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Recurrent petroclival meningiomas: clinical characteristics, management, and outcomes

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Abstract

This study seeks to elucidate the prognostic predictors and outcomes of recurrent/progressive petroclival meningiomas (PCMs). We reviewed our cohort of 39 recurrent/progressive PCMs (27 females, 69.2 %) and analyzed the results from the literature. Twenty-three patients underwent reoperations, 2 received radiotherapy alone, and 14 declined any treatment. During a follow-up of 70.4 months, 7 patients experienced a 2nd recurrence/progression (R/P) and 18 patients died. In the 23 patients, gross total resection (GTR), subtotal resection (STR), and partial resection (PR) were achieved in 8, 8, and 7 patients, respectively. The percentage of the 2nd R/P-free survival of GTR, STR, and PR was 88 %, 67 %, and 40 %, respectively. The overall survival following the 1st R/P of GTR, STR, and PR was 88 %, 63 %, and 33 %, respectively. Patients rejecting treatment suffered from significantly poor overall survival (7 %; p = 0.001) and short survival duration (42.0 months; p = 0.016) compared with that of the patients receiving treatment (67 % and 86.9 months). The GTR was the only independent favorable predictor. In the 21 included studies with 98 recurrent/progressive PCM patients, 17 patients presented with a 2nd R/P and 10 died of a 2nd R/P; patients undergoing observation had a significantly poor tumor regrowth control rate compared with patients undergoing surgery (p = 0.004) or radiotherapy alone (p < 0.001). Proactive treatment should be performed for patients with recurrent/progressive PCMs. Observation can lead to relentless outcome. GTR as a preferential therapeutic strategy should be pursued as far as possible on the condition of minimal functional impairment.

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References

  1. Abdel AK, Sanan A, van Loveren HR, Jr Tew JM, Keller JT, Pensak ML (2000) Petroclival meningiomas: predictive parameters for transpetrosal approaches. Neurosurgery 47:139–152

    Google Scholar 

  2. Al-Mefty O, Fox JL, Smith RR (1988) Petrosal approach for petroclival meningiomas. Neurosurgery 22:510–517

    Article  CAS  PubMed  Google Scholar 

  3. Angeli SI, De la Cruz A, Hitselberger W (2001) The transcochlear approach revisited. Otol Neurotol 22:690–695

    Article  CAS  PubMed  Google Scholar 

  4. Bambakidis NC, Kakarla UK, Kim LJ, Nakaji P, Porter RW, Daspit CP, Spetzler RF (2008) Evolution of surgical approaches in the treatment of petroclival meningiomas: a retrospective review. Neurosurgery 62:1182–1191

    Article  PubMed  Google Scholar 

  5. Behari S, Tyagi I, Banerji D, Kumar V, Jaiswal AK, Phadke RV, Jain VK (2010) Postauricular, transpetrous, presigmoid approach for extensive skull base tumors in the petroclival region: the successes and the travails. Acta Neurochir (Wien) 152:1633–1645

    Article  Google Scholar 

  6. Bootz F, Keiner S, Schulz T, Scheffler B, Seifert V (2001) Magnetic resonance imaging–guided biopsies of the petrous apex and petroclival region. Otol Neurotol 22:383–388

    Article  CAS  PubMed  Google Scholar 

  7. Brandt MG, Poirier J, Hughes B, Lownie SP, Parnes LS (2010) The transcrusal approach: a 10-year experience at one Canadian center. Neurosurgery 66:1017–1022

    Article  PubMed  Google Scholar 

  8. Bricolo AP, Turazzi S, Talacchi A, Cristofori L (1992) Microsurgical removal of petroclival meningiomas: a report of 33 patients. Neurosurgery 31:813–828

    Article  CAS  PubMed  Google Scholar 

  9. Canalis RF, Black K, Martin N, Becker D (1991) Extended retrolabyrinthine transtentorial approach to petroclival lesions. Laryngoscope 101:6–13

    Article  CAS  PubMed  Google Scholar 

  10. Cantore G, Delfini R, Ciappetta P (1994) Surgical treatment of petroclival meningiomas: experience with 16 cases. Surg Neurol 42:105–111

