Background
Incidental discovery accounts for 30% of newly-diagnosed intracranial meningiomas. There is no consensus on their optimal management. This review aimed to evaluate the outcomes of ...different management strategies for these tumors.
Methods
Using established systematic review methods, six databases were scanned up to September 2017. Pooled event proportions were estimated using a random effects model. Meta-regression of prognostic factors was performed using individual patient data.
Results
Twenty studies (2130 patients) were included. Initial management strategies at diagnosis were: surgery (27.3%), stereotactic radiosurgery (22.0%) and active monitoring (50.7%) with a weighted mean follow-up of 49.5 months (SD = 29.3). The definition of meningioma growth and monitoring regimens varied widely impeding relevant meta-analysis. The pooled risk of symptom development in patients actively monitored was 8.1% (95% CI 2.7–16.1). Associated factors were peritumoral edema (OR 8.72 95% CI 0.35–14.90) and meningioma diameter ≥ 3 cm (OR 34.90 95% CI 5.17–160.40). The pooled proportion of intervention after a duration of active monitoring was 24.8% (95% CI 7.5–48.0). Weighted mean time-to-intervention was 24.8 months (SD = 18.2). The pooled risks of morbidity following surgery and radiosurgery, accounting for cross-over, were 11.8% (95% CI 3.7–23.5) and 32.0% (95% CI 10.6–70.5) respectively. The pooled proportion of operated meningioma being WHO grade I was 94.0% (95% CI 88.2–97.9).
Conclusion
The management of incidental meningioma varies widely. Most patients who clinically or radiologically progressed did so within 5 years of diagnosis. Intervention at diagnosis may lead to unnecessary overtreatment. Prospective data is needed to develop a risk calculator to better inform management strategies.
Systematic review.
To conduct a systematic review identifying existing definitions of cauda equina syndrome (CES) and time to surgery in the literature for patients with CES.
A systematic review was ...conducted in accordance with the PRISMA statement. Ovid Medline, Embase, CINAHL Plus, and trial registries were searched from October 1st, 2016, to 30th December 2022, and combined with articles identified from a previous systematic review by the same authors (studies published 1990-2016).
A total of 110 studies (52,008 patients) were included. Of these only 16 (14.5%) used established definitions in defining CES, including Fraser criteria (n = 6), British Association of Spine Surgeons (BASS) (n = 5), Gleave and MacFarlane (n = 2), and other (n = 3). Most reported symptoms were urinary dysfunction (n = 44, 40%%), altered sensation in the perianal region (n = 28, 25.5%) and bowel dysfunction (n = 20, 18.2%). Sixty-eight (61.8%) studies included details on time to surgery. There was an increase in percentage of studies defining CES published in the last 5 years compared to ones from 1990-2016 (58.6% vs 77.5.%, P = .045).
Despite Fraser recommendations, substantial heterogeneity exists in reporting of CES definitions, and a start point for time to surgery, with most authors using self-defined criteria. A consensus is required to define CES and time to surgery, to allow consistency in reporting and study analysis.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Cauda Equina Syndrome (CES) is an emergency condition that requires acute intervention and can lead to permanent neurological deficit in working age adults. A Core Outcome Set (COS) is the minimum ...set of outcomes that should be reported by a research study within a specific disease area. There is significant heterogeneity in outcome reporting for CES, which does not allow data synthesis between studies. The hypothesis is that a COS for CES can be developed for future research studies using patients and healthcare professionals (HCPs) as key stakeholders.
Qualitative semi-structured interviews with CES patients were audio-recorded, transcribed and analysed using NVivo to identify the outcomes of importance. These were combined with the outcomes obtained from a published systematic literature review of CES patients. The outcomes were grouped into a list of 37, for rating through two rounds of an international Delphi survey according to pre-set criteria. The Delphi survey had an overall response rate of 63% and included 172 participants (104 patients, 68 HCPs) from 14 countries who completed both rounds. Thirteen outcomes reached consensus at the end of the Delphi survey and there was no attrition bias detected. The results were discussed at an international consensus meeting attended by 34 key stakeholders (16 patients and 18 HCPs) from 8 countries. A further three outcomes were agreed to be included. There was no selection bias detected at the consensus meeting. There are 16 outcomes in total in the CESCOS.
