Konvexitätsmeningeome

Transcription

1 Department of Neurosurgery Neurochirurgische Klinik Konvexitätsmeningeome DGNC Fortbildung Seeheim 2014

2 Frühe Beschreibung von Tumoren der Hirnhaut Felix Platter ( ) Erstbeschreibung, 1614 Johann Salzmann ( ) Erstabbildung, 1727 Laurence Heister ( ) 1. Operation, 1743 Antoine Louis ( ) 1. wiss. Abhandlung, 20 Fälle, 1774 Jean Cruveilhier ( ) Klassifikation, 1829 Felix Platter ( ) Pionier der pathologischen Anatomie in Basel Erstbeschreibung eines Tumors der Meningen 1614 Ernest Blasius ( ) Habilitation Fungi durae matris, 1829

3 Klassifikation von Tumoren der Hirnhaut Exostosis seu excrescentia cranii osseospongiosa Salzmann, 1730 de tumore capitis fungoso Heister und Crelius, 1734 Fungus durae matris Pecchioli, 1838 Psammoma Wirchow, 1859 Ursprung aus den Pacchionischen Granulationen Cleland, 1864 Bezeichnung Meningioma Cushing, 1928 Meningioma ( WHO Klassifikation) Bailey/Busy, 1931

4 Frühe Operationen von Tumoren der Hirnhaut Heister & Crellius & Kaufmann 1. Dokumenierte Operation eines Meningeoms 1743, Patient verstribt an Infektion Zanobi Pecchioli ( ) Professor in Siena 1. Erfolgreiche Operation 1835 William MacEwen ( ) Professor in Glasgow erfolgreiche OP eines Meningeom 1879 William W Keen ( ) 1. Meningeomoperation in den USA 1887 Sir William MacEwen ( ) Harvey Cushing ( ), Boston Pionier der modernen Klassifikation und Chirurgie der Meningeome

5 Frühe Operationen von Tumoren der Hirnhaut Heister & Crellius & Kaufmann 1. Dokumenierte Operation eines Meningeoms 1743, Patient verstribt an Infektion Zanobi Pecchioli ( ) Professor in Siena 1. Erfolgreiche Operation 1835 William MacEwen ( ) Professor in Glasgow erfolgreiche OP eines Meningeom 1879 William W Keen ( ) 1. Meningeomoperation in den USA 1887 Harvey Cushing ( ), Boston Pionier der modernen Klassifikation und Chirurgie der Meningeome

6 Convexity Meningiomas Subtypes precoronal, coronal, postcoronal, paracentral, parietal, temporal, occipital Majority located anterior to the central sulcus as there is increased spinale Meningeome density of arachnoid granulations anterior and adjacent to the coronal suture

7 extracerebraler und dura-ständiger Tumor homogene und kräftige Kontrastmittelaufnahme wenig Umgebungsreaktion Dural Tail Sign

8 Dural Tail prevalence in meningiomas is reported to be 52% - 78% occurs in 22% - 32% of brain tumors not limited to meningiomas hypervascularity possible cause of enhancement, tumor invasion also suggested

9 when should surgery be considered what are the surgical techniques what is the likelyhood of recurrence and what promotes recurrence what is the role of radiation therapy what outcomes can be expected

10 Decision making in convexity meningiomas more art than science when should surgery be considered Observation of patients older than 70 with tumors less than 3 cm and little edema In patients younger than 70 with tumors less than 3 cm and little edema guided by patiens wishes Recently more aggressive approach

11 Decision making in convexity meningiomas more art than science Meningioma diagnosed by imaging alone University of Pittsburgh reported 35% 1 University of Maryland reported 62% 1 The 10 year rate of establishing a diagnosis other than meningioma reported as low as 2.3% 1 Convexity meningioma WHO grade I slow growth homogeneous enhancement smooth contour calcifications no edema iso or hypointense on T2 not reliably coupled to histological grade 1 Flickinger JC, Kondziolka D, Maitz AH et al. Gamma knife radiosurgery of imagediagnosed intracranial meningioma. Int J Radiat Oncol Biol Phys, 2003

