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Table of Contents    
NI FEATURE: THE EDITORIAL DEBATE-- PROS AND CONS
Year : 2016  |  Volume : 64  |  Issue : 5  |  Page : 873-874

Surgery versus radiosurgery in control of facial pain caused by small meningiomas of the petrous apex


Department of Neurosurgery, Hospital Garcia de Orta, Lisbon, Portugal

Date of Web Publication12-Sep-2016

Correspondence Address:
Manuel Cunha e Sá
Department of Neurosurgery, Hospital Garcia de Orta, Lisbon
Portugal
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.190285

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How to cite this article:
Cunha e Sá M. Surgery versus radiosurgery in control of facial pain caused by small meningiomas of the petrous apex. Neurol India 2016;64:873-4

How to cite this URL:
Cunha e Sá M. Surgery versus radiosurgery in control of facial pain caused by small meningiomas of the petrous apex. Neurol India [serial online] 2016 [cited 2019 Aug 19];64:873-4. Available from: http://www.neurologyindia.com/text.asp?2016/64/5/873/190285




The article by Ahmed et al., reports the experience of the authors in the treatment of trigeminal neuralgia (TN) caused by meningiomas of the petrous apex of size smaller than 3 cms. They rightfully argue that some of these tumors present with facial pain and that this pain is not always medically controlled. In their hands, the surgical removal of these smaller tumors proved beneficial in terms of facial pain control, and carried minimal morbidity. This reality seems to be reinforced by the fact that radiosurgery (RS) Gamma Knife (GK) treatment is, in Egypt, a more expensive modality of treatment, as compared to surgery.

In their analysis, they have found that larger tumors, presence of complications, preoperative difficulty in imaging the trigeminal nerve root, as well as pain in the ophthalmic division of trigeminal nerve negatively affect the degree of postoperative pain relief.[1]

The size of the series is small in absolute numbers but compares favorably with other reports on the treatment of tumor-related TN. Small numbers, as stated by the authors, is always a problem, especially when trying to generalize conclusions and validate them outside one's individual institutional universe.

It would have been interesting if the authors would have extended their analysis of factors positively or negatively influencing pain, both before and after the operation, and included all meningiomas in this location, regardless of their size and the treatment options adopted. Would size of the tumor and V1 pain distribution consistently hold as negative influencers of outcome? How could this help us in the interpretation of factors? Another interesting issue would have been the one of consistency of the tumor and its intimacy of contact with the nerve. The authors initially touch on these extremely important issues but when dealing with the conclusions and outcomes, they mention the presence of complications, of not being able to preoperatively identify on imaging studies the TGN root, but do not actually dwell into the important detail of the difficulties they encountered during surgical excision of the lesions.

The focus of the article is on the control of trigeminal pain caused by these meningiomas. No matter how important this goal may be, it needs to be appraised against the global picture of the disease. The indications to treat a meningioma in this location, as well as that of the treatment we elect to recommend, are multifactorial. Age as well as medical and neurological condition of the patient are of paramount importance, as should also be the surgical experience and individual results of the surgeon. Another vital factor to be accounted for is the impact of resection on the long-term growth containment of a tumor, which often times is not amenable to a Simpson I resection. Can the control of the disease be secured with RS without tumor reduction (in cases when a gross total resection is not possible) or is it more efficacious in its aftermath? For smaller tumors, the argument applies differently. We have the option of looking at the control of the symptoms, in this case TN, or we may choose to include it in the vaster perspective of the expected behavior of the tumor, in other words, the control of its growth. Here again, we need to compare larger numbers and experiences in order to reach a conclusion that we may feel comfortable to propagate.