    Article  CAS  PubMed  Google Scholar 

  11. CASTELLANO F, RUGGIERO G (1953) Meningiomas of the posterior fossa. Acta Radiol Suppl 104:1–177

    CAS  PubMed  Google Scholar 

  12. Chen LF, Yu XG, Bu B, Xu BN, Zhou DB (2011) The retrosigmoid approach to petroclival meningioma surgery. J Clin Neurosci 18:1656–1661

    Article  PubMed  Google Scholar 

  13. Couldwell WT, Fukushima T, Giannotta SL, Weiss MH (1996) Petroclival meningiomas: surgical experience in 109 cases. J Neurosurg 84:20–28

    Article  CAS  PubMed  Google Scholar 

  14. Da SEJ, Leal AG, Milano JB, Da SLJ, Clemente RS, Ramina R (2010) Image-guided surgical planning using anatomical landmarks in the retrosigmoid approach. Acta Neurochir (Wien) 152:905–910

    Article  Google Scholar 

  15. Danner C, Cueva RA (2004) Extended middle fossa approach to the petroclival junction and anterior cerebellopontine angle. Otol Neurotol 25:762–768

    Article  PubMed  Google Scholar 

  16. Dong CC, Macdonald DB, Akagami R, Westerberg B, Alkhani A, Kanaan I, Hassounah M (2005) Intraoperative facial motor evoked potential monitoring with transcranial electrical stimulation during skull base surgery. Clin Neurophysiol 116:588–596

    Article  PubMed  Google Scholar 

  17. Erkmen K, Pravdenkova S, Al-Mefty O (2005) Surgical management of petroclival meningiomas: factors determining the choice of approach. Neurosurg Focus 19:E7

    Article  PubMed  Google Scholar 

  18. Ferch RD, Biggs M, Morgan MK (1999) The zygomaticotemporal approach with medial petrosectomy for intradural lesions. J Clin Neurosci 6:340–343

    Article  PubMed  Google Scholar 

  19. Fukuda M, Oishi M, Hiraishi T, Saito A, Fujii Y (2012) Pharyngeal motor evoked potentials elicited by transcranial electrical stimulation for intraoperative monitoring during skull base surgery. J Neurosurg 116:605–610

    Article  PubMed  Google Scholar 

  20. Goel A (1999) Extended lateral subtemporal approach for petroclival meningiomas: report of experience with 24 cases. Br J Neurosurg 13:270–275

    Article  CAS  PubMed  Google Scholar 

  21. Goel A, Muzumdar D (2004) Conventional posterior fossa approach for surgery on petroclival meningiomas: a report on an experience with 28 cases. Surg Neurol 62:332–340

    Article  PubMed  Google Scholar 

  22. Gupta SK, Salunke P (2012) Intradural anterior petrosectomy for petroclival meningiomas: a new surgical technique and results in 5 patients: technical note. J Neurosurg 117:1007–1012

    Article  PubMed  Google Scholar 

  23. Hao S, Feng J, Zhang L, Tang J, Wu Z, Zhang J (2011) Rapid recurrence of petroclival meningioma in Werner syndrome: case report. Clin Neurol Neurosurg 113:795–797

    Article  PubMed  Google Scholar 

  24. Hayashi N, Sato H, Tsuboi Y, Nagai S, Kuwayama N, Endo S (2010) Consequences of preoperative evaluation of patterns of drainage of the cavernous sinus in patients treated using the anterior transpetrosal approach. Neurol Med Chir (Tokyo) 50:373–377

    Article  Google Scholar 

  25. Hitselberger WE, Horn KL, Hankinson H, Brackmann DE, House WF (1993) The middle fossa transpetrous approach for petroclival meningiomas. Skull Base Surg 3:130–135

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  26. Ichimura S, Kawase T, Onozuka S, Yoshida K, Ohira T (2008) Four subtypes of petroclival meningiomas: differences in symptoms and operative findings using the anterior transpetrosal approach. Acta Neurochir (Wien) 150:637–645

    Article  CAS  Google Scholar 

  27. Ichinose T, Goto T, Ishibashi K, Takami T, Ohata K (2010) The role of radical microsurgical resection in multimodal treatment for skull base meningioma. J Neurosurg 113:1072–1078

    Article  PubMed  Google Scholar 

  28. Javed T, Sekhar LN (1991) Surgical management of clival meningiomas. Acta Neurochir Suppl (Wien) 53:171–182

    Article  CAS  Google Scholar 

  29. Jia G, Wu Z, Zhang J, Zhang L, Xiao X, Tang J, Meng G, Geng S, Wan W (2010) Two-bone flap craniotomy for the transpetrosal-presigmoid approach to avoid a bony defect in the periauricular area after surgery on petroclival lesions: technical note. Neurosurg Rev 33:121–126

