|Year : 2018 | Volume
| Issue : 2 | Page : 184-188
Surgical results and outcome of sphenoid wing en plaque meningioma
Mohamed Shaban, Mostafa Abdelsamie, Ahmed Taha
Department of Neurosurgery, Faculty of Medicine, Al-Azher University, Damietta, Egypt
|Date of Submission||09-Mar-2018|
|Date of Acceptance||06-Jun-2018|
|Date of Web Publication||27-Feb-2019|
Department of Neurosurgery, Faculty of Medicine, Al-Azher University, Damietta
Source of Support: None, Conflict of Interest: None
Background Sphenoid wing en plaque meningioma is a subgroup of meningiomas defined by its particular sheet-like dural involvement and its disproportionately large bone hyperostosis. Sphenoid wing en plaque meningiomas are also called spheno-orbital meningiomas and pterioneal meningiomas en plaque. It represents 2–9% of all meningiomas and they are mainly located in the sphenoid wing.
Objective The aim of this study was to analyze the outcome, surgical results, and recurrence rate in a series of 20 patents.
Patients and methods This respective descriptive analytical study includes 20 patients with sphenoid wing en plaque meningiomas, who were surgically treated between 2010 and 2014.
Results There were 14 women and 6 men, the mean age was 45 years (range: 20 and 70 years), six patients presented by extension of the dural component into the orbit, seven patients with cavernous sinus infiltration, adjuvant radiation therapy was performed for five patients after the surgery. After follow-up at 4 years, seven patients developed tumor recurrence, three patients submitted to surgical treatment, and four patients to radiation therapy. Patients without tumor extension to the orbit or cavernous sinus had the best prognosis, while patients with tumor extension, the recurrent rate was high.
Conclusion Postoperative radiation therapy is indicated in cases with residual tumor in cavernous sinus and superior orbital fissure involvement is frequent and should be considered within surgical limits.
Keywords: cavernous sinus, meningioma, proptosis, sphenoid wing
|How to cite this article:|
Shaban M, Abdelsamie M, Taha A. Surgical results and outcome of sphenoid wing en plaque meningioma. Al-Azhar Assiut Med J 2018;16:184-8
|How to cite this URL:|
Shaban M, Abdelsamie M, Taha A. Surgical results and outcome of sphenoid wing en plaque meningioma. Al-Azhar Assiut Med J [serial online] 2018 [cited 2020 Jul 9];16:184-8. Available from: http://www.azmj.eg.net/text.asp?2018/16/2/184/253092
| Introduction|| |
En plaque meningiomas represent a particular type of meningioma that have infiltrated the dura in a diffuse sheet-like appearance forming a thin layer that closely follow the contours of the inner table of the skull. The term en plaque was first used by Cushing and Eisenhardt  to describe this particular growing pattern, differentiating it from the most common type were designed (en masse).
These tumors are mainly a bone disease as symptoms and prognoses are affected mostly by bone invasion and extension instead of intradural involvement . Bone hyperostosis is much more extensive and is responsible for clinical manifestations. Differential diagnosis includes fibrous dysplasia, osteoma, and metastasis. This is particularly evident in sphenoid wing en plaque meningiomas that usually present as progressive proptosis . Diagnosis of en plaque meningioma is determined by radiological and clinical features rather than its histological appearance. It represents 2–9% of all meningiomas and is mainly located in the sphenoid wing, although they have been described in other skull regions . They are 3–6 times more frequent in women. Total removal of sphenoid wing en plaque meningiomas is difficult because of its extensive bone and dural involvement; as a result, these tumors have high recurrence rates, cavernous sinus involvement is responsible for recurrence in many cases .
In this study, we analyze the outcome, surgical results, and recurrence rate in a series of 20 patents.
| Patients and methods|| |
The present study was a retrospective descriptive analytical studies of 20 patients with sphenoid en plaque meningiomas who underwent surgery treated in the period from 2010 to 2014 in the Neurosurgery Department, Al-Azhar University, Faculty of Medicine (New Damietta). The clinical records were reviewed and analyzed for presenting symptoms, surgical results, radiation therapy, follow-up, and recurrent rate.
All patients had brain and orbit computed tomography (CT) and MRI scans. Axial and coronal CT bone window scans were excellent for visualization of the hyperostosis. On CT scans, the typical features were significant hyperostosis of the great wing of the sphenoid and this is usually extended to involve the adjacent bone. This included the bones of the middle cranial fossa, the lateral orbital wall, the orbital roof and the walls of the sphenoid sinus. The edges of the hyperostotic bone were rough and brush like.
