by Simpson IV, followed by Simpson III. Different results were found by Ajler et al (2017),[29] in whose study parassagittal tumors showed Simpson II resection in 85.7% of cases, Simpson III in 10.7%, while Simpson IV represented only 3.6% of the cases.

When compared with the changes in KPS scores, the type of resection did not interfere with recent postoperative outcomes with negative/poor clinical outcomes (worsening in KPS differentials, with negative values: [Table 4]). However, after 5 years of follow-up, patients with wider resections, not associated with subtotal resection, showed better clinical outcomes and KPS scores than the patients who underwent Simpson-IV resection; there were no Simpson-V resections in the current study. These findings are in line with those of the study by Jensen and Lee (2012),[30] who showed that subtotal resections were associated with worse clinical outcomes, as well as worse overall survival and disease-free survival rates.

For the individuals who underwent total radiological resection, recurrence rates were higher the closer the resection type was to Simpson IV. The recurrence rate for these patients was 20.51%, which is comparable to the range reported by Rogers et al (2015),[15] of 7% to 23%, in their systematic review of multiple studies on survival and recurrence in meningiomas after 5 years of follow-up.

The difference pointed out in [Fig. 7], with the ordinal median corresponding to Simpson II in patients with disease-free survival after 5 years, is supported by the findings of Mirimanoff et al. (1985);[31] in their study, the Simpson resection index was inversely proportional to the recurrence rates. These findings contrast with those of the work by Sughrue et al. (2011),[24] who proposed that there was no statistical difference among type-I to -III resections regarding recurrence rates. For them, the difference only lies in comparison to grade-IV and -V resections.

However, larger series point to different outcomes for Simpson I compared with type-II and -III (grouped), and type-IV and V (grouped) resections.

In the present study, regarding the independent variables analyzed, in addition to Simpson, there was a statistical difference in the mean age of the patients with recurrence, which was lower than the ages of those without tumor recurrence. An average age of 42 years among the subjects with tumor evidence compared with the average age of 55 years among those without tumor evidence is consistent with the findings of El-Khatib et al. (2011),[32] who reported an age ≥ 50 years as a risk factor for inadequate tumor control. Ajler et al. (2017),[29] on the other hand, did not find a correlation between recurrence and age. The findings of the current study may be related to underlying genetic factors not assessed during data collection.

Patients who underwent partial resection presented worse clinical outcomes and poorer disease control throughout the follow-up period: 44% of the patients who underwent partial resection experienced tumor enlargement during the follow-up, compared with 20.51% of those who underwent total resection. In the literature, the rate of local recurrence of partially-resected meningiomas ranges from 37% to 62% after 5 years of follow-up and from 52% to 100% after 10 years of follow-up, according to the systematic review by Rogers et al. (2015)[15] and is supported by the 2021 review by the United Kingdom's National Institute for Health and Care Excellence (NICE).[33] The data found in the present study are consistent with the those of the current literature.

The total number of patients with remaining lesions after 5 years of follow-up was of 33 out of the 86 patients included. There was no difference in the predilection for reoperation based on histological type, indicating that this was not a determining factor for reoperation in this population. It is important to note that, although there were 36 patients with residual lesions intraoperatively, deaths were included in this statistic, resulting in a slightly lower number of patients at the end of the study. These data partially contradict findings from the NICE (2018).[33]

In the current study, the presence of a higher histological grade significantly correlated with the need for retreatment and tumor recurrence/regrowth. For us, the clinical impact of atypical lesions on this outcome is more significant than in “benign” lesions classified as WHO grade I. This discrepancy likely stems from the follow-up period of the present study (5 years). Systematic reviews demonstrate that low-grade meningiomas have extensive survival, although the long-term recurrence rate is higher than currently reported in short-term follow-up studies (up to 10 years).[34]

In the current study, for patients with WHO grades II and III, treatments during follow-up included observation or surgical reoperation in cases of recurrence. Only 3 patients received radiotherapy, all with benign lesions but with voluminous residual tumors following partial resection.

Mair et al. (2011)[35] describes the role of radiotherapy as a predictive factor in local disease control in grade-II meningiomas. Several studies[36] [37] report a low survival rate after recurrence, with an average time to lesion reappearance of 44 months (which is consistent with the data found in the present study), and it is associated with reduced survival.

In the current study, the number of deaths related to recurrence was low in the sample studied, suggesting the presence of other factors, beyond those analyzed, that may have influenced the survival of these patients.

 

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Conclusion

Although most cases analyzed presented with benign histological types, factors such as age, tumor site, and type of treatment employed were determinants of the prognosis of these patients. The importance of safe surgical resection as a factor for cure and long-term quality of life is emphasized. Therefore, we highlight the need for early diagnosis and therapy to achieve better outcomes in the population affected by this tumor and recommend conducting prospective studies to evaluate other variables for clarification, particularly the risk factors for mortality and recurrence.

 

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Conflict of Interests

The authors have no conflict of interests to declare.

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Eingereicht: 02. November 2024

Angenommen: 28. März 2025

Artikel online veröffentlicht:
01. Juli 2025