This case involves an otherwise healthy 40-year-old female who had a large noncancerous tumor removed from the membrane surrounding her brain. Pathology revealed higher than the normal cell proliferation, but the pathologist did not diagnose the lesion as an atypical or malignant tumor. After the brain surgery, the patient felt persistent weakness in her legs. Subsequent spinal imaging revealed a spine tumor which was subsequently resected. The surgeon did not order follow up imaging or refer the patient for radiosurgery. 5 years later, the patient’s condition began to rapidly deteriorate. It was discovered that the lesion had recurred and increased in size. The patient underwent a second craniotomy for resection and suffered complications as a result. The patient suffered permanent brain damage and lost much of her mental function. It was alleged that initial post-operative imaging may have revealed a residual tumor. An expert neurosurgeon with experience treating patients with atypical tumors was sought to review the records and opine on the standard of care.
Question(s) For Expert Witness
- 1. What is the standard imaging surveillance for a patient with an atypical meningioma and/or multiple meningiomas within a short period?
- 2. What is the role of radiosurgery in the treatment of residual atypical meningiomas?
Expert Witness Response E-007891
I am a board-certified neurosurgeon with 30+ years of experience. I am currently the chief of service, chair of the neurosurgery department, and program director at my institution. I think it is fair to say that many neurosurgeons maintain close (at least annual) surveillance of residual meningiomas. The literature related to recurrence rates for these tumors given extent of resection is widely available. Radiosurgery has a role, although there is controversy surrounding re-operation vs radiosurgery. Generally, residual atypical meningioma is not ignored. Non-malignant residual meningiomas are also usually followed carefully. After reading this case summary, I have some questions: Do we have any idea why follow up did not occur in this case? Was the patient seen regularly? Were scans scheduled but skipped by patient? My first instinct is that the case seems strange, although examples of lapsed follow up and surveillance can occur from time to time.