Risk factors, surgical outcome, and quality of life in patients with cranial or spinal meningioma

Meningiomas comprise approximately 30-38% of all cranial tumours and represent the largest group of primary intracranial and intraspinal tumours. Gliomas, of any grade, account for approximately 28% and glioblastomas 15% of the cranial tumours, as comparison. Roughly 2% of all meningiomas are spinal, constituting 25-45% of all spinal intradural tumours. Despite extensive research in this field, there is still no consensus on the best strategies for surgical resection, follow-up, and supplementary treatments. Risk factors for meningioma development and factors affecting health-related quality of life (HRQoL) and return to work for this heterogenous patient group are poorly understood. This thesis aimed to study population-based cohorts with cranial and spinal meningiomas to bring greater clarity to some of these questions. In study I, a 25-year follow-up of patients with parasagittal meningiomas was conducted, revealing that radical resection was of great importance to reduce recurrence, morbidity, and tumour mortality. Furthermore, more than 15 years of radiological follow-up was necessary to detect late recurrences. Study II evaluated the surgical results for meningiomas that engaged major venous sinuses, demonstrating that microscopic radicality was difficult to achieve and that supplementary stereotactic gamma knife radiosurgery was beneficial and should be considered as an adjuvant treatment directly after surgery. In study III, a large epidemiologic survey of a female Swedish population was conducted to understand a possible connection between sex hormones and risk of developing a meningioma during and after pregnancy. Contradictory to our hypothesis, there was no increased risk for diagnosing a meningioma during pregnancy or 1-year postpartum, thus indicating that pregnancy should not be seen as a risk factor for meningioma. Study IV on spinal meningiomas revealed that surgery was associated with a significant improvement in neurological function independently predicted by a shorter time from diagnosis to surgery and the degree of spinal cord compression. Elderly patients benefitted to same degree as non-elderly patients from surgical intervention without increased complications. Study V analysed the HRQoL and frequency of return to work among patients operated on for a spinal meningioma. Ninety-six percent of patients were satisfied with the surgical results. Despite a high median age at surgery, and unlike cranial meningiomas or lumbar spinal stenosis, the HRQoL at long-term follow-up was equivalent to a matched sample of the general population. All patients working before their operation returned to work postoperatively, most of them within three months. Study VI evaluated long-term follow-up and HRQoL for patients treated for cranial WHO grades 2 and 3 meningiomas. Despite dismal prognoses with 93% of the mortality attributed to meningiomas, a large subgroup comprising both grades 2 and 3 was alive at 10 years follow- up after one operation or operations supplemented with gamma knife radiosurgery, showing a longer overall survival compared to previous reports. In contrast, fractionated radiotherapy and chemotherapy had little benefit when introduced for recurrent or progressive disease. The surviving meningioma patients showed HRQoL measurements comparable to those of the general population, except for significantly more anxiety and depression. Despite suffering from a chronic disease and in contrast to previous reports, all patients who were working before surgery returned to work after surgery. In conclusion, based on the findings of this thesis, we recommend long-term radiological follow-up and supplementary gamma knife radiosurgery for tumour control of cranial meningiomas. The effects of sex hormones are multi-faceted and require further in-depth studies. Spinal meningiomas should be treated rapidly after diagnosis for all ages to promote excellent neurological outcomes and HRQoL measures. Despite the chronic nature of the disease, subgroups of WHO grades 2 and 3 meningiomas can yield long-term outcomes and HRQoL measures

Health-Related Quality of Life and Return to Work after Surgery for Spinal Meningioma: A Population-Based Cohort Study

Spinal meningiomas are the most common primary spinal intradural tumor. This study aimed to assess Health-related quality of life (HRQoL) and the frequency of return to work in patients surgically treated for spinal meningiomas, in comparison to the general population. Variables were collected from patient charts, EQ-5D-3L, and study specific questionnaires. Patients who had been operated between 2005–2017 were identified in a previous study and those alive in 2020 (104 of 129) were asked to participate. Eighty-four patients (80.8%) with a mean follow-up of 8.7 years, responded and were included. Data was compared to the Stockholm Public Health Survey 2006, a cross-sectional survey of a representative sample of the general population. Analysis for potential non-response bias showed no significant differences. Women in the meningioma sample scored more problems than men with regards to mobility (p = 0.048). There were no significant differences concerning EQ-5Dindex (p = 0.325) or EQVAS (p = 0.116). The correlation between follow-up time and EQ-5Dindex was low (r = 0.167). When comparing HRQoL to the general population sample, no significant differences were found within the EQ-5D-3L dimensions, EQ-5Dindex or EQVAS. Those who postoperatively scored 3–5 on mMCs scored significantly more problems in the EQ-5D-3L dimension mobility (p = 0.023). Before surgery, 41 (48.8%) of the spinal meningioma patients were working and after surgery all returned to work, the majority within three months. Seventy-eight (96%) of the patients would accept surgery for the same diagnosis if asked today. We conclude that surgery for spinal meningiomas is associated with good long-term HRQoL and a high frequency of return to work

