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Table of Contents    
Year : 2012  |  Volume : 60  |  Issue : 1  |  Page : 50-54

Does bony hyperostosis in intracranial meningioma signify tumor invasion? A radio-pathologic study

1 Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
2 Department of Neuropathology, All India Institute of Medical Sciences, New Delhi, India

Date of Submission10-Sep-2011
Date of Decision01-Oct-2011
Date of Acceptance28-Nov-2011
Date of Web Publication7-Mar-2012

Correspondence Address:
Deepak Agrawal
Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.93589

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 » Abstract 

Background: While operating intracranial meningiomas, neurosurgeons commonly drill the hyperostotic bone and put the bone flap back. Objective: To determine whether bony changes seen in meningioma are due to tumor invasion or reactionary changes. Materials and Methods: This prospective study, conducted over 10 months (October 2010- July 2011) included consecutive patients with intracranial meningiomas. Preoperatively, computed tomography (CT) was done in all patients and reviewed by two neurosurgeons for associated bony hyperostosis. During surgery, a piece of bone showing hyperostosis was taken for histopathological evaluation for tumor invasion. In absence of hyperostosis, the bone sample was taken from the bone in contact with the dural attachment of the tumor. Results: This study included 40 consecutive patients who underwent resection for intracranial meningiomas. Radiological evidence of hyperostosis was present in 30 (75%) patients. On histopathological examination, tumor invasion of the bone was seen in eight (20%) patients. These included seven patients who demonstrated hyperostosis and one patient without hyperostosis. Convexity meningiomas (n=12) showed the highest rate of bony invasion (33.3%). Conclusions: A significant number of patients with radiological hyperostosis have tumor invasion of the bone. The authors recommend that one should remove the bone (flap) whenever possible in order to achieve total excision of the tumor and use synthetic material to cover the defect.

Keywords: Bony hyperostosis, histopathology, meningioma, radiology, tumor invasion

How to cite this article:
Goyal N, Kakkar A, Sarkar C, Agrawal D. Does bony hyperostosis in intracranial meningioma signify tumor invasion? A radio-pathologic study. Neurol India 2012;60:50-4

How to cite this URL:
Goyal N, Kakkar A, Sarkar C, Agrawal D. Does bony hyperostosis in intracranial meningioma signify tumor invasion? A radio-pathologic study. Neurol India [serial online] 2012 [cited 2021 Jun 13];60:50-4. Available from:

 » Introduction Top

The association between meningioma and hyperostosis was first described by Brissaud and Lereboullet in 1903. [1] However, the cause of hyperostosis has remained controversial. It has been hypothesized by several authors that hyperostosis may be a manifestation of tumor invasion. [2],[3],[4],[5],[6],[7],[8],[9],[10] However, some believe that these bony changes represent nothing else but reactionary changes. [2],[5],[6],[8],[9],[11],[12],[13],[14],[15],[16],[17],[18] As a common practice, neurosurgeons drill the hyperostotic bone and replace the bone flap in cases of intracranial meningiomas. This study aims at determining whether the bony changes seen in meningioma can be attributed to tumor invasion and consequently leaving the bone flap in situ may be the same as leaving a part of the tumor behind.

 » Materials and Methods Top

This prospective study included consecutive patients with a preoperative diagnosis of intracranial meningiomas who were operated between October 2010 and July 2011. Two neurosurgeons individually examined the preoperative magnetic resonance imaging (MRI) and computed tomography (CT) scans to assess for bony thickening overlying the tumor. Hyperostosis was defined as bony thickening in opposition to the tumor as compared to the adjoining bone. It was considered to be present if there was consensus among the two surgeons. The meningiomas were classified according to their location. During surgery, a piece of bone showing hyperostosis (in proximity to the tumor) was taken for histopathological evaluation for tumor invasion along with the tumor tissue. In absence of hyperostosis, the bone sample was taken from the bone in contact with the dural attachment of the tumor. The tumor tissue was processed routinely, while the bone was decalcified and then processed. Hematoxylin and eosin-stained slides of tumor tissue and the bone sample were examined by two neuropathologists. Immunohistochemistry was performed on the tumor tissue when required. The tumor tissue was assessed for tumor grade and type according to the World Health Organization (WHO) 2007 classification along with MIB-1 Labeling Index. The bone sample was screened for any evidence of tumor invasion.