On T1 intensity MRI, the lesion was isointense or hypointense, while on T2 intensity, the lesion showed slight hyperintense signal. It underwent marked Gadolinium enhancement which is a typical feature of meningioma. The hyperostotic bone showed different radiological picture and did not enhance. To be classified as an en plaque meningioma, the tumors had to meet the following criteria: sheet-like dural involvement, extensive bone hyperostosis, and large bone invasion in relation to dural or intradural involvement.
Those with nonhyperostotic sphenoid wing meningioma, cavernous sinus meningioma with secondary orbital involvement, primary optic nerve sheath meningioma, and clinoidal meningioma were excluded.
| Results|| |
Twenty patients with en plaque sphenoid meningiomas were surgically treated, 14 female patients representing 70% of all patients and six male patients representing 30% of all patients (females : male ratio is 3 : 1). The mean age at the time of surgery was 45 years (range: 20–70 years). The most common presenting compliant was proptosis in 18 (90%) patients and also three women complained of visual impairment (15%). Four patients noted temporal erosion swelling and three patients with pain in the orbital region ([Table 1]).
When planning the surgical treatment of the sphenoid wing meningioma, the extension of both tumor components, dural/intradural and bone involvement have to be taken into consideration.
In this study, the bone components were located by definition in the greater wing of the sphenoid in all patients, and in seven patients also to the lesser wing, in three patients, the pterygoid process was invaded. The dural components were located in the anterior region of the temporal fossa in 12 patients, six patients presented extension into the orbit, and seven patients with cavernous sinus infiltration.
The surgery of sphenoid wing meningioma en plaque poses a great technical challenge because of the complicated anatomical boundaries of the orbits, the cavernous sinus, and the cranial nerves and vascular structures in the medial aspect of the sphenoid wing . The 20 patients were submitted to pterional craniotomy followed by extradural removal of the invaded bone. This approach provides a sufficient access to the orbit apex and the base of the middle cranial fossa to reach the bone and soft tissue and decompress the superior orbital fissure and the optic canal.
Superolateral orbitotomy was also performed in most cases, allowing orbital decompression and removal of tumor in cases with intraorbital involvement. After bone removal, when needed, the dura was opened and the dural/intradural component was removed. In the six patients with orbital extension, the dura was opened to remove this tumor component.
Cavernous sinus tumor extension in seven patients was not removed in any of the seven patients with cavernous sinus involvement in seven patients, the dural component was confined to the temporal fossa, presenting no extension into the orbital cavity or cavernous sinus. It was possible to remove the tumor with Simpson grade II resection. In all other cases, we performed a subtotal resection. Cranioplasty was performed in seven patients with a titanium mesh.
Most histopathological analysis of removed tumors met features of the WHO grade I meningioma.
Proptosis improved in 16 patients out of 18 patients after surgery. Twelve patients obtained a complete resolution while the other four patients improved significantly. Five patients presented a transient oculomotor deficit and three patients developed a transient cerebrospinal fluid leak that was managed conservatively. The three patients presented visual field defect, two patients achieved slight recovery of the visual field, while the other achieved no recovery of the visual field. In our study, there was one case mortality.
Adjuvant radiation therapy was performed in five patients with residual tumors in the form of radiation therapy in three cases, and stereotactic radiotherapy in two cases. After a mean follow-up of 4 years, seven patients developed tumor recurrence (35%). None of the patients submitted to immediate radiation therapy had recurrence.
We can summarize the follow-up data into the following groups:
- Group 1: patients without any tumor extension to cavernous sinus or orbit, none of these patients developed tumor recurrence.
- Group 2: seven patients with tumor extension to cavernous sinus: three of these were treated by surgery and adjuvant radiotherapy. and four patients with surgery alone. None of the patients with surgery and radiotherapy developed recurrence, while three out and four patients with surgery alone developed recurrence.
- Group 3: six patients presented with orbital extension. One of them was treated with surgery and selective radiotherapy (SRT) and the other five patients with surgery alone without any therapy, while four out of five patients with surgery alone developed recurrence.
| Discussion|| |
Sphenoid wing en plaque meningiomas are a clinical and pathological subgroup of meningiomas defined by its particular sheet-like dural involvement and its disproportionately large bone hyperostosis . Therefore, the diagnosis is determined by this particular growing pattern rather than histological appearance . The ratio of female: male in this particular type of meningioma is higher than other types of meningioma, ranging from 4 : 1 to 7 : 1 in some series . In our study, the female to male ratio is about 3 : 1.
MRI is the best modality to assess the extension of dural/intradural involvement, while CT scan allows better visualization of bone involvement. Some CT feature of hyperostosis are characteristic or suggestive of en plaque meningioma, periosteal pattern of hyperostosis, inward bulging of the vault lesion, surface irregularity of the hyperostotic bone, and intracranial changes .
