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Proposal of a new grading system for meningioma resection: the Copenhagen Protocol

  • Technical Note - Tumor - Meningioma
  • Published:
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Abstract

Introduction

The extent of meningioma resection is the most fundamental risk factor for recurrence, and exact knowledge of extent of resection is necessary for prognostication and for planning of adjuvant treatment. Currently used classifications are the EANO-grading and the Simpson grading. The former comprises radiological imaging with contrast-enhanced MRI and differentiation between “gross total removal” and “subtotal removal,” while the latter comprises a five-tiered differentiation of the surgeon’s impression of the extent of resection. The extent of resection of tumors is usually defined via analyses of resection margins but has until now not been implemented for meningiomas. PET/MRI imaging with 68Ga-DOTATOC allows more sensitive and specific imaging than MRI following surgery of meningiomas.

Objective

To develop an objective grading system based on microscopic analyses of resection margins and sensitive radiological analyses to improve management of follow-up, adjuvant therapy, and prognostication of meningiomas. Based on the rationale of resection-margin analyses as gold standard and superior imaging performance of 68Ga DOTATOC PET, we propose “Copenhagen Grading” for meningiomas.

Results

Copenhagen Grading was described for six pilot patients with examples of positive and negative findings on histopathology and DOTATOC PET scanning. The grading could be traceably implemented and parameters of grading appeared complementary. Copenhagen Grading is prospectively implemented as a clinical standard at Rigshospitalet, Copenhagen.

Conclusion

Copenhagen Grading provided a comprehensive, logical, and reproducible definition of the extent of resection. It offers promise to be the most sensitive and specific imaging modality available for meningiomas. Clinical and cost-efficacy remain to be established during prospective implementation.

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Authors and Affiliations

  1. Department of Neurosurgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark

    Jeppe Haslund-Vinding, Jane Skjoth-Rasmussen, Lars Poulsgaard, Kaare Fugleholm, Christian Mirian, Andrea Daniela Maier, Frantz Rom Poulsen, Jiri Junior Bartek, Morten Ziebell & Tiit Mathiesen

  2. Department of Pathology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark

    Andrea Daniela Maier & Frantz Rom Poulsen

  3. Department of Neurosurgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK

    Thomas Santarius & Frantz Rom Poulsen

  4. Department of Clinical Neuroscience, Section for Neurosurgery, Karolinska Institutet, Stockholm, Sweden

    Frantz Rom Poulsen, Jiri Junior Bartek, Petter Förander, Bjarne Winther Kristensen, David Scheie & Tiit Mathiesen

  5. Department of Neurosurgery, Odense University Hospital, University of Southern Denmark, Odense, Denmark

    Frantz Rom Poulsen

  6. Department of Radiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark

    Frantz Rom Poulsen & Vibeke Andrée Larsen

  7. Department of Clinical Medicine and Biotech Research and Innovation Center (BRIC), University of Copenhagen, Copenhagen, Denmark

    Frantz Rom Poulsen & Bjarne Winther Kristensen

  8. Department of Clinical Physiology, Nuclear Medicine and PET, Copenhagen University Hospital, Copenhagen, Denmark

    Frantz Rom Poulsen & Ian Law

  9. Department of Neurosurgery, Geneva University Hospital, Geneva, Switzerland

    Frantz Rom Poulsen & Torstein Meling

  10. Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark

    Frantz Rom Poulsen & Tiit Mathiesen

  11. Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden

    Frantz Rom Poulsen, Jiri Junior Bartek & Petter Förander

Authors
  1. Jeppe Haslund-Vinding
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  2. Jane Skjoth-Rasmussen
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  3. Lars Poulsgaard
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  4. Kaare Fugleholm
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  5. Christian Mirian
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  6. Andrea Daniela Maier
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  7. Thomas Santarius
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  8. Frantz Rom Poulsen
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  9. Torstein Meling
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  10. Jiri Junior Bartek
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  12. Vibeke Andrée Larsen
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  13. Bjarne Winther Kristensen
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  14. David Scheie
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  15. Ian Law
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  16. Morten Ziebell
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  17. Tiit Mathiesen
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Contributions

JHV and TM drafted the manuscripts. JHV made the illustrations and collected data with IL, ADM, BWK and DS. TM, JHV, MZ, JSR, LP, KF, IL, BWK, and DS participated in the original design of the Copenhagen Grading for Meningioma. The remaining authors all gave thorough input in their field of expertise and helped design the final draft. All authors read and approved the final manuscript

Corresponding author

Correspondence to Jeppe Haslund-Vinding.

