1) Hyperostosis is seen in 25-49% of intracranial meningiomas and its cause is still debated. (2) The study found that 23.5% of meningiomas with radiological hyperostosis showed tumor invasion into the bone on histology. (3) The authors recommend removing any bone in contact with the tumor to achieve a complete resection, as tumor invasion can occur even without hyperostosis on imaging.
💎VVIP Kolkata Call Girls Parganas🩱7001035870🩱Independent Girl ( Ac Rooms Avai...
The Significance of Removing Hyperostotic Bone in Intracranial Meningioma Surgery
1. The Significance of Hyperostosis in
Intrancranial Meningioma and How It
Affects the Management
Nishant Goyal, Deepak Agrawal
Department of Neurosurgery
All India Institute of Medical Sciences, New Delhi, India
2. Introduction
O Association between meningioma and
hyperostosis
O Hyperostosis is seen in 25-49 % of
intracranial meningiomas*
•Cushing H. The cranial hyperostoses produced by meningeal endotheliomas. Arch
Neurol Psychiatry 1922; 8: 139-154
•Cushing H, Eisenhardt L. Meningiomas: Their Classification, Regional Behavior,
Life History and Surgical End Results. Springfield, Charles C Thomas, 1938.
• Frazier CH, Alpers BJ. Meningeal fibroblastomas of the cerebrum. Arch Neurol
Psychiatry 1933; 29: 935–989.
• Spiller WG. Hemicraniosis and cure of brain tumor by operation. JAMA 1907; 49:
2059–2065.
3. Introduction
O Cause of hyperostosis still a matter of
debate
O Occurs as a reactionary change to meningioma
O Due to tumor invasion into the bone
O Common practice is to drill the
hyperostotic bone & place the bone flap
back
4. Hypothesis
O Bone changes seen in meningioma can
be attributed to tumor invasion
O Leaving the bone flap in situ may be same
as leaving a part of the tumor behind
5. Methods
O Study design: Prospective
O Study period : October 2010- July 2011
(10 months)
O Consecutive patients with a preoperative
diagnosis of intracranial meningioma who
underwent surgery
6. Methods
O Inclusion criteria-
O All cases of intracranial meningioma (on
histopathology) who were operated in our
institute during study period
O Exclusion criteria-
O Intracranial tumors other than meningioma (on
histopathology)
O Tumors in which bone biopsy was not
available
7. Methods: Radiology
O Preoperative MR imaging and CT scans
O Examined individually by two neurosurgeons
to assess for bone thickening overlying the
tumor
O Present when there was consensus among
the two
O The cases of meningioma were classified
according to location
10. Methods
Patients with preoperative diagnosis
of intracranial meningioma
Hyperostosis Hyperostosis
present absent
Bone sampling done Bone sampling done from
from hyperostotic bone in contact with the
region dural attachment of the
tumor
11. Methods: Histopathology
O Tumor tissue was processed as is routine for
histopathological examination
O Bone was decalcified and then processed
O Hematoxylin and eosin stained slides of
tumor tissue and bone sample were
examined by two neuropathologists
12. Methods: Histopathology
Features assessed on histopathology:
WHO Grade and Type of meningioma
MIB-1 labeling index (MIB-1 LI)
Presence of tumor invasion into the bone
13. Results
Total number of cases with
preoperative diagnosis of intracranial
meningioma (n= 49)
Histopathological
examination
Non meningioma (n=9) Intracranial
(Excluded) meningioma
(n=40)
Study group
24. Meningiomas (n=40)
Radiological evidence of hyperostosis
Hyperostosis Hyperostosis
present (n= 30) absent (n= 10)
Histological evaluation of bone
Bone No bone Bone No bone
invasion invasion invasion invasion
(n=7) (n=23) (n=1) (n=9)
25. Results (n=40)
O Of the eight cases showing tumor invasion
into the bone on histology
O Seven had hyperostosis on radiology
O One without hyperostosis
26. Results (n=40)
Location Number Tumor invasion
of cases present
Convexity 12 4 (33.3%)
Parasagittal & peritorcular, falcine 16 2 (12.5%)
and tentorial
Skull base 12 2 (16.7%)
Total 40 8 (20%)
27. Results (n=40)
O Tumor invasion into the bone
O Three cases of meningothelial meningiomas
(3 out of 8 cases; 37.5%)
O Five cases of transitional meningiomas (5 out
of 19 cases; 26.3%)
O Tumor invasion into the bone did not show
any significant correlation with WHO
grade, type and MIB-1 labeling index in our
study (p>0.05)
32. Discussion
O A number of studies have upheld the
principle that clinical success in meningioma
surgery is related to the extent of resection
Bikmaz K, Mrak B, Al-Mefty O. Management of bone-invasive, hyperostotic sphenoid
wing meningiomas. J Neurosurg 2007; 107: 905–912
Jääskeläinen J. Seemingly complete removal of histologically benign intracranial
meningioma: Late recurrence rate and factors predicting recurrence in 657 patients-A
multivariate analysis. Surg Neurol 1986; 26: 461-469
Al-Mefty O, Kadri PA, Pravdenkova S, Sawyer JR, Stangeby C, Husain M. Malignant
progression in meningioma: documentation of a series and analysis of cytogenetic
findings. J Neurosurg 2004; 101: 210–218
33. Discussion
O In 1957, Simpson elaborately described the
importance of degree of resection in
preventing recurrence in meningioma
Simpson Excision Recurrence at 10 yrs
Grade
I 9%
II 19%
III 29%
IV 40%
Simpson D. The recurrence of intracranial meningiomas after surgical treatment. J
Neurol Neurosurg Psychiatry 1957; 20: 22-39.