    Article  PubMed  Google Scholar 

  30. Jung HW, Yoo H, Paek SH, Choi KS (2000) Long-term outcome and growth rate of subtotally resected petroclival meningiomas: experience with 38 cases. Neurosurgery 46:567–575

    Article  CAS  PubMed  Google Scholar 

  31. Karmarkar S, Bhatia S, Saleh E, Taibah A, Russo A, Mazzoni A, Sanna M (1995) The system of modified transcochlear approaches for intradural skull base lesions. Indian J Otolaryngol Head Neck Surg 47:266–281

    Google Scholar 

  32. Kawase T, Shiobara R, Toya S (1994) Middle fossa transpetrosal-transtentorial approaches for petroclival meningiomas. Selective pyramid resection and radicality. Acta Neurochir (Wien) 129:113–120

    Article  CAS  Google Scholar 

  33. Kaylie DM, Horgan MA, Delashaw JB, McMenomey SO (2004) Hearing preservation with the transcrusal approach to the petroclival region. Otol Neurotol 25:594–598

    Article  PubMed  Google Scholar 

  34. King WA, Black KL, Martin NA, Canalis RF, Becker DP (1993) The petrosal approach with hearing preservation. J Neurosurg 79:508–514

    Article  CAS  PubMed  Google Scholar 

  35. Li D, Hao SY, Wang L, Tang J, Xiao XR, Zhou H, Jia GJ, Wu Z, Zhang LW, Zhang JT (2013) Surgical management and outcomes of petroclival meningiomas: a single-center case series of 259 patients. Acta Neurochir (Wien) 155:1367–1383

    Article  Google Scholar 

  36. Li PL, Mao Y, Zhu W, Zhao NQ, Zhao Y, Chen L (2010) Surgical strategies for petroclival meningioma in 57 patients. Chin Med J (Engl) 123:2865–2873

    Google Scholar 

  37. Little KM, Friedman AH, Sampson JH, Wanibuchi M, Fukushima T (2005) Surgical management of petroclival meningiomas: defining resection goals based on risk of neurological morbidity and tumor recurrence rates in 137 patients. Neurosurgery 56:546–559

    Article  PubMed  Google Scholar 

  38. Mathiesen T, Gerlich A, Kihlstrom L, Svensson M, Bagger-Sjoback D (2007) Effects of using combined transpetrosal surgical approaches to treat petroclival meningiomas. Neurosurgery 60:982–992

    PubMed  Google Scholar 

  39. Mathiesen T, Lindquist C, Kihlstrom L, Karlsson B (1996) Recurrence of cranial base meningiomas. Neurosurgery 39:2–9

    Article  CAS  PubMed  Google Scholar 

  40. Matsui T (2012) Therapeutic strategy and long-term outcome of meningiomas located in the posterior cranial fossa. Neurol Med Chir (Tokyo) 52:704–713

    Article  Google Scholar 

  41. Mayberg MR, Symon L (1986) Meningiomas of the clivus and apical petrous bone. Report of 35 cases. J Neurosurg 65:160–167

    Article  CAS  PubMed  Google Scholar 

  42. Mortini P, Mandelli C, Franzin A, Giugni E, Giovanelli M (2001) Surgical excision of clival tumors via the enlarged transcochlear approach. Indications and results. J Neurosurg Sci 45:127–140

    CAS  PubMed  Google Scholar 

  43. Nanda A, Javalkar V, Banerjee AD (2011) Petroclival meningiomas: study on outcomes, complications and recurrence rates. J Neurosurg 114:1268–1277

    PubMed  Google Scholar 

  44. Natarajan SK, Sekhar LN, Schessel D, Morita A (2007) Petroclival meningiomas: multimodality treatment and outcomes at long-term follow-up. Neurosurgery 60:965–981

    Article  PubMed  Google Scholar 

  45. Nishimura S, Hakuba A, Jang BJ, Inoue Y (1989) Clivus and apicopetroclivus meningiomas–report of 24 cases. Neurol Med Chir (Tokyo) 29:1004–1011

