An evidence-based framework for postoperative surveillance of meningioma

Abstract

Background: Meningiomas frequently recur after surgery. Existing guidelines for postoperative surveillance are based on customary practices or limited data. This may result in excessive or inadequate surveillance.

Methods: We compared 8 studies involving 1519 resected meningiomas with postoperative follow-up ranging from 7 to 23 years. Meningiomas were stratified using the World Health Organization and Simpson grading systems, and progression-free survival data were compared. Recurrence patterns were validated using 2 additional studies involving 2463 meningiomas.

Results: Incompletely resected meningiomas of all grades displayed recurrences throughout the observation period. The 5-year and 10-year cumulative incidence of recurrence for completely resected Grade 1 meningiomas was 10% and 20%, with no recurrences beyond 11 years. For completely resected Grade 2 meningiomas, the 5-year and 10-year cumulative incidence of recurrence was 24% and 50%, with ongoing recurrences throughout the observation period. Elevated recurrence rates for Grade 1/2 meningiomas persisted beyond 5 years. For completely resected Grade 3 meningiomas, the 5-year cumulative incidence of recurrence was 63%, and all recurred before 10 years.

Conclusions: Postoperative magnetic resonance imaging (MRI) at 48 h to determine the extent of resection and at 4 months to detect rapid regrowth is recommended. For completely resected Grade 1 meningiomas, annual MRI followed by discontinuation of surveillance if there is no recurrence after 11 years is reasonable. For completely resected Grade 2 meningiomas, annual MRI indefinitely is recommended. For Grade 3 meningiomas, MRI every 3-4 months for 2 years, followed by every 6 months indefinitely, is recommended. Incompletely resected meningiomas should be followed indefinitely.

Keywords: follow-up; meningioma; recommendations; recurrence; surveillance.

Figure 1.

Flow diagram for selection of publications for comparative study of meningioma recurrence. A literature search in July 2023 using the PubMed database was performed with the retrieval of select articles on meningioma recurrence after applying inclusion and exclusion criteria.

Figure 2.

Comparative analysis of progression-free survival (PFS) for WHO Grade 1 meningioma. (A) Kaplan-Meier analyses from 7 separate studies evaluating PFS of patients with WHO Grade 1 meningiomas. Studies that exclusively analyzed meningiomas that underwent complete/gross total resection (GTR) are indicated. Data from Olar et al. was separated into a group of meningiomas undergoing GTR or a group of meningiomas undergoing subtotal resection (STR) to assess the effects of EOR on PFS. (B) Kaplan-Meier analysis using combined data from 4 studies that evaluated PFS for WHO Grade 1 meningiomas underwent GTR. A separate Kaplan-Meier analysis utilized data from 4 studies where WHO Grade 1 meningiomas that underwent either GTR or STR were considered together (GTR + STR). The log-rank test was used to calculate statistical significance.

Figure 3.

Comparative analysis of progression-free survival (PFS) for WHO Grade 2 meningioma. (A) Kaplan-Meier analyses from 8 separate studies evaluating PFS of patients with WHO Grade 2 meningiomas. Studies that exclusively analyzed meningiomas that underwent complete/gross total resection (GTR) are indicated. The remaining studies did not specify EOR and were presumed to include meningiomas that underwent GTR as well as meningiomas that underwent subtotal resection (GTR + STR). (B) Kaplan-Meier analysis of PFS using combined data from 4 studies examining WHO Grade 2 meningiomas that underwent GTR. A separate Kaplan-Meier analysis utilized data from 5 studies where WHO Grade 2 meningiomas that underwent either GTR or STR were considered together (GTR + STR). The log-rank test was used to calculate statistical significance.

Figure 4.

Comparative analysis of progression-free survival (PFS) for WHO Grade 3 meningioma. (A) Kaplan-Meier analyses from 7 separate studies evaluating PFS of patients with WHO Grade 3 meningiomas. Studies that exclusively analyzed meningiomas that underwent complete/gross total resection (GTR) are indicated. The remaining studies did not specify EOR and were presumed to include meningiomas that underwent GTR as well as meningiomas that underwent subtotal resection (GTR + STR). (B) Kaplan-Meier analysis of PFS using combined data from 3 studies examining WHO Grade 3 meningiomas that underwent GTR. A separate Kaplan-Meier analysis utilized data from 5 studies where WHO Grade 3 meningiomas that underwent either GTR or STR were considered together (GTR + STR). The log-rank test was used to calculate statistical significance.

Figure 5.

Validation comparative analysis of progression-free survival (PFS) for WHO Grade 1 and WHO Grade 2 meningiomas. (A) Kaplan-Meier analyses from 2 independent studies (Gousias et al. and Behling et al.) evaluating PFS of patients with WHO Grade 1 meningiomas that underwent complete resection (Simpson Grades 1 and 2). (B) Kaplan-Meier analyses from 2 independent studies (Gousias et al. and Behling et al.) evaluating PFS of patients with WHO Grade 1 meningiomas that underwent incomplete/subtotal resection (STR) (Simpson Grades 3 and 4). (C) Kaplan-Meier analyses from 2 independent studies (Gousias et al. and Behling et al.) evaluating PFS of patients with WHO Grade 2 meningiomas that underwent complete resection (Simpson Grades 1 and 2). Of note, Behling et al. included WHO Grade 3 meningiomas along with their analysis of WHO Grade 2 meningiomas. (D) Kaplan-Meier analyses from 2 studies (Gousias et al. and Behling et al.) evaluating PFS of patients with WHO Grade 2 meningiomas that underwent incomplete/STR (Simpson Grades 3 and 4). Of note, Behling et al. included WHO Grade 3 meningiomas along with their analysis of WHO Grade 2 meningiomas.

Figure 6.

An evidence-based framework for postoperative meningioma surveillance.