12 Decision making in convexity meningiomas more art than science Meningioma diagnosed by imaging alone WHO 2007 WHO grade II % WHO grade I 65% WHO grade III 1-3% Small convexity meningioma that the patient insisted be removed. was a malignant meningioma Peter M. Black, Andrew P. Morokoff, Jacob Zauberman. Neurosurgery 2008

13 N= 643 recurrence-free survival overall survival Perry A (2006) Meningiomas. In: McLendon R, Rosenblum M, Bigner DD (eds) Russell & Rubinstein s pathology of tumors of the nervous system, 7th edn. Hodder Arnold, London, pp

14 Decision making in convexity meningiomas more art than science Observation and risk of progression 37% of meningiomas showed progression over an observation of 3.9 years 1.6% risk per year (6.4% over 4 years) of becoming symptomatic Study of Yano and Kuratsu 2006 not limited to convexity meningiomas Yano S, Kuratsu J. Indications for surgery in patiens with asymptomatic meningiomas. J Neurosurg 105: , 2006

15 Decision making in convexity meningiomas more art than science Observation and risk of progression very low growth rate through life absolute growth rates vary between 0.03 and 2.62 cm3/year, with relative growth rates ranging between 0.48% and 72.2% surgical resection should be performed when growth rate is greater 1 cm3/year multiple convexity meningiomas, symptomatic lesions, those that display growth should be resected

16 Surgical technique all cases with image guidance skin flap 1 cm beyond planned craniotomy bone flap 1-2 cm beyond dural involvement small dural opening and (extensive) decompression dural opening and dissection of clivage plane

17 Decision making in convexity meningiomas more art than science Risks associated with surgery of convexity meningiomas 0 % surgical mortality 5.5 % morbidity 0 % recurrence in 163 WHO I convexity meningiomas 1 1 Morokoff AP, Zaubermann J, Black PM. Surgery for convexity meningiomas. Neurosurgery 2008

18 0 % surgical mortality 5.5 % major morbidity 0 % recurrence in 163 WHO I convexity meningiomas 1 median tumor diameter was 3.5 cm (range, cm)

19 0 % surgical mortality 5.5 % major morbidity - overall complication rate 9.4 % - New deficite in 1.8% * all with preoperative deficite * all increased hemiparesis * all > 4cm - two-thirds of complications occurred in age group < 65

20 11 deaths during the total follow-up period. Ten of these were in patients aged 65 years or older, and none were meningioma- or surgery-related overall recurrence rate during the follow-up period 4.3% median follow-up 28 months

21 overall 5-year RFS rate, including all histological grades, was 85% (n=7) median time to recurrence was 14 months mean time to recurrence was 28 months among the benign tumors, there were only two recurrences, both within 5 years of first surgery, making the recurrence rate 1.8%. both of these recurrences were reported as having borderline atypia. median follow-up 28 months

22 5-year recurrence rates for atypical tumors and anaplastic (n=3) tumors were 27.2% and 50%, respectively true Simpson Grade I resections can only realistically be achieved with convexity meningiomas. this series may effectively represent a comparison of the recurrence rates by histological grading ( keeping the extent of resection variable constant) median follow-up 28 months

23 Professor Donald Simpson AO

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25 possible causes of recurrence: - inadequate resection - multifocality of tumor cells in the dura - and de novo tumor formation Simpson felt that the most likely reason was unrecognized spread of tumor cells at the time of operation, particularly through the falx or the tentorium.

26 Dural multifocality of disease beyond the margin of the tumor has been postulated by others (2, 13, 21). Residual tumor cells in thickened arachnoid have also been proposed as a source of recurrence (6, 21).

