Treatment Strategies for Primary Cavernous Sinus Meningiomas: A Systematic Review and Meta-analysis

Introduction: The natural history of cavernous sinus meningiomas (CSMs) demonstrates capricious and unpredictable growth, which adds to the challenge of managing them effectively given their proximity to critical neurovascular structures. Current treatment modalities for CSMs include observation alone, radiation therapy, stereotactic radiosurgery (SRS), and/or surgery, the latter having become less infrequent due to the high risk of complications. Given the dearth in long-term outcomes following these treatment strategies in the contemporary era, this work sought to quantitatively synthesize the existing literature regarding efficacy and safety of various treatment modalities for patients with primary CSMs.

Methods: A systematic review was conducted and reported adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The PubMed database was searched for records concerning “cavernous sinus meningioma” meshed with either “observation,” “radiotherapy,” “radiosurgery,” or “surgery”. Records were assessed using title-and-abstract-screening, followed by full text review using predefined eligibility criteria. Relevant records with full-texts in the English language having patient data of primary CSM that were published between 2001–2021 were deemed eligible for inclusion. Clinical data were abstracted, and study quality was assessed using the “Case Series Quality Appraisal Checklist”, with two reviewers randomly assigned to each record. The primary outcome was progression-free survival (PFS. at 5 years and 10 years. The key secondary outcomes were radiographic growth or reduction, and cranial nerve symptom worsening or improvement. Meta-analysis was conducted using random-effects modeling and visualized using forest plots. Funnel plots were created to assess publication bias.

Results: 760 relevant records were identified, of which ten studies were deemed eligible, including 9 studies on SRS for CSM and one on observation alone ([Fig. 1]). Significant heterogeneity in reporting of outcomes, inconsistent reporting distinguishing primary and adjuvant radiotherapy treatments, and lack of volumetric response assessment across studies were found. For patients given SRS, the pooled 5-year progression free survival (PFS) was 94% (95% CI 90–96%), while the 10-year PFS was 85% (95% CI 78–89%) ([Fig. 2]). Radiological reduction was seen in 57% (95% CI 49–65%) and radiological progression was seen in 6% (95% CI 3-10%) ([Fig. 3]). CSM patients given SRS had cranial nerve symptom improvement in 51% (95% CI 73–92%) and worsening in 5% (95% CI 3–10%) of cases ([Fig. 4]). For the observation-only study, 5-year PFS was 90% (±4.2%) and 10-year PFS was 82% (±5.7%), while tumor progression was not observed.

Conclusions: The existing literature lacks high quality evidence regarding long-term comparative outcomes of various treatment modalities. However, SRS for patients with CSM was most commonly found to be reported, where 5-year and 10-year PFS rates were 94% and 85% respectively. Inconsistent definitions and reporting of outcomes combined with lack of volumetric response assessment limit interpretations related to the long-term efficacy of primary SRS on confined CSM lesions. Limited data from studies on observation alone confirms these tumors progress slowly. Prospective, multi-center, registry-based efforts are warranted to guide evidence-based practice for CSM.

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
05 February 2024