    Article  CAS  Google Scholar 

  46. Ohba S, Kobayashi M, Horiguchi T, Onozuka S, Yoshida K, Ohira T, Kawase T (2011) Long-term surgical outcome and biological prognostic factors in patients with skull base meningiomas. J Neurosurg 114:1278–1287

    PubMed  Google Scholar 

  47. Panigrahi M, Venkateswaraprasanna G (2006) Transpetrosal approach. J Neurosurg 105:336–338

    Article  PubMed  Google Scholar 

  48. Park CK, Jung HW, Kim JE, Paek SH, Kim DG (2006) The selection of the optimal therapeutic strategy for petroclival meningiomas. Surg Neurol 66:160–166

    Article  PubMed  Google Scholar 

  49. Pensak ML, Van Loveren H, Tew JJ, Keith RW (1994) Transpetrosal access to meningiomas juxtaposing the temporal bone. Laryngoscope 104:814–820

    CAS  PubMed  Google Scholar 

  50. Ramina R, Neto MC, Fernandes YB, Silva EB, Mattei TA, Aguiar PH (2008) Surgical removal of small petroclival meningiomas. Acta Neurochir (Wien) 150:431–439

    Article  CAS  Google Scholar 

  51. Roberti F, Sekhar LN, Kalavakonda C, Wright DC (2001) Posterior fossa meningiomas: surgical experience in 161 cases. Surg Neurol 56:8–21

    Article  CAS  PubMed  Google Scholar 

  52. Salvetti DJ, Nagaraja TG, Levy C, Xu Z, Sheehan J (2013) Gamma Knife surgery for the treatment of patients with asymptomatic meningiomas. J Neurosurg 119:487–493

    Article  PubMed  Google Scholar 

  53. Samii M, Ammirati M, Mahran A, Bini W, Sepehrnia A (1989) Surgery of petroclival meningiomas: report of 24 cases. Neurosurgery 24:12–17

    Article  CAS  PubMed  Google Scholar 

  54. Samii M, Gerganov VM (2011) Petroclival meningiomas: quo vadis? World Neurosurg 75:424

    Article  PubMed  Google Scholar 

  55. Samii M, Tatagiba M, Carvalho GA (2000) Retrosigmoid intradural suprameatal approach to Meckel’s cave and the middle fossa: surgical technique and outcome. J Neurosurg 92:235–241

    Article  CAS  PubMed  Google Scholar 

  56. Schlake HP, Goldbrunner RH, Milewski C, Krauss J, Trautner H, Behr R, Sorensen N, Helms J, Roosen K (2001) Intra-operative electromyographic monitoring of the lower cranial motor nerves (LCN IX-XII) in skull base surgery. Clin Neurol Neurosurg 103:72–82

    Article  CAS  PubMed  Google Scholar 

  57. Seifert V (2010) Clinical management of petroclival meningiomas and the eternal quest for preservation of quality of life: personal experiences over a period of 20 years. Acta Neurochir (Wien) 152:1099–1116

    Article  Google Scholar 

  58. Sekhar LN, Swamy NK, Jaiswal V, Rubinstein E, Hirsch WJ, Wright DC (1994) Surgical excision of meningiomas involving the clivus: preoperative and intraoperative features as predictors of postoperative functional deterioration. J Neurosurg 81:860–868

    Article  CAS  PubMed  Google Scholar 

  59. Shi W, Shi JL, Xu QW, Che XM, Ju SQ, Chen J (2011) Temporal base intradural transpetrosal approach to the petoclival region: an appraisal of anatomy, operative technique and clinical experience. Br J Neurosurg 25:714–722

    Article  PubMed  Google Scholar 

  60. Spallone A, Makhmudov UB, Mukhamedjanov DJ, Tcherekajev VA (1999) Petroclival meningioma. An attempt to define the role of skull base approaches in their surgical management. Surg Neurol 51:412–420

    Article  CAS  PubMed  Google Scholar 

  61. Sughrue ME, Rutkowski MJ, Aranda D, Barani IJ, McDermott MW, Parsa AT (2010) Treatment decision making based on the published natural history and growth rate of small meningiomas. J Neurosurg 113:1036–1042

    Article  PubMed  Google Scholar 

  62. Sughrue ME, Rutkowski MJ, Shangari G, Chang HQ, Parsa AT, Berger MS, McDermott MW (2011) Risk factors for the development of serious medical complications after resection of meningiomas. Clinical article. J Neurosurg 114:697–704