This is the first study in the literature that has determined the core outcomes in CES using a transparent international consensus process involving healthcare professionals and CES patients as key stakeholders. This COS is recommended as the most important outcomes to be reported in any research study investigating CES outcomes and will allow evidence synthesis in CES.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Summary
Purpose: Doublecortin (DCX) is a microtubule‐associated protein with regulatory roles in radial and tangential migration of neurons during cortical development. In normal adult cortex there ...is restricted expression, and DCX is widely used as a marker of neurogenesis. Imperfect corticogenesis is thought to underpin many focal cortical pathologies in epilepsy surgical series, including focal cortical dysplasia (FCD). The aim was to study DCX expression patterns in such lesions compared to normal developing and mature cortex.
Method: Cases of FCD types Ia (13) and IIb (4), pediatric hippocampal sclerosis (HS) (5), temporal lobe sclerosis (5), glioneuronal tumors (5), gray matter heterotopia (3), and control tissues (16) from a wide age range 20 gestational weeks (GW) to 85 years were studied using immunohistochemistry to DCX.
Results: In controls and all epilepsy cases, perinuclear labeling of small round cells (SRCs) and satellite perineuronal cells was observed in both postmortem and surgical tissues. In FCD Ia up to the age of 4 years, prominent DCX‐positive (DCX+), immature cells were present along the junction of layers I and II, with processes extending into the molecular layer. These cell types were not a significant feature in other pathologies, which showed multipolar DCX+ cells or labeling of dysmorphic cells throughout the cortex.
Discussion: Persistent cellular DCX expression is confirmed in normal adult cortex. Characteristic expression patterns in layer II of FCD Ia could indicate delayed or abnormal cortical maturation rather than ongoing cytogenesis. This could be indicative of enhanced local cortical plasticity as well as a potential diagnostic feature of this type of pathology.
STUDY DESIGN.This is a systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.
OBJECTIVE.To assess the outcomes reported in trials ...and observational studies of surgery for cauda equina syndrome (CES), and to inform the development of a core outcome set.
SUMMARY OF BACKGROUND DATA.Scoping searches revealed that there were inconsistencies in which outcomes were reported and how they were measured in research studies for patients who had undergone surgery for CES.
METHODS.Ovid Medline, Embase, CINAHL Plus, and trial registries were searched from January 1, 1990 to September 30, 2016 with the term “cauda equina syndrome.” Inclusion and exclusion criteria were applied according to study design, diagnosis, procedure, publication date, language, and patient age. Data extracted included demographics, study design, the outcomes reported, and their definition. We also assessed variation in the use of terminology for each outcome domain.
RESULTS.A total of 1873 articles were identified, of which 61 met the inclusion criteria. Of these, 737 outcomes reported verbatim were categorized into 20 core outcome domains and 12 subdomains with a range of 1 to 141 outcomes per outcome domain or subdomain. The most commonly reported outcomes were bladder function (70.5%), motor function (63.9%), and sensation (50.8%). Significant variation in the terms used for each outcome was documented, for example, bladder function outcome domain had 141 different terms.
CONCLUSION.There is significant heterogeneity in outcomes reported for studies after surgery for CES patients. This indicates a clear need for the development of a core outcome set, which has been registered as number 824 on the COMET (Core Outcome Measure in Effectiveness Trials) database.Level of Evidence1
Abstract
OBJECTIVE
Core Outcome Sets (COS) define the minimum outcomes that should be measured and reported in all clinical trials for a specific health condition or health area. The aim was to ...develop two COS for intracranial meningioma; one for clinical trials (COSMIC: Intervention) and one for observational studies (COSMIC: Observation).
METHODS
A study advisory group was formed with representation from international stakeholders of charities (IBTA, TBTC, brainstust), neurosurgery societies (SBNS, BIMS) and neuro-oncology societies (BNOS, EANO, EORTC, ICOM, RANO-PRO, SNO). Two systematic literature reviews and trial registry searches were performed to identify outcomes reported in published and ongoing 1) meningioma clinical trials, and 2) studies of incidental/untreated meningioma. Outcomes were deduplicated and categorised. Individuals were recruited from stakeholder groups (including meningioma patients and carers, healthcare professionals, researchers) to participate in 2-round, international, modified eDelphi surveys. The final core outcome sets were ratified through online consensus meetings.
RESULTS
The COSMIC: Intervention systematic review identified 660 verbatim outcomes, rationalized into 24 Delphi survey items. Following the consensus meeting, 15 outcomes were included in the final set. For COSMIC: Observation, 267 verbatim outcomes were identified and rationalized into 17 Delphi survey items. 16 outcomes were included in the final set. There were eight core outcomes common to both COSMIC: Intervention and COSMIC: Observation COS, namely tumour growth, physical, emotional, and neurocognitive functioning, overall quality of life, progression-free survival, meningioma specific mortality and overall survival. Role and social functioning were core outcomes in COSMIC Observation but not COSMIC intervention.
