JUDICIOUS RESECTION AND OR RADIOSURGERY FOR PARASAGITTAL MENINGIOMAS - OUTCOMES FROM A MULTICENTER REVIEW/

BACKGROUND: Parasagittal meningiomas, especially when associated with the middle or posterior third of the superior sagittal sinus, pose dif ficult management challenges. Initial surgical excision is associated with high morbidity and frequent tumor recurrence after subtotal resec tion. Neurological deficits are cumulative when multiple resections ar e required. No consistent management approach exists for patients with such tumors. In addition to observation, management options include r esection, stereotactic radiosurgery, or fractionated radiation therapy used alone or in combination. METHODS: Sixteen centers where resectio n, gamma knife radiosurgery, and/or radiation therapy were available p rovided management data on 203 patients with histologically benign men ingiomas from the time of initial diagnosis through follow-up after ra diosurgery. The timing of resections, parameters of radiosurgery, rate s of tumor control, morbidity, and functional patient outcomes were st udied. The median follow-up duration in this study was 3.5 years (maxi mum, 33 yr after presentation and 6 yr after radiosurgery). RESULTS: T he tumors were located in the anterior superior sagittal sinus in 52 p atients, at the middle of the sinus in 91, and at the posterior portio n of the sinus in 60. The mean tumor volume at the time of radiosurger y was 10 cc. In patients who underwent radiosurgery as the primary the rapy (n = 66), the 5-year actuarial tumor control rate was 93 +/- 4%. No clinical failure (need for additional therapy or worsened neurologi cal function) occurred in patients who had smaller tumors (<7.5 cc) an d who had never undergone resection (n = 41), The 5-year control rate for patients with previous surgery was only 60 +/- 10%; the control ra te for the radiosurgery-treated Volume was 85%. Most failures resulted from remote tumor growth. Multivariate analyses identified significan tly decreased tumor control with increasing tumor volume (P = 0.002) a nd previous neurological deficits (P = 0.002). The rate of transient, symptomatic edema after radiosurgery was 16%, was more common with lar ger tumors, and occurred within 2 years. Of 33 patients who were emplo yed at the time of radiosurgery for whom a minimum of 1 year of follow -up data were available, 30 remained employed (91%). A decrease in fun ctional status after radiosurgery was noted in only 3 of 33 (9%) emplo yed and 7 of 77 (9%) unemployed patients. CONCLUSION: In patients with smaller tumors (<3 cm in diameter) and patent sagittal sinuses, we ad vocate radiosurgery alone as the first surgical procedure. Patients wi th larger tumors and those with progressive neurological deficits resu lting from brain compression should first undergo resection. Planned s econd-stage radiosurgery should be performed soon afterward for any re sidual tumor nodule or neoplastic dural remnant. Multimodality managem ent may enhance long-term tumor control, reduce the need for multiple resections, and maintain the functional status of the patient.