    Article  PubMed  Google Scholar 

  63. Tahara A, de Jr Santana PA, Calfat MM, Panagopoulos AT, da Silva AN, Zicarelli CA, Pires DAP (2009) Petroclival meningiomas: surgical management and common complications. J Clin Neurosci 16:655–659

    Article  PubMed  Google Scholar 

  64. Taniguchi M, Perneczky A (1997) Subtemporal keyhole approach to the suprasellar and petroclival region: microanatomic considerations and clinical application. Neurosurgery 41:592–601

    CAS  PubMed  Google Scholar 

  65. Terasaka S, Asaoka K, Kobayashi H, Yamaguchi S, Sawamura Y (2010) Natural history and surgical results of petroclival meningiomas. No Shinkei Geka 38:817–824

    PubMed  Google Scholar 

  66. Tokoro K, Chiba Y, Murai M, Hayashi A, Kyuma Y, Fujii S, Yamamoto I (1996) Cosmetic reconstruction after mastoidectomy for the transpetrosal-presigmoid approach: technical note. Neurosurgery 39:186–188

    Article  CAS  PubMed  Google Scholar 

  67. Tu YK, Yang SH, Liu HM (1999) The transpetrosal approach for cerebellopontine angle, petroclival and ventral brain stem lesions. J Clin Neurosci 6:336–340

    Article  PubMed  Google Scholar 

  68. Van Havenbergh T, Carvalho G, Tatagiba M, Plets C, Samii M (2003) Natural history of petroclival meningiomas. Neurosurgery 52:55–64

    PubMed  Google Scholar 

  69. Watanabe T, Katayama Y, Fukushima T, Kawamata T (2011) Lateral supracerebellar transtentorial approach for petroclival meningiomas: operative technique and outcome. J Neurosurg 115:49–54

    Article  PubMed  Google Scholar 

  70. Xiao X, Zhang L, Wu Z, Zhang J, Jia G, Tang J, Meng G (2013) Surgical resection of large and giant petroclival meningiomas via a modified anterior transpetrous approach. Neurosurg Rev. doi:10.1007/s10143-013-0484-8

    PubMed Central  Google Scholar 

  71. Yamakami I, Higuchi Y, Horiguchi K, Saeki N (2011) Treatment policy for petroclival meningioma based on tumor size: aiming radical removal in small tumors for obtaining cure without morbidity. Neurosurg Rev 34:327–335

    Article  PubMed  Google Scholar 

  72. Yang J, Fang T, Ma S, Yang S, Qi J, Qi Z, Cun E, Yu C (2011) Large and giant petroclival meningiomas: therapeutic strategy and the choice of microsurgical approaches - report of the experience with 41 cases. Br J Neurosurg 25:78–85

    Article  PubMed  Google Scholar 

  73. Zentner J, Meyer B, Vieweg U, Herberhold C, Schramm J (1997) Petroclival meningiomas: is radical resection always the best option? J Neurol Neurosurg Psychiatry 62:341–345

    Article  CAS  PubMed Central  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Tiantan Xili 6,, Chongwen District, Beijing, 100050, People’s Republic of China

    Da Li, Shu-Yu Hao, Liang Wang, Jie Tang, Xin-Ru Xiao, Gui-Jun Jia, Zhen Wu, Li-Wei Zhang & Jun-Ting Zhang

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  1. Da Li
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Comments

Atul Goel and Manu Kothari, Mumbai, India

All meningiomas, like finger prints or a pinna, are different. They are different in terms of clinical presenting features, radiological imaging characters, and histological subtleties, and more importantly, in the pattern of their behavior. All meningiomas can be classified into good or bad only in retrospect. Petroclival meningiomas are as benign or as aggressive as meningiomas elsewhere. Suffice to say at the very outset that a petroclival meningioma, but for its proximity to the brainstem, is as ordinary as a convexity meningioma or a neurofibroma under the skin. Both do not and cannot differ in their essential behavior. The ‘malignant’ fault of a petroclival meningioma is its proximity to the brainstem and its occasional proclivity to ensnare it. Petroclival meningioma should be christened as benign microscopically, malignant behaviorally, or rather positionally.

Between the idea (of benignancy)

And the reality (of behavior),

Between the scene (under the microscope)

And the seer (the pathologist)

Falls the shadow (of ambiguity).