Descriptive statistics including mean and frequency distributions were calculated for all variables, using SPSS software Version 15. Categorized data was analyzed by Chi-Square/Fischer Exact test. P value <0.05 was considered as the level of statistical significance.

 » Results Top

A total of 58 patients were initially enrolled in the study. On histopathology, nine of these patients were diagnosed to have lesions other than meningioma and were therefore excluded from the study. Of the 49 patients, nine were further excluded as the skull bone was not sampled from the representative area. The remaining 40 meningiomas were included in this prospective study.

Of the 40 patients included, 18 were males and 22 were females (ratio 0.8: 1). The median age of the patients at the time of surgery was 45.5 years (range 20-65 years; mean 44.3 ± 11.9 years) [Table 1]. Convexity meningiomas were most common (12 cases), followed by parasagittal and peritorcular (10 cases) and sphenoid wing meningiomas (10 cases). The others were falcine (four cases), tentorial (two cases) and one case each of optic nerve sheath meningioma and olfactory groove meningioma [Table 1]. Radiological evidence of hyperostosis was present in 30 (75%) patients [Table 2], [Figure 1]. In all these cases, the hyperostosis was confirmed intra-operatively.
Figure 1: Flowchart showing the histological results of bone biopsy in study patients

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Table 1: Radiological and histopathological features of meningiomas

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Table 2: Comparison of tumor location with hyperostosis and invasion into bone

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On histopathological examination, 36 cases belonged to WHO Grade I and four cases were WHO Grade II. Transitional meningiomas were most common (19 cases; 47.5%). MIB-1 labeling index ranged from 1 to 15% (mean = 3.5) [Table 1]. Tumor invasion into the bone was seen in eight (20%) of the 40 cases. These included seven which demonstrated hyperostosis and one without hyperostosis [Figure 1],[Figure 2] and [Figure 3], [Table 1]. No significant correlation was noted between hyperostosis and tumor invasion of the bone (P=0.65). Convexity meningiomas (n=12) showed the highest rate of bone invasion (33.3%) (P=0.21). The other cases showing tumor invasion into the bone were located in the sphenoid wing (two cases), parasagittal region (one case) and in the falx (one case) [Table 2]. Two cases of convexity meningioma did not show hyperostotic changes on radiology. However, on histopathology, one case (in which bone was biopsied from under the dural attachment) showed tumor invasion of the bone. Tumor invasion of the bone was present in three cases of meningothelial meningiomas (3 out of 8 cases; 37.5%) (P=0.32) and five cases of transitional meningiomas (5 out of 19 cases; 26.3%) [Table 1]. Tumor invasion of the bone did not show any significant correlation with WHO grade and MIB- 1 labeling index in our study.
Figure 2: Preoperative T1 sagittal (a) and coronal (b) images of contrast-enhanced MRI brain showing two well-defined lesions in the left anterior falcine region with moderate contrast enhancement. The bone overlying the larger lesion is increased in thickness, as seen on CT images (c). Photomicrograph of the tumor showing features of a meningothelial meningioma (WHO Grade I) with psammoma bodies (arrow) (original magnification, 100×) (d). Photomicrograph of bone biopsy showing the tumor infiltrating between bony trabeculae (original magnification, 100×) (e)

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Figure 3: Preoperative T1 contrast axial (a) and coronal (b) sections of MRI brain showing a lateral sphenoid wing meningioma with contrast enhancement and dural tail. Contrast CT head (c) showing abundant hyperostosis of the temporal bone and the lateral sphenoid wing; 100× (d) and 200× (e) magnification photomicrographs of the same patient showing a transitional meningioma (WHO Grade I) infiltrating between bony trabeculae and causing destruction of the underlying bone

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 » Discussion Top

The association between meningioma and hyperostosis is well known. [19] Hyperostosis is seen in 25-49% of meningiomas [16],[20],[21],[22] and was present in 75% of cases of meningioma studied in this series. The high incidence in our series may be due to inclusion of a greater number of meningomas involving the convexities and sphenoid wing, which are known to be associated more frequently with hyperostosis. [20],[23] In our study, we found that the maximum number of cases showing hyperostosis were convexity and sphenoid wing meningiomas.