Ethics declarations

Ethics approval

Implementation of Copenhagen Grading is a Quality Assurance Project approved by the Department of Neurosurgery, Rigshospitalet. Specific ethics approval in not relevant per Danish legislation.

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Not applicable.

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All authors have given their consent.

Competing interests

The authors declare no competing interests.

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Comments

All meningiomas, such as fingerprints, nose prints, or a pinna, are different. [1,2] They are different in terms of clinical presenting features, radiological imaging characters, and histological subtleties, and more importantly in the pattern of their behavior and outcome. The "malignant" fault of a meningioma is its proximity to the brain and spinal cord and its occasional proclivity to ensnare neural structures. Meningioma should be christened as benign microscopically, malignant behaviourally, or rather positionally.

Between the idea (of benignancy)

And the reality (of behaviour),

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)

The authors present a novel grading system “Copenhagen grading” to assess the extent of meningioma resection and to improve the management of follow up, adjuvant therapy and prognostication.

All meningiomas can be classified into Good or Bad, only in retrospect. Evaluation after several years of treatment can determine the true colors of the tumors. You can remove the tumor, the whole tumor, and nothing but tumor without removing the tumor diathesis or the ability to form the tumor.

Presenting symptoms, meningioma location, extensions, relationship with adjoining structures, vascularity, and consistency vary, making the management unique in every case. Likewise, the cellularity and the growth pattern of all meningiomas are different. Some indicators such as extradural or extracranial extension and involvement of dural sinuses (including cavernous sinus) are indicative of a higher growth potential and an enhanced propensity to recur. Histological grading may help in prognosticating the long-term outcome.

The recurrences depend more on the growth pattern of the tumor. The rate of recurrence of a meningioma is independent of the extent of tumor resection. The radicality of resection will also depend on the aggression and extensions of the meningioma. More extensive the presence of the tumor, 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 best imaging techniques and the most evolved operative microscopes do not touch the basic character of a neuraxial tumor. There lies a message for the neurosurgeon: "Less is more."

Assessing or grading the tumor is good, but it can essentially be a futile exercise. From a surgeon's perspective it appears that surgery is the only practical fact. The answer to treatment of meningiomas is safe resection to obtain symptom-free time for the patient, an act that can be repeated when mandatory.

Atul Goel

Mumbai,India

References:

1. Goel A, Kothari M. Editorial: Cavernous sinus meningiomas. J Neurosurg. 2010;113:1085

2. Goel A, Kothari M. Meningiomas: Are they curable? J Craniovertebr Junction Spine. 2016 Jul-Sep;7(3):133-4.

When coming up with a new grading system, this is usually based on large series, long-term consistent application and more often a consortional effort to demonstrate applicability beyond single institution borders. Therefore, this cannot be more than a proposal derived from a very small patient group which in some institutions is less than a week’s load. Nonetheless, it is an interesting approach to add in a more refined way the evaluation of procedural quality to the big picture of meningioma grading. Very elaborate molecular based grading systems for meningioma have been published or accepted for high-ranking publication this year, providing a very elaborate in-depth analysis of cellular heterogeneity and tumor biology which is bound to have a highly important impact on the clinical course. Nonetheless, even with equal molecular characteristics, the fate of a patients is as much determined by the quality of the resection. In that aspect, an attempt to improve the assessment of the surgical result is relevant and the proposed evaluation by the Copenhagen group is one option.

Manfred Westphal

Hamburg, Germany

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Haslund-Vinding, J., Skjoth-Rasmussen, J., Poulsgaard, L. et al. Proposal of a new grading system for meningioma resection: the Copenhagen Protocol. Acta Neurochir 164, 229–238 (2022). https://doi.org/10.1007/s00701-021-05025-5

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