Meningioma June2011

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Meningioma June2011

  1. 1. Evidence based surgical meeting: “ Is it necessary to perform a Simpson grade I resection of a meningioma in order to prevent/ reduce the rate of recurrence/ regrowth?” Scholar: Dr Stavros KOUSTAIS Advanced Scholar: Dr Tim SIU Date: 2 nd June 2011
  2. 4. “ Is it necessary to perform a Simpson grade I resection of a meningioma in order to prevent/ reduce the rate of recurrence/ regrowth?”
  3. 5. <ul><li>Searchable question </li></ul><ul><li>P – pts with intracranial meningioma </li></ul><ul><li>I – Surgery & Simpson grade I </li></ul><ul><li>C – Surgery & Simpson grade II, III, IV </li></ul><ul><li>O – local recurrence of meningioma </li></ul><ul><li>Difficulty with PICO format </li></ul>
  4. 6. <ul><li>Searchable question </li></ul><ul><li>“ What is the recurrence rate in patients following Simpson grade I or II meningioma resection?” </li></ul><ul><li>Databases </li></ul><ul><li>Medline – using MeSH </li></ul><ul><li>Scopus using keywords </li></ul>
  5. 9. Scopus
  6. 10. <ul><li>Medline </li></ul><ul><li>96 articles </li></ul><ul><li>19 relevant. </li></ul><ul><li>Scopus </li></ul><ul><li>124 articles </li></ul><ul><li>further 4 articles identified </li></ul>
  7. 11. <ul><li>Not in the articles found </li></ul>
  8. 12. <ul><li>One further article identified from March edition of Journal of Neurosurgery </li></ul>
  9. 13. <ul><li>Level of evidence (NHMRC) </li></ul><ul><li>Level 1: ✗ </li></ul><ul><li>Level 2: ✗ </li></ul><ul><li>Level 3: ✔ (Retrospective cohort) </li></ul>
  10. 14. <ul><li>Simpson D. The recurrence of intracranial meningiomas after surgical treatment, JNNP 20:22-39, 1957 </li></ul><ul><li>1938 – 1954 </li></ul><ul><li>242 pts with intracranial meningioma (Oxford series) </li></ul><ul><li>High post-op mortality rates </li></ul><ul><li>Recurrence = purely clinical </li></ul><ul><li>44 recurrences (Oxford series) </li></ul><ul><li>Five grades of resection described </li></ul><ul><li>Grade I – 9% recurrence </li></ul><ul><li>Grade II – 16% recurrence </li></ul><ul><li>Grade III – 29% recurrence </li></ul><ul><li>Grade IV – 39% recurrence </li></ul>
  11. 15. <ul><li>Sughrue ME et al. The relevance of Simpson grade I and II resection in modern neurosurgical treatment of WHO grade I meningioma. J Neurosurg 113:1029-1035, 2010 </li></ul><ul><li>To determine if Simpson’s grading scale is still relevant in modern neurosurgical practice </li></ul><ul><li>Retrospective cohort </li></ul><ul><li>1991 – 2008 </li></ul><ul><li>373 pts with WHO grade I meningioma </li></ul><ul><li>Skull base >> convexity meningioma </li></ul><ul><li>Approximately 30% received pre-op embolisation </li></ul><ul><li>Gross total resection in 70% of cases </li></ul><ul><li>Mean length F/U 3.7 yrs (6 months – 18 years) </li></ul><ul><li>Five year recurrence / progression-free survival: </li></ul><ul><li>Grade I – 95% </li></ul><ul><li>Grade II – 85% NO SIGNIFICANT DIFFERENCE </li></ul><ul><li>Grade III – 88% </li></ul><ul><li>Grade IV – 81% </li></ul>
  12. 16. <ul><li>Sughrue ME et al. Results with judicious modern neurosurgical management of parasagittal and falcine meningiomas. J Neurosurg 114:731 – 737, 2011 </li></ul><ul><li>Retrospective cohort </li></ul><ul><li>1991 – 2007 </li></ul><ul><li>135 pts with large, symptomatic para – falcine / sagittal meningiomas </li></ul><ul><li>Median length F/U 7.6 yrs (1.7 – 18.6) </li></ul><ul><li>No difference in rates of tumour control in pts who received subtotal resection for WHO grade I tumour compared with those undergoing gross total resection. </li></ul><ul><li>Advocate alternative approach to meningioma management – removing as much tumour as possible while preserving major cortical veins and leaving tumour remnants that involve the superior saggital sinus. </li></ul><ul><li>If WHO Grade I -> close observation – +/- stereotactic radiosurgery </li></ul>
  13. 18. <ul><li>Sughrue ME et al. Risk factors for the development of serious medical complications after resection of meningiomas. J Neurosurg 114:697 – 704, 2011 </li></ul><ul><li>Retrospective cohort </li></ul><ul><li>1993 – 2007 </li></ul><ul><li>834 pts – craniotomy and resection of meningioma </li></ul><ul><li>73% gross total resection </li></ul><ul><li>6.8% experienced serious complications </li></ul><ul><li>Pneumonia </li></ul><ul><li>Renal failure </li></ul><ul><li>Arrhythmia </li></ul><ul><li>DVT & PE </li></ul><ul><li>Death ( 0.5%) </li></ul><ul><li>Significant risk factors </li></ul><ul><li>New neurological deficit </li></ul><ul><li>Age > 65 yrs </li></ul><ul><li>Hypertension </li></ul><ul><li>Being on > 2 cardiac meds pre-op </li></ul>
  14. 21. <ul><li>Reflection and further analysis </li></ul><ul><li>Are the rates of recurrence in Simpson’s landmark paper still valid in modern neurosurgical practice? </li></ul><ul><li>Do we need to perform Simpson grade I resections for meningiomas, or do we need to adjust our surgical strategy and treatment according to the patient’s requirements? </li></ul><ul><li>Is there a shift in the modern management of meningiomas? </li></ul><ul><li>How long do we need to follow up patients following meningioma resection? </li></ul>
  15. 22. <ul><li>Need to define a more specific research question. </li></ul><ul><li>Set up Medline literature alerts on more topics to improve my academic knowledge. </li></ul><ul><li>Benefited from this EBS search as I became familiar with some of the current concepts of meningioma management. </li></ul>

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