A bone infiltration is responsible for most symptoms but the extension of surgical resection and recurrent rate are affected mostly by dural infiltration . Total removal of en plaque meningiomas of the sphenoid wing is very difficult to achieve . These tumors are located in a complex anatomic area and they tend to spread into the foramina and fissure of the basal cranium involving the temporal fossa, the orbit, and the cavernous sinus .
Ringel and colleagues reported 63 patients with spheno-orbital meningioma, 76% of whom had tumor residuals after surgery. Radical resection attempts carry a high risk of postoperative neurological morbidity, especially in cases with orbital and cavernous sinus extension .
Some authors consider surgery limits the extension to cavernous sinus and superior orbital fissure . As was the aim of this study, our surgical planning was to relieve symptoms rather than radical resection especially in the tumor infiltration orbit and cavernous sinus. As adequate resection of en plaque sphenoid wing meningiomas is difficult to achieve, recurrence rates have been as high as 35–50%. Despite that some authors presented encouraging total resection rates from 60 to up to 80% . In our study, we have a recurrence rate of 35% mostly in patients with orbit and cavernous involvement.
As regards preoperative visual field defect, some authors reported that patients with severe deficit are unlikely to improve with surgical decompression, while some authors reported improvements ranging from 27 to 79% after surgery . In our study, only one patient out of three patients with visual field deficit improved postoperatively.
Superolateral orbitotomy was also performed in most cases, according to clinical status and pathological anatomy. The transorbital approach is typically used for lesions located solely in the anterior orbit. An anteromedial microorbitotomy can be performed to treat lesions located in the anteromedial orbit. A small operative field limits this approach . A lateral orbitotomy permits retraction of the globe laterally to expose the medial tumor, and this can expand the operative field. For lesions located in the superior temporal or inferior compartment of the orbit a lateral orbitotomy can be performed.
The extent of resection from the lateral rim of the orbit bone and the sphenoid ridge depends on the location of the tumor (superiorly compared with inferiorly), as well as the depth of the tumor .
Currently, Newman and Jane  advocate the use of a lateral orbitotomy in which a Burke incision is made. Transcranially, the orbit can be reached by a pterional, frontotemporal, supraorbital ridge, or subfrontal approach.
A frontotemporal route can be used to approach primary orbital tumors that extended intracranially. This approach provides good exposure of the intraorbital contents, including the optic canal. This is achieved by excising the orbital roof and the lateral orbital wall. The optic nerve can be identified intradurally to facilitate resection of the orbital roof .
The frontotemporal approach also provides good exposure of the anterior and middle cranial fossae. A pterional approach can be used to reach sphenoid wing meningiomas that invade the orbit; this approach permits radical resection of the greater and lesser wings of the sphenoid bone, as well as exposure of the lateral orbit, optic canal, and the supraorbital fissure, foramen rotundum, and foramen ovale.
Fraizer  first advocated the removal of the orbital rim to obtain additional exposure of orbital contents. Jane et al.  modified this approach by removing the supraorbital bone flap in one piece. Colohan et al.  introduced the concept of using the frontal sinus to access the anterior cranial fossa, thereby providing better cosmesis.
Jho  has advocated a minimally invasive approach: through an eyebrow incision one can gain access to the posterior orbit and anterior clinoid by an orbital roof craniotomy. Maroon et al.  have advocated a pterional approach and radical resection of the greater and lesser wings of the sphenoid.Postoperative radiation therapy is still a controversy; some authors recommend postoperative radiation treatment after subtotal resection if there is dural or cavernous sinus invasion and also as soon as follow-up neuroimaging demonstrates recurrent tumor , whereas other authors do not use postoperative radiotherapy routinely for patients with residual tumor . In this study, we restricted radiation treatment for patients with only orbital and cavernous sinus involvement, and recurrence rate for patients with orbital and cavernous sinus invasion treated with surgery alone was high compared with those treated with combined surgery and radiotherapy .
| Conclusion|| |
All infiltrating bone of the great wing of sphenoid bone should be removed to decrease recurrence of sphenoid wing en plaque meningiomas and to relieve the symptoms.
Total removal of en plaque sphenoid wing meningioma is very difficult and carries high risk of postoperative morbidity. It is a challenging tumor that poses some particular issues in dealing with cavernous sinus and orbit involvement.
Radiation therapy has been demonstrated to be effective in controlling tumor growth and should be considered for cases with residual tumor in cavernous sinus and orbit.
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Conflicts of interest
There are no conflict of interest.
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