(modified from The Hallow Men by T.S. Eliot)

A meningioma is a fibrocellular mass that in a ‘predetermined’ fashion starts somewhere in the meninges and remains ‘discreetly silent’ before being detectable or impinging on the consciousness of the patient. A plethora of theories speculate on its cause, to no avail. The cause/course/cure of any meningioma is not known and is unlikely to be known.

The course is totally unpredictable, ranging from sheer indolence to accretional aggressiveness. In a way, the meningioma is not causal, but is coursal, being an integrated predetermined part of the biological trajectory of the person dictated by time or age. The so-called surgical cure or more truly care, for any tumor anywhere and of any type, is debulking by the swipe of a surgical blade. You can only debulk, for the dream of total removal is one of a mirage. Even if it were removed totally, the next normal meninx can throw a meningiomatous tantrum.

A meningioma

Tells a tale

A normal meninx

Is waiting to tell

The surgical philosophy for all tumors, benign or malignant, is to remove the tumor radically and then fold the hands and wait for it to recur. The term radical resection has to be defined and clearly understood. One must realize that ‘once a meningioma always a meningioma’. The aim of surgery can never be ‘cure’ of the meningioma. Surgery can be summarized to be ‘space creating solution;’ for a ‘space occupying lesion’, albeit accompanied by the more meaningful debulking of the tumor. The success of surgery will be maximum space creation, minimal bulk, and safe outcome. Any complication or neurological deficit is related to inadequate understanding and evaluation or less than perfect execution of operation. The difficult terrain of a petroclival meningioma makes the likelihood of complications higher. The recurrences depend more on the growth pattern of the tumor than with the extent of resection. The radicality of resection will also depend on the aggression and extensions of the meningioma. The more extensive is the presence of the tumor, the more difficult is the resection and the likelihood of recurrence is higher. More circumscribed meningiomas are easier to remove and the long term outcome is better.

The aim of surgery for recurrent meningiomas remains the same. Create maximal space and debulk and then again wait for the tumor to recur. The possible difficulties during surgery make the issues more challenging for the surgeon. It is, therefore, mandatory for the surgeon to assess the lesion, its location, and the difficulties that can be associated with surgery in a recurrence situation and then take appropriate decision. It is right that the authors have resorted to treat recurrent petroclival tumors surgically and have resorted to radiotherapy only when the knife could not be wielded on the meningioma. Surgery per se is lesion far and no further, unless it hurts vessels/nerves/brain on its way. Radiotherapy has necessarily a field impact, charring not only the tumor but also many a vessel or nerve, and for that reason, is to be deployed only under compulsion. Chemotherapy has no role for a meningioma is too dull to be affected by the best chemotherapy. A good neurosurgeon is one who knows when NOT to operate. A good meningioma surgeon is one who will prefer to leave a bit or more of meningioma rather than risk damage to a nerve or a blood vessel.

Much as a normal diploid dividing cell is potentially malignant so is any part of any normal meninx is potentially a meningioma, meningioendothelioma, and meningiosarcoma, all mercifully rare in a crescendo order. Most meningiomas, ‘benign’ to the microscope, make noise late in life and lend themselves to partial or ‘total’ surgical ablation, promising to come back the way it did to start with. Each meningioma is unique and unamenable to any genetic analysis, prevention, chemotherapy, or radiation. It is best lived with, ablated when diseasing and re-ablated when it recurs to disease again.

Volker Seifert, Frankfurt, Germany

There is no question that petroclival meningiomas are correctly considered to be the most difficult skull base tumors to be treated by neurosurgeons.

Petroclival meningiomas are almost exclusively operated on by very experienced and excellent skull base neurosurgeons with an exceptional high experience in complex brain tumor surgery. Despite these facts, it is obvious from the modern data on petroclival meningioma surgery that in general, in only one third to one fourth of the patients the tumor could be removed gross totally, that surgical mortality still occurs in a number of patients, and that especially the permanent quality of life reducing morbidity remains high.

During the last two decades of advanced skull base surgery, it has become clear from increasing experience during surgery of petroclical meningiomas that the clinical result and the radicality of surgery is not, or only to a lesser extent, defined by the surgical approach chosen to explore the tumor but by the biological behaviour of this treacherous subgroup of meningiomas especially in regard to the tumor–brain stem interface.