The cause of hyperostosis in meningioma has long been a matter of debate. There are various hypotheses which aim at explaining this phenomenon including preceding trauma, [15],[20],[22],[24],[25],[26],[27],[28],[29],[30] irritation of the bone by the tumor without bony invasion, [16],[17],[18] stimulation of osteoblasts in normal bone by factors secreted by tumor cells, [5],[6],[8],[9] production of bone by the tumor itself [11],[12],[13],[14],[15] and vascular disturbances caused by the tumor. [2],[11],[12],[13],[14],[15] In 1934, Echlin suggested a direct association between hyperostosis and tumor invasion of the bone. [5] Since then, tumor invasion as a cause of hyperostosis has been gaining ground. [2],[3],[4],[5],[6],[7],[8],[9],[10],[19] This study shows the presence of tumor cells in the bone overlying a meningioma in 20% of the cases. In cases showing hyperostosis, the tumor cells were present in 23.3%. These results indicate that tumor invasion into the bone is present in a significant number of patients with meningioma, especially those showing hyperostosis. While the fact that tumor cells are seen in the overlying bone has been established by this study, it remains to be elucidated whether tumor invasion is the cause or the result of bony changes. The former scenario seems less likely as a number of meningiomas not showing tumor invasion of the bone had hyperostosis on radiology (23 out of 32 cases not showing tumor invasion as shown in [Table 1]), thus negating the possibility that the invading tumor cells are responsible for the increased bone production. Also, the occasional occurrence of tumor invasion without hyperostosis (one out of ten) rules out the possibility of tumor invasion occurring as a result of hyperostosis. It is more likely that reactionary changes in the bone due to the close proximity to the tumor and their shared blood supply lead to production of growth factors which stimulate bone production, leading to hyperostotic changes with attendant release of chemotactic factors that attract the tumor cells into the bone matrix. We hypothesize that there may be a common pathogenetic pathway, yet to be explained, which leads to both the bony changes and tumor invasion into the bone.

In his landmark study published in 1957, Simpson elaborately described the importance of the degree of resection in preventing recurrence in meningiomas. He noted recurrence rates of 9, 19, 29 and 40% in Simpson Grade I through IV respectively. [31] Although the series was reported prior to the advent of CT, MRI and microneurosurgery, a number of subsequent studies on the rate of recurrence in meningioma have upheld the principle that clinical success in meningioma surgery is related to the extent of resection. [19],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44] Therefore, in order to achieve complete excision and ensure lower recurrence rate, one should also remove the bone infiltrated by the tumor. However, it is not possible to predict which patients are likely to show bone invasion on the basis of either preoperative radiology or intra-operative pathological evaluation as invasion can occur without hyperostosis on radiology and frozen section examination of bone is not feasible. Therefore, in order to achieve higher Simpson grade of tumor excision, one should remove as much bone in contact with the tumor as possible whenever feasible. In skull base meningiomas, this can be achieved by drilling the bone, especially the hyperostotic areas. In cases of convexity meningioma, which showed the highest rate of tumor invasion into the bone (33% in our study), one should not replace the bone flap and instead use an artificial bone flap to cover the defect.

 » Conclusions Top

Our study shows that a significant number of patients with radiological hyperostosis have tumor invasion into the bone. However, the absence of hyperostosis does not mean the absence of tumor invasion. The authors recommend that one should remove the bone (flap) whenever possible in order to achieve total excision of the tumor and use synthetic material to cover the defect.