Current Knowledge on Spinal Meningiomas—Surgical Treatment, Complications, and Outcomes: A Systematic Review and Meta-Analysis (Part 2)

Background: Most of the knowledge on spinal meningiomas is extrapolated from their intracranial counterparts, even though they are considered separate entities. This review aimed to systematically summarize studies covering different aspects of spinal meningiomas and their management. Methods: Databases were searched for all studies concerning spinal meningiomas dating from 2000 and onwards. When possible, a meta-analysis was performed. Results: Neurological outcomes of surgery were consistently favorable across studies, with a complication rate of 7.9% and 78.9% of the patients demonstrating good postoperative neurological function (McCormick score 1–2). The most relevant predictors of unfavorable outcomes were poor preoperative status, longer time from diagnosis to surgery, and surgery of recurrent tumors. The recurrence rate after surgery was estimated at 6%. Meta-analysis and/or survival analysis revealed that higher WHO grade (p < 0.001), higher Simpson grade (p < 0.001), ventral tumor location (p = 0.02), and male sex (p = 0.014) were all associated with higher odds of recurrence. However, the meta-analysis did not show any difference between Simpson grade 1 and grade 2 with respect to the odds of recurrence (p = 0.94). Surgery provided immediate and durable health-related quality-of-life improvement, as well as a high frequency of return to work. Conclusion: Spinal meningioma surgery is a relatively safe procedure with a low risk of tumor recurrence and high likelihood of favorable postoperative outcomes

Current Knowledge on Spinal Meningiomas Epidemiology, Tumor Characteristics and Non-Surgical Treatment Options: A Systematic Review and Pooled Analysis (Part 1)

Background: Spinal meningiomas are the most common primary intradural spinal tumors. Although they are a separate entity, a large portion of the knowledge on spinal meningiomas is based on findings in intracranial meningiomas. Therefore, a comprehensive review of all the literature on spinal meningiomas was performed. Methods: Electronic databases were searched for all studies on spinal meningiomas dating from 2000 and onward. Findings of matching studies were pooled to strengthen the current body of evidence. Results: A total of 104 studies were included. The majority of patients were female (72.83%), elderly (peak decade: seventh), and had a world health organization (WHO) grade 1 tumor (95.7%). Interestingly, the minority of pediatric patients had a male overrepresentation (62.0% vs. 27.17%) and higher-grade tumors (33.3% vs. 4.3%). Sensory and motor dysfunction and pain were the most common presenting symptoms. Despite a handful of studies reporting promising findings associated with the use of non-surgical treatment options, the literature still suffers from contradictory results and limitations of study designs. Conclusions: Elderly females with WHO grade 1 tumors constituted the stereotypical type of patient. Compared to surgical alternatives, the evidence for the use of non-surgical treatments is still relatively weak

Health-related quality of life and return to work after surgery for spinal meningioma:A population-based cohort study

SIMPLE SUMMARY: Spinal meningioma is the most common primary intradural spinal tumor. Although histologically benign, the tumors often cause neurological deficits. Health-related quality of life (HRQoL) is defined as the aspects of quality of life which are most affected by ill health and is a measure of self-perceived health status. Despite many studies evaluating the neurological outcome after surgery for spinal meningiomas, no study has been concerned with the HRQoL and frequency of return to work. In this population-based cohort study, we reviewed 84 cases of surgically treated spinal meningiomas, with a mean follow-up of 8.7 years, to assess their HRQoL compared to a sample of the general population. We found that HRQoL after surgery was equal to the normal population, and the frequency of return to work was 100%, often within three months of surgery. Thus, surgical treatment of spinal meningiomas should not be considered a threat to long-term quality of life. ABSTRACT: Spinal meningiomas are the most common primary spinal intradural tumor. This study aimed to assess Health-related quality of life (HRQoL) and the frequency of return to work in patients surgically treated for spinal meningiomas, in comparison to the general population. Variables were collected from patient charts, EQ-5D-3L, and study specific questionnaires. Patients who had been operated between 2005–2017 were identified in a previous study and those alive in 2020 (104 of 129) were asked to participate. Eighty-four patients (80.8%) with a mean follow-up of 8.7 years, responded and were included. Data was compared to the Stockholm Public Health Survey 2006, a cross-sectional survey of a representative sample of the general population. Analysis for potential non-response bias showed no significant differences. Women in the meningioma sample scored more problems than men with regards to mobility (p = 0.048). There were no significant differences concerning EQ-5D(index) (p = 0.325) or EQ(VAS) (p = 0.116). The correlation between follow-up time and EQ-5D(index) was low (r = 0.167). When comparing HRQoL to the general population sample, no significant differences were found within the EQ-5D-3L dimensions, EQ-5D(index) or EQVAS. Those who postoperatively scored 3–5 on mMCs scored significantly more problems in the EQ-5D-3L dimension mobility (p = 0.023). Before surgery, 41 (48.8%) of the spinal meningioma patients were working and after surgery all returned to work, the majority within three months. Seventy-eight (96%) of the patients would accept surgery for the same diagnosis if asked today. We conclude that surgery for spinal meningiomas is associated with good long-term HRQoL and a high frequency of return to work