27 Light microscopy showed clusters of meningioma cells.. in the thick arachnoid membranes of. 10 out of 11 cases.

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29 22 of 36 cases tumor within dural tail of those 70% with dural invasion

30 dural tail and normal dura was referenced and marked

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32 0 Simpson grade 1 + 2cm margin Kinjo et al WHO I no local recurrence > 50% at > 5 years * Kinjo T, Al-Mefty O, Kanaan I Grade zero removal of supratentorial convexity meningiomas. Neurosurgery 33(3): , 1994

33 Decision making in convexity meningiomas more art than science Risks associated with surgery of convexity meningiomas CLASS Algorythm 1 risk factors (comorbidity, location, age) vs. benefit (size and symptoms) score >1 1.9% risk of poor outcome score 0-1 4% risk of poor outcome score <2 15% risk of poor outcome 1 Sade B, Lee J. Proceedings of 5th Int Conference on Meningiomas and cerebal veins. 2006

34 36 studies comprising 459 patients devascularization to induce necrosis + prior to surgery may facilitate resection facilitate surgery by reducing blood loss and operating time.10,12,35 reduce intraoperative complications and increase the ability to obtain a total resection at the time of surgery vessel embolization when blood supply vis-à-vis the surgeon s line of sight may increase the ability to achieve gross-total resection of both skull base and large supratentorial meningiomas.35,38 tumoral hemorrhage ischemia from untargeted edema worsening mass effect hydrocephalus cranial nerve deficits seizures, and infection.7 9

35 36 studies comprising 459 patients

36 36 studies comprising 459 patients

37 36 studies comprising 459 patients 438 patients (95.4%) had no neurological deficits after embolization 21 complications (4.6%) directly related to the embolization, - including infection, hemiparesis, facial palsy, disseminated intravascular coagulation, glaucoma, tumor swelling, transient SIADH, dysphagia, cranial nerve deficit

38 36 studies comprising 459 patients 438 patients (95.4%) had no neurological deficits after embolization Out of the 21 complications % (n = 18) were minor - 4.8% (n = 1) were major - 9.5% (n = 2) were fatal

39 ACE rechts ACE links ACI rechts

40 36 studies comprising 459 patients Chun JY, McDermott MW, Lamborn KR, Wilson CB, Higashida R, Berger MS. Delayed surgical resection reduces intraoperative blood loss for embolized meningiomas. Neurosurgery 50: , 2002

41 Based on the studies included in this review, delaying surgery may not add any significant increased risk However, some of the senior authors are aware of several anecdotal cases in which preoperative embolization resulted in significant tumor necrosis and edema with acute neurological decline, requiring an emergency tumor resection

42 36 studies comprising 459 patients For large cranial vault meningiomas, the main blood supply usually arises from branches of superficial temporal, occipital, middle meningeal, and/or posterior meningeal arteries, all of which are accessible surgically early during the exposure. For large skull base meningiomas, blood supply generally arises from petrous/cavernous/pial internal carotid artery branches or vertebrobasilar branches, all of which are difficult or impossible to selectively catheterize safely.

43 .gain most from preoperative embolization is the giant convexity lesion with such exuberant and multidirectional blood supply that simply opening the bone flap can result in catastrophic blood loss.

44 Anaplastisches Potential von Konvexitätsmeningeomen und Schädelbasismeningeomen

45 WHO before 2000 / 2007 WHO 2007 WHO grade II patients in Germany WHO with grade III non-benign meningiomas WHO grade II % WHO grade I 90% WHO grade I 65% WHO grade III 1-3%

46 2007

47 Atypical meningioma WHO grade II with sheet-like growth and increased mitotic activity (arrows).

48 Atypical brain invasive meningioma WHO II

49 Invasion other than brain may be WHO I dural spread bone invasion muscle invasion

50 Anaplastic meningioma WHO III

51 Supraorbital approach for meningiomas of the anterior skull base WHO Grade I meningothelial transitional psammomatous angiomatous secretory mucious atypical WHO Grade II 0.8% reclassified by WHO %

52 WHO WHO grade I 95% WHO grade II 4.6 % WHO grade III 0.4%