 » References Top

1.Brissaud Lereboullet P. [Two cases of hemicranios]. Rev Neurol 1903;11:537-40.  Back to cited text no. 1
2.Bonnal J, Thibaut A, Brotchi J, Born J. Invading meningiomas of the sphenoid ridge. J Neurosurg 1980;53:587-99.  Back to cited text no. 2
3.Castellano F, Guidetti B, Olivecrona H. Pterional meningiomas "en plaque." J Neurosurg 1952;9:188-96.  Back to cited text no. 3
4.Derome PJ, Guiot G. Bone problems in meningiomas invading the base of the skull. Clin Neurosurg 1978;25:435-51.  Back to cited text no. 4
5.Echlin F. Cranial osteomas and hyperostoses produced by meningeal fibroblastomas. Arch Surg 1934;28:357-405.  Back to cited text no. 5
6.Globus JH. The meningiomas. Trans Assoc Res Nerv Ment Dis 1937;16:210-65.  Back to cited text no. 6
7.Kim KS, Rogers LF, Lee C. The dural lucent sign: Characteristic sign of hyperostosing meningioma en plaque. AJR Am J Roentgenol 1983;141:1217-21.  Back to cited text no. 7
8.Maroon JC, Kennerdell JS, Vidovich DV, Abla A, Sternau L. Recurrent spheno-orbital meningioma. J Neurosurg 1994;80:202-8.  Back to cited text no. 8
9.Pompili A, Derome PJ, Visot A, Guiot G. Hyperostosing meningiomas of the sphenoid ridge-clinical features, surgical therapy, and long-term observations: Review of 49 cases. Surg Neurol 1982;17:411-6.  Back to cited text no. 9
10.Pieper DR, Al- Mefty O, Hanade Y, Buencher D. Hyperostosis associated with meningioma of the cranial base: Secondary changes or tumor invasion. Neurosurgery 1999;44:742-7.  Back to cited text no. 10
11.Freeman H, Forster FM. Bone formation and destruction in hyperostoses associated with meningiomas. J Neuropathol Exp Neurol 1948;7:69-80.  Back to cited text no. 11
12.Heick A, Mosdal C, Jorgensen K, Klinken L. Localized cranial hyperostosis of meningiomas: A result of neoplastic enzymatic activity? Acta Neurol Scand 1993;87:243-7.  Back to cited text no. 12
13.Landow H, Kabat EA, Newman W. Distribution of alkaline phosphatase in normal and neoplastic tissues of the nervous system. Arch Neurol Psychiatry 1942;48:518-30.  Back to cited text no. 13
14.Nasu H. Ferment histochemische untersuchungen an meningeomen. Acta Neuropathol (Berl) 1964;3:627-37.  Back to cited text no. 14
15.Penfield WG. Cranial and intracranial endotheliomata-hemicraniosis. Surg Gynecol Obstet 1923;36:657-74.  Back to cited text no. 15
16.Cushing H. The cranial hyperostoses produced by meningeal endotheliomas. Arch Neurol Psychiatry 1922;8:139-54.  Back to cited text no. 16
17.Kennedy F. Tumours of the intracranial cavity. In: Nelson, editor. Loose Leaf Living Medicine. London: Thomas Nelson and Sons; 1920. p. 119-36.  Back to cited text no. 17
18.Phemister DB. The nature of cranial hyperostosis overlying endothelioma of the meninges. Arch Surg 1923;6:554-72.  Back to cited text no. 18
19.Bikmaz K, Mrak B, Al-Mefty O. Management of bone-invasive, hyperostotic sphenoid wing meningiomas. J Neurosurg 2007;107:905-12.  Back to cited text no. 19
20.Cushing H, Eisenhardt L. Meningiomas: Their Classification, Regional Behavior, Life History and Surgical End Results. Springfield: Charles C Thomas; 1938.  Back to cited text no. 20
21.Frazier CH, Alpers BJ. Meningeal fibroblastomas of the cerebrum. Arch Neurol Psychiatry 1933;29:935-89.  Back to cited text no. 21
22.Spiller WG. Hemicraniosis and cure of brain tumor by operation. JAMA 1907;49:2059-65.  Back to cited text no. 22
23.De Jésus O, Toledo MM. Surgical management of meningioma enplaque of the sphenoid wing. Surg Neurol 2001;55:265-9.  Back to cited text no. 23
24.Alpers BJ, Harow R. Cranial hyperostosis. Arch Neurol Psychiatry 1932;28:339-56.  Back to cited text no. 24