Long-Term Follow-Up and Predictors of Functional Outcome after Surgery for Spinal Meningiomas: A Population-Based Cohort Study

Spinal meningiomas are the most common adult primary spinal tumor, constituting 24–45% of spinal intradural tumors and 2% of all meningiomas. The aim of this study was to assess postoperative complications, long-term outcomes, predictors of functional improvement and differences between elderly (≥70 years) and non-elderly (18–69 years) patients surgically treated for spinal meningiomas. Variables were retrospectively collected from patient charts and magnetic resonance images. Baseline comparisons, paired testing and regression analyses were used. In conclusion, 129 patients were included, with a median follow-up time of 8.2 years. Motor deficit was the most common presenting symptom (66%). The median time between diagnosis and surgery was 1.3 months. A postoperative complication occurred in 10 (7.8%) and tumor growth or recurrence in 6 (4.7%) patients. Surgery was associated with significant improvement of motor and sensory deficit, gait disturbance, bladder dysfunction and pain. Time to surgery, tumor area and the degree of spinal cord compression significantly predicted postoperative improvement in a modified McCormick scale (mMCs) in the univariable regression analysis, and spinal cord compression showed independent risk association in multivariable analysis. There was no difference in improvement, complications or tumor control between elderly and non-elderly patients. We concluded that surgery of spinal meningiomas was associated with significant long-term neurological improvement, which could be predicted by time to surgery, tumor size and spinal cord compression

Long-Term Follow-Up, Treatment Strategies, Functional Outcome, and Health-Related Quality of Life after Surgery for WHO Grade 2 and 3 Intracranial Meningiomas

Progression-free survival (PFS) and overall survival (OS) for WHO grade 2 and 3 intracranial meningiomas are poorly described, and long-term results and data evaluating the routine use of supplementary fractionated radiotherapy (RT) or stereotactic radiosurgery (SRS) has been inconclusive. The aim of this study was to determine the long-term PFS and OS at a center that does not employ routine adjuvant RT. For this purpose, a retrospective population-based cohort study was conducted of all WHO grade 2 and 3 meningiomas surgically treated between 2005 and 2013. The cohort was uniformly defined according to the WHO 2007 criteria to allow comparisons to previously published reports. Patient records were reviewed, and patients were then prospectively contacted for structured quality-of-life assessments. In total, 51 consecutive patients were included, of whom 43 were WHO grade 2 and 8 were grade 3. A Simpson grade 1–2 resection was achieved in 62%. The median PFS was 31 months for grade 2 tumors, and 3.4 months for grade 3. The median OS was 13 years for grade 2, and 1.4 years for grade 3. The MIB-1-index was significantly associated with an increased risk for recurrence (p = 0.018, OR 1.12). The median PFS was significantly shorter for high-risk tumors compared to the low-risk group (10 vs. 46 months; p = 0.018). The surviving meningioma patients showed HRQoL measures comparable to that of the general population, with the exception of significantly more anxiety and depression. All patients who worked before surgery returned to work after their treatment. In conclusion, we confirm dismal prognoses in patients with grade 2 and 3 meningiomas, with tumor-related deaths resulting in severely reduced OS. However, the cohort was heterogenous, and a large subgroup of both grade 2 and 3 meningiomas was alive at 10 years follow-up, suggesting that a cure is possible. In addition, fractionated radiotherapy and chemotherapy had little benefit when introduced for recurrent and progressive diseases