CONCLUSIONS
The COSMIC study has defined the core outcome sets for use in future meningioma clinical trials and studies. Role and social functioning were important to incidental meningioma patients and likely reflects the anxiety and uncertainty around clinical treatment. International stakeholder agreement should ensure widespread use and adoption.
Thoracic disc herniation (TDH) is a rare occurrence comprising of only 0.25-0.75% of all herniated discs in any region. Limitations in direct visualization remains a surgical challenge for complete ...and safe resection of TDH. In this case report, we describe the use of a 3D intraoperative imaging system (O-arm system
) coupled with percutaneous pedicle markers placed under fluoroscopic guidance to circumvent the current limitations in visualisation for a patient with a giant calcified TDH using an anterolateral approach. There was an improvement in overall visualisation and ease of procedure, leading to a successful surgery. Post-op, there was a significant improvement in the motor power of the patient.
Celotno besedilo
Dostopno za:
DOBA, IJS, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Abstract
AIMS
There is increasing interest in the clinical management of patients with incidental and untreated intracranial meningioma. Determining balance between observation and intervention is a ...key research priority. However, heterogeneity of outcome measurement and reporting has hampered knowledge progress. This systematic review aimed to summarise the outcomes measured and reported in such studies.
METHOD
A systematic literature search was performed to identify published full-texts describing active monitoring of adult cohorts with incidental and untreated intracranial meningioma. Reported outcomes were extracted verbatim, along with an associated definition and method of measurement if provided. Deduplication, grouping, and classification of verbatim outcomes was performed to identify unique outcomes reported in the literature.
RESULTS
Thirty-three published articles and one ongoing study were included, describing 32 unique studies: retrospective n=27, cross-sectional n=3, prospective n=2. 271 verbatim outcomes were reported, of which 90 were defined. Following deduplication, 181 unique verbatim outcomes remained and were grouped into 53 unique ‘non-verbatim’ outcomes. Those reported most frequently included: volume of tumor n=18, growth of tumor n=30, absolute growth rate n=18, relative growth rate n=17, need for surgery n=21, and progression-free survival n=11.
CONCLUSION
Harmonisation of outcome measurement and reporting across clinical studies of incidental and untreated intracranial meningioma could facilitate knowledge progress for this priority research area. The unique outcomes identified from this systematic literature review will be prioritised through an eDelphi survey and consensus meeting of key stakeholders (including patients), in order to develop a Core Outcome Set (COS) for use in future clinical studies.
Abstract
AIMS
Meningioma clinical trials have assessed interventions including surgery, radiotherapy, and pharmacotherapy, but heterogeneity of outcome measurement and reporting often precludes ...comparative analysis of trial results. This systematic review aimed to summarise the outcomes measured and reported in such trials.
METHOD
Systematic literature and trial registry searches were performed to identify published and ongoing intracranial meningioma clinical effectiveness trials. Reported outcomes were extracted verbatim, along with an associated definition and method of measurement if provided. Deduplication, grouping, and classification of verbatim outcomes was performed to identify unique outcomes reported in the literature.
RESULTS
Thirty published articles and 18 ongoing studies were included, describing 47 unique studies: phase II n=33, phase III n=14. Common interventions included: surgery n=13, radiotherapy n=8, and pharmacotherapy n=20. 660 verbatim outcomes were reported, of which 85 were defined. Following deduplication, 416 unique verbatim outcomes remained and were grouped into 119 unique ‘non-verbatim’ outcomes. Those reported most frequently included: blood loss n=15, need for blood transfusion n=12, radiographic response to treatment n=19, eye toxicity after radiotherapy, gastrointestinal toxicity from pharmacotherapy n=40, haematological toxicity from pharmacotherapy n=31, metabolic and nutrition toxicity from pharmacotherapy n=42, progression-free survival n=46, and overall survival n=37.
CONCLUSION
Outcome measurement and reporting across meningioma clinical trials is heterogeneous and may preclude comparative analysis of trial results. The unique outcomes identified from this systematic literature review will be prioritised through an eDelphi survey and consensus meeting of key stakeholders (including patients), in order to develop a Core Outcome Set (COS) for use in future meningioma clinical trials.
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