25.Archibald E. Surgical affections and wounds of the head. In: Bryant J, Buck A, editors. American Practice of Surgery. New York: William Wood and Co.; Vol. 4. 1908. p. 3-378.  Back to cited text no. 25
26.Ashhurst AP. Case of jacksonian epilepsy caused by brain tumor. Ann Surg 1920;72:402-6.  Back to cited text no. 26
27.Fuchs. A successfully operated case of brain tumor. Wien Klin Wochenschr 1910;23:1701.  Back to cited text no. 27
28.Spiller WG. Cranial hyperostosis associated with underlying meningeal fibroblastoma. Arch Neurol Psychiatry 1929;21:637-40.  Back to cited text no. 28
29.Sternberg H. [Exostosis of the cranial vault is an inner endothelium of the dura]. Klin Wochenschr 1919;56:178.  Back to cited text no. 29
30.Tattersall J. A case of cerebral tumor with tumor of the skull. J Ment Sci 1917;63:250-2.  Back to cited text no. 30
31.Simpson D. The recurrence of intracranial meningiomas after surgical treatment. J Neurol Neurosurg Psychiatry 1957;20:22-39.  Back to cited text no. 31
32.Adegbite AB, Kahn MI, Paine KW, Tan LK. The recurrence of intracranial meningiomas after surgical treatment. J Neurosurg 1983;58:51-6.  Back to cited text no. 32
33.Chan RC, Thompson GB. Morbidity, mortality and quality of life following surgery for intracranial meningiomas: A retrospective study in 257 cases. J Neurosurg 1984;60:52-60.  Back to cited text no. 33
34.Jääskeläinen J. Seemingly complete removal of histologically benign intracranial meningioma: Late recurrence rate and factors predicting recurrence in 657 patients-A multivariate analysis. Surg Neurol 1986;26:461-9.  Back to cited text no. 34
35.Kallio M, Sankila R, Hakulinen T, Jääskeläinen J. Factors affecting operative and excess long-term mortality in 935 patients with intracranial meningioma. Neurosurgery 1992;31:2-12.  Back to cited text no. 35
36.Marks SM, Whitwell HL, Lye RH. Recurrence of meningiomas after operation. Surg Neurol 1986;25:436-40.  Back to cited text no. 36
37.Miller DC. Predicting recurrence of intracranial meningiomas: A multivariate clinicopathologic model-Interim report of the New York University Medical Center Meningioma Project. Neurosurg Clin N Am 1994;5:193-200.  Back to cited text no. 37
38.Mirimanoff RO, Dosoretz DE, Linggood RM, Ojemann RG, Martuza RL. Meningioma: Analysis of recurrence and progression following neurosurgical resection. J Neurosurg 1985;62:18-24.  Back to cited text no. 38
39.Yamashita J, Handa H, Iwaki K, Abe M. Recurrence of the intracranial meningiomas with special reference to radiotherapy. Surg Neurol 1980;14:33-40.  Back to cited text no. 39
40.Al-Mefty O, Kadri PA, Pravdenkova S, Sawyer JR, Stangeby C, Husain M. Malignant progression in meningioma: Documentation of a series and analysis of cytogenetic findings. J Neurosurg 2004;101:210-8.  Back to cited text no. 40
41.Eisenberg MB, Al-Mefty O, DeMonte F, Burson GT. Benign nonmeningeal tumors of the cavernous sinus. Neurosurgery 1999;44:949-55.  Back to cited text no. 41
42.Mathiesen T, Lindquist C, Kihlström L, Karlsson B. Recurrence of cranial base meningiomas. Neurosurgery 1996;39:2-9.  Back to cited text no. 42
43.Nakasu S, Nakasu Y, Nakajima M, Matsuda M, Handa J. Preoperative identification of meningiomas that are highly likely to recur. J Neurosurg 1999;90:455-62.  Back to cited text no. 43
44.Olmsted WW, McGee TP. Prognosis in meningioma through evaluation of skull bone patterns. Radiology 1977;123:375-7.  Back to cited text no. 44


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2]

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