Journal of Clinical Neuroscience 22 (2015) 690–695
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Clinical Study
Analysis of prognostic factors and treatment of anaplastic meningioma in China Hongda Zhu a,1, Qing Xie a,1, Yu Zhou a, Hong Chen b, Ying Mao a, Ping Zhong a, Kang Zheng a, Yongfei Wang a, Yin Wang b, Liqian Xie a, Mingzhe Zheng a, Hailiang Tang a, Daijun Wang a, Xiancheng Chen a, Liangfu Zhou a, Ye Gong a,⇑ a b
Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, 12# Wu Lu Mu Qi Road, Shanghai 200040, China Department of Neuropathology, Huashan Hospital, Fudan University, Shanghai, China
a r t i c l e
i n f o
Article history: Received 2 February 2014 Accepted 25 October 2014
Keywords: Anaplastic meningioma Overall survival Progression free survival Radiotherapy Recurrence
a b s t r a c t Meningioma is the most frequently reported primary brain and central nervous system tumor. However, malignant meningioma is rare with the anaplastic subtype the most common. This subtype of meningioma is fatal with a high recurrence rate and poor survival. A retrospective review of anaplastic meningioma patients treated in one of the largest neurosurgical centers in China between 2003 and 2008 was conducted. From 70 identified patients, seven were lost to follow-up, but the remaining 63 patients were studied for prognostic factors. The mean follow-up time was 84.9 ± standard deviation (SD) of 19.7 months. Tumor recurred in 35 out of 63 (55.6%) patients. Thirty-three (52.4%) patients had died by the most recent follow-up, and the median overall survival (OS) was 70.0 ± 9.7 months. The 3 year and 5 year survival rates were 68.3% and 54.7%, respectively. The median progression-free survival (PFS) was 52.0 ± 9.9 months, whereas the 3 year and 5 year PFS rates were 60.2% and 43.9%, respectively. We found that preoperative KPS, extent of tumor resection, radiotherapy, tumor location and previous history of meningioma were factors related to PFS. In the non-recurrent group, the preoperative Karnofsky Performance Scale (KPS), extent of tumor resection and radiotherapy correlated with PFS. However, multivariate analysis identified radiotherapy as the only independent factor affecting PFS (p = 0.007). Additionally, MIB-1 proliferation index failed to identify a cut-off point to predict the prognosis for anaplastic meningioma. This study provides an overview of the epidemiology and treatment of anaplastic meningioma in China using a large population. Ó 2014 Elsevier Ltd. All rights reserved.
1. Introduction According to recent data (2006–2010) from the Central Brain Tumor Registry of the United States (CBTRUS), meningioma accounts for 35.8% of all primary brain and central nervous system tumors, and is the most frequently reported histology in adults [1,2]. Malignant meningioma is rare, and only 1.54% of all cases of primary and central nervous system tumors reported in CBTRUS are malignant meningiomas. In addition, malignant meningioma has three variants, namely, anaplastic, rhabdoid, and papillary, which are classified as Grade III based on the World Health Organization (WHO) Classification of Tumors of the Central
⇑ Corresponding author. Tel.: +86 021 5288 8682; fax: +86 021 6249 0665. E-mail address: [email protected] (Y. Gong). Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China. 1
http://dx.doi.org/10.1016/j.jocn.2014.10.023 0967-5868/Ó 2014 Elsevier Ltd. All rights reserved.
Nervous System [3]. Anaplastic meningioma exhibits characteristic histological features, with either obviously malignant cytology or a markedly elevated mitotic index (20 or more mitoses per 10 high power fields) without papillary architecture or rhabdoid cytology [2,3]. Anaplastic meningioma is often fatal, with the median survival being less than 2 years, and the 5 year survival between 35% to 61% [4–10]. Most previous studies have small sample sizes or follow up of less than 5 years, due to its rarity. Thus, anaplastic meningioma patients treated at one of the largest neurosurgical centers in China between 2003 and 2008 were retrospectively reviewed.
