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Surgical management of ocular symptoms in spheno-orbital meningiomas. Is orbital reconstruction really necessary?

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Abstract

Spheno-orbital meningioma (SOM) is an intriguing tumor because of the many different factors that can influence clinical and oncological outcome after treatment. Reasoning that outcome indicator measurement is key to improving therapy, we retrospectively evaluated the management of proptosis and other ocular symptoms in 47 patients surgically treated for SOM at our department in the last 10 years. This patient series was characterized by a high rate of tumor infiltration of the extradural cranial base. Clinical outcome was assessed by comparing preoperative and postoperative ophthalmological and neurological signs. Acute postoperative complications were reported, and clinical and radiological outcome was assessed at 4–6 months, 12 months, and the last follow-up. Proptosis (measured by Hertel exophthalmometry), visual acuity, visual field defect (measured by Goldmann perimetry), diplopia (measured by the Hess-Lancaster test), and other disturbances were rated as normalized, improved, or unchanged/worsened. The most common presenting symptoms were proptosis (95.7 %), visual impairment (51 %), and cranial nerve deficit (38.2 %). Surgery via the frontotemporal approach was performed in all 47 cases, with the primary aim to relieve symptoms/signs and maximize tumor resection. Bony orbital reconstruction was never performed. Complete resection was achieved in 51 % of cases (Simpson grades I and II) with minimal morbidity. At a mean follow-up of 52 months (range, 12–112), proptosis normalized in 90.9 % and improved in the remaining patients, visual acuity normalized in 20.8 % and improved in 45.8 % patients, cranial nerve deficit subsided in all but two cases. The recurrence rate was 29.7 %. One of the gold standards of surgical treatment, normalization of proptosis, can be achieved by accurate resection of the superior and lateral orbital walls. In this setting, careful reconstruction of the frontobasal dura is far superior to bony reconstruction. Complete tumor resection should not be pursued at the expense of increased morbidity.

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Conflict of interests and source of funding: none declared

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Authors and Affiliations

  1. Section of Neurosurgery, Department of Neurological, Neuropsychological, Morphological and Movement Sciences, University of Verona, University Hospital, Verona, Italy

    Andrea Talacchi & Antonella De Carlo

  2. Section of Dentistry and Maxillo-Facial Surgery, Department of Surgical Science, University of Verona, University Hospital, Verona, Italy

    Antonio D’Agostino & Pierfrancesco Nocini

  3. Institute of Neurosurgery, Department of Neurosciences, University of Verona, University Hospital, P. Stefani 1, 37126, Verona, Italy

    Andrea Talacchi

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  1. Andrea Talacchi
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  2. Antonella De Carlo
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  3. Antonio D’Agostino
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  4. Pierfrancesco Nocini
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Correspondence to Andrea Talacchi.

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Comments

Vladimír Beneš, Prague, Czech Republic

Authors Talacchi et al. presented an excellent study of 61 patients harboring spheno-orbital meningiomas. Although retrospective, this study is well conducted and its methodology is clear. When dealing with these challenging tumors, a responsible neurosurgeon is always torn between effort for maximal tumor removal and maximal preservation of neurological function. Besides excellent surgical results and meticulous description of technique, authors are presenting very important mental paradigm, which is more and more often articulated in modern neurosurgery. Nowadays, having well-established second-line treatment modalities such as radiosurgery, it is impossible to sacrifice function for the sake of complete tumor removal. It is necessary to keep in mind the patient’s best interest regarding neurological, neuropsychological, and cosmetic result as well. From this point of view, tailored orbital decompression advocated by the authors instead of orbital wall reconstruction seems to be better strategy. Proportion of patient with normalized proptosis (eye bulb symmetry was achieved in 91 %) together with radical resection achieved in 51 % with minimal neurological morbidity makes a good standard for all neurosurgeons dealing with these tricky lesions. This article is definitely worth to be printed, read, and discussed.

