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Management of Atypical Cranial Meningiomas, Part 1: Predictors of Recurrence and the Role of Adjuvant Radiation After Gross Total Resection

Sun, Sam Q. BS*,‡; Kim, Albert H. MD, PhD*,§; Cai, Chunyu MD, PhD; Murphy, Rory K.J. MD§; DeWees, Todd PhD; Sylvester, Peter BS; Dacey, Ralph G. MD§; Grubb, Robert L. MD§; Rich, Keith M. MD§; Zipfel, Gregory J. MD§; Dowling, Joshua L. MD§; Leuthardt, Eric C. MD§; Leonard, Jeffrey R. MD§; Evans, John RN§; Simpson, Joseph R. MD, PhD; Robinson, Clifford G. MD; Perrin, Richard J. MD, PhD; Huang, Jiayi MD; Chicoine, Michael R. MD§

doi: 10.1227/NEU.0000000000000461
Research-Human-Clinical Studies: Editor's Choice
Editor's Choice

BACKGROUND: Indications for external beam radiation therapy (EBRT) for atypical meningiomas (AMs) remain unclear.

OBJECTIVE: To analyze features associated with recurrence in AM patients after gross total resection (GTR) and to assess the relative benefit of EBRT in a retrospective cohort study.

METHODS: One hundred fifty-one primary AMs after GTR (88 female patients; median follow-up, 45.0 months) were examined for possible predictors of recurrence (age, sex, location, volume, bone involvement, brain invasion). The Fisher exact and Wilcoxon rank-sum tests were used to analyze the association between these predictors and use of EBRT. The impact on recurrence for these predictors and EBRT was analyzed with Kaplan-Meier and Cox regression.

RESULTS: Of 151 patients, 13 (8.6%) experienced recurrence after GTR (median, 47.0 months). Multivariate analysis identified elevated mitotic index (P = .007) and brain invasion (P = .002) as predictors of recurrence. Larger volume (P = .96) was not associated with recurrence but was more likely to prompt EBRT (P = .001). Recurrences occurred in 11 of 112 with GTR (9.8%; median, 44 months) and 2 of 39 with GTR/EBRT (5.1%; median, 133 months). The 2-, 5-, and 10-year progression-free survival rates after GTR vs GTR/EBRT were 97%, 86%, and 68% vs 100%, 100%, and 78%. Kaplan-Meier analysis demonstrated no difference in progression-free survival or overall survival after GTR vs GTR/EBRT (P = .8, P > .99).

CONCLUSION: Brain invasion and high mitotic rates may predict recurrence. After GTR of AMs, EBRT appears not to affect progression-free survival and overall survival, suggesting that observation rather than EBRT may be indicated after GTR.

ABBREVIATIONS: AM, atypical meningioma

EBRT, external beam radiation therapy

GTR, gross total resection

LC, local control

MI, mitotic index

OS, overall survival

PFS, progression-free survival

WHO, World Health Organization

Washington University School of Medicine, St. Louis, Missouri; and

§Department of Neurosurgery,

Pathology and Immunology, and

Radiation Oncology, Washington University, St. Louis, Missouri

Correspondence: Albert H. Kim, MD, PhD, Assistant Professor of Neurological Surgery, Washington University School of Medicine, CB 8057, 660 S Euclid Ave, St. Louis, MO 63110. E-mail:

* These authors have contributed equally to this article.

Received December 27, 2013

Accepted May 24, 2014

Copyright © by the Congress of Neurological Surgeons