2. Patients and methods Seventy anaplastic meningioma patients, with 73 surgical specimens, were diagnosed at the main branch of Huashan Hospital, Neurosurgical Group Hospitals, Shanghai, China, between 2003 and 2008. Among these patients, three had a second operation
H. Zhu et al. / Journal of Clinical Neuroscience 22 (2015) 690–695
on recurrent tumors during that period. In addition, 12 rhabdoid meningioma, 17 papillary meningioma and 4286 overall meningioma cases were surgically treated at Huashan Hospital. Using the WHO 2007 criteria, two experienced neuro-pathologists, Dr. Hong Chen and Dr. Haixia Chen, checked and confirmed the diagnosis of each case. Immunohistochemical staining was carried out using monoclonal antibodies to epithelial membrane antigen (M/S Dako Patts, Copenhagen, Denmark; 1:50 dilution), vimentin (M/S Dako Patts; 1:100 dilution), estrogen receptor (ER) (Signalway [SAB], Shanghai, China; 1:200 dilution), and progesterone receptor (PR) (Signalway, SAB; 1:200 dilution). Telomerase activity was detected using a modified telomeric repeat amplification protocol as described previously [11]. Unfortunately, we lost contact with seven patients during the follow-up period, and had to exclude them from final outcome analysis. Thus, the remaining 63 patients were reviewed for their age, sex, tumor location, previous history, extent of resection, MIB-1 proliferation index, recurrence rates, Karnofsky Performance Status (KPS), and use of radiotherapy after operation. The extent of resection was determined from the surgical records and graded according to Simpson’s grading scale. For statistical analysis, the possible prognostic factors were dichotomized as follows: age (
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Clinical Study
Analysis of prognostic factors and treatment of anaplastic meningioma in China Hongda Zhu a,1, Qing Xie a,1, Yu Zhou a, Hong Chen b, Ying Mao a, Ping Zhong a, Kang Zheng a, Yongfei Wang a, Yin Wang b, Liqian Xie a, Mingzhe Zheng a, Hailiang Tang a, Daijun Wang a, Xiancheng Chen a, Liangfu Zhou a, Ye Gong a,⇑ a b
Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, 12# Wu Lu Mu Qi Road, Shanghai 200040, China Department of Neuropathology, Huashan Hospital, Fudan University, Shanghai, China
a r t i c l e
i n f o
Article history: Received 2 February 2014 Accepted 25 October 2014
Keywords: Anaplastic meningioma Overall survival Progression free survival Radiotherapy Recurrence
a b s t r a c t Meningioma is the most frequently reported primary brain and central nervous system tumor. However, malignant meningioma is rare with the anaplastic subtype the most common. This subtype of meningioma is fatal with a high recurrence rate and poor survival. A retrospective review of anaplastic meningioma patients treated in one of the largest neurosurgical centers in China between 2003 and 2008 was conducted. From 70 identified patients, seven were lost to follow-up, but the remaining 63 patients were studied for prognostic factors. The mean follow-up time was 84.9 ± standard deviation (SD) of 19.7 months. Tumor recurred in 35 out of 63 (55.6%) patients. Thirty-three (52.4%) patients had died by the most recent follow-up, and the median overall survival (OS) was 70.0 ± 9.7 months. The 3 year and 5 year survival rates were 68.3% and 54.7%, respectively. The median progression-free survival (PFS) was 52.0 ± 9.9 months, whereas the 3 year and 5 year PFS rates were 60.2% and 43.9%, respectively. We found that preoperative KPS, extent of tumor resection, radiotherapy, tumor location and previous history of meningioma were factors related to PFS. In the non-recurrent group, the preoperative Karnofsky Performance Scale (KPS), extent of tumor resection and radiotherapy correlated with PFS. However, multivariate analysis identified radiotherapy as the only independent factor affecting PFS (p = 0.007). Additionally, MIB-1 proliferation index failed to identify a cut-off point to predict the prognosis for anaplastic meningioma. This study provides an overview of the epidemiology and treatment of anaplastic meningioma in China using a large population. Ó 2014 Elsevier Ltd. All rights reserved.
1. Introduction According to recent data (2006–2010) from the Central Brain Tumor Registry of the United States (CBTRUS), meningioma accounts for 35.8% of all primary brain and central nervous system tumors, and is the most frequently reported histology in adults [1,2]. Malignant meningioma is rare, and only 1.54% of all cases of primary and central nervous system tumors reported in CBTRUS are malignant meningiomas. In addition, malignant meningioma has three variants, namely, anaplastic, rhabdoid, and papillary, which are classified as Grade III based on the World Health Organization (WHO) Classification of Tumors of the Central
⇑ Corresponding author. Tel.: +86 021 5288 8682; fax: +86 021 6249 0665. E-mail address: [email protected] (Y. Gong). Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China. 1
http://dx.doi.org/10.1016/j.jocn.2014.10.023 0967-5868/Ó 2014 Elsevier Ltd. All rights reserved.
Nervous System [3]. Anaplastic meningioma exhibits characteristic histological features, with either obviously malignant cytology or a markedly elevated mitotic index (20 or more mitoses per 10 high power fields) without papillary architecture or rhabdoid cytology [2,3]. Anaplastic meningioma is often fatal, with the median survival being less than 2 years, and the 5 year survival between 35% to 61% [4–10]. Most previous studies have small sample sizes or follow up of less than 5 years, due to its rarity. Thus, anaplastic meningioma patients treated at one of the largest neurosurgical centers in China between 2003 and 2008 were retrospectively reviewed.
2. Patients and methods Seventy anaplastic meningioma patients, with 73 surgical specimens, were diagnosed at the main branch of Huashan Hospital, Neurosurgical Group Hospitals, Shanghai, China, between 2003 and 2008. Among these patients, three had a second operation
H. Zhu et al. / Journal of Clinical Neuroscience 22 (2015) 690–695
on recurrent tumors during that period. In addition, 12 rhabdoid meningioma, 17 papillary meningioma and 4286 overall meningioma cases were surgically treated at Huashan Hospital. Using the WHO 2007 criteria, two experienced neuro-pathologists, Dr. Hong Chen and Dr. Haixia Chen, checked and confirmed the diagnosis of each case. Immunohistochemical staining was carried out using monoclonal antibodies to epithelial membrane antigen (M/S Dako Patts, Copenhagen, Denmark; 1:50 dilution), vimentin (M/S Dako Patts; 1:100 dilution), estrogen receptor (ER) (Signalway [SAB], Shanghai, China; 1:200 dilution), and progesterone receptor (PR) (Signalway, SAB; 1:200 dilution). Telomerase activity was detected using a modified telomeric repeat amplification protocol as described previously [11]. Unfortunately, we lost contact with seven patients during the follow-up period, and had to exclude them from final outcome analysis. Thus, the remaining 63 patients were reviewed for their age, sex, tumor location, previous history, extent of resection, MIB-1 proliferation index, recurrence rates, Karnofsky Performance Status (KPS), and use of radiotherapy after operation. The extent of resection was determined from the surgical records and graded according to Simpson’s grading scale. For statistical analysis, the possible prognostic factors were dichotomized as follows: age (
