Is surgery justified for 80-year-old or older intracranial meningioma patients? A systematic review

Since the number of elderly people with intracranial meningiomas (IM) continues to rise, surgical treatment has increasingly become a considerable treatment option, even in very old (≥ 80 years old) meningioma patients. Since little is known about whether meningioma surgery in this age group is safe and justified, we conducted a systematic review to summarize the results of surgical outcomes in very old meningioma patients. We performed a systematic literature search in Pubmed, Cochrane Library, and Scopus databases. Primarily, we extracted 1-month and 1-year survival rates, and 1-year morbidity rates, as well as information about preoperative morbidity, operative complications, meningioma size, location, histology, and peritumoral edema. Quality of the included studies was evaluated by Cochrane Collaboration Handbook and Critical Appraisal Skills Program. From the 1039 reviewed articles, seven retrospective studies fulfilled our eligibility criteria. Motor deficits (27–65%) and mental changes (51–59%) were the most common indications for surgery. One-month and 1-year mortality rates varied between 0–23.5% and 9.4–27.3%, respectively. Most of the operated IM patients (41.2–86.5%) improved their performance during postoperative follow-up. Impaired preoperative performance and comorbidities were most commonly related to higher postoperative mortality. None of the studies fulfilled the criteria of high quality. Based on the evidence currently available, surgical treatment of very old IM patients seems to improve the performance of highly selected individuals. Given the rapid increase of the aging population, more detailed retrospective studies as well as prospective studies are needed to prove the outcome benefits of surgery in this patient group. Electronic supplementary material The online version of this article (10.1007/s10143-020-01282-7) contains supplementary material, which is available to authorized users.

Search terms as written:

meningioma AND surgery AND (80 years or older)
Search terms expanded:

TITLE-ABS-KEY (meningioma AND (surgery OR operation) AND (elderly OR aged) AND ("80 years" OR "ninth decade" OR octogenarian))
Publications: 36 (37 in update) The PICO principle was also used to define the eligibility criteria to determine which studies would be included for further analyses. Specifically, in order to be included, studies needed to have 80year-old or older IM patients (Patient) who underwent surgical tumor resection (Intervention), and to assess postoperative morbidity or mortality (Outcome). We excluded commentaries, case reports, case series (n < 5), letters, book chapters, reviews and animal studies. There were no restrictions based on language, publication year or publication area.

Cochrane Library
From the included studies, we extracted the following data: publication year, country, IM case number, median/mean age, age range, proportion of males and females, type of design, indications for surgery, preoperative functional status, comorbidities, size of IM, location of IM, histology of IM, peritumoral edema of IMs, extent of tumor resection, short-term (one-month) mortality, complications, short-term morbidity, long-term (more than one year) morbidity, long-term mortality, duration of follow-up, postoperative performance, postoperative independence, recurrence rates, surgical treatment of recurrent IMs and prognostic factors for postoperative morbidity and mortality.

Quality of included studies
According to the Cochrane Collaborator Handbook, we used a domain-based analysis to evaluate the quality of each included study; the checklist of Critical Appraisal Skills Program (CASP) guided the systematic evaluation. In total, we formed six individual domains to assess the potential source of different biases and methodological shortcomings in fundamental areas. All included studies were classified as low, unknown, or high risk of bias by each of the six domains. If the study fulfilled the low risk criteria in all six domains, it was classified as high quality. Otherwise, the study was categorized as low quality.

Meningioma characterization
Meningiomas may vary significantly in several tumor characteristics, which in turn may affect the surgical outcome. Therefore, in order to be classified as low risk of bias, studies needed to present complete characterization of reported meningiomas, including location, size, histology and the existence of peritumoral edema.

Preoperative morbidity
Preoperative physical condition and comorbidities may naturally affect the postoperative outcome.
To be classified as low risk of bias, studies needed to assess preoperative morbidity by at least one proper measurement (e.g. American Society of Anesthesiologists (ASA) Score).

Extent of resection
The extent of surgery may also affect the postoperative outcome. For example, traumatic differences between complete removal (Simpson grade I) and simple decompression with/without biopsy can be enormous. Therefore, to be classified as low risk of bias, studies needed to report the extent of surgery.

Comprehensive outcome assessment
In addition to survival, assessment of physical condition, performance, independence and other possible complications or morbidities provides fundamental information about the safety of surgical treatments. Therefore, to be classified as low risk of bias, studies needed to assess not only postoperative mortality but also postoperative morbidity by at least one variable at one time point.

Prospective design
To provide possible risk factors for poor postoperative outcomes, or to provide high-quality evidence from surgical outcomes, retrospective studies have significant risks for different biases.
Therefore, to be classified as low risk of bias, studies needed to be performed prospectively.