William T. Couldwell, Salt Lake City, USA

Talacchi and coauthors have reviewed the outcome of 47 patients treated with spheno-orbital meningiomas over a 10-year period at their institution. They achieved complete removal in 51 % and recurrence in 29 % of cases. They note the efficacy and reduction in proptosis with radical resection of the roof and lateral wall of the orbit, without formal orbital bony reconstruction. They provide a comprehensive approach based on accurate outcome measurements (ophthalmologic, neurological, and oncological).

This approach is very similar to the type of surgery we perform as well. Some years ago, we adopted a very aggressive approach to the removal of the tumor in the bone and orbit, as I was personally not satisfied with lesser removals. We have studied the outcome with an aggressive approach and found that lesser removals do not achieve adequate reduction in proptosis (manuscript in press). Similarly, the authors of the present manuscript note that reduction in proptosis was not achieved without adequate bone removal. We also strive to remove all involved periorbita, which is often infiltrated with tumor. In careful follow-up study, enopthalmus has not been noted in our experience as well.

I congratulate the authors on their careful review and follow-up in this group of patients.

Johannes Schramm, Bonn, Germany

This series of 47 patients with surgery for spheno-orbital meningioma is large enough to allow conclusions to be drawn. What I like about the study was the use of recognized test methods for the three main symptoms, proptosis, visual field defects, and diplopia, a feat rarely accomplished in many other series.

The patient series is very typical regarding the incidence of proptosis, field defects, and cranial nerve deficits when presenting for a surgery. The outcome appears to be rather good with normalization of proptosis in 90.9 %, while it was only 77 % in our own series [1]. The authors deserve recognition for their low-complication rates and the relatively high rates of normalization of visual acuity and field defects. Like many other authors, this group routinely removed not only the lateral wall of the orbit but also the involved parts of the orbital roof.

Reading the article, I was surprised by the statement that “…the tumor is usually extraconal and dissectible from the preserved periorbita….” In their series, the authors obviously found the tumor only “…occasionally…” intraconal. And consequently, “…the periorbita is not normally opened….” In only 7 of 47 cases, they operated within the cone of the orbital content and its cover, the periorbita. The fact that they did not have to go under the periorbita and did not have to manipulate the intraorbital contents may be an explanation for the low rate of complications.

Concerning the need for a reconstruction of orbital roof and lateral wall, we agree with the authors that this is normally not necessary. Their technique of suspension of the dura (or lyophilized dura), partly supplemented by the use of sponge and fibrin glue, was very successful; there was no case of enopthalmus or pulsating eye bulb in the series. Other authors have found the same [2, 3]. In our own series [1] we never used bony reconstruction, only combination of gelfoam and fibrin glue, but we had two cases of enophthalmus in 63. We still believe that this only proves that the reconstruction with fibrin glue and gelfoam was insufficient; it does not prove the necessity for a bony reconstruction of the roof or even both walls.

In summary, I agree with the authors that routine bony reconstruction of the orbital walls appears not to be necessary, and this study also made clear that, once the necessity arises to resect tumor infiltrated periorbita with intraconal tumor, a higher-complication rate has to be expected.

References

1. Ringel F, Cedzich C, Schramm J: Microsurgical technique and results of a series of 63 spheno-orbital meningiomas. Neurosurgery 60 ONS suppl 2: ONS 214-ONS 222, 2007.

2. DeMonte F, Tabrizi P, Culpepper SA, Suki D, Soparkar CN, Patrinely JR: Ophthalmological outcome after orbital entry during anterior and anterolateral skull base surgery. J Neurosurg 97:851–856, 2002.

3. Maroon JC, Kennerdell JS, Vidovich DV, Abla A, Sternau L: Recurrent sphenoorbital meningioma. J Neurosurg 80:202–208, 1994.

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Talacchi, A., De Carlo, A., D’Agostino, A. et al. Surgical management of ocular symptoms in spheno-orbital meningiomas. Is orbital reconstruction really necessary?. Neurosurg Rev 37, 301–310 (2014). https://doi.org/10.1007/s10143-014-0517-y

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