Schmieder Kirsten, Engelhardt Martin, Wawrzyniak Sebastian, Börger Sandra, Becker Kurt, Zimolong Andreas
Department of Neurosurgery, Medical Faculty Mannheim, Germany.
GMS Health Technol Assess. 2010 Mar 16;6:Doc02. doi: 10.3205/hta000080.
Meningiomas are the most common benign intracranial neoplasms with a slow growth presented as the intracranial lesion. These tumors are without any symptoms for a long time. At the time of diagnosis it is frequently an asymptomatic tumor. In that case the therapist may well suggest a wait-and-see strategy. The therapy of meningiomas focuses firstly on the microsurgical treatment. Volume reduction can be achieved immediately after treatment. Stereotactic radiosurgery is an important non-invasive treatment option for recurrent tumors or meningiomas with partial resection. The technical equipment for the stereotactic radiosurgery is a cost intensive investment. In this context the high precision of the intervention, presented as a low invasiveness of the treatment, is an important factor. The aim of this assessment is to identify the chances and limitations of the diverse treatment options and to estimate their outcome for different localisations of meningiomas.
In December 2007 a systematic literature search was conducted using the most relevant medical databases. The whole strategy and the used search terms were documented. The literature search was supplemented with an internet and literature based hand search on law, ethics and economics. Primary studies and systematic reviews which report relevant outcomes are included in this analysis. The current assessment is based on the available evidence that was found at the time of the literature search.
A total of 31 publications for the medical focus of assessment and three reports from the economical hand search were included. In general, it is not possible to identify neither randomised clinical trials or prospective, contrasting cohort studies nor studies summarising results from such studies. The results presented in the literature published by surgeons strongly vary regarding localisation of meningiomas. Publications not differentiating between the localisation of meningiomas indicate a progression free survival rate of five years in 77 to 97% of the cases after complete surgical resection of the tumor, in 18 to 70% of the cases after subtotal resection and for patients who had undergone surgical resection and a combined radiotherapeutical treatment of their meningiomas a five year progression free survival rate between 82 and 97%. Other treatment options like hormone therapy or treatments to stop tumor growth had been used unsuccessfully so far. Based on the results presented regarding economic evaluation, costs resulting from radiosurgical treatment are lower in contrast to costs resulting from surgical resection. However, it has to be taken into account that costs resulting from radiosurgical treatment strongly depend on the number of patients treated in total with the radiosurgical equipment.
Due to the strong dependencies between the results from surgical therapy and the localisation of the tumor, it is only possible to derive recommendations on whether or not to perform the surgical therapy with respect to the localisation of the tumor. Only for patients with tumors with a spinal localisation or WHO Grade I meningiomas with a cortical localisation, primary treatment with by means of microsurgery can be suggested. For all other localisations of the tumor, alternative treatment by radiosurgery should be discussed. From the literature identified, a clear recommendation of one or the other therapy however can not be deduced. Thus, there is a strong need for randomised clinical trials or prospective or contrasting cohort studies, which compare rigorously microsurgery with radiosurgery concerning different localisations of tumors.
脑膜瘤是最常见的颅内良性肿瘤，生长缓慢，表现为颅内病变。这些肿瘤长期无症状。在诊断时，通常是无症状肿瘤。在这种情况下，治疗师很可能会建议采取观察等待策略。脑膜瘤的治疗首先侧重于显微外科治疗。治疗后可立即实现体积缩小。立体定向放射外科是复发性肿瘤或部分切除的脑膜瘤的重要非侵入性治疗选择。立体定向放射外科的技术设备是一项成本高昂的投资。在这种情况下，以治疗的低侵入性呈现的干预高精度是一个重要因素。本评估的目的是确定不同治疗选择的机会和局限性，并估计其对不同部位脑膜瘤的治疗结果。
2007年12月，使用最相关的医学数据库进行了系统的文献检索。记录了整个策略和使用的检索词。文献检索还辅以基于互联网和文献的关于法律、伦理和经济学的手工检索。报告相关结果的原始研究和系统评价纳入本分析。当前评估基于文献检索时发现的现有证据。
共纳入31篇评估医学重点的出版物和3篇经济手工检索报告。一般来说，既无法确定随机临床试验、前瞻性对比队列研究，也无法确定总结此类研究结果的研究。外科医生发表的文献中呈现的结果在脑膜瘤的定位方面差异很大。未区分脑膜瘤定位的出版物表明，肿瘤完全手术切除后，77%至97%的病例五年无进展生存率，次全切除后18%至70%的病例，以及接受手术切除并对其脑膜瘤进行联合放射治疗的患者，五年无进展生存率在82%至97%之间。到目前为止，其他治疗选择，如激素治疗或阻止肿瘤生长的治疗均未成功。根据经济评估结果，与手术切除产生的成本相比，放射外科治疗产生的成本较低。然而，必须考虑到，放射外科治疗产生的成本很大程度上取决于使用放射外科设备治疗的患者总数。
由于手术治疗结果与肿瘤定位之间存在强烈相关性，因此只能根据肿瘤定位得出是否进行手术治疗的建议。仅对于脊髓部位肿瘤或皮质部位的世界卫生组织I级脑膜瘤患者，可建议首选显微外科治疗。对于肿瘤的所有其他部位，应讨论放射外科替代治疗。然而，从已确定的文献中无法推断出对一种或另一种治疗的明确建议。因此，迫切需要进行随机临床试验或前瞻性或对比队列研究，严格比较显微外科手术与放射外科手术在不同肿瘤部位的疗效。