34. Discussion
O Simpson Grade I excision of
meningioma
O Macroscopically complete removal of
tumor with excision of its dural attachment
and any abnormal bone
O What is abnormal bone?
35. Discussion
O Our study shows that it is not possible to
predict which patients are likely to show bone
invasion on the basis of
O Preoperative radiology, as invasion can
occur without hyperostosis on radiology
O Intra-operative pathological evaluation of
bone is not feasible by frozen section
examination
36. Discussion
O Therefore, in order to achieve better
Simpson grade of tumor excision one should
remove as much bone in contact with the
tumor as possible in all cases
37.
38.
39. Limitation
O The possibility of sampling error can not
be completely ruled out
O The actual incidence of bone invasion is
likely to be higher than in our study
40. Conclusion
O A significant number of patients (23.5% in
our study) with radiological hyperostosis
have tumor invasion into the bone
O However, the absence of hyperostosis
does not mean the absence of tumor
invasion
41. Conclusion
O We recommend that one should remove
the bone (flap) whenever possible in
order to achieve complete excision of
intracranial meningioma in close proximity
to bone and use synthetic material to
cover the defect.
Good morning everyone. I am going to talk about the relationship between hyperostosis and bone invasionin meningioma. And how it affects the management.
Association between meningioma and hyperostosis is well established.The incidence of hyperostosis ranges between 25 and 50% in various series
The cause of hyperostosis still is a matter of debate. Some believe it occurs as a reactionary change to meningioma. While others think it to be secondary to tumor invasion into the bone. The common practice today is to drill the hyperostotic bone and place the bone flap back.
The aim of this study was to assesswhether bony changes seen in meningioma can be attributed to tumor invasion and whether leaving the bone flap in situ might be same as leaving a part of the tumor behind.
Therefore, we conducted a prospective study over a period of 10 months, in which we enrolled all the patients with a preoperative diagnosis of intracranial meningioma, who underwent surgery at our institute.
Only those cases that were confirmed as meningioma on the histopathology were included.We excluded any case in which a bone biopsy was not available. ???planumsphenoidalemeningioma???
The Preoperative imaging was individually studied by two neurosurgeons to assess for bony thickening. Hyperostosis was said to be present when there was consensus among the two. The cases were classified according to location.
This is an example of a case of left frontal convexity meningioma, which reveals hyperostosis of the overlying bone.
This is a case of left lateral sphenoid wing meningioma, in which the overlying bone does not show any thickening.
During the surgery, a piece of bone was sent for pathological evaluation. In cases showing hyperostosis, this bone was taken from the hyperostotic area.While in the remaining cases, bone sampling was done from bone in contact with the dural attachment of the tumor
The features assessed on histopathology were
Of the 49 cases that were initially enrolled, 9 were found to be tumors other than meningioma on histopathology and therefore exluded.The remaining 40 cases formed the study group.
Of these 40 cases, 22 were females and 18 were males.
Most of the patients were in 30-60 years’ age group. It is noteworthy that 35 of the 40 patients were younger than 60 years of age.
On radiology, hyperostosis was seen in 30 patients, i.e. 75% of the cases.
The convexity and skull base meningiomas showed a higher incidence of hyperostosis, that is 83 %.
On histopathology, transitional meningioma was most common.
36 out of 40 cases belonged to WHO grade I, while there were 4 WHO grade II tumors.
On histopathology, tumor invasion into the bone was seen in 8 patients, i.e. 20% of the cases.
Of the 30 cases showing hyperostosis, bony invasion by the tumor was seen in 7 cases. Of the 10 cases not showing hyperostosis, one case showed tumor invasion into the bone.
Looking at these figures the other way around. Of the eight cases
Convexitymeninigoma had the highest incidence of bone invasion by the tumor, i.e. 33%. There was no significant correlation between tumor location and tumor invasion into the bone.
Three of the eight cases of meningothelialmeningiomas showed tumor invasion into the bone.Where as, bone was invaded by the tumor in five of the 19 tranitionalmeningiomas.The other histological types did not show tumor invasion into the bone.
This is a case of anterior 1/3 falcinemeningioma, which reveals overlying hyperostosis. On histopathology, it was found to be a meningothelialmeningioma. The bone biopsy revealed tumor invasion into the bone.
This is a case of right lateral sphenoid wing mengingoma, which shows thickening of the overlying bone. The biopsy of the bonerevealed tumor invasion between the bony trabeculaealongwith destruction. Here is a high power view of the same. (transitional)
This case of right frontal convexity meningioma had no overlying hyperostosis. However, on histopathology, it revealed tumor invasion into the bone.(transitional meningioma)
To quote Harvey Cushing,” There is nothing more gratifying in the whole realm of surgery than the successful removal of a meninigoma with subsequent perfect functional recovery.” These words are as true today as they were 90 years back.
Simpson defined grade I excision of meningioma as…However, the question arises, “ what constitutes abnormal bone??” In our opinion, any bone which has been infiltrated by the tumor cells should be labeled as abnormal.
Also,intraoperativehistopathological evaluation of the bone is not feasible by frozen section.Bone can not be cut on a freezing microtome before decalcification.
. . . As it might be infiltrated by the tumor cells
In our study, the probability of sampling error can not be ruled out. However, if there were sampling error, the actual incidence of bone invasion will be higher than what has been reported here.