Kondziolka et al.,[2] published their results with the radiosurgical (Gamma Knife; GK) treatment of petroclival meningiomas and found that their 10-year tumor growth control was not too different from what is expected from an initial Simpson I resection. The series of Beute et al.,[3] included 450 cases of TN treated with GK. It also included 14 cases of tumor-related TN (TRTN). The pain control in the latter group was similar to that achieved for idiopathic TN with a 75%, 60% and 58% adequate pain control rate, respectively, at 1, 3 and 5 years. Due to the problem of pain recurrence after RS treatment of TN, Paek et al.,[4] secured better results by targeting the tumor mass as well as the TN root. In his article of 1996, Barker et al.,[5] discussed the issue of the possible etiology of pain in tumor-related TN and proposed that apart from just relieving pressure on the nerve due to the tumor bulk, one should also actively seek the anatomical points on the nerve where microvascular compression may need to be performed. Microvascular decompression may be required directly due to a concomitant vascular compression; or indirectly, caused by the tumor mass shifting the nerve towards a blood vessel. Properly relieving these vascular and tumor related contacts from the TN, as is performed for patients with idiopathic TN, was responsible for significant relief from TN in his series (21 out of 23 TRTN cases). In the series by Chung et al.,[6] the results of GK RS directed at TRTN cases were poorer than those obtained for idiopathic TN.[7] The authors seem to believe that this worse effect is due to poor visualization of the TN during surgery, and therefore, inadequate targeting of the TN root entry zone. He recommended prior surgical decompression of the tumor followed by RS treatment, if subsequently required, for his patients.

In his article in 2001, Regis et al.,[8] again go back to the issue of what causes the pain and its relief in TN and TRTN. They stress the fact that facial pain with typical TN characteristics is usually associated with posterior fossa benign tumors encroaching upon the Vth nerve whereas tumors in the middle fossa may cause both the typical TN pain or the so called atypical facial pain (AFP). The latter carries a worse prognosis in terms of pain control and is admittedly due to a more peripheral compression of the TN. Again, their results with TRTN utilizing RS were not encouraging (based on the opinion of the authors themselves) and they tend to recommend a surgical approach when deemed feasible. The explanation for these less successful results seems to lie in the inability to target the root of the TN and also due to the fact that the essential component of the radiation dosage is focused on the tumor mass itself rather than on the root entry zone of the TN, which may be the actual point of origin of TN.

It is easy to empathize with the authors recommendations especially because they were able to carry out these resections with enormous proficiency, and therefore, with minimal morbidity. If these results can be maintained for larger series, their option is, in my mind, superior to other alternatives. Not only does surgery have a highly beneficial effect on facial pain but also enables a more complete (if not often definitive) resection of a tumor which, if left alone to grow to a bigger size, will certainly pose greater therapeutic difficulties in the future.

 
 » References Top

1.
Ahmed AH, Alfiki A, Adel MF, M. Alsawy MFM, Al-Dash MF, Zein M, et al., Role of surgery for small petrous apex meningiomas causing refractory trigeminal neuropathy in the minimally invasive era. Neurol India 2016;64:973-9.  Back to cited text no. 1
    
2.
Flannery TJ, Kano H, Lunsford LD, Sirin S, Tormenti M, Niranjan A, et al. Long-term control of petroclival meningiomas through radiosurgery. J Neurosurg 2010;112:957-64  Back to cited text no. 2
    
3.
Verheul JB, Hanssens PE, Lie ST, Leenstra S, Piersma H, Beute GN. Gamma Knife surgery for trigeminal neuralgia: A review of 450 consecutive cases. J Neurosurg 2010;113 Suppl: 160-7.  Back to cited text no. 3
[PUBMED]    
4.
Kim SK, Kim DG, Se YB, Kim JW, Kim YH, Chung HT, Paek SH. Gamma Knife surgery for tumor-related trigeminal neuralgia: Targeting both the tumor and the trigeminal root exit zone in a single session. J Neurosurg 2016, Jan 22:1-7. PubMed PMID: 26799302.  Back to cited text no. 4
    
5.
Barker FG 2nd, Jannetta PJ, Babu RP, Pomonis S, Bissonette DJ, Jho HD. Long-term outcome after operation for trigeminal neuralgia in patients with posterior fossa tumors. J Neurosurg 1996;84:818-25.  Back to cited text no. 5
    
6.
Chang JW, Chang JH, Park YG, Chung SS. Gamma knife radiosurgery for idiopathic and secondary trigeminal neuralgia. J Neurosurg 2000;93 Suppl 3:147-51.  Back to cited text no. 6
[PUBMED]    
7.
Niranjan A, Lunsford LD. Radiosurgery for the management of refractory trigeminal neuralgia. Neurol India 2016;64:624-9.  Back to cited text no. 7
[PUBMED]  Medknow Journal  
8.
Régis J, Metellus P, Dufour H, Roche PH, Muracciole X, Pellet W, Grisoli F, Peragut JC. Long-term outcome after gamma knife surgery for secondary trigeminal neuralgia. J Neurosurg 2001;95:199-205.  Back to cited text no. 8
    




 

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