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Letter of response to: spheno-orbital meningiomas

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LETTER TO THE EDITOR (BY INVITATION) - TUMOR - MENINGIOMA
Letter of response to: spheno-orbital meningiomas
Jonathan Shapey
1
&K. Barkas
1,2
&J. Jung
1
&R. Gullan
1
&S. Barazi
1
&R. Bentley
3
&C. Huppa
3
&N. W. Thomas
1
Received: 8 October 2019 /Accepted: 8 October 2019
#Springer-Verlag GmbH Austria, part of Springer Nature 2019
Dear editor,
We are grateful to Professors Amirjamshidi and
Abbassioun for their comments on our research and for draw-
ing attention to their work. We were not previously aware of
this study and acknowledge that we could have included it in
our bibliography of related literature.
However, there are several points ofdifference between our
study and that of Amirjamshidi et al.s[1]. Firstly, their defi-
nition of a spheno-orbital meningioma only included those
patients with en plaquedisease involving the bone. The
authors comment that in some cases soft tumour tissue extend-
ed extracranially beneath the temporalis muscle, but there is
no mention of intradural involvement. In contrast, all patients
in our study had an intradural tumour, often associated with
bony disease. We agree with Amirjamshidi and Abbassioun
that a standard pterional approach is not as effective as an
orbitozygomatic craniotomy or lateral orbitotomy when trying
to access the superior orbital fissure or when inferior drilling is
required for tumour removal. However, performing surgery
via a small lateral orbitotomy approach would not have been
appropriate for our patients because of the difficulty in achiev-
ing adequate intradural tumour resection when approaching
the tumour from below, and the difficulty in achieving ade-
quate decompression of the optic nerve via this approach. The
incidence of post-operative visual deficit (25%) and
enophthalmos (5.3%) was also higher in Amirjamshidi
et al.s study which may have resulted from a more restricted
approach.
In conclusion, we maintain that a standard or modified
mini-orbitozygomatic craniotomy allows the optimum access
to larger tumours, particularly those with intradural involve-
ment and those with visual problems, and that good cosmetic
outcomes may be achieved when combining this approach
with the use of custom-made implants [2].
References
1. Amirjamshidi A, Abbasioun K, Amiri RS, Ardalan A, Hashemi
SMR (2015) Lateral orbitotomy approach for removing
hyperostosing en plaque sphenoid wing meningiomas. Description
of surgical strategy and analysis of findings in a series of 88 patients
with long-term follow up. Surg Neurol Int 6:79
2. Shapey J, Jung J, Barkas K, Gullan R, Barazi S, Bentley R, Huppa C,
Thomas NW (2019) A single centres experience of managing
spheno-orbital meningiomas: lessons for recurrent tumour surgery.
Acta Neurochir 161(8):16571667
PublishersnoteSpringer Nature remains neutral with regard to jurisdic-
tional claims in published maps and institutional affiliations.
This article is part of the Topical Collection on Tumor - Meningioma
*Jonathan Shapey
jshapey@doctors.org.uk
1
Department of Neurosurgery, Kings College Hospital, London SE5
9RS, UK
2
Department of Neurosurgery, Hellenic Red Cross Hospital,
Athens, Greece
3
Department of Oral and Maxillofacial Surgery, KingsCollege
Hospital, London, UK
https://doi.org/10.1007/s00701-019-04103-z
Acta Neurochirurgica (2019) 161:2571
/Published online: 9 November 2019
... Intradural extension may be in various forms from a thin lesion to the large en-plaque meningiomas. Hyperostosis is commonly seen in whole skull base but especially involve the walls of superior orbital fissure (SOF) and optic canal (OC) (1,13,19). The d ifferential diagnosis includes osteoma, fibrous dysplasia and osteoblastic metastasis of the skull (20). ...
... Intradural and extradural approach with large frontotempotal craniotomy is the main technique for surgical removal of SOM (1,4). But frontotemporal craniotomy is usually difficult in these patients because of hypertrophic sphenoid wing and temporal bone. ...