The reasons for incomplete tumor removal are multiple and have been defined in recent articles on petroclival menigiomas, including hard or fibrous structure of the tumor, no, as mentioned, clear arachnoid interface between tumor and pia of the brain stem and encasement of cerebral vessels and cranial nerves.

This has led over the years to the now generally accepted treatment concept in petroclival meningiomas consisting of an attempt of not over aggressive surgical tumor removal with decompression of tthe brain stem and judiciuos intraoperative judgement of the “safe” amount of tumor resection with preservation of vital cerebral vessels and cranial nerves especially lower cranial nerves. The author of this comment has, over the years, together with other experienced skull base surgeons, been a strong proponent of this patient oriented concept, integrated into a modular approach of PCM treatment.

Despite the fact that the majority of surgically treated PCM patients are consequently left with a tumor remnant, the percentage of patients with a relentlessly growing, and in the end, life threatening remaining tumor is, according to the author’s experience and the literature, small, the majority of tumor remnants being stable over a long observation period.

However, no doubt, there are patients with a continuously growing tumor remnant and this exceptionally deep and well written article by Li et al. from the Beijing Tian Tan Hospital, for which the authors are to be commended, deals with this very problematic, albeit small group of patients.

This article is by far too extensive and too multi-faceted to be touched on in detail during this comment; however, I agree and also disagree with the final and generalizing conclusion of the authors that “Proactive treatment should be performed for patients with recurrent/progressive PCM.”

In my opinion, the main aspect which should guide the decision making process in these patients should be the amount of the initial tumor resection and the postoperative clinical outcome.

If , like in the case presented in their article (Fig. 3), the tumor could be almost completely removed during the first surgery, it can be assumed that the tumor was soft, that there was a perfect arachnoid interface as dissection plane, and that there was no relevant cranial nerve or vessel encasement. Relying on some surgical luck, it can be assumed that these conditions will remain the same for the second surgery, and therefore, surgery should be undertaken.

However, the circumstances are completely different if during the initial surgery, the surgeon had been forced to restrict his surgery to subtotal or even only partial removal. Assuming he was a surgeon with high expertise then there was a reason or better several reasons why he used his thoughtful intraoperative judgement and left tumor behind, and again, as already pointed out, these reasons would have been hard tumor texture, no reliable dissection plane, and vessel and nerve encasement !

Why should this have changed after surgery and during the period in which regrowth of the tumor remnant had occurred. The surgeon will face exactly the same problems during recurrent surgery as during the initial surgery only with an even more complex and higher magnitude, because now the scaring induced by the previous surgery will increase the surgical difficulties as every surgeon knows, thereby rendering any attempt at radical removal of the recurrent tumor impossible and also dangerous as the results of the authors clearly demonstrate.

So in this scenario, which surely applies to the majority of recurrent PCMs, repeated surgery should definitely not be the way to go.

The surgeon should be able to make a clear judgement whether repeated treatment in any specific case of recurrent PCM is really indicated considering a large variety of patient specific aspects, e.g. growth speed of the recurrent tumor, clinical picture, and neurological deficits of the patient, age, life expectancy, concomitant disease, and patients expectance.

If he comes to the conclusion that the patient should or must be treated, he should be aware of the above mentioned surgical aspects: radical initial surgery, incomplete initial surgery because of relevant intraoperative aspects preventing complete removal.

In the first scenario, repeated surgery can be attempted; in the second scenario modern, expert guided, paradigms of radiosurgery or repeated radiosurgery should be tried eventually in conjunction with the experimental application of modern chemotherapy methods, with which, for example, convincing preliminary results have been achieved in recurrent, vestibular schwannomas.

So, notwithstanding the excellent work of Li and coworkers, the treatment of recurrent petroclival meningiomas can definitely not be guided by generalized recommendations, but should be the result of an intensive discussion of a board of experienced experts of neurosurgery, radiosurgery, and neurooncology, considering the individual patient and his preservation of quality of life as the ultimate target of treatment.

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Li, D., Hao, SY., Wang, L. et al. Recurrent petroclival meningiomas: clinical characteristics, management, and outcomes. Neurosurg Rev 38, 71–87 (2015). https://doi.org/10.1007/s10143-014-0575-1

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  • DOI: https://doi.org/10.1007/s10143-014-0575-1

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