Clinical Outcomes Following Re-Operations for Intracranial Meningioma

Abstract

The outcomes following re-operation for meningioma are poorly described. The aim of this study was to identify risk factors for a performance status outcome following a second operation for a recurrent meningioma. A retrospective, comparative cohort study was conducted. The primary outcome measure was World Health Organization performance. Secondary outcomes were complications, and overall and progression free survival (OS and PFS respectively). Baseline clinical characteristics, tumor details, and operation details were collected. Multivariable binary logistic regression was used to identify risk factors for performance status outcome following a second operation. Between 1988 and 2018, 712 patients had surgery for intracranial meningiomas, 56 (7.9%) of which underwent a second operation for recurrence. Fifteen patients (26.8%) had worsened performance status after the second operation compared to three (5.4%) after the primary procedure (p = 0.002). An increased number of post-operative complications following the second operation was associated with a poorer performance status following that procedure (odds ratio 2.2 [95% CI 1.1-4.6]). The second operation complication rates were higher than after the first surgery (46.4%, n = 26 versus 32.1%, n = 18, p = 0.069). The median OS was 312.0 months (95% CI 257.8-366.2). The median PFS following the first operation was 35.0 months (95% CI 28.9-41.1). Following the second operation, the median PFS was 68.0 months (95% CI 49.1-86.9). The patients undergoing a second operation for meningioma had higher rates of post-operative complications, which is associated with poorer clinical outcomes. The decisions surrounding second operations must be balanced against the surgical risks and should take patient goals into consideration.

Keywords: complications; meningioma; outcomes; re-operations; recurrence; surgery.

Figure 1

Swimmer Plot showing the treatment pathways for each patient in the cohort. The key is provided to the right. Individuals with no surgery at the beginning of treatment strategy were incidental, with primary and subsequent operations occurring at a later point during follow-up.

Figure 2

Sankey diagram demonstrating changes in performance status from initial diagnosis (A), after primary operation (B), before re-operation (C), and 6 months after re-operation (D). The length of the nodes and links between nodes are proportional to the number of patients. Red links indicate a worsening of performance status. Green links indicate improved performance status. Grey links indicate no change in performance status.

Figure 3

Stacked bar charts demonstrating post-operative complications graded according to Landriel-Ibañez classification (A,B) and Clavien-Dindo classification (C). The Landriel-Ibañez classification includes both surgical (A) and medical (B) complications. Frequency of each grade is demonstrated within the bars.

Figure 4

Kaplan Meier graphs demonstrating progression free survival with a log rank test between operation one and operation two (A); percentage at risk table is provided. Overall survival is demonstrated along with 95% confidence intervals (B). Censoring on both graphs is demonstrated by crosses on the curve.