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Surgical removal of sphenoorbital meningiomas is challenging for neurosurgeons. The aim of study is to share our experience on sphenoorbital meningiomas and to provide a picture of the current state of the art in surgical treatment of these tumors. The data of 13 cases of sphenoorbital meningioma who were operated between 2006 and 2013 was reviewed retrospectively. Intraorbital extension was present in 10 cases while sphenoid bone invasion was detected in 9 cases. All patients underwent surgical treatment after the radiological evaluation with magnetic resonance imaging and computed tomography. The degree of resection and the clinical outcome of all patients were analyzed. Extended pterional approach with a large frontotemporal craniotomy was performed in all cases. Simpson's grade I and II excision was achieved in 4 (31%) cases while subtotal excision (Simpson's grade III or higher) was performed in 9 cases. The main reason for subtotal excision was the cavernous sinus invasion. Optic canal decompression was performed in patients with intraorbital invasion. Although total removal is the main objective of surgery, the sphenoorbital meningiomas are difficult to resect especially with cavernous sinus invasion. But in the meantime, it is not recommended to take any excessive risks to achieve a greater degree of resection for a benign tumor. Endoscopic approach is an option for inferomedial orbital parts of these tumors.
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Background Spheno-orbital meningiomas are complex tumours involving the sphenoid wing and orbit. Various surgical strategies are available but treatment remains challenging and patients often require more than one surgical procedure. This study evaluated whether smaller surgical approaches and newer reconstructive methods impacted the surgical and clinical outcomes of patients undergoing repeat surgery. Methods We retrospectively analysed the medical records of consecutive patients who underwent surgery for a spheno-orbital meningioma at a single tertiary centre between 2005 and 2016. We recorded procedural details and analysed complications, postoperative visual status and patient-reported cosmetic outcome. Results Thirty-four procedures were performed in 31 patients (M:F 12:22, median age 49 years) including 19 (56%) primary operations and 15 (44%) repeat procedures. Seven patients (20.5%) had a pterional craniotomy, 19 (56%) had a standard orbitozygomatic craniotomy and 8 (23.5%) underwent a modified mini-orbitozygomatic craniotomy. Calvarial reconstruction was required in 19 cases with a variety of techniques used including titanium mesh (63%), PEEK (26%) and split calvarial bone graft (5%). Total tumour resection (Simpson grade I–II) was significantly higher in patients undergoing primary surgery compared with those having repeat surgery (41% and 0%, respectively; p = 0.0036). Complications occurred in 14 cases (41%). Proptosis improved in all patients and visual acuity improved or remained stable in 93% of patients. Cosmetic outcome measures were obtained for 18 patients (1 = very poor; 5 = excellent): 1–2, 0%; 3, 33%; 4, 28%; 5, 39%. Tumour recurrence requiring further surgery occurred in four patients (12%). There was no significant difference in clinical outcomes between patients undergoing primary or repeat surgery. Conclusion Spheno-orbital meningiomas are highly complex tumours. Surgical approaches should be tailored to the patient but good clinical and cosmetic outcomes may be achieved with a smaller craniotomy and custom-made implants, irrespective of whether the operation is the patient’s first procedure.
Full-text available
Article
Sphenoid wing meningiomas extending to the orbit (ePMSW) are currently removed through several transcranial approaches. Presenting the largest surgical cohort of hyperostosing ePMSW with the longest follow up period, we will provide data supporting minilateral orbitotomy with excellent exposure for wide resection of all compartments of the tumor. A retrospective survival analysis is made of the data cumulated prospectively during a period of 34 years, including 88 cases of ePMSW with a mean follow up period of 136.4 months. The impact of preoperative variables upon different outcome measures is evaluated. Standard pterional craniotomy was performed in 12 patients (C) while the other 76 cases underwent the proposed modified lateral miniorbitotomy (LO). There were 31 men and 57 women. The age range varied between 12 and 70 years. Patients presented with unilateral exophthalmos (Uex) ranging between 3 and 16 mm. Duration of proptosis before operation varied between 6 months and 16 years. The status of visual acuity (VA) prior to operation was: no light perception (NLP) in 16, light perception (LP) up to 0.2 in 3, 0.3-0.5 in 22, 0.6-0.9 in 24, and full vision in 23 patients. Postoperatively, acceptable cosmetic appearance of the eyes was seen in 38 cases and in 46 mild inequality of < 2 mm was detected. Four cases had mild enophthalmos (En). Among those who had the worst VA, two improved and one became almost blind after operation. The cases with VA in the range of 0.3-0.5 improved. Among those with good VA (0.5 to full vision), 2 became blind, vision diminished in 10, and improved or remained full in the other 35 cases. Tumor recurrence occurred in 33.3% of group C and 10.5% of group LO (P = 0.05). The major determinant of tumor regrowth was the technique of LO (P = 0.008). Using LO technique, the risky corners involved by the tumor is visualized from the latero-inferior side rather than from the latero-superior avenue. This is the crucial milestone to achieve aggressive removal of all the involved compartments of the lesion. Satisfactory cosmetic result is reported using mini LO technique after widely exposing and removing the hyperostotic bone down to the subtemporal fossa with only simple repair